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A
TREATISE
DISEASES   OE   THE   EYE,
               W. LAWRENCE,  F. R. S.

SURGEON EXTRAORDINARY TO THE QUEEN; SURGEON TOST. BARTHOLOMEW'S HOSPITAL
      AND LECTURER ON SURGERY AT THAT HOSPITAL ; SURGEON TO BETHLEM
           AND BRIDEWELL HOSPITALS; AND LATE SURGEON TO THE
                  LONDON OPHTHALMIC INFIRMARY.
       FROM THE  LAST  LONDON  EDITION,

             WITH NUMEROUS ADDITIONS, AND


   SIXTY-SEVEN  ILLUSTRATIONS

              BY ISAAC HAYS,  M. D.,

SURGEON TO WILL'S HOSPITAL, PHYSICIAN TO THE PHILADELPHIA ORPHAN ASYLUM,
    MEMBER OP THE AMERICAN PHILOSOPHICAL SOCIETY, &C, &C, &C.
7/y#)
y - "_J*t—*m^ -••-J/**If J «rVs'

     PHILADELPHIA:
LEA &  BLANC HARD.

           1843.
\ 
VVkV
  Entered, according to the Act of Congress, in the year one thousand eight hundred
and forty.two, by
                        LEA  &   BLANCHARD,
in the Clerk's Office of the District Court of the Eastern District of Pennsylvania. 
ADVERTISEMENT
         TO THE


AMERICAN EDITION.
  The character of this work is too well established to require a word of com-
mendation.  It is justly considered the best we possess on the subject.
  The present, is a reprint of the last London edition, which appeared in 1841,
completely revised and greatly enlarged, by the author; and to it considerable
additions have been made by the Editor.
  Sixty seven illustrations are introduced, many of them from original draw-
ings, the whole engraved by Mr. R. S. Gilbert.
  Several subjects omitted in the original, are treated of; in supplying which, as
well as on other occasions, free use has been made of the valuable Treatise of Mr.
Mackenzie.   The catoptric  examination of the  eye, and its value as a means
of diagnosis; the recent investigations into the structures of the orbit, &c, are
all fully considered.
  The results, are given, of the Editor's own experience in relation to the treat-
ment  of most of the important diseases, derived from more than twenty years
devotion to the  subject, during all which period  he has been attached to some
public institution for the treatment of Diseases of the Eye.
  It would have gratified the Editor to have given fuller details on some sub-
jects,  and introduced a few which are not noticed;  but he was restrained by
the fear of increasing too much the size of the work, and thus rendering it more
costly than was desirable.
  The Editor's additions are enclosed in brackets, and are in different type from
the rest of the work. 
* 
ADVERTISEMENT
      TO THE


FIRST  EDITION.
  The basis of the following Treatise consists of the Lectures on the
Anatomy, Physiology, and Diseases of the Eye,'which I delivered at the
London Ophthalmic Infirmary.  The subjects are now considered in
greater detail; the opinions and experience of others are quoted and ex-
amined ;  and cases are introduced, for practical illustration, wherever
it could be done with advantage.
  To have treated of the Anatomy and Physiology of  the Eye at full
length, would have been inconsistent with the limits and objects of this
work.  The short account of those  subjects given in the lectures has
been retained, merely for the purpose of introduction and explanation,
in reference  to the pathological and practical part of the Treatise.
                                            W. LAWRENCE.
    Whitehall Place, June 29, 1833. 
ADVERTISEMENT
TO THE
SECOND EDITION.
  This Edition has been committed to press after a  careful revisal of
the whole work.   The arrangement has been altered in many repects,
so as to make  it more methodical, and thus to  facilitate reference.
Much additional matter has been introduced throughout; a larger and
fuller page having been adopted, that the bulk  of the volume might not
be inconveniently increased.   The subject of squinting and the new
operation for its removal have been fully considered.
                                                       W. L.
   Whitehall Place, November, 1840. 
CONTENTS.
Introduction  .
General view of the subject
Mode of study  .
History    .       .       •
[Horizontal section of eye-ball] .
[Lachrymal organs]
Anatomy of the eye-ball
Form and composition of the globe
Sclerotica
Cornea
Vessels of the cornea   .
Nerves of the cornea
Choroid coat
Pigmentum
Blood-vessels of the choroid
Corpus ciliare
[Annulus albidus]
Iris        .       .       •
Blood-vessels of the iris
Nerves
Colour .       .       .       •
Muscularity
Membrana pupillaris    .
Arachnoid coat of the eye  .
Retina, and optic nerve
Mem bran e of Jacob
Connexions of the coats
Ciliary ligament
Vitreous humour
Zonula ciliaris
Crystalline lens
Aqua Morgagni
Capsule of the lens
Aqueous humour   .
Membrane of the aqueous humour
Physiology of the eye-ball   .
Light
Its reflection and refraction
Page
   25
   ib.
   27
   ib.
   36
   ib.
   38
   ib.
   39
   42
   44
   45
   ib.
   46
   47
   49
   ib.
   50
   51
   52
   ib.
   53
   55
   56
   58
   ib.
   60
   ib.
   61
   62
   ib.
   63
   64
   65
   ib.
   66
   ib.
   67
 Action of the transparent media of
   the eye on light .
 Movements of the iris, and conse-
   quent changes in the state of the
   pupil    ....
 Independent and associated actions
   of the iris
 Muscularity of the iris"?
 Use of the pigmentum .
 Situation of the impression on the
   retina    .
 Its size ....
 Inversion of the image on the retina
 Single vision with two impressions
 Course of  the fibres in the optic
   nerves and the chiasma .
 [The eye as a catoptric instrument]
 Anatomy of the appendages of the
   eye      .
 The muscles of the globe
 [Anatomical relations]
 [Ocular fasciae].
 Nerves     .
 Other contents of the orbit; perior-
   bita  ....
 Eye-brow   ....
 Eye-lids; their muscles.
 Component tissues of the eye-lids  .
 Tarsi; sebaceous glands
 Cellular substance of the  lids
 Ciliary margins
 Cilia; canthi
Conjunctiva
C. palpebralis
C. scleroticse; c. cornea?
Lachrymal organs; gland   .
Puncta ; sac; nasal duct
Caruncula lachrymalis
Semilunar fold of the  conjunctiva
Page

  67


  71

  72
  74
  ib.

  76
  77
  ib.
  78

  79
  ib.

  81
  ib.
  83
  84
  85

  ib.
  86
  87
  89
  ib.
  90
  91
  ib.
  92
  ib.
  93
  94
  95
  96
  ib. 
Vlll
CONTENTS.
CHAPTER 1.
PATHOLOGY OF THE EYE—INFLAMMATION—CLASSIFICATION OF OPHTHALMIC

                                DISEASES.
            SECTION I.

Pathology of the eye   .

            SECTION II.
Page
  96
98
Inflammation
Varieties of inflammation; acute and
  chronic  ....  100
                                 Page
Various effects .       .       •      103
Common and specific      .       .   ib.
Varieties from difference of texture  104
Other modifications       •      •   ib.
            SECTION  III.

Arrangement of the subject
105
CHAPTER II.
AFFECTIONS OF THE EYE-LIDS.
            SECTION 1.

Injuries   ....   106
Wounds of the eye-brows and eye-
  lids                              ib.
Poisoned wounds  .       .       .   107
Malignant pustule     .       .       ib.
Scalds and burns  .       .       .   108
Amaurosis from wounds of the eye-
  brow   .      .       .       .    ib.
Ecchymosis of the eye-lids    .      113

            SECTION II.

Inflammation  of the eye-lids and
  their consequences  .       .      114
Inflammation  of the cellular tex-
  ture ; abscess   .       .       .    ib.
Erysipelatous  inflammation  of the
  lids     .      .       .       .115
[Carbuncle of the eye-lids]    .       ib.
CEdema   .      .       .       .116
Emphysema    .      .      .       ib.
Ophthalmia tarsi  .       .       .    ib.
Catarrhal inflammation .      .      117
Lippitudo .      .       .       .    ib.
Psorophthalmia       .            120
Scrofulous inflammation   .           ib.
Inflammation of the lids with ulcera-
  tion    .             •       .    ib.
Hordeolum     .             .122
Secondary inflammations  .       .   123
Thickening  and induration  of the
  margins (tylosis).       .       .    ib.
Loss of the eye-lashes (ptilosis)       124

            SECTION  III.
Ulcerations
Syphilitic diseases
124
 ib.
Syphilitic  ulcerations
Cancer of the lower eye-lid
            SECTION IV.

Changes of figure and position
Ptosis
Lagophthalmus
Paralysis of the orbicularis palpe
  brarum
Blepharospasmus
Ectropium  .
Operations of Jaeger and Dieffen
  BACH
Operation of Jaeger for lagophthal
  mus
Transplantation of skin for the repaii
  or restoration of the lids
Entropium
Treatment by concentrated acid; by
  removing a portion of skin
Operations  of  Messrs. Crampton
  and Guthrie
Excision of the cilia
Trichiasis  .
Distichiasis
[Additional observation on inverted
  cilia;]


            SECTION V.

Morbid connexions of the  eye-lids
Ancyloblepharon ; symblepharon
Expicanthus
SECTION  VI.
Tumours
Neevi materni
125
127
133
 ib.
135

 ib.
 ib.
 ib.

137

139

 ib.
142

143

144
146
 ib.
147

 ib.
149
 ib.
150
151
 ib. 
CONTENTS.
IX
Encysted tumours
Half-encysted tumours
Tarsal tumours .
Page
  151
  153
   ib.
Chalazion or grando
Milium and phlyctenula
Verruca?; pediculi .
Page
 154
  ib.
 155
CHAPTER III.
INJURIES OF THE EYE-BALL.
            SECTION I.

Wounds of the globe      .       .  156
Conjunctiva; ecchymosis, accidental
  and spontaneous .      .      .    ib.
Wounds of the globe, their  nature
  and general treatment       .     157
Cornea     ....  158
Foreign bodies in the anterior cham-
  ber      ...           ib.
Gunshot injuries of the eye     .     160
Injuries by exploded percussion caps    ib;
Wounds of the  cornea with prolap-
  sus iridis....  161
Injuries of the eye from gunpowder    ib.
Sclerotica  ....  162
Iris    ....     163
Detachment of  the  iris  from the
  ciliary ligament .       .       .  164
Effusion of blood into the anterior
  chamber .       .       .           ib
Discolouration of the iris or aqueous
  humour  .      .       .       .    ib.
Wounds of the  choroid and ciliary
  body—effusion of blood before or
  behind the iris  .       .       .  165
Crystalline lens and capsule    .      166
Traumatic cataract        .       .   167
Dislocated lens forced  through the
  sclerotica       .       .       .   168
Extraction of the dislocated lens       ib.
[Additional remarks on dislocation of
  lens]       .       .       .170
Wounds of vitreous humour       .   170
Retina  ....      172
Sympathetic  influence  on  the unin-
  jured eye    .       .       .      173
Cases of amaurosis, internal inflam-
  mation and atrophy from injuries   173
Cases of sympathetic  inflammation
  affecting the opposite eye    .      175


            SECTION II.

Injuries of the eye from foreign sub-
.  stances passing betweeu the lids   175
Various irritating matters      .      176
Effect of lime      .       .          177
Particles of dust under the upper lid   ib.
Metallic particles  sticking in the
  cornea      .       .       .      178
CHAPTER  IV.
CAUSES OF OPHTHALMIC INFLAMMATION.
Immediate or exciting causes
Injuries; chemical irritants
Contagious matters; excessive exer-
  tion; atmospheric causes
Strong lights
Remote or predisposing causes
Light or dark eyes—morbid disposi-
  tions
Excessive exertion of the organ
. 180	Unhealthy 6tates of constitution	185
ib.	Plethora ....	187
	Constitutional weakness	ib.
181	Determination of blood to the head	ib.
. 182	Disordered functions and deficient	
184	excretion	ib.
-	Impaired nervous energy	188
ib.	Idiopathic and sympathetic inflam-	
. 185	mations	189
CHAPTER V.
TREATMENT OF OPHTHALMIC INFLAMMATION.
SECTION I.		Local bleeding—cupping .	194
		Leeches—-scarifications	195
Treatment of acute inflammation	190	Purgatives and diet	196
General indications	191	Other internal remedies; antimony	ib.
Loss of blood	192	Mercury; counter-irritation	197
General bleeding 2	ib.	Local applications	199
 
X
CONTENTS.
            SECTION  II.

Treatment of chronic ophthalmia
General means .
Local measures; counter-irritation
Use of stimuli and astringents; vi
  num opii
Page
 201
 202
 204

 205
                                Page
Various saline substances in solution  206
Nitrate of silver
General summary of treatment in
  ophthalmic inflammation.
 ib.

209
CHAPTER VI.
DIVISIONS AND CLASSIFICATION OF OPHTHALMIC INFLAMMATIONS.-

              CATARRHAL INFLAMMATION OF THE CONJUNCTIVA.
-SIMPLE AND
Divisions and classification .       .  209
Simple inflammation of the conjunc-
  tiva     .      .      .       .211
Catarrhal ophthalmia; its nature       ib.
Causes    ....  212
Symptoms
Prognosis; diagnosis
Treatment
Use of astringents .
213
214
215
216
CHAPTER  VII.
PURULENT OPHTHALMIA.--PURULENT OPHTHALMIA OF NEWLY-BORN INFANTS.
Nature  and general character  of
  purulent ophthalmia    .       . 218
Purulent ophthalmia of infants      219
Symptoms and progress    .       .   ib.
Effects        .       .       .     221
Mode of examining the eye       .   222
Causes ....      224
Prognosis   ....   225
Treatment     .       .       .      226
Purulent ophthalmia in children   .   229
CHAPTER VIII.
PURULENT OPHTHALMIA IN THE ADULT.
Character     ...      231
Symptoms and progress   .       .   233
Purulent ophthalmia  in  its  milder
  form    .      .       .       .234
Effects of the inflammation    .      239
Diagnosis; prognosis: causes      .   241
Direct communication by application
  of discharge    .       .          242
Indirect or atmospheric contagion     247
Arguments against contagion     .   248
General result of evidence respect-
  ing contagion   .       .       .   250
Treatment     .       .       .      253
Treatmentof acute purulent ophthal-
  mia  .      .   '    .       .       ib.
General measures   .      .      .   ib.
Local applications     .       .      256
Astringents and tonic medicines   .  257
Treatment  of  purulent ophthalmia
  in its milder form      .      .  260
Treatment of the thickened and gra-
  nulated conjunctiva     .      .  261
[Additional  remarks on granulated
  conjunctiva]     .      .      .   264
CHAPTER IX.
GONORRHEAL OPHTHALMIA.
            SECTION I.

Acute  gonorrhoea!  inflammation of
  the conjunctiva   .      .       .   271
Symptoms and progress       .       ib.
Effects; sloughing of the cornea   .   273
Suppuration and ulceration     .       ib.
Interstitial deposition      .       .   ib.
Diagnosis; prognosis
Causes
Direct  application  of  gonorrhceal
  matter  .      .
Metastasis
Treatment
Incisions of the  sclerotic conjunc-
  tiva
276
277

 ib.
279
280

283 
CONTENTS.
XI
conjunctiva
SECTION II.	SECTION III.	Page
Page	Gonorrheal inflammation of the ex-	
Eal inflammation of the	ternal tunics and iris	288
i . . .288	Rheumatic nature of this disease	289
CHAPTER X.		
ERYSIPELATOUS OPHTHALMIA ;  PUSTULAR OPHTHALMIA ?  STRUMOUS OR SCROFU-

                            LOUS OPHTHALMIA.
            SECTION  I.
Erysipelatous ophthalmia   .       .  292

            SECTION  II.
Pustular ophthalmia      .       .  292

            SECTION III.
Scrofulous ophthalmia     .       .  293
Scrofulous constitution .      .     293
Exciting causes of scrofula       .  294
Symptoms and  course of scrofulous
  ophthalmia      .       .      .  295
Effects  .      .       .      .298
Diagnosis  ....  299
Prognosis                          ib.
Causes; treatment; general means  300
Local treatment
303
CHAPTER XL
VARIOLOUS MORBILLOUS, AND SCARLATINOUS OPHTHALMIA.

                       3061 Morbillous and  scarlatinous  oph-
Variolous ophthalmia
Secondary variolous ophthalmia
309    thalmia
310
CHAPTER  XII.
VARIOUS AFFECTIONS OF THE CONJUNCTIVA.
Granulated conjunctiva—ulcers     311
Pterygium ; general description    .  312
Pterygium tenue ; crassum          314
Malignant pterygium     .       .  315
Diagnosis, treatment   .      .      ib.
Pterygium pingue .             .  317
Dry conjunctiva             .      ib.
Discolouration of the conjunctiva by
  nitrate of silver  .      .      .  318
Polypi, warts and other excrescences  319
Cartilaginous formations   .      .  320
Tumours                          ib.
       with hairs .      .      .  321
       encysted       .      .      323
CHAPTER XIII.
DISEASES OF THE SCLEROTICA.
            SECTION I.

Inflammation
Symptoms and progress
Diagnosis   .

            SECTION II.

Rheumatic ophthalmia;  Catarrho-
  rheumatic ophthalmia
323
324
326
326
Chronic rheumatic ophthalmia  .     328
Catarrho-rheumatic ophthalmia    .  330

           SECTION III.

Staphyloma sclerotica;    .       .  330

           SECTION IV.

Cysts and tumours of the sclerotica  332 
xu
CONTENTS.
  CHAPTER XIV.

DISEASES OF THE CORNEA.
            SECTION I.
                               Page
Inflammation      .      .       .  333
Acute corneitis with suppuration    331
Evacuation of matter by puncture  .  336
Symptoms of corneitis .      .    337
Prognosis   ....  339
Treatment                         ib.
Partial inflammation of the cornea .  340
Strumous corneitis    .      .    341
Inflammation with vesication      .  342
Vascularity of the cornea      .     342

           SECTION III.

Ulceration of the cornea  .      .  342
Hernia cornea;  .      .      .     345
            DISEASES OF THE AQUEOUS

            SECTION I.

Internal inflammations of the eye    359
Artificial dilatation of the pupil    .  360

           SECTION II.

Inflammation of the aqueous mem-
  brane    ....  364
Symptoms                         ib.
Treatment.       .     .      .365
Diagnosis     .       .      .     366

            SECTION III.

Hypopyon     .      .      .      368
Question of opening the cornea to
   let out the matter   .            369
           SECTION IV.

                                Page
Opacity of the cornea     .       .  345
Arcus senilis   .       .      .      ib.
Other opacities    .       .       •  346
Treatment     .       .      -347
Effect of treatment in the various
  forms of opacity      .      .     349
Congenital opacity of the cornea   .  350
Staphyloma	. 351
Causes ....	354
Treatment .	ib.
Adaptation of an artificial eye .	356
Conical cornea	. 357
MEMBRANE AND CHAMBERS.

            SECTION IV.

Evacuation of the aqueous humour   371


            SECTION V.

Effusion of blood and other matters
  into the anterior chamber    .      ib.
Haemophthalmus  .      .         ib.
Hypolympha; hypogala.       .     375


            SECTION VI.

Enlargement of the  cavity contain-
  ing the aqueous humour; dropsy of
  the anterior chamber    .      .  375
Congenital dropsy     .       .      ib.
Other cases      .      .        376
SECTION II.
SECTION V.
CHAPTER  XV. 
CONTENTS.                            Xlll
       CHAPTER XVI.


    DISEASES OF THE  IRIS.


INFLAMMATION OF THE IRIS ; IRITIS.
SECTION I.
                                Page
General account of iritis  and its
  treatment        .      .      .   276
General character of iritis     .      377
Change of colour; effusion of lymph   378
Abscess   .       .      .      .   379
Motions of the iris, and state of the
  pupil   .       .       .      .381
Increased redness of the eye  .       ib.
State of the cornea and aqueous hu-
  mour    ....  382
Intolerance of light, and pain  .      383
General symptoms  .       .      .   ib.
Progress and extension of the  in-
  flammation      .       .      .  384
Effects; gradual recovery     .       ib.
Change of texture and colour in the
  iris      ....  385
Adhesions of the pupil  .      •      ib.
Adventitious membranes   .      .  386
Closure of the pupil; atrophy of the
  globe and synchisis     .      .  387
Impaired vision                     ib.
Causes    ....  388
 Whether iritis is caused by the use
  of mercury     .      .      .  389
Prognosis     .       .       .      390
Treatment;  antiphlogistic means;
  and  mercury     .     .       .   391
Whether the use of mercury is essen-
  tial   ....
Beneficial action of mercury after or
  with direct depletion
Caution against  its indiscriminate
  and excessive employment
Its favourable action in small doses
  under certain circumstances
Local employment of mercury .
Belladonna
Operation of mercury  .
Local applications: vinum opii, blis-
  ters  ....
Precaution against relapse .
Oil of turpentine

            SECTION II.

Acute and chronic iritis

            SECTION III.
Page

 393

 894

 395

   ib.
 397
   ib.
 398
Syphilitic iritis
Diagnosis
SECTION IV.
Arthritic iritis
Scrofulous iritis
400
 ib.
 ib.
402
404
405
406
408
CHAPTER XVII.
MALFORMATIONS AND VARIOUS AFFECTIONS OF THE IRIS.
Congenital deficiency . . 409	and ciliary body .	. 414
Coloboma iridis . . 410	Tumours growing from the iris	415
Change of colour; spotted iris; pro-	Myosis	. 416
lapsus iridis . . . 411	Mydriasis	ib.
Synechia anterior and posterior . 413	Tremulous iris . ,	ib.
Fungous execrescences from the iris		
CHAPTER XVIII.
FORMATION OF AN ARTIFICIAL PUPIL.
            SECTION I.

General and preliminary considera-
  tions  ....     417
States of the eye requiring the ope-
  ration       .       .        .     418
Diagnosis  ....  420
Prognosis     .       .       .     422
Position of the artificial pupil
Previous considerations
Various operations .


            SECTION II.

Operation by incision
424
425
427
428 
XIV
CONTENTS.
                                Page
Methods of Cheselden, Wenzkl     428
         Janin   .       .      •   429
         Sir W. Adams     .       ib.
         Maunoir       .      •   431
[More particular account  of Mau-
  noir's method]  .       .      •   433
           SECTION III.

Operation by excision   .      .      434
Method of Mr. Gibson     .      .   435
        Mr. Tyrrell             437
SECTION  IV.
Operation by separation;  cored ialy-
of  Scarpa   and
  sis
The  operation
  Schmidt
The operation by detachment and
  strangulation
Langenbeck's operation
Reisinger's double hook
Operation by separation and excision
[Distortion].      .              •
Formation of  an artificial pupil  in
  the sclerotica
Page

 438
 ib.

441
 ib.
443
444
447

448
CHAPTER XIX.
AFFECTIONS OF  THE  CHOROID  COAT, RETINA,  VITREOUS  HUMOUR, LENS, AND
SECTION I.
CAPSULE.
Affections of the choroid coat     .  449
Choroiditis     .       .      .       ib.
Inflammation of the orbiculus cili-
  aris  ....      452
Deficiency of pigment     .      .   ib.

            SECTION II.
Inflammation of the retina .	452
Cases	453
Inflammation of the internal tunics	
generally .	455
Internal inflammation of the eye con-	
sequent on fever	457
Arthritic inflammation of the inter-	
nal tunics	460
Glaucoma	463
Symptoms ....	ib.
Causes .
Seat of disease
Diagnosis
Prognosis; treatment
[Additional remarks]
SECTION  IV.
SECTION  V.
464
 ib.
466
 ib.
467
Affections of the vitreous humour    468
Hypertrophy; ecchymosis; synchisis  ib.
Change of structure and consistence  469
Affections of the lens and capsule
Inflammation
Calcareous and bony change
Spontaneous passage into the ante-
  rior chamber    .      .       .  472
470
 ib.
471
CHAPTER  XX.
AMAUROSIS AND OTHER DEFECTS OF SIGHT.
            SECTION  I.

General observations
Divisions of amaurosis  .

            SECTION II.

Amaurosis from  affections of the
  brain    ....

           SECTION III.

Amaurosis from diseases of the optic
  nerve    ....
474
475
478
482
           SECTION IV.

Amaurosis from affection of the re-
  tina     ....   485
Symptoms of amaurosis;  impaired
  and altered sight    .       .      489
Progress of the disease    .       .   490
State of the pupil and iris       .      492
Other symptoms   .       .       .   494
Causes; age; the disease sometimes
  congenital      .       .          495
Hereditary disposition         .       jD-
General causes;  plethora  .       .   495
Excessive exertion of the organ       ib. 
CONTENTS.
XV
                                 Page
Determination to the head .       .   497
Sympathetic influences .       .       ib.
Syphilis    .       .      .       .498
Gout and rheumatism  .       .       ib.
Narcotic poisons,  and various other
  substances    .       .       .      499
Diagnosis  ....   501
Prognosis      .       .       .      502
Treatment; antiphlogistic measures   503
Use of mercury        .       .      504
Counter-irritation  .      .       .   505
Cases   ....      506
Local applications .      .       .   511
Emetics        .       .       .      512
Electricity ....   514
Sternutatories; stimuli and tonics    515
Use of strychnia   .      .       .   517
[Case illustrating its efficacy]  .      519

             SECTION  V.

Particular kinds of nervous affection   520
Affection of the retina from exces-
  sive exertion     .      .       .    ib.
                                 Page
Symptomatic and sympathetic amau-
  rosis  ....      522
Amaurosis from debility    .       .   524
[Hysteric amaurosis]  .       .      529
Amaurosis from affection of the ner-
  vus trigeminus      .       .       ib.
Amaurotic cat's-eye       .       .   532
Muscae volitantes     .       .      534
[Diagnosis]        .       .       .   535
Cause   ....      536
Treatment ....   537
Hemeralopia   .       .       .      538
Congenital and hereditary hemera-
  lopia     ....   540
Nyctalopia     .      .       •      541
[Hemiopia]....   543
Want of power to distinguish colours   547

            SECTION VI.

Near sight and far sight   .       .   555
Nearsightedness; myopia      .      556
Farsightedness    .      ,       .   563
[Irregular refraction]   .       .      567
CHAPTER XXI.
CATARACT.
             SECTION I.
General description of the disease;
   its causes and treatment; various
   operations
Colour and situation of the opacity;
   state of vision
State of iris and pupil  .
Diagnosis by a catoptric examination
Various species of cataract; the len-
   ticular
Morgagnian cataract
Capsular cataract
Capsulo-lenticular cataract.
Varieties of colour and consistence
Mature  and immature; complica
   tions ; adhesions of the pupil
Glaucoma—amaurosis  .
Varieties dependent on age
Causes  ....
Treatment .
Prognosis
Time for  operating
Operations
Preparation of the patient  .
Various operations

            SECTION II.

Extraction of the cataract
Questions of operating on both eyes
   at the same time
Instruments; various knives
572

573
574
575

576
579
580
581
583

584
585
 ib.
586
 ib.
587
588
589
 ib.
590
591

 ib.
592
Position of the patient  .       .      593
Fixing the eye     .       .       .   594
Division of the cornea  .       .      595
Superior section    .       .          596
Division of the capsule and removal
  of the lens      .       .       .599
Escape of vitreous humour     .      600
Exterior and inferior section;  infe-
  rior section      .       .       -   601
Treatment after the operation  .      602
Inflammation      .       .       .   604
Prolapsus iridis .       .       .      605
Cases fit or unfit for extraction    .   606


            SECTION III.

Depression or couching    .       .   60^
Reclination     .       .       .      609
After treatment    .       .       •   610
Absorption of the depressed lens      611


            SECTION IV.

The operation by solution or  absorp-
  tion      ....   613
Whether the lens is removed by ab-
  sorption or solution   .       .      615
Danger from the passage  of a hard
  lens or hard fragments into the an-
  terior chamber   .       .       .   616
Capsule not absorbed   .       .       ib. 
XVI
CONTENTS.
Keratonyxis
[Jacobs' needle and mode of operating
  with]    .
Operation when  the  capsule  is
  opaque, and the pupil adherent  .

            SECTION V.

Congenital cataract; its nature
Whether  really congenital
Page
 617

 618

 620
620
621
Affecting  several members of the
  same family
Operation  on infants
Operation on opaque capsule
Various proceedings
Anterior operation on the infant
Posterior
Proper age for the operation
Secondary  cataract
CHAPTER  XXII.
GENERAL AFFECTIONS OF THE GLOBE.
            SECTION  I.

Inflammation of the globe  .    .    628
Symptoms,.....ib.
Effects.....630
Diagnosis.....631
Treatment.....632
Ophthalmitis arthritica  .     .    .   ib.
            SECTION II.

Inflammation and destructive suppu-
  ration of the eye, as a secondary
  effect of phlebitis    .     .     .   ib.
           SECTION III.
Sympathetic ophthalmia.    .    .  635

            SECTION IV.
Hydrophthalmia   ....  637

            SECTION V.

Atrophy of the eye     .    .     .  639
Collapse of  the globe from suppura-
  ration.....ib.

           SECTION VI.

Exophthalmia     ....  640
CHAPTER  XXIII.
MALIGNANT DISEASES OF THE EYE.
            SECTION  I.

Fungous growths not malignant

            SECTION  II.

Carcinoma of the eye

           SECTION III.

Fungus haematodes of the  eye
Symptoms and progress
Seat and nature of the disease
Diagnosis;  cancer and  melanosis;
  age of the patient
Effusion of lymph after injuries .
Effusion of pus from internal inflam-
  mation    .....
641
644
649
 ib.
652

658
659

660
Yellow  appearance in the pupil of
  doubtful seat and nature    .    .   661
Treatment; question of extirpation    662
Cases of supposed success     .    .   663
Proposal of evacuating the globe at
  an early period     .     .    .     664
Objections   .....   665
Use of mercury  .     .    .    .     667
Cases of fungus  haematodes  .    .   668

            SECTION IV.

Melanosis of the eye  .    .    .     673
Ca8es......675

           SECTION V.

Extirpation of the eye     .     .     ggfj 
CONTENTS.
XVU
CHAPTER XXIV.
OSSIFICATIONS.  CALCULOUS CONCRETIONS.   ENTOZOA IN THE EYE.
            SECTION I.        Page
Ossification of various parts of the
  eye.....682

            SECTION II.
Calculous concretions.    .     .    648

           SECTION III.
Entozoa in the eyes of man and
  other vertebral ia ....  685
Filaria in the aqueous humour   .
Filaria under the conjunctiva and in
  the lens.....
Filaria and monostoma in the  lens
Distoma in lens  ....
Cysticercus in the anterior chamber
Cysticercus  in the  subconjunctival
  tissue.....
Page

  ib.

 687
  ib.
 688
  ib.

 690
CHAPTER XXV.
AFFECTIONS OF THE ORBIT.
            SECTION I.

Injuries.....690
Penetrating  wounds; protrusion  of
  the globe.....691
            SECTION II.

Acute inflammation and suppuration
  of the orbital cellular texture    .  692
            SECTION III.

Chronic abscess in the orbit  .     .  693
Propagation of inflammation to the
  contents of the cranium   .     .  694
           SECTION IV.

Protrusion of the globe from changes
  of obscure nature    .    .     .  695
            SECTION  V.

Induration of the  orbital cellular
texture
699
           SECTION VI.

Tumours in the orbit     .    .     .69
Operation of extirpation    .     .   700
Steatomatous tumours    .    .     . 701
Medullary tumours    .    .     .   702
Encysted tumours  .... 704
Cysts containing hydatids   .     .   707
           SECTION VII.

Aneurismal affections in the orbit    708
Aneurism by anastomosis    .     .   ib.
Aneurism of the ophthalmic artery   710
           SECTION VIII.

Affections of the muscles in the orbit
Injuries—paralytic affections
Ophthalmoptosis—irregular motions
Nystagmus; tetanus; monoblepsis
Squinting; general description
Causes    ....
State of the affected muscles .
Thickening and  induration  of  the
  cellular texture .
Treatment.....
Operation of dividing the recti mus
  cles.....
711
 ib.
712
713
 ib.
715
719

720
721

722 
XV111
CONTENT*.
Cases proper for the operation
Position of the patient  .
Operation on the  internal straight
  muscle  with the curved director
  and knife     ....
Operation with forceps and scissors
Operation with blunt hook  .
Specula for separating and fixing the
  eye-lids.....
Double convergent strabismus
[Editor's method of operating]
Treatment after the operation
Page
 723
 724
725
727
 ib.

728
730
731
734
                                  Page
Effects of the operation on the inter-
  nal straight muscle  .     .    .  735
Effects on the position and  motions
  of the eye.....ib.
Effects on vision     .    .     .     736
Causes of failure in the operation  .  737
Incomplete division of the tendon or
  of cellular  adhesion  .    .    .  738
Unnatural eversion;  prominence of
  the eye.....ib.
[Results of the operation,  &c.]   .     740
Luscitas.....741
CHAPTER  XXVI.
AFFECTIONS OF THE LACHRYMAL ORGANS.
             SECTION I.

Injuries of the lachrymal apparatus   742
Foreign  substances in the puncta
  lachrymalia    .                  ib.


             SECTION II.

Diseases of the lachrymal gland    .   742
Enlargement and induration    .     743
Hydatid of the lachrymal gland    .   747
            SECTION III.

Epiphora, or watery eye     .     .  747
Stillicidium lachrymarum  .    .     ib.


            SECTION IV.

Diseases of the semilunar membrane
  and caruncula lachrymalis    .    749
Encanthis.....ib
             SECTION V.
 Affections  of the lachrymal sac and
   nasal duct ....
 Capillary aperture of the sac
 Inflammation of the internal angle  .
 Acute inflammation of the sac  ° .
 Chronic inflammation of the lachry-
   mal sac  ....
 Permanent obstruction of the  nasal
   duct    ....
 Hernia sacci lachrymalis
 Hydrops sacci lachrymalis  .
 Various modes of treatment;  probe
   and syringe  .
Injection of the sac with quicksilver
Tube in the nasal duct
Enlargement of the duct by catgut.
Introduction of instruments from the
  nose  .
Use of the silver style     .
[Treatment by dilatation with Anel's
  probes]
[Morgan's curved probe]  .
[Congenital absence of nasal duct] .
 749
  ib.
  ib.
 750

 752

 754
 755
  ib.

  ib.
 756
 757
 758

  ib.
759

 760
762
763 
LIST   OE   WOOD   CUTS.
Fig. 1. Horizontal section of the eye-ball......36
    2. Lachrymal organs........ib.
     3. Muscles of the eye-ball   -......        81
    4. Ectropium, operation for.......137
     5.      "     Dieffenbach's operation for   -    -    -     -     -  138
    6.      "           "         "                                   ib.
     7.      "      Ammon's       "                                  140
     g      a        <(            «
     9.      "      Hornor's        "                                  140
    10.      "           "         "                                   ib.
    11. Entropium, Crampton's operation for.....144
    12. Epicanthus, Ammon's operation for......150
    13. Pustular ophthalmia.........    293
    14. Pterygium (membranous)........314
    15.      "          "       (thick)......ib.
    16. Congenital tumours,  with hairs growing from them -    -    - 321
    17.      »          "         "                                   322
    18. Staphyloma  scleroticae........331
    19. Staphyloma  corneae.........351
   20. Conical cornea.........357
   21. Prolapsus of the iris (synechia  anterior,).....413
   22. Artificial pupil, Cheselden's operation for     -                   428
   23.      "        Wenzel's operation for     -    -     -         -  ib.
   24. Sir W. Adams iris knife........429
   25. Maunoir's iris scissors........431
   26. Maunoir's triangular flap.......430
   27. Artificial pupil resulting from.......ib.
   28.      "         "      "    (Maunoir's operation)  -              434
   29. Maunoir's operation  as described by Mr. Mackenzie -    -    -   ib.
   30. Artificial pupil resulting from the above operation   -    -    -    ib.
   31. Gibson's hook.........435
   32. Gibson's forceps.........ib.
   33. Gibson's  iris scissors........ib.
   34. Artificial pupil, by iridencleisis......442
   35. Reisinger's hooked forceps.......444
   36. Central opacity of cornea, with  synechia anterior    -     -    -    447
   ■17. Artificial pupil, by distortion.......448 
XX
LIST OF WOOD CUTS.
 38. Silver Blunt hook.........448
 39. Diagram..........568
 40.     «        «        «       "       "        "       "       569
 41      u        n       u       a       "        «       »        j[),
 42. Narrow curved knife, cutting in the concavity for  enlarging inci-
       sion of cornea in the extraction of cataract  -                   592
 43.     "       "      "      in the  concavity for same    -     -  ib.
 44. Curette     -    -     -........ib.
 45. Beer's cataract knife........593
 46. Tyrrell's improved Beer's knife......ib.
 47. Superior section of cornea for  cataract, showing the puncture of
       cornea on temporal side      ...          -            595
 48.     "         "         "            showing the knife carried
       across the anterior chamber  and the cornea  punctured on  the
       nasal side.........596
 49. Exterior and inferior section of cornea  with Wenzel's knife      -  ib.
 50. Daviel's scissors.........598
 51. Saunder's needle.........608
 52. Scarpa's needle.........ib.
 53. Operation for depression........609
 54. Jacob's needle for keratonyxis,......618
 55.   "      "    magnified view of point.....ib.
 56. Curved needle for keratonyxis......620
 57. Adventitious membrane in pupil......628
 58. Cysticercus in anterior chamber with proboscis elongated   -    689
 59.     "       "      "      «       "       retracted  -      -  ib.
 60. Steel wire speculum........731
 61. Forceps...........732
 62. Scissors for operation for strabismus.....ib.
63. Blunt-hook for raising muscle in operation for strabismus  -     - 733
 64. Anel's probe     --.......74g
 65. Ware's nail-headed style........ 759
66. Operation for opening lachrymal sac.....ib.
67. Morgan's curved probe  for dilating nasal duct through the nose  - 727 
TREATISE
ON
DISEASES   OF    THE   EYE.
                         INTRODUCTION.

   The object of the following pages is to describe the nature and
 treatment of diseases of the eye, including under that expression, not
 only the globe itself, but the several auxiliary parts, called its appen-
 dages.  The anatomy and physiology of the organs will be conside-
 red merely in reference to practical purposes.
   It is hardly necessary to enlarge on the importance of the subject,
 or to prove formally that a knowledge of it is indispensable to medical
 practitioners.   Every one feels that sight is the most valuable of the
 senses; that it not only  is, in itself, the most important inlet of know-
 ledge, the  most valuable medium of our communication with sur-
 rounding persons  and objects, but also  that it is essential to  the full
 enjoyment  of our other  senses; to the free exercise of almost all our
 other  faculties and endowments; so that these lose more than half
 their value when sight is gone.  Hence blindness is one of the great-
 est calamities that can befal human nature, short of death; and some
 would perhaps prefer the termination  of  existence to its continu-
 ance in the  solitary and dependent state, to which life is  reduced by
 the privation of this precious sense.
   Loss of sight is  the greatest misfortune even to the  rich, who can
 alleviate it  by purchasing the aid and services of others.   How much
 more severely must it be felt by the poor, by the middle and lower
 classes of society, that  is, by the great majority of mankind; who,
 being rendered incapable of labour, and having their minds unculti-
 vated, find  their existence reduced to a  dreary blank,  dark, solitary,
and cheerless, burdensome to themselves and to those around them.
Even our great poet, who might have  been  supposed to find every
 alleviation and resource that such an affliction admits of, in his high-
ly-gifted mind, and the exhaustless stores of knowledge with which
it was furnished, repeatedly reverts to his blindness, and always in
       4 
26
INTRODUCTION.
a tone of anguish and despondency characteristic of recent misfor-
tune :—

                        " Thus with the year
                Seasons return; but not to me returns
                Day, or the sweet approach of eve or morn,
                Or sight of vernal bloom, or summer's rose,
                Or flocks, or herds, or human face divine;
                But cloud instead, and ever-during.dark
                Surround me, from  the cheerful ways of men
                Cut off, and for the book of knowledge fair
                Presented with a universal blank
                Of Nature's works,  to me expunged and  rased,
                And wisdom at one entrance quite shut out."

  It often depends on the surgeon whether the  patient shall retain
or lose, recover or remain  bereft of vision.   Common external in-
flammation of the eve, if  neglected or improperly treated, by rende-
ring the  transparent anterior portion of  the organ more  or  less
opaque, proportionally injures vision; inflammation of the iris, when
unchecked, causes contraction of the pupil and  effusion  of  lymph,
which prevents  the passage of  light into the eye.  Affection of the
nervous structure, if  not arrested in its  beginning, terminates inevi-
tably in diminution or loss of sight.  Such distressing results have
too often been promoted by modes of treatment, in favour of which
the sanction of names that have enjoyed public confidence might be
adduced.   The success of operations for cataract, or artificial pupil,
depends entirely on the knowledge, discrimination, and dexterity of
the operator.   The cases now alluded to are matters of daily occur-
rence, and make up  the  bulk of ophthalmic practice.  The  serious
responsibility,.which this view of the subject unfolds,.wjll impel every
conscientious practitioner to turn his anxious  attention to the affec-
tions of this important organ, and  to embrace all opportunities of
acquiring that  knowledge, which will enable  him to act  decisively
and effectually on occasions-of such momentous consequence.
  ]f there are any, to whom the pleasure connected with the acqui-
sition of knowledge,  the satisfaction flowing, from the consciousness
of important duties rightly performed, and  the gratitude so warmly
expressed for  the  inestimable benefits of averting blindness  or re-
storing sight, should not prove an incentive sufficiently powerful to
the study of ophthalmic medicine and  surgery,  their case must be
deemed desperate; unless, indeed, their  minds, insensible to  higher
feelings and nobler motives, should  obey the  impulse of self-interest
and fear; unless they should be affected by the prospect of disgrace
and injury, which ignorance and its inseparable  blunders must en-
tail.  The consequences  of wrong  treatment cannot be  concealed
here, as in the obscure  affections  of internal organs;  the  visible
changes of structure are obvious  to external observation, and the
unfortunate individual, whose sight is injured or destroyed by unskil-
ful treatment, serves as a  lasting  memorial  of  the  incapacity  and
rashness to which he owes his misfortune.  The study of diseases of
the eye is therefore now justly regarded  as an essential part of gene- 
INTRODUCTION.                       27
ral medical education; but it is more particularly so to country prac-
titioners, who are thrown entirely on their own resources; who can-
not, as in the metropolis, and some large cities, call in the aid of su-
perior talent and knowledge.
   Although the  importance of  the subject must be admitted, it may
be doubted  whether the ophthalmic branch ought to be separated
from the rest of medicine and surgery, as it must be, to a certain ex-
tent, by devoting to it separate  courses of lectures  and treatises, and
by instituting ophthalmic hospitals.  The diseases of the eye, in gene-
ral hospitals, are inadequate, from the smallness of their number, to
the purposes of practical study, particularly that of exemplifying the
various operations.  Thus these institutions have been inefficient in
reference to this.important department.   As the general body of sur-
geons did not understand  diseases of the  eye, the public naturally
resorted  to  oculists, who, seeing  such cases in greater numbers, be-
came better acquainted with the symptoms, diagnosis, and treatment;
and especially more skilful in the operative  department.    At the
same time, the subject being imperfectly understood,  was neglected
in the general surgical courses, in  which many important affections
of the eye were entirely unnoticed, and the whole inadequately ex-
plained.   Thus students, who resorted to London for the completion of
their professional studies, had  really no means of learning this  im-
portant department of the profession, which was tacitly  abandoned,
even by the hospital  surgeons, and turned  over to the oculists.
The  latter, not  being conversant  with the principles derived from
anatomy, physiology, and general pathology, attended merely to the
organ, and  relied almost exclusively on what is comparatively of lit-
tle importance, local treatment.   Hence ophthalmic surgery, being in
a  manner dismembered from the general science,  was reduced to  a
very low ebb.   Until within a few  years, it was, in this country at
least, in a state of almost total darkness.
   It thus became desirable to establish an express and  distinct school
for diseases of  the  eye:  not because the  principles  of treatment
differ from those applicable to  disease in general; nor because any
peculiar mode of study is required; but in order to supply a deficiency
in the existing sources of  professional instruction;  to provide for the
affections of this important organ, those means of information, which
the general hospitals neither do, nor could afford, consistently with
their  requisite attention to their other important objects.   This pro-
ceeding,  which  at first view seems calculated to complete and per-
petuate the separation, was the only rational mode of  reuniting oph-
thalmic practice to general surgery.
   It was the object of the London ophthalmic infirmary to apply the
general principles  of pathology and therapeutics  to the  elucidation
and  treatment of diseases of the  eye.  Hence it is  a  law of the
establishment, that the medical officers of the  institution  shall be se-
selected from those who have been regularly educated as physicians
and surgeons.  The great field of obsevation which  it affords has been
thrown open to  the  public; thus enabling  the general  body of the
profession, and particularly medical  students, to acquire easily, and 
2S
INTRODUCTION.
in a  short time, a full knowledge ot th.s  department   [h« °PPor
tunities afforded at this institution are not intended nor calculat^ to
make oculists; but to impart to surgeons and physicians a knowledge
of ophthalmic diseases.                                _.  , „,..„„
  Some may doubt whether the affections of this organ afford matter
for a separate course of lectures or treatise. The eye although smal
in bulk, is complicated in structure.  It is made up of several distinct
or dissimilar tissues,  and it exhibits  all the affections to  which each
of these  is  liable.  Although  its component structures  are for the
most  part analogous to what  we meet with in  other  parts ot  the
body, and consequently must be subject to morbid affections essentially
similar to those occurring elsewhere,  yet  the office  and  form ot  the
organ, the union of its component parts, and the nature of many of
them are so peculiar, as to give a strong character of individuality to
its diseases.   We do not, at the first view, recognise in affections of
the eye the same  diseased processes with which we are familiar in
other parts; we seem to be contemplating something  peculiar and
unusual, and this more especially in the diseases of the peculiar tissues.
This individual and distinct character of ophthalmic  diseases both ac-
counts for their having  been detached and considered as a separate
branch of surgery, and, in conjunction with their  number, justifies
the appropriating to them distinct  courses of lectures and treatises.
The extent of  the subject may be estimated  from  the circumstance
that Professor Beer,  of Vienna, occupied in his course of instruction
ten months, giving five or six lectures weekly.   His course, too, seems
to have been on the practical part of the subject; for he is styled pro-
fessor of practical ophthalmology ; while another celebrated teacher,
Prochaska,  was  professor of general  ophthalmology in the same
school.
  The course of proceeding in learning the diseases of the eye, must
be the same as that for diseases  in general.   The art of treating dis-
eases, or medicine, taken in its  most  extensive sense, is founded  on
the sciences of anatomy, physiology, pathology, and therapeutics;
in other words, a knowledge of the healthy structure and  function
must  be first obtained; then that of diseased  structure and function;
and, lastly, the  external agencies capable  of influencing  the body, so
as to remove disease or restore health, must be  studied.
  The more thoroughly any organ  has been investigated, anatomi-
cally, physiologically, and pathologically, the better shall we be pre-
pared to treat its diseases.   In this respect the eye is advantageously
circumstanced; its anatomy is well known;  its physiology clearly
made out.   A  considerable portion of the organ is external, and the
transparency of the  front enables us to see much of its interior.  We
can observe the phenomena of disease, and the effect of remedies in
some of its  internal structures, in such parts as are  elsewhere hidden
from our view.  The observations  thus made on the eye are appli-
cable to the illustration  of disease  and treatment  in other organs.
Hence if the general principles of medical  science throw light on
ophthalmic  affections, the history and progress of the latter recipro-
cally afford valuable data for general pathology. 
INTRODUCTION.
29
  But, can the diseases  of any organ be well studied alone ?  Can
they advantageously be  made the subject of detached and separate
investigation and treatment?  The numerous organs which make up
the human body, although various in structure and office, are  all  in-
timately connected and mutually dependent.  They are merely sub-
ordinate parts of one machine;  and they all concur, each in its own
way, in producing one general result, the life of the individual.  All
the leading arrangements are calculated to give a character of unity
to the  organization and living  actions  of  our  frame.   There is a
common source of  nutrition for the whole body; a single centre of
circulation ; hence all parts are  immediately dependent for their nou-
rishment and growth, and  for the materials of their various exertions,
on the digestive organs and the circulating system.   There is a com-
mon place of union for sensations and volitions:  the nervous system
associates the actions of the various organs, and combines them for
the common purposes of the economy;  by means of it, the various
organs co-operate in the healthy state, and suffer together, or sympa-
thize in disease.   Thus  the individual organs  are  not  independent.
The causes of their natural functions, and of those deviations  which
constitute disease, are not to be found within themselves, but mostly
in the  state of the constitution, or in that of some leading system of
organs.  Hence, in order to understand any part  of the body, we
must know the whole;  and this  holds equally good in disease as in
health.  Suppose a person complains of weak sight, we shall  not be
able to remedy the defect if we attend to the eye only, for probably
there may be no visible alteration in  the organ.  We must look to
the state of the circulation in the head, to the condition of the diges-
tive organs;  we must inquire into the patient's  habits, into  his diet,
into his general mode of living, as well as into the causes which may
be acting on the eye.  Until  this analysis has been made, we cannot
know  the causes of disease, nor can we arrive at  clear grounds of
treatment.  We ultimately find that the eye must be cured, not  by
any direct or local measures, but by those of general influence;  by
loss of blood, purging, change of diet, and of other habits.
   In such  a system, then, of intricate connexion and mutual influ-
ence, each part will be  best understood  by him  who has the clearest
notions of the  general  economy.  Even the practical proceedings
will be most judiciously conducted by those who are in the habit of
treating disease generally; who do  not  confine  their attention to  the
part.  This confinement is prejudicial, by producing and confirming
habits of partial and narrow  views, by leading  to neglect of mutual
relations and influences, by encouraging local treatment.  Exclusive
attention to a small corner of the animal structure causes a confine-
ment of mental vision, analogous to the nearsightedness which  me-
chanics contract by  constantly poring over the minute objects of
their attention.   All the habits of the oculist lead to a separation and
insulation of the  organ.  The  part is  detached from  the system,
treated by washes, drops,  ointments ; and this inefficient trifling im-
pedes the progress of ophthalmic surgery.  We want, instead of this,
general and comprehensive views, the aid of analogy and contrast; 
30
INTRODUCTION.
the whole field of medicine and  surgery must be laid  under contri-
bution for the  principles which are to guide us in learning the nature
and treatment of ophthalmic disease.  Professed oculists have done
little  for the science, either  here or abroad.   The  only real and
valuable improvements have proceeded from  men of extensive ana-
tomical knowledge, and of great general insight into disease.
  History.—"The separation of the ophthalmic department from  the
rest of surgical  practice, has generally  been considered of recent
occurrence; it is, on the contrary, very ancient, and perhaps coeval
with  medicine itself.   Among the Egyptians, to whom we trace
the origin of arts and sciences, each class of  diseases  had its physi-
cian ;  and we  find from Herodotus,  that Cyrus sent to Amasis, the
king of Egypt, for an oculist.   The Greeks and the Romans had their
oculists, as  is evident, not only from their writings,  but from  the
inscriptions on ancient marbles and seals.  That Augustus and Tibe-
rius were thus provided is apparent from the following inscriptions:—
P. Mius Mimetus  Augusti medicus ab oculis; Tit. Lyrius  Tiberii
medicus ocularius.*  There is no doubt  that oculists were at least as
numerous  in ancient Rome as in any modern city.
  The  Greeks, the Romans,  and the Arabians  were ignorant of
anatomy, and  could not, therefore, be acquainted with the  essential
nature of disease, that is, the altered structure of organs; nor connect
with those changes, which really constitute disease, their appropriate
external signs  or symptoms.   This disadvantage, however, is not so
great  in diseases of the eye as in many other affections,because most
of them are externally visible, and obvious enough without anatomi-
cal knowledge.  Hence  the  Greeks, who were good observers of
nature had noticed  most  forms  of  ophthalmic disease, in many in-
stances described  them  well  and  distinguished  them accurately.
The extent of their knowledge is evidenced by the imperishable re-
cords of language;  for  many of the diseases still bear the names
given  to them  by the Greek writers.  Celsus contains a summary
of all  that was known in his time.   Although he was ignorant of the
seat of cataract, he has described the operation of couching excel-
lently and concisely, not omitting the important subjects of previous
preparation  and after treatment, for which his directions are judi-
cious.
  In  the fifteenth, sixteenth,  seventeenth, and first  half of the eigh-
teenth century, the management of the diseases of the eye was  left
to quacks, to mountebanks, and itinerant practitioners.  There were
many of them, both in our own country and on the continent.  It is
not, however, worth while to draw their names and  their writings
from  the  oblivion   to  which they  have been quietly  consigned.
The French writers on this subject, Maitre-Jan, St. Yves, and Janin,
were  more  respectable than their  cotemporary  brethren in other

  * These, and other similar inscriptions, are quoted by Haller from Gruter and
other authorities. Wai.ch has collected every thing relating to the subject in his
Sigillum Medici Ocularii Romani ; Jcnfe, 1772. 8vo.  Haller, Bill. Chir. v. 1, lib 1,
§ 24. 
INTRODUCTION.
31
countries.  The anatomy of the organ began to be  more carefully
cultivated by the Germans about the middle of the eighteenth cen-
tury, when Zinn, Professor of Anatomy at Gottingen, published  his
excellent Descriptio Anatomica Oculi Humani.   At a more recent
period, Soemmerring produced his Icones Oculi Humani, a work of
unrivalled beauty and accuracy, exhibiting an  almost perfect set of
engravings.  Professor Fred. Arnold has lately enriched this depart-
ment of anatomy with two  important works ; in one* of which he
has considered and examined all the principal points in the structure
of the  eye, while  in the otherf he has  exhibited  its anatomy in a
series of new and beautiful figures.  This anatomical work  may be
consulted with interest and  instruction, even after  that of Soemmer-
ring: it carries our knowledge farther, especially in the minute com-
position of the organ.  An acquaintance with these works is neces-
sary to.those, who wish to understand the subject thoroughly.
  The pathology of the eye was in a very imperfect state until with-
in recent times.  Boerhaave made an attempt on the  subject, but  his
work,  De Morbis  Oculorum, is  of no  value.   Some idea  may be
formed of the amount of his pathological knowledge, from his asser-
tion* about the power of mercury to dissolve cataracts; he says,
" mercurius scepe perfectas cataractas? solvit."
  The Germans  have had  the greatest share in  advancing our
knowledge of ophthalmic diseases.  Richter, Surgical Professor at
Gottingen, deservedly enjoyed  the highest  reputation in Germany,
both for his general knowledge of Surgery, and for his acquaintance
with diseases of the eye,  to which he paid great attention in his prac-
tice and  writings.   In his Chirurgische  Biblioihek  (Bibliotheca
Chirurgica) which takes up the subject from the point where Hal-
ler's Bibliotheca Chirurgica leaves off, and comes down to 1797, he
has carefully analyzed all new publications  on ophthalmic disease.
The best account of the subject, at the time  of its  publication, is to
be  found  in  his Anfangsgriinde  der Wundarzneykunst, (Elements
of Surgery,) of which  the whole third volume and part of the second
are devoted to  diseases of the eye.
  But the most important era in the history of ophthalmic surgery
is the establishment of the Vienna school of ophthalmology.  The
Austrians  have not only the honour of having instituted the first
public establishment expressly appropriated to the  advancement of
this hitherto neglected branch of. the profession, but of having pre-
ceded all the rest of Europe by many years.  The views which directed
the  formation of this institution were so judicious,  and the persons
successively appointed to preside over it showed themselves  so well
fitted for the task, by their talents and knowledge,  that the ophthal-
mic department of surgery has probably been more  improved by this
school, than by the previous exertions of all other countries.  The
establishment owes its origin  to  Joseph Barth, a  native of  Malta,

  * Anatomische und Physiologische Untersuchungen uber das Augc des Menschen ;
4to. ]832.
  t  Tabulx Anatomica; folio, fasciculus II. 
;w
introduction.
 who repaired to Vienna, in order to indulge  a strong inclination,
 which  he had felt from  his earlier years, for the study of anatomy
 and surgery.  His  attention was accidentally directed to diseases of
 the eye. from seeing many persons in a state of hopeless  blindness.
 His proficiency in this department was soon well known ; and hence
 he was appointed lecturer on ophthalmic surgery in the university of
 Vienna, in 1773.   Soon afterwards, certain wards were assigned  for
 ophthalmic patients, in the general civil hospital, and a regular course
 of oral and  clinical  instruction was established.   Barth  wrote
 nothing except a short tract on the mode of performing extraction
 without an assistant; but he is considered to have  set  the example
 of those new and more correct views of ophthalmic disease, which
 are disclosed in the works of various German writers.*
   Schmidt, who was educated by  Barth, published a work on dis-
 eases of the lachrymal  organs, and a valuable essay on Iritis.  He
 also edited, in conjunction with Professor  Himly, of Gottingen,  an
 interesting periodical, devoted to ophthalmology (Ophthahnologische
 Bibliothek,) of which three volumes appeared, from 1801 to 1807.
   Beer is more generally known than either Barth  or Schmidt, as
 he was professor of ophthalmic medicine in the university of Vienna,
 for many years, at  a time when  the  high reputation of the  school
 attracted  students  from all parts  of Europe,  and as  he published
 many works.  The last and principal of these,f in 2 vols. 8vo, 1812
 and 1817, devoted  to the  history, pathology, treatment, and opera-
 tive surgery of the   eye, was the most comprehensive work  on the
 subject at  the time of its publication.   It contains accurate descrip-
 tions and histories, and consequently sound diagnostic precepts; but
 I cannot speak so favourably of the pathology and treatment.   The
 compendium  of Weller,J which  was  translated by the  late Dr.
 Monteath of Glasgow, is chiefly founded on the work of Beer.§
   Professor Himly  published, in 1800, his observations  on the effect
 of certain narcotics  in dilating  the  pupil, and on the  advantages
 to be derived from  their use in various  diseases and operations on
 the eye.

  * Beer has given a biographical account of Barth, in the Medicinische Jahrbucher,
 vol. v. p. 169.
  t Lehre von den Augenkrankheiten,  als Leitfaden zu seiner bffentlichen rode-
 sungen.
  They  who are inclined to study the history of ophthalmology, will find assistance
 from a work  of Beer, on the plan of Haller's Bibliotheca Chirurgica.  It is in Ger-
 man, with aGerman and a Latin title.  The latter  is Bibliotheca Ophthalmica, in qua
Iscnpta ad Morbos Oculorum facientia, a rerum initiis usque adfinem anni 1797, bre-
viter recementur: it is in three thin volumes 4to. In his Syntagma  de Ophthalmologia
 veterum,  Wallroth has  brought together, from the earliest writers, all that they have
 said respecting the anatomy, physiology, and diseases of the eye
  t Die Krankheiten des menschlichen Auges, ein praktisches Handbuch fur angehende
 Aerzte.   The third edition which is considerably enlarged, bears date, Berlin, 1&26.
  § In the first volume of the Quarterly Journal of Foreign Medicine and Surgery,
there is  an interesting description of the Medical School  of Vienna, in which the
 arrangements of the ophthalmic department are particularly noticed
  B«r has riven a minute account of the ophthalmic clinical'department, (Avgen
ehnifc,) according to its new arrangement in 1812, in the Medicinische  Jahrbucher des
 Aaiserl. Konigl. Oesterretchischen Staates; vol. iv. st. 4, p. 157—173 
INTRODUCTION.
33
  Langenbeck, professor of  anatomy and  surgery at Gottingen,
where he succeeded  Richter, has kept up  the  reputation of the
university for general  and ophthalmic surgery.  In his Chirurgische
Bibliothek, which begins from the termination of Richter's, and which,
in a second series, under the title of JVeue Chirurgische Bibliothek,
has been continued nearly to the present time, he  has  noticed and
analyzed all new books on diseases  of the eye.
  The Journal der Chirurgie und  Augen-heilkunde of Graefe and
Walther, which has been regularly published since 1820, and the
Magazin of Rust,  contain  numerous  contributions and notices re-
specting this department of surgery.  In 1830, Professor Von Ammon
of Dresden began the  publication of a quarterly periodical, devoted
to this subject exclusively, under the title of Zeitschrift fur die Oph-
thalmologic: five volumes had appeared, when the work was discon-
tinued in 1837.  Professor Ammon then devoted himself to an under-
taking, for which he had been long collecting materials ; namely, a
large work in folio, entitled Clinical Representations of the Diseases
and  Malformations of  the  Human Eye, Eyelids,and  Lachrymal
Organs, from Original  Observations and Investigations.  The first
and second parts were published at  Berlin in 1838.  The former, on
Diseases of the Eye, contains twenty-three coloured plates, on which
three hundred and seventy-seven figures are represented; the latter,
on Diseases of the Eyelids, Orbit, and Lachrymal Apparatus, has two
hundred and ten figures on twelve plates.   The third part, which is
to exhibit the malformations of the  eye and  its appendages, has not
yet reached this  country.   The  author proposes to  publish  subse-
quently a manual of ophthalmic  medicine, which will be a scientific
and practical commentary on the facts exhibited in  the  Clinical
Representations.   These Clinical Representations, which  are very
creditable to  the industry and perseverance of  the Author, contain
many interesting and  instructive facts and delineations.  We could
not expect to have  nearly six  hundred figures well executed.  It  is
difficult  and  costly even to approach to accuracy in  coloured en-
gravings of morbid changes; and this difficulty is  particularly felt in
the eye.  Accordingly, while many of Von Ammon's figures fail en-
tirely as representations of morbid  phenomena, I cannot speak very
favourably of their execution generally; they are far too numerous
to be done well.
  From the sources now mentioned, a knowledge may be  obtained
of the numerous publications, which have appeared in  Germany on
this apparently favourite subject.  I cannot pretend to notice  them
in detail; but shall refer to the most useful and  interesting  in treat-
ing of particular subjects.   I  will  only mention  two recently pub-
lished general and  comprehensive works, by authors of experience
and reputation;  viz. the Handbuch der  Theoretischen und  Prak-
tischen Augen-heilkunde, in 3 vols. 8vo,  by A. Rosas, the  present
professor of  ophthalmic  medicine in  the university of Vienna; and
the Lehre von den Augenkrankheiten of J.  C. Juengken, in one vol.
8vo, of nearly one thousand closely printed pages.   The latter author
       5 
34                         introduction.

had previously published (in  1829) a volume nearly as large  on the
operative surgery of the eye.
  The first impulse to  the  scientific study  of ophthalmic  medicine
and surgery in England, was given by the London Ophthalmic In-
firmary, which was established in 1804, but not thrown open  to stu-
dents for the purposes of observation and instruction till 1810.  Mr.
Saunders,  who founded it, in conjunction with Dr. Farre, had re
ceived a regular education in anatomy and surgery at St. Thomas's
and Guy's Hospitals.   We are indebted to him  for the  important
improvement of operating for cataract on infants; and  his instruc-
tive posthumous observations, edited by his friend and  colleague,*
leave no doubt that, if  his life had been spared, he would have done
much more for the improvement of the science.
  Dr. Farre set the example, at this infirmary, of applying the gene-
ral principles of pathology  and therapeutics to the elucidation and
treatment  of ophthalmic  diseases,   in the  clinical illustration of
cases, the exposition of curative indications, and simplicity of treat-
ment, he could not be surpassed.   All who have  had the advantage
of his instructions will  remember them with gratitude and respect;
and will regret that he has not. communicated to the public, through
the press, the interesting results of his long practice, his close  obser-
vation, and mature  reflection.
  The example of the Vienna Ophthalmic school, has been followed
in the principal cities of Germany ;f while that of the London Oph-
thalmic Infirmary has led to  the formation  of similar institutions in
many parts of England, and even in the foreign dependencies  of this
country, for example in the East Indies.  Hence  ample opportuni-
ties now exist for the study of oph:halmic diseases; while  from the
knowledge of the subject being generally diffused through the  pro-
fession,  patients afflicted with disorders of this precious organ, may
find effectual relief in almost  all situations.  Of the institutions de-
voted to diseases of the eye in this kingdom, two  deserve particular
mention, those  of Glasgow and  Birmingham; since the intelligent
and  able surgeons  who preside over  them, not only lecture regu-
larly on the subject,J but have communicated the  results  of their
observations to the profession in highly interesting and valuable pub-
lications.§
  Scarpa's Observations on the principal Diseases of the Eye,  which

  * A Treatise on some Practical Points relating to the Diseases of the Eye, by the late
J. C. Saundkhs. Second Edition. 181fi.
  \ V'a ^r nUS ^"^V1 !ni;iit,Itions established  on the  continent for the treatment
and study of lipases or the Eye, are  enumerated by Dr. Bkgkr  in Ammo*'* Zeitschrift;
vo . v. Das Auge vom Slandpuncte  der Medicinal  Polizei betrachtet.  In the  same
volume, the present state ot the ophthalmic clinic in Vienna and Prague is described;
Leber erne Ophlhalmologische Rnse nach Wien und Pra<r  von  Dr Thune
  [t Dr. Maekenz.e is Lecturer on the Eye  n,  the University of Glasgow, and Mr.
Mjdd cmore .s Professor of Ophthalmic Medicine in the Royal School of M. d cine Br
rn.ngham. Lectures on  the  Eye are also given  in the Manchester Royal School of
Medicine  and Surgery, by Mr. Wa.kcr, and in Guy's Hospital School, London, oy Mr.

  k W. Mackenzie  Practical Treatise on Diseases of the Eye;  third edition lRzlfl P
M.ddlemore, 7', ealise on Douses of the Eye, and its APpeJdagcs;l vol. 8v'o!  1835 
INTRODUCTION.
35
have been translated into English by Mr. Briggs, were considered a
valuable contribution to  surgical literature, when they first appeared
(in 1801.)   They are far behind the present state of knowledge on
the subject.

   [Ophthalmic Medicine has not received in the United States, the attention
bestowed upon  it in Europe.  By a  few practitioners, it has  been culti-
vated assiduously, but by  the mass of the  profession it  has been wholly
neglected.  The Treatise  of  Dr.  Prick,* the  manual of  Dr. Littell,t the
small popular treatise of  Dr. Wallace,^ with  some  contributions  in the
medical journals constitute the whole of our  Ophthalmic  literature.
   This condition of the science must in a great degree be attributed to its not
being taught in our medical schools. In all of these, with a single exception,
it forms  a part of the general  surgical  course and is summarily treated, or
rather professed  to be treated, in three or four lectures.  The merit of
forming  the exception to this rule is due to the Vermont Academy of Medi-
cine, at Castleton, in  which a chair of Ophthalmic Medicine and Surgery
was established about a year since.   A very  creditable effort has  also been
made by the College  of Physicians and Surgeons, New York, to afford to
students the means of acquiring a knowledge of ophthalmic diseases.   Lec-
tures on the subject,  with  clinical instruction at the New York  Infirmary
for Diseases of  the Eye, form part of the Spring course established under
the auspices of the school.
   These examples, it is to be hoped, will not long  remain without being
imitated.  The means of instruction are ample, a sufficient number of In-
stitutions especially  designed for the  treatment of  those  labouring under
Ophthalmic diseases, being at the  present  period in successful operation.
Thus  in New York, the  Eye and Ear Infirmary established in 1820, in
Boston,  the Massachusetts Charitable Eye and Ear Infirmary, and in Phil-
adelphia the Wills Hospital for the  Blind and Lame, a noble charity, afford
the amplest  means  for clinical instruction.   Eye Infirmaries have  also
been  established  in Albany, Baltimore, Rochester, &c, which  with due
encouragement might be made available for the same purpose.]

  * A Treatise on the Diseases of the Eye ; including the doctrines and pract:ce of the
most eminent modern surgeon?, and particularly those of Prof. Beer.   By Gkokge Fiuck,
M. D.  Baltimore. 1823.
  t A Manual of the Diseases  of the Eye.  By S. Litvell, Jr., M. D., Philad. 1837.
  t A Treatise on the Eye, containing discoveries of the causes of ne;ir and far sight.
edness, and of the affections of the retina, with remarks on the use of medicines aa
substitutes for spectacles. By  Wm, Clay Wallace, Oculist.  New York.  1839. 
( 36  )
Fig. 2.
Fig. 1.
 
( 37  )
REFERENCES  TO  THE  PLATE.
Fig. 1.—HORIZONTAL SECTION OF THE EYE-BALL*
  1. Sclerotica.
  2. Sheath of the optic nerve, or canal
of fontana.
  3. Circular venous sinus of the iris.
  4. Proper substance of the cornea.
  4'. Conjunctiva  extending  over  the
cornea.
  5. Arachnoidea oculi.
  6. Membrane of the anterior chamber
of the aqueous humour.   Of the two dot-
ted lines, one points to the membrane of
Descemet, the other to the supposed con-
tinuation of that membrane over the an-
terior surface of the iris.
  7. Choroid.
  8. Annulus albidus.
  9. Ciliary Ligament.
  10, 10'. Ciliary body, consisting of
(10') a pars non-fimbriata, and (10) a pars
fimbriata formed by the ciliary  processes.
   11. Ora serrata of the ciliary  body.
   12. Iris.
  13. Pupil.
  14. Membrane  of the pigment.
  15. Delicate membrane lining the pos-
terior chamber of the aqueous  humour.
  16. Membrane  of Jacob.
  17. The optic nerve surrounded by its
grn«ral  neurilema.
  17'. The fibres of the optic nerve, con-
sisting of fasciculi of primitive tubules.
  18. Central artery of the retina.
  19. Papilla conica of the optic nerve.
  20. Retina.  The situation of its vas-
cular layer is indicated by a dotted line.
  21. Central transparent  point of the
retina.
  22. Vitreous body.
  23. Hyaloid membrane.
  24. Canalis hyaloideus.
  25. Zonula ciliaris. In the plate, none
of its fimbriated part is seen, being con-
cealed by the ciliary processes.
  26. Canal of Petit.
  27. Crystalline lens.
  28. Anterior wall of the capsule of the
lens.
  29. Posterior wall  of the  capsule of
the lens.
  30. Posterior chamber of the aqueous
humour.
  31. Anterior chamber of the aqueous
humour.
Fig. 2.—LACHRYMAL ORGANS.t
  a, a. Puncta lachrymalia.
  a, b, c, d. Lachrymal canals.
  6, b. The small blind dilatations pre-
sented by the lachrymal  canals where
they bend inwards to the lachrymal sac.
  e,f, g. Lachrymal sac.
  e. Blind end of lachrymal sac.
  g. Termination of lachrymal  sac  at
which point the passage is slightly con-
tracted.
  h, i.  Nasal duct.
  i.  Opening  of nasal  duct into the
nose.
  k, I.  Lachrymal gland.
  * By T. Wharton  Jones, from Dr.  Mackenzie's " Practical Treatise on the Dis.
eases of the Eye."
  t From Sornmerring's u Icones Oculi humani." 
( 38 )
            ANATOMY OF THE  EYE-BALL.

  The human eye is  very nearly  spherical,  and  hence have arise!
the expressions applied  to  it in English, of globe, ball, and  apple o
the eye, and  the  corresponding terms in other  languages; the Ger
mans speak of the eye-apple (augapfel,) in the  same  sense  as  we use
eye-ball.   When  measured  on the  outside, the  antero-posterior and
transverse diameters are nearly the same; the  former may be a little
longer than the latter.  The average length  of each  is  somewhat
less than an inch,  [about  19-20ths of an inch.]   A vertical section
dividing it into an anterior and  a  posterior half, presents  a  circular
outline; but a horizontal division into an upper  and lower  half, ex-
hibits a posterior portion, which is part of  a larger sphere, and  an ante-
rior, which is  a small  segment of a smaller sphere.   The  former of
these constitutes five-sixths, the  latter, one-sixth, of the  eye-ball. The
greatest deviation from the spherical  figure of  the globe occurs where
these  two  portions  are united; a  slight circular depression being
produced  where   the  posterior  division  or segment  of  the  larger
sphere bends  inwards to join  the anterior, or  segment of the smaller
sphere.
  The real size  of the eye  varies little  in different individuals: the
apparent differences depend  on the size of the palpebral fissure, and
the depth at which the eye-ball is placed in the orbit.
  The essential constituents of  the eye are, transparent  media  to re-
fract  the  rays of light; a nervous expansion  to receive the impres-
sion produced by the rays thus refracted; and  certain membranous
opaque  coverings, surrounding, connecting, and  protecting the fore-
going parts, as well as contributing to their more perfect  action.
  The component textures  of  the eye-ball are  usually arranged under
the two-fold division of coats and humours.  The membranous cover-
ings and the nervous  expansion, constitute the  coals, tunics, or mem-
branes: the  humours  are the  transparent media, with  the exception
of the cornea, which belongs to the  coats.   The arrangement, al-
though not founded on the  clearest grounds, is  convenient  enough;
and we have the further reason for  retaining it, of its being established
in the language of anatomy by long and  universal  usage.   We must
remember,  however, that the word  humour is used in a merely  tech-
nical  sense, being inapplicable in its  ordinary acceptation  of  fluid, to
the crystalline lens and capsule, and  to the vitreous body.
  The external stratum  of the globe  is  composed of  the  sclerotica
and  cornea; the  latter being the anterior transparent part, and the
former covering the rest of the eye.  When these are removed, we
see a membranous covering, distinguished by  its  deep brown colour,
the choroid  coat,  equal  in extent to  the  sclerotica;  to  this is closely 
ANATOMY  OF THE EYE-BALL.
39
united, in front, the iris, which  is placed at a  short distance behind
the cornea, and perforated  near its centre by a round opening, called
the pupil, for admitting the light into the interior of  the  eye;  the re-
moval of the choroid exposes the retina, or the nervous  expansion.
The three  coverings just enumerated, i. e. the sclerotica wilh the cor-
nea, the  choroid with the iris, and the retina, are arranged one within
the other,concentrically like the layers of an onion: they may be called
respectively the fibrous, vascular, and nervous strata of  the eye-ball.
   The humours  are three,—1st, the vitreous, which fills  the  whole
concavity of the retina, and forms  about four-fifths of the entire  bulk
of the globe; 2dly,  the crystalline called also crystalline lens, a nearly
spherical body, imbedded  in the front of the vitreous humour; 3dly, the
aqueous, a  small quantity of clear water, filling up the space  between
the cornea and the front of the crystalline  lens, in  which space the
iris is situated.
   Only the  external or  fibrous stratum is complete, that is, closed in
all directions; the  vascular layer is perforated in front by  the pupil;
and the nervous leaves a  still greater  deficiency, which is filled by
the crystalline lens.
   The membranous layers  circumscribe a space, which  may be  call-
ed the cavity of the eye-ball,  and which is  subdivided into three une-
qual compartments; the posterior, and largest, bounded by  the retina,
contains the  vitreous  humour, with  the imbedded  lens;  the  two an-
terior, called the chambers of the  eye,  are enclosed by the  cornea,
crystalline,  and ciliary  processes, separated by the  iris, through the
pupillary aperture  of  which  they communicate, and  filled with the
aqueous humour.
   Having thus  mentioned, in  a general way, the  parts  which  make
up the globe of the eye, I shall make a few  observations on the struc-
ture of each, with  the  view of rendering the description of their  mor-
bid affections more intelligible.
   Sclerotica.—[1. Fig. L] In dissecting and examining ihe eye-ball, we
observe  that it does not collapse, but  that it  retains its figure; this de-
pends on its external investment or sclerotic coat (Albuginea; tunica fi-
brosa-, Lederhaut, weisse Haut, Germ.)  The word sclerotica, which is
of Greek extraction, (from <r>aj^V) means hard; the sclerotic coat, there-
fore, is the firm covering of the eye; it  is  the most dense, compact,
and unyielding texture in the organ.  The cornea resembles it in com-
pactness, density, and consequent firmness, though it is perfectly trans-
parent, while the sclerotic is entirely opaque.  In the  older  writers the
term cornea  is applied to both ihese structures; the  cornea, properly
so called, being denominated  cornea lucida; and the sclerotic, cornea
opaca.   The  sclerotic covers  the posterior  five-sixths  of  the  globe,
leaving in front a circular vacancy filled  by the cornea.   Behind, and
a little on the inner or nasal side of the axis of the eye-ball, it is per-
forated by the optic nerve.  The long and  short ciliary arteries and
veins, the venae vorticosas,  and  the ciliary nerves also  perforate the
membrane.
   The firmness of the sclerotic is  such that it retains its figure  when
divided  and  emptied  of its  contents;  small portions cut  out of the 
40
ANATOMY OF THE EYE-BALL.
membrane preserve their form, and  regain it  immediately on the pres-
sure being removed, after  they have  been squeezed together.   vvnen
this  coat is removed,  the  other component parts of the  globe are so
much  softer and more delicate in their texture, that the ball no longer
retains its regular figure.                                     ,   ,
  The sclerotic  coat  belongs to that  class of  membranes which ana-
tomists call  fibrous,  such  as  the  dura  mater and periosteum.   L>ke
such structures,  it  is  white, or  bluish  white,  somewhat  glistening,
and  possesses  some elasticity.  It is  made  up  of  the  same  kind ot
fibres which compose the  tendons and ligaments; and these fibres are
so closely compacted  and interwoven, that, in the  ordinary  state of
the  part, they can scarcely  be  distinguished;*  they  are  much  less
fibrous than in certain portions of the dura mater, and we  might sup-
pose the tunic to be  made of  condensed cellular  texture.  If, how-
ever, we dissect  it carefully, we shall observe, in some parts, the glis-
tening,  shining aspect, which  denotes a  fibrous structure;  while in
many  animals, the fibres  being  more  loosely interwoven, are  quite ob-
vious; and in certain forms of disease, when the coat is  distended, and
rendered thinner, the fibrous  structure is  very clear.   This organiza-
tion  gives  the sclerotica that firmness which fits  it for  covering the
softer  parts  of  the globe.  It  has nothing to do  with vision,  but  is
merely subservient to the purpose of supporting, connecting, and pro-
tecting the more vascular  and  delicate structures composing the inte-
rior  of the  eye.  The density  and  resistance of the sclerotic  are so
considerable, that no  force, which can be applied with  the fingers or
forceps,  will  lacerate  it;  when,  therefore, the  vascular parts within
the globe are actively  inflamed, this coat becomes  so  tense, as almost
to convey the idea  of the hardness  of stone.  The  sclerotica is not
of uniform thickness  throughout.   If we divide  the globe  into  an an-
terior and a  posterior half, by a vertical section, the sclerotica will be
found  much thicker in the  latter than  in the former division.  The
thickest  part of the membrane is  at the.  entrance of the optic nerve,
and  on the adjacent posterior  aspect of the globe;  it is here about one-
twentieth of an  inch  in thickness.    Tracing  it forwards,  we find  it
becoming  gradually thinner, to the extent of one-third or one-half of
the measure just mentioned.   The thinnest portion of the membrane is
at the middle, or greatest diameter  of the globe:  it becomes again a
little thicker where it joins the  cornea in  front.  Thus the combined
  * Arnold states, as the result of careful microscopical examination, that the sclerotica
really consists of condensed cellular texture.  He found no appearance of primitive fibres
or cylinders, but merely a cellular mass permeated by an extremely fine and close net-
work of lymphatics, and he has represented these in the 2d figure of the 1st plate of his
instructive  and  interesting work, Anatomische und  Physiologische  Untersuchungen
uber das Auge dts  Menschen. 4to. 1832.  Mascagm had already observed and delineated
the same facts; Prodromo delta grande  Analomica; tab. 6 and  14   The microscopical
researches of Arnold on the cellular texture, had  led him to conclude that it consists of
lymphatics, with vesicles of fat in greater or smaller number, and  blood-vessels of va-
rious size.  Mascagki had previously formed the same conclusion, which had been con-
firmed by FoHMann ,fr.,m his injections of the lymphatics.  The serous and  fibrous
membranes, being composed ot cellular texture, exhibit the same structure so far as the
lymphatics are concerned.—Arnold's  Untersuchungen, Einltitung, 
ANATOMY OF THE EYE-BALL.
41
action of the  four recti muscles  will  produce a pressure on the eye-
ball where  the sclerotic is  thinnest.   These anatomical facts have
suggested the hypothesis, in which the adaptation of the eye to vision
at different  distances is explained  by changes in  the length of its axes.
The thinner portion of the sclerotica, however, is sufficiently firm to re-
tain its form when removed from  the eye; and we cannot tear it with
the fingers or forceps.
   The external surface of  the sclerotica  is rough and cellular.  It is
covered  in  front by the conjunctiva.  Under this membrane it affords
attachment  to the tendons of the muscles moving the eye, which are
inserted  into it in the same way as tendons are attached to bones in
other situations.  The four  recti  lie upon the  membrane to  a con-
siderable extent from before  backwards;  while, in the space circum-
scribed by them, it  is  covered by fat.  The internal surface  of the
membrane is smooth, connected to the choroid by short, soft, and easily
lacerated cellular threads, partially tinged by the dark pigment, and
hence sometimes called lamina sclerotica fused.
   The opposed surfaces of the sclerotica and  choroid have a moist ap-
pearance, though we do not observe any distinct  fluid.
   The external surface and the substance of the membrane are of a pure
white colour, without any appearance of red vessels.  In the healthy state
it contains few vessels circulating red blood.  It reddens, however, under
the excitement of disease, when the vessels are so numerous as to give
the membrane a general red tinge.   The white of the eye depends on the
sclerotica, which is seen through the semi-transparent conjunctiva; in the
same way the reddened state of the membrane, when inflamed, or any
other morbid changes in its anterior portion  are plainly  visible exter-
nally.
   When we trace the optic nerve to the  eye-ball, it seems to be im-
planted in the back of the sclerotica.  The fibrous sheath of the nerve
and the tunic are continuous  at this point; their substance is intimately
blended, although the  sclerotic is here much thicker than  the nervous
sheath.   The  dispute whether the sclerotica is a production or continua-
tion of the dura mater, through the nervous  sheath, is merely verbal.
The parts in question are closely analogous in structure, and inseparably
united.   In  consequence of this union,  the cornea, the sclerotica, the
sheath of the optic nerve, the dura mater, and the periosteum of the orbit,
constitute a series of  continuous  fibrous   structures,  an arrangement
which affords explanation of various pathological phenomena.  The optic
nerve enters the globe  by a round aperture in the sclerotica.  This has
been described as being occupied by a circular portion of membrane per-
forated by many small openings, and hence  called lamina cribrosa.  This
notion has arisen from observing the effect of squeezing the end of the
nerve, when the choroid and  retina have been removed from the cup of
the sclerotic; the medullary matter is then expressed in  numerous mi-
nute portions.   It is forced  out from the terminations of the neurilema-
tous tubes; and a careful dissection will show clearly, that the opening
in the sclerotica is a simple round foramen.
  A circular groove [3. Fig. L] is seen in the sclerotica, on its inner sur-
face, at its anterior termination, where  it  joins the cornea and  is con-
nected to the ciliarv ligament.   It has been called the canal of Fontana,
       6 
42
ANATOMY OF THE EYE-BALL.
having been pointed out by him in the eye of an ox.  It is a venous tube,
receiving veins of the iris, called circulus  venosus iridis  by Arnold,*
who regards it as a venous sinus, bearing the same relation to the scle-
rotica that the sinuses of the head do to the dura mater.   He says, farther,
that this vessel and its nature were well known to Hovius; that it often
receives injection  through the arteries, but cannot  be  filled from  the
veins, probably on account of valves.
  Cornea.—[4. Fig. 1.]   The cornea,^ which covers one-sixth of  the
globe, differs widely in  appearance  from the sclerotica, but  resembles
it in the firmness  and resistance of its structure.  Thus  it  is fitted to
protect  the exposed anterior portion of the eye, while its perfect trans-
parency allows the free passage of light into the interior of  the globe.
No force applied by the fingers or forceps can lacerate it, although,  ex-
ternally, it appears a delicate kind of membrane.
  The cornea and sclerotic are so firmly  united, that they may, to all
intents and purposes, be considered as one continued investment of  the
eye; as constituting a kind of case for lodging and protecting the more
delicate essential structures of the organ.  They may,  indeed, be sepa-
rated by long maceration, but in the recent subject, the  resistance is as
great at the line of junction as at any other part, and we may consider
them as consolidated into one substance.   The sclerotica  is brought to
a thin edge at its anterior termination, and  the  circumference of  the
cornea  ends by a similar margin ; but the former is bevelled off on  the
inside,  and the latter on  the outside, so that the sclerotica overlaps  the
cornea  at the point of union.   Hence the circumference of the cornea is
smaller externally than  internally : hence, too, the anterior chamber  ex-
tends beyond the external circumference of the cornea.
  In some points of structure there is a striking difference between  the
cornea  and the sclerotic.   The former is composed of  several layers,
connected by cellular tissue, in the interstices of which there  is a small
quantity of clear fluid:  this can be squeezed out in minute drops, when
the cornea of a recent eye is divided.  If we  make an incision into  the
substance, we can turn back with the forceps several successive laminae:
these, however, are quite artificial, being more or less numerous, accord-
ing to the pains we take in the preparation  of them.   The facility with
which the several portions are separated in such  a dissection, and  the
freedom with which they glide over each other, when squeezed between
the finger  and  thumb, show  that the component parts of this mem-
brane are loosely connected together.  In consequence of this loose and
spongy  structure, the cornea  swells when soaked in  water.   The  tex-
ture of  the layers, when  torn up in the manner described, is fibrous; and
we must refer  the cornea to that class of  structures.  Although  the
sclerotic and cornea are so  different in external appearance, and on
cursory examination, arguments  may be  adduced  in  favour of  the
opinion formerly entertained, that they are merely parts of one continu-
ous structure. -The essential character of the tissue in both  is fibrous;
the circulating vessels are few and small in both.  There  is little diffe-

  * Anatomische und-physiologische Untersuchungen ; p. 10__14.
  + Chelius ilber die durchsichtige Hornhaut, Carlsruhe, 1818; Clemkns  Tunica. Cornea
el Humoris aquei Monographia physiologicopathologica, Goettin«r, 1816 '  Ala„ ;„ u „„,■'
Scdptores Ophthal. v. 1.                              "       A,so m R^'"9. 
                      ANATOMY OF THE EYE-BALL.                   43

rence between them in the early periods of  fetal existence, when  the
cornea  is opaque.  When examined with  the microscope, they  are
nearly alike, both consisting, in great part, of minute lymphatic vessels
arranged in the form of a close net-work, and continued from one mem-
brane into  the  other.*   Again, the cornea  is frequently so assimilated
to the  sclerotica by morbid  change, that the boundary between  them
can no longer be traced.
   Pressure  on the globe, in the dead  state, renders the cornea opaque,
more or less completely according to the degree of  force  employed;
when the pressure is remitted, it again becomes transparent.
   It has not been ascertained whether a similar effect  may be produced
by analogous causes in the living eye; for example, whether the general
tension produced by increase of the contents of the globe, may render
the cornea opaque.  Mr. Wardrop supposed that this would happen,
and hence advised the plan of evacuating the  aqueous  humour, to dimi-
nish  tension.
   In thickness the cornea is equal to the thickest portion of the sclero-
tica.   In resistance to  the knife it may be compared to parts of car-
tilaginous structure ; it is so firm that we are obliged to use some force
in penetrating it with a knife or needle.  When we first operate on the
eye, we find much greater resistance  to the entry of an instrument than
the transparency of the membrane would have led  us  1o  anticipate.
The fibrous structure, and the loose connexion of the  parts, lead to
another risk, namely, that of the point of an instrument passing between,
instead of going completely through them.   The density and compact-
ness of the cornea, the  resistance which it  consequently offers, and its
being composed of parts in some  degree loosely connected, are circum-
stances which should be constantly borne in mind in  operating on  this
membrane.
   The cornea  in the human  eye forms a pretty regular portion of a
sphere, and is of equal  thickness  [about one-thirtieth of an inch] at the
circumference and in the centre; it is consequently convex on its exter-
nal or anterior surface, and concave on its posterior surface.   Although
it appears like a homogeneous membrane, we consider it  to be made up
of three different structures.   The anterior  surface is a  mucous  mem-
brane, being a continuation of the conjunctiva;  [4'.  Fig. 1.] the great
bulk of the part is made up of the fibrous, or fibro-cartilaginous struc-
ture already described, and  usually called the corneal lamince; the in-
ternal surface is a firm, cartilaginous, perfectly transparent membrane,
adhering closely to the  proper corneal substance, and  called membrane
of the aqueous humour, \ [6. Fig. 1.] being supposed to secrete, or to have
a share in  secreting that  fluid.  Dr. JacobJ observes, that  this  mem-
brane preserves its transparency after maceration, or  immersion in  hot
water, acid, or spirit, all which render the corneal laminae opaque;  and
that it separates from  the latter when the cornea is  immersed in  any
fluid capable of corrugating it, after which it can easily be detached,
and exhibited  in  a distinct  state.  He  adds, that  it  passes under the

  * Arnold's Untersuchungen; p. 16 and 23.
  t It was first noticed by Descf.mrt, and  is sonctimes named  after him.  Observations
sur la Choroide in the Mem.prcsentcs a /' Acad, des Sc. toin. v. 1759.
  1 Medico Chir. Trans, vol. xii. p. 503. 
44                   ANATOMY OF THE EVE-BALL.

sclerotic for a short  distance between it and the ciliary ligament, and
terminates with a defined edge.   According to this representation, the
cornea consists of three different structures; the anterior or mucous
layer, the fibro-cartilaginous substance in the middle, and the membrane
of the aqueous humour lining the internal or posterior surface.   These,
and especially the first two, are most firmly united, we might say con-
solidated, into one apparently uniform  transparent structure.
  Vessels of the cornea.—No  blood-vessels can be seen in the normal
state of the cornea, even with the assistance of magnifying powers;
and it has been found in general equally impracticable to discover them
after injection.  Both Soemmerring and  Eble  failed in their  attempts.
The former has given a beautiful view of the conjunctival vessels in a
child six months old, after injection.  Numerous arteries come forwards
on the conjunctiva scleroticse in all directions, and ramify in the mem-
brane:  they produce, in fact,  numerous minute branches, closely ar-
ranged  and  interwoven  so as to form  an  apparently uniform red border
round the cornea, on which, however, not a single twig can be traced.
These vessels are so minute,  that a  magnifying  power is necessary to
prove that the red margin is made up of vessels.*  Eble gives a mag-
nified view of the  conjunctival arteries,  delineating clearly the superfi-
cial and deeper-seated ramifications  in the  conjunctiva,  and on  the
sclerotica.   From the arterial net-work of the membrane, minute twigs,
in countless number, run in straight  lines  towards the  margin  of the
cornea, and there end abruptly, as if cut ofT.f
  Professor Roemer of Vienna has succeeded  better in his injections,
having  filled the  arteries of the conjunctiva cornea? in an infant  two
months old, he says, that the arteries of the ocular conjunctiva coming
from the lachrymal, palpebral,  and muscular arteries, form a superficial
and deeper-seated net-work on the anterior part of the sclerotica.  That
the superficial is made up of branches from the palpebral and lachrymal
arteries, which take a serpentine course towards the cornea,-unite to-
gether,  and join the more deep-seated  plexus.   That the latter consists
of much slenderer  tubes, coming from the muscular and ciliary arteries,
uniting  round the margin of the  cornea  with  the superficial Vessels so
as to form a vascular corona or circle (Gefass-kranzj situated  over the
circulus venosus.   From this circle numerous minute twigs proceed at
all points in straight lines towards the centre of the cornea, dividing in
their course into two or three still finer  tubes.   At last they bend in-
wards  and  seem to enter the substance of the cornea.J
  The  minute vessels of the cornea  are often injected  with  blood, in
great numbers, under inflammation both acute and chronic.  From their
number, minuteness, and close arrangement, they sometimes give to the
membrane a general redness, in which the individual vessels are hardly
distinguishable without the aid of a lens.   In the injections of Professor
Roemer, as well  as in the vascularity of inflammatory excitement, the
corneal vessels seem to be derived from those of the conjunctiva.

  *  Icones Oculi humani; tab. v. fig. 12. The figure is twice the natural size.  See also
the explanation of the figure at p. 77.
  +  Ueber den Ban und die Krankheiten der Bindehautdes Augapfels p. 59. tab ii ficr 11
  t Bemerkungen uber die arteriellen Gefdsse der Bindehaut des Augapfels • in Ammon's
Zeitschrift, vol. v.                                            ' 
ANATOMY OF THE EYE-BALL.
15
  Whether there are  others more deeply seated coming from those  of
the sclerotica, or ramified in the membrane of the aqueous humour, or
of both descriptions;  and how  far  the  vessels from  these  different
sources, if such exist, communicate together, or otherwise, are points
not yet ascertained.   We see, however, daily, that the vital processes,
whether physiological  or  pathological, are carried  on as rapidly and
perfectly in the cornea, as in any of the parts most abundantly supplied
with red blood.  Wounds of  this part unite by adhesion as quickly as
in any other part of the frame.  It is subject to inflammation, both acute
and chronic,  with the various  results of mortification, suppuration, ulce-
ration, serous effusion, interstitial deposition, and increase  in the num-
ber and size of vessels.
  That the cornea possesses an immense abundance of lymphatic ves-
sels  has  been  proved, both by injections of them with mercury by
Fohmann, and by the microscopical examinations  of Mascagni and
Arnold.   The membrane seems almost made up of lymphatic plexuses
or net-works, intricately interwoven.  These are found in the conjunc-
tival layer, and  throughout the corneal substance, being equally abun-
dant in every slice, from whatever  part of the  membrane it may be
taken.*  The lymphatic trunks, filled with mercury, and constituting a
continuous stratum under the conjunctival covering of the cornea, are
represented  by Arnold in his  Tabulae Analomica; fascic. II. tab.  2,
Fig. 10.  They terminate in a lymphatic plexus of the conjunctiva scle-
rotica?, exhibited as injected with mercury in the 7th figure of the same
plate.  A close net-work of small  ramifications surrounds the cornea,
while  the trunks pass backwards  towards  the circumference of the
globe.
   The presence of  nerves in the cornea has  not hitherto been  demon-
strated.  It has been  lately asserted by Schlemm,! but positively denied
by ArnoldJ after the most careful  investigation in the larger animals
and man.  [Still more recently, Pappenheim asserts that he has suc-
ceeded in tracing nerves from the  sclerotica into the substance of the
cornea.  See American J. Med. Sc. Aug. 1840, p. 439.]
   Choroid coat  (chorioidea,  vascular membrane, aderhaut,  Germ.)
[1. Fig. 7.]   This membrane covers the globe from  the  entrance  of
the optic nerve, where it  is firmly  attached  to the perforation in the
sclerotica, to the anterior termination of the latter, and reaches to the
circumference of the  crystalline capsule.  It is thin, soft, and delicate,
remarkable for its dark  colour, and  great vascularity.  Its numerous
vessels are often found filled with blood after death, and the membrane
acquires  a deep red  throughout, when they have  been successfully
injected with size and vermillion.   The basis of the membrane is alto-
gether vascular and cellular; microscopical examination,  after a suc-
cessful minute injection, presents to our view a congeries of minute
vessels, an intricate vascular net-work, of which the  component parts
are united by cellular texture, and  nothing else.   The dark  colour of
the membrane arises from the deposition  into its structure of a colour-
ing matter, called pigmentum nigrum., which  may be considered as ad-
ventitious, and not essential to the membrane.

  * Arnold's Untersuchungen; p. 20—23. pi. I. fig. 2.
  t Encyclopadischcs Worterbuch; b. iv. p. 22, 23.          t Lib. cil. 27, 28. 
16
ANATOMY OF THE EVE-BALL.
  In order to estimate the internal structure of the choroid coat, we
must examine it in the injected state.  If we then survey it with the aid
of magnifying powers, we find that it consists entirely of arterial and
venous ramifications, connected by cellular texture : hence it has been
sometimes called tunica vasculosa oculi.
  Its composition is analogous to that of the pia mater or vascular mem-
brane of the brain, of which it  has been sometimes regarded as a con-
tinuation, through  the vascular  investment  of the optic nerve.   The
neurilema, however, is not continued  into  the choroid, as the fibrous
sheath is into the sclerotica ; there is no direct connexion between them,
and the choroid must therefore be considered as a separate and inde-
pendent membrane.
  The same observations  may be made with respect to the iris, a  part
closely connected with the choroid, though differing very much in other
points of structure.   The  basis, or essential part  of its  texture is com-
pletely vascular.  The best views of these parts have been furnished by
Soemmerring and Arnold.  These consummate  anatomists  have exhi-
bited in several figures the minute structure  of the choroid and  iris with
the utmost accuracy and fidelity.  We perceive  at once, upon inspect-
ing their figures, that the objects have been correctly delineated, from
the character of truth and nature which distinguishes  them, and from
the variety and peculiarity in the different details,  which are evidently
drawn from actual observation, and could  not have been supplied by
the fancy of the artist.  A certain portion of the  internal surface of the
choroid exhibits a number of radiated  folds, called the ciliary processes.
One of Soemmerring's engravings represents a portion of the choroid
coat, with three of the ciliary processes, and a portion of the corre-
sponding internal  surface  of  the iris, forming a  small  segment of the
pupillary  circle.  The beautiful  vascular structure  of these  parts is
represented as  it appeared under a  magnifying power  increasing it by
twenty-four diameters.  Soemmerring mentions that the artist spent six
weeks in making the  drawing, and nearly put out  his  eyes in the pro-
cess.   In the second plate of his  second  fasciculus, Arnold delineates
the same parts, as well as  the vascular arrangement on  the correspond-
ing external surface: he  also represents the blood-vessels of these struc-
tures, under  various  aspects, in other figures.  It  must,  1 think, be
allowed that the work of Arnold carries the minute anatomy of the eye
farther than that of Soemmerring, to which it is at  the same time equal
in execution.
  In the recent eye, the pigment sticks fast  to the choroid, but if it be
allowed to remain  some time in water, the  colouring matter  is easily
disengaged from the membrane; it comes off on  the hand or linen, and
diffuses itself through the water like Indian ink.  Longer maceration
discharges it entirely, leaving the texture of the  choroid uninjured, but
altered to a  grayish  colour.  After immersion  in spirit, the  pigment
will come off, particularly from  the internal surface  of the membrane,
in masses of different size.  This colouring  substance is called pigmen-
tum nigrum, a name which is appropriate enough  when applied to the
eye of the sheep, bullock,  and many other  animals,  which have it of
the deepest jet black ; but, in the human eye, the tint of this substance
is dark brown,  of a deeper shade in some eves than  in others.  In fair
individuals the choroid coat is of a light brown.  In the human subject, 
ANATOMY OF THE EYE-BALL.
47
 therefore, the colouring matter cannot properly be called pigmentum
 nigrum, and it is more correctly termed by foreign anatomists pigmentum
fuscum.
   The pigment, possessing a reddish hue in the fetus, does not attain its
 full depth of colour till after birth, and becomes lighter in old age.  In
 morbid states of the choroid it is changed in colour, quantity, or consis-
 tence.  It seems to be deposited from the vessels of the choroid, without
 any intermediate structure; nothing like gland can be detected.   It has
 usually been regarded as  an inorganic substance spread over the inte-
 rior of the eye to darken it, and thus  render it more perfect as an optical
 instrument.  Seme represent it as contained in a membrane or a cellu-
 lar texture.*  In opposition  to this view, Arnold! states that the most
 careful microscopical examination after minute injection of the eye, de-
 tects no blood-vessels, and that no trace of lymphatics can be seen in it.
 It appears under the microscope as a black granular mass, consisting of
 globules and a dark  substance.   The latter may be more or less abun-
 dant, and sometimes the globules are found alone.   These globules are
 represented as nearly spherical by Arnold,J and in some degree trans-
 parent in the centre.  Mr. Jones§ describes and delineates them as mi-
 nute flat  bodies, of  hexagonal forms, joined  together  by their edges,
 consisting of a transparent nucleus surrounded by colouring matter.
   Arnold|| represents that the choroid is not covered externally by the
 pigment,  except in cases where the colouring matter is abundant; that
 in eyes with light irides, and  in old subjects, the corresponding surfaces
 of the choroid  and sclerotica are not  coloured, but clear, smooth, and
 shining.  Hence the internal surface of the latter could not in such cases
 be called lamina fusca.
   The whole internal surface of the  human choroid is of the brown
 colour; but in the bullock  and most quadrupeds, a certain portion of the
 internal surface possesses  tints peculiarly bright  and vivid.  In the  cat
 it is a bright yellow, in the stag a very beautiful blue, in the sheep a
 greenish  blue.   This coloured portion of the choroid coat  is called
 the  tapetum or carpet;  there is no part corresponding to it in the hu-
 man eye.
   Ruysch, who took much pains to inject the blood-vessels of the eye,
 and examined the structure of the choroid in man and animals, divided
 the membrane into two layers, and  called the external, choroid, while
 his son gave the name of  tunica  Ruyschiana to the internal.   This se-
 paration can be effected, at least  partially, in the eyes of animals, more
 particularly in the situation of the tapetum; and the same thing can be
 accomplished in the human eye, especially when it has'lain a little time
 in spirit.  This separation is quite an  artificial affair; the choroid is a
 sino-le membrane, of which we can form a just notion only in that view.
 If we take the uninjected membrane we could not distinguish the vascu-

   [* Gmelin believed this membrane to be analogous to the rete malpighianum of the skin,
 and presumed that it would exist in a colourless state in albinous animals.  This supposi.
 tion Mr. Wharton Jones says he  has found to be well founded, but that the plates are cir-
 cular, not hexagonal.—Edin. Med. «$' Surg. Jour., xl. p. 81.]
   t Anat. u. physiol. Untersuchungen, p. 62.     t Tab. Anat. fasc. II. tab. 2, fig. 24.
   $ Mackenzie's Practical Treatise on Diseases of the Eye.  3d Edit.  Introduction,
 p. 26.                                   II Lib. cit. p. 60. 
48
ANATOMY OF THE EYE-BALL.
lar net-works belonging to the supposed distinct lamina?.   When we ex-
amine an injected choroid,  we immediately perceive that the arteries
are distributed on the interior, while the veins occupy the exterior of the
membrane, an arrangement  corresponding to the different functions per-
formed by the two orders of vessels.  The arteries and veins of the cho-
roid form net-works interwoven with each other, and making up together
a single structure.  They are principally arterial on the inner surface;
the minute arteries  and veins are united in the  interior,  and covered
externally by the large  venous trunks  known  by  the  name of vasa
vorticosa.
   The arrangement of the ultimate vascular ramifications of the choroid
has been beautifully delineated by Soemmerring in figures  illustrating a
short paper*  in the Memoirs of the Academy of Sciences at Munich,
vol. vii.   He represents the vessels of the choroid, as they appear under
a strong magnifying power  in a portion of the membrane of certain size
taken from the corresponding part of the globe in an infant and an adult,
in  the  calf, the salamander  (water newt,) and the common fowl.  He
found that the choroid vessels are as large in a small as in  a larger eye,
so that the choroid of a small animal might be represented as, in a cer-
tain sense, a  piece or part of the choroid of a large animal;  that their
distribution is characteristic in each species; that the  ciliary arteries,
having divided and subdivided, form at last an arrangement of flattened
cylindrical vessels, nearly uniform  in size, partly communicating  toge-
ther, and  forming so close a  net-work as to leave no room for finer rami-
fications, and partly continued into corresponding venous tubes.  Hence
it appears that the  choroid  is most richly supplied  with  blood-vessels,
containing nothing in addition to these but cellular texture, and that no
secreting or exhaling tubes can be  discovered in it.          •
  The arteries of the membrane are the posterior ciliary, which are nu-
merous, and perforate the sclerotica round and near  the insertion of the
optic  nerve;  and the anterior ciliary, in smaller number, which pass
through the fibrous tunic in the situation of the ligamentum ciliarc.  The
former may be regarded  as the proper arteries of the choroid ; the latter
are principally ramified in the ligamentum ciliare, and inosculate freely
with the greater arterial  circle of the iris.  The veins terminate chieflv
in  four trunks, which perforate the sclerotica a little behind the greatest
transverse diameter of the globe.   From each of these trunks, as  from
a centre, branches, generally describing a more or  less arched course,
spread  in all  directions  over the  choroid, forming  so many vascular
whorls;  hence the appellation of vasa vorticosa.   There are also poste-
rior  and anterior ciliary veins: the vasa vorticosa  inosculating freely
with  both these, and with each other, form a venous net-work, which
constitutes the exterior  layer of the choroid, while  the arterial' plexus
forms the interior or  tunica Ruyschiana.   The distribution of these ves-
sels, as well as of those belonging to the iris, is represented with inimi-
table beauty  in six figures of Arnold's  second  plate, viz. fig. 16—21.
Icones Anat.   Nerves have not been discovered in the choroid
   The external surface  of the choroid presents a uniform appearance
excepting a narrow portion in front,forming the ligamentum ciliare, which
» Ueber dasfeinste Gefdssnetz der Aderhaut im Augapfel. 
ANATOMY OF THE EYE-BALL.
4G
remains to be  described.  The internal surface is also uniform until it
approaches within two lines  and a half of the edge of the cornea: here
we observe a dentated  line (ora serrata,) [11, fig. 1.]  in front of which
the membrane  exhibits  a number of longitudinal folds, arranged in a ra-
diated manner, and reaching to the circumference of the lens ; these are
the ciliary processes, and  the part  in question, taken altogether, is the
ciliary  body (corpus ciliare.)  [10. fig. 1.]   This is best seen when the
globe has been divided  by  a  vertical section into an anterior and  a pos-
terior half, the  vitreous humour and lens having been left undisturbed.
Looking through the former, we see a beautiful deep brown ring, about
three lines broad, a little narrower on the nasal side, surrounding the
lens.   The posterior boundary of this is the ora, serrata; the back  part
of the ring is a  smooth surface (pars nonfimbriata corporis ciliaris;) [10'.
fig. 1.] the anterior portion of it, about a line in breadth (pars fimbriata,)
[10. fig. L] presents a series of dark and white folds alternately arranged,
which are the  ciliary processes.  The white lines arise by hardly visible
striae, which enlarge as they pass forwards, and form white elongated folds
closely  arranged, separated by dark intervals, and broader, thicker, and
more elevated, the nearer they approach to the lens.   The deep colour
of the corpus ciliare is derived from a thick layer of pigment, which ad-
heres more  closely than the  corresponding  covering of the  choroid.
  [W hile the inner surface of the choroid forms the ciliary ring, its outer surface
presents the annulvs albidus or a. gangliformis [8. fig, 1.] the anterior edge
of which unites  to the inner surface of the sclerotica and constitutes the ciliary
ligament.   9. fig. 1.  Mr. T. W. Jones describes  the annulus albidus as a
body of a peculiar  texture, enclosed between the two layers, into which the
choroid is divisible  anteriorly, and  having the form of a fiat circular band,
about one eighth of an inch broad, thick anteriorly, and thin posteriorly.]
   Some have regarded the ciliary body as a peculiar  structure, distinct
from the choroid.   They are, however, perfectly continuous; no distinc-
tion is  visible  externally.  In  essential  circumstances the structure is
alike, consisting of a vascular basis, of which the peculiar character in
the ciliary processes is represented by Soemmerring  and Arnold, with
unrivalled beauty, with pigment deposited in the texture.
  The  notion  entertained by Kepler that the ciliary  body produces
changes in the interior  of the eye connected with the adaptation of the
organ to vision at different distances, led many  anatomists and physio-
logists to maintain that the ciliary processes are muscular, and capable
of moving the crystalline lens.   This point was thoroughly examined by
the careful and accurate Zinn, who  came to the conclusion that the tex-
ture of  the part is purely vascular, and exhibits nothing like muscular
structure.  The same  view  is entertained by Arnold ;*  who says, " in
repeated examinations  of the ciliary processes under the microscope, I
could never  detect  any muscular  structure, although muscular fibres,
however pale,  are  readily recognised as such in microscopic observa-
tions.   When uninjected, the ciliary processes appear to consist of cel-
lular texture; but, after successful  injection, they  are seen to be  made up
entirely of blood-vessels.   Neither have I discovered  any nerves in this
structure by  similar or  other modes of investigation."
7
* Untersuchungen, p. 58. 
50
ANATOMY OF THE EYE-BALL.
  Iris.  iReqenbogen-haur.Germ.) [12. fig. l.]-The im, which fills up
the circular space left by the anterior termination of thechoroid coat, is a
part of considerable importance from its situaiion, and its office 01 regu-
lating the quantity of light admitted into the eye, from its diseases, and its
connexion with most of the important operations performed on the organ;
while an equal degree of  interest attaches to it physiognomically, Irom
its brilliance, its various tints, and the animation it imparts to the coun-
tenance.  Its  external appearance  must be familiar to every one who
has looked at  the human face; it is the part in which the colour of the
eye, popularlv speaking, resides,—the brilliantly coloured portion of the
organ situated behind "the cornea, and  close in front of the crystalline
lens, in  the midst of the aqueous humour, in  which humour it freely
moves.   The  opening in the centre, which is circular in the human eye,
when in a healthy and natural state, is the pupil.   In the sheep and bul-
lock it is oblong, and its  figure varies in different animals.   The term
iris, properly speaking,  is  applied  to the  anterior surface of the mem-
brane, to that part which  is distinguished by the brilliancy of its colour;
from which attribute, together with the variety of its tints in different
individuals, the name seems to have  been derived.  The colour of the
iris varies very much in different persons, but in all it is distinguished by
a greater or less degree of brilliance.   This characteristic belongs only
to the anterior surface, for the posterior is covered by pigmentum, indeed
by a thick and dark stratum of it, and therefore resembles the surface
of the choroid, being  black in animals, and dark  brown in the human
species.  This posterior surface is called the uvea.  In  employing the
terms iris and uvea, we  must remember that  the membrane is single,
and not separable into layers, except by artificial  dissection.
   It has been disputed whether the iris is flat or convex on its anterior
surface.   I believe that it is flat in the healthy eye, but would not assert
that  it  may not vary  in this  respect  independently of disease.   The
Soemmerrings* have represented it  as perfectly flat; while the figures of
Arnold| give it a slight convexity.
   We distinguish two surfaces, an anterior (iris,) and a posterior (uvea.)
On the former, when the  part is laid  in water, minute flocculi are visi-
ble.   It also exhibits numerous nearly parallel larger and  smaller lines
and fibres, proceeding like radii  from the circumference  towards  the
centre : these sometimes  unite  so as to  form arches. An irregular line
divides  this surface more  or less distinctly into two  portions ; an exter-
nal, or larger circle (annulus externus, or ciliaris,)  and an internal, or
smaller circle, (annulus inlernus, or pupillaris.)
   The posterior surface of the iris presents a number of faintly marked
lines, converging from its circumference towards the pupil.   Dr. Jacob
considers that its pigment is covered and  secured in its situation  by a
very delicate  membrane: it may be easily turned down from the iris as
a distinct structure.  When this has  been removed, and  the surface
washed, the iris has a grey appearance, and  exhibits numerous  fibres
converging from the ciliary processes towards the pupil.  " The latter

   * S. T Sokmmkrring, Icones  Oculi humani, tab. 8. W. Soemmering de Oculorum Sec
Secttone horizontal',.                                           vcuiormn CfC
   t Arnold Untersuchungen, tab. 3. fig. 2.  Jcoues Anat. fat,c II. tab. 2. fig. 4 
ANATOMY OF THE EYE-BALL.
51
 opening," says Dr. Jacob, " is immediately surrounded by a well defined
 distinct circle, about the twentieth part of an inch in diameter, of a denser
 structure than the rest of the iris;  this is what has been long described
 as the orbicular muscle, or constrictor of the pupil."*
   The iris  has  two  margins; an external or ciliary, attached  to the
 corpus ciliare, an internal or pupillary, which is the border of the cen-
 tral opening.  The  situation of this opening, however, is not  exactly
 central;  it deviates a little towards the inside, so  that the iris is nar-
 rower on the  nasal than on the temporal side of the pupil.  This diffe-
 rence, which  was, I  believe, first noticed by Soemmerring, is immedi-
 ately recognisable in the  living eye.  The  ciliary  margin is the only
 fixed part of the iris, all the rest is loose and unconnected, floating in or
 washed by  the aqueous humour.  The very  edge of the pupil, which is
 thin and sharply defined, is coloured by the pigment; we might say, the
 pupillary margin is formed by the uvea, rather than the iris.  The dia-
 meter of the pupil varies in an inverse ratio to the  quantity of light to
 which  the eye is exposed:  in a strong light it is  contracted, and the
 iris  proportionally expanded; when the  light  is diminished in  quan-
 tity, the opening is enlarged, and the iris, in a corresponding degree,
 contracted.
   The notion that the iris is a continuation of the choroid, or, in other
 words, that these two are  parts of one and the same continuous struc-
 ture, is contradicted, not only by the obvious differences between them
 in organization  and function, but also by the mode of union, by the dis-
 tinct sources of vascular  supply in the  two cases,  and  by the  total
 absence of nerves in the one instance, while the other part is furnished
 with them as abundantly as any organ in the body.   The anterior cir-
 cular edge of the ligamentum ciliare, and of the corpus ciliare, forms a
 groove or plait, in which  the outer or ciliary edge, or the greater cir-
 cumference of the iris is set; the  union not  being firm or intimate, but
 such, that the iris can be drawn away without injury either to it, or to
 the ciliary body or ligament.  If the cornea and the front of the scle-
 rotica are carefully removed from the human eye, so as to  leave the
 choroid and the ciliary ligament uninjured, the iris can  be drawn away
 easily so as to show that it is  connected to  the choroid, not  by conti-
 nuity of substance, but merely by the long and anterior ciliary arteries,
 by the ciliary nerves, and an easily  lacerable cellular texture.
   Blood-vessels of the iris.—The arteries of the iris are the two long
 ciliary (the  external  and internal,) and the anterior ciliary, about six
 in number.  The long ciliary arteries perforate the sclerotica towards
 the back of the globe, one on the inner, one on the outer side: they pass
 forward between the sclerotica and choroid, along the middle of the
 globe, to  the ligamentum ciliare, where each of them divides into two
 branches, which run round the greater circumference  of the iris, and
uniting  together, constitute  the greater arterial circle of the iris.   The
short ciliary arteries pass through the sclerotica in the front of the eye,
and join the circle before described.   Numerous branches proceed from
this circle, and run in a nearly parallel direction  along  the iris, inoscu-
lating in the situation of the lesser circle, so  as to form the lesser arte-
Medico Chir. Trans, vol. xii. p. 513, 514. 
52
ANATOMY OF THE EYE-BALL.
rial circle of the iris.   The veins of the iris pour their contents into the
circular venous sinus, [3. fig. 1.]  situated at the  circumference of the
cornea, from which anterior ciliary veins proceed.*
  Nerves of the iris.—The ciliary nerves, proceeding  chiefly from the
ophthalmic ganglion, penetrate the sclerotica towards  the back of the
globe, run forwards, under the appearance of larger or smaller white
threads,  between the sclerotica and choroid, to the ligamentum ciliare,
in which they appear  to  be lost.  Soemmerring  considers  that  they
really terminate here, and regards the  ligamentum ciliare as a kind of
ganglion formed by their expansion and union : hence he calls  it  annulus
gangliformis.-f   ArnoldJ says  that though  he could trace the ciliary
nerves through  the ligamentum  ciliare, and follow them  even to the
edge of the pupil in animals, for example, in the dog, he could  not suc-
ceed in fresh human eyes; on  the contrary, they became so  soft, as if
they were resolved into cellular texture, that he could not  follow them
any farther.   He did  not succeed better with microscopical examina-
tions: for, although he saw white threads in the iris, looking like nerves,
he could not connect them with the ciliary nerves.  He  accomplished
the  point at  last, in an eye which had been  kept in alcohol, and, using
a fine needle, followed the nerves through  the ligamentum  ciliare, in
which  they  divide and  subdivide, ultimately producing  small white
threads taking a  somewhat undulating course,  and lost in the iris,
where  they  can  be traced nearly  to the pupil.  He has delineated them
in a beautiful figure, where they are seen ending in a close net-work of
branches in  the  ligamentum ciliare, from which the nerves of  the iris
proceed.§
  Not  only does  the colour of this  part vary in different individuals,
but  different hues are found in one and the same iris.  Sometimes diffe-
rent tints are intermixed throughout, as in  light blue, grey, greenish,
and brownish grey eyes.  The inner circle is often of a different colour
from the outer;  for example, it may be of an orange or ochrey tint in
blue or grey eyes.  Usually there are three distinct colours in the same
iris; the circumference, the middle, and the inner circle exhibiting tints
more or less different.  Occasionally,  the two irides are naturally diffe-
rent ; and sometimes one-fourth or one-half is brown, the rest being blue
or grey.   I  saw a gentleman of  florid  complexion, with much colour
in the face, and dark hair.   His  right iris was grey, with a slight blue
tinge;  the left light brown, except about one-fifth, which  was grey like
the  right.  In respect  to these varieties there is a  marked  difference
between the human species and animals. It may be said of all animals,
in their natural or wild state, that the colour of the iris is constant in the
same  species.  Domesticated  animals, with greater diversities in the
general colour of the body, have, in some degree, a corresponding diver-
sity in  that of the iris ;  but in no instances are there such  numerous dif-
ferences as in the human subject.
  The colour of the iris generally corresponds to  that of the integu-
ments: it varies according to the complexion of the individual  and the
colour of the hair.   In  those of fair complexion and light hair, the iris

  »  Arnold, tab. 2, fig. 18 and 19.       + Icones Oculi humani; tab. 5, fig. 7 and 9
  J  Untersuchungen, p. 77.             § Tab. Anat. fasc. II. tab. 2, fig. 22. 
ANATOMY OF THE EYE-BALL.
53
is either blue  or grey, or of some light tint; such  persons  are said, in
common language, to have light eyes.  In persons of dark  complexion
and hair, the iris has a deeper tint, dark grey, brown in various shades,
of which the deepest is called black.  In the human subject, the iris is
never, strictly speaking, black;  the eyes, which we call black, are of a
dark brown, and they always accompany dark hair, and complexions
more or less swarthy.*   The individuals of the German race are distin-
guished by the lightness of their hair, the fairness and ruddiness of their
complexion, and by blue or light grey eyes.  This  combination of phy-
sical characters is  remarked by  Tacitus,  in his  treatise De Moribus
Germanorum (rutilae comas, ccerulei oculi;) where rutilce probably means
the colour which we call flaxen; this sort of hair, and  light blue eyes,
are circumstances which characterize the German race at  this day as
strongly as at the time when  Tacitus described them.   All the dark-
complexioned races, the Sclavonians,  the  Celts, the Orientals (as the
Turks and the inhabitants of the western parts of  Asia) and the dark-
coloured races, properly so called,  have dark hair and the darkest irides.
In the Negro this characteristic is most striking, for the iris  is so ex-
tremely dark that you are  obliged  to look closely to distinguish  between
it and the pupil.
   In the eye, as well as in the hair and in the skin, the colouring sub-
stance seems  to be something  adventitious, which does not belong to
the basis or natural texture of the part: for, when the colouring sub-
stance  is removed, the fundamental structure remains.   This is the
case with respect to the  individuals called Albinoes, who are distin-
guished  by a peculiar and  almost morbid kind of whiteness; whose hair
has a white, almost satiny appearance, and whose skin is  of a  dead,
sickly white.  In these  individuals the colouring  substance  of the cho-
roid coat, and of the iris is deficient; and  the pupil, instead  of  being
black, is of a rose or pink colour; the  iris  has  the same pink  tint in a
greater or less degree, but its colour is never so  deep  as that of the
pupil.  The  choroid pigment, and that  of  the uvea are entirely want-
ing;  but the iris often possesses a little colour, light blue or grey; its
texture is at  the same time so thin, from the absence of the uvea, that
the red of the choroid is partially seen  through it.  The  colour of the
iris and pupil  in these cases depends on the multitude of  blood-vessels
entering into the texture  of  the  former, and of  the choroid,  If we
examine the eyes of such individuals, after the vessels have been injected,
the choroid coat presents  the appearance of a uniform red membrane
without any colouring substance.  In the ferret, and in the white rabbit,
there is the same deficiency of colouring substance, and the red colour
of their eyes is well  known.
   The iris is considerably thicker than the choroid, except at the pupil-
lary ring, which is terminated by a thin and sharp edge.   It is soft and
loose in texture, being apparently made up of blood-vessels,  nerves, and
a  fine connecting cellular tissue.    Whether it  has also  fibres, and
whether  these are muscular, are questions  which  have been  long de-
bated, and are not yet decided.

  * [Examples of very dark-brown eyes in  persons of fair complexion  and flaxen hair,
are not very uncommon in the United States.] 
54
ANATOMY OF THE EYE-BALL.
   Sir Everard Home not only believed in the muscular structure of the
iris, but considered the point so clear as not to admit of dispute.  And
it  might justly be so regarded, if the figures which he has given of  the
structure, from the observations and drawings  of  Mr. Bauer could be
regarded as accurate.*  He admits the radiated fibres of the iris to be
vascular, and has represented themf not very correctly.   He places the
muscular structure on the posterior or uveal aspect, making it  to con-
sist of a sphincter round the pupil,  and  of radiated fibres in the circum-
ference, giving them as  obviously  muscular  a character as could be
seen in the orbicular muscle of the  mouth or eyelids.J   Arnold has  ex-
amined this subject with his usual  industry and accuracy.   He details
the conflicting opinions of many celebrated anatomists and physologists,
and proceeds to the result of his  own inquiries, which  he prosecuted
both in fresh and macerated  eyes, without  and with injection of  the
blood-vessels, under various magnifying powers, and with different  de-
grees of light.  When a fresh iris,  not injected and properly freed from
pigment, is magnified thirty, forty-eight, or seventy times in diameter, it
appears as a membrane formed of  cellular texture, in which numerous
fibres are observed running from without inwards in a serpentine course:
on careful examination these are found to  be vessels.   Besides these,
and threads, which  are  recognised as  twigs of the ciliary  nerves, no-
thing could be  seen in the shape  of  fibres, such  as they   have  been
described by  several  anatomists, and  so plainly  delineated by Home.
The cellular texture in the greater part of the iris is thin, loose, and
spongy, forming on  the anterior surface a net-work with meshes of va-
rious size; but it  becomes  condensed  towards  the pupil, and is com-
pacted into  a firm ring, which constitutes the  pupillary margin.  No
circular.fibres, could be discovered by the most  careful and attentive
examination.  The  iris,  then, consists of  numerous  blood-vessels, of
many nerves,  and of cellular texture, which  forms a continuous ring at
the pupil.   If  we cut through the iris, and examine the  cut  edge  with
the microscope, we find  the cellular texture accumulated in larger quan-
tity round the pupil, so that the iris presents here  a tumid  ring.  The
substance is a little thinner in the  middle  than at  the ciliary margin.
The same results are obtained by examining the  iris  after  it has  been
macerated, the cellular nature of the organ being  however more appa-
rent, and the blood-vessels less easily recognisable.   The latter are more
conspicuous after successful injection, when the distention of the vessels
renders the  cellular texture less conspicuous.  If the iris is split into
two laminae, the same results are obtained by examining them.§  When
examined by the  microscope,  after successful  injection, the iris seems
composed almost entirely of vessels; although some of these are not of
the smallest size, they do not appear to  contain  red  blood: at least,

iv* lP86°fi  TQan$aCti°nS' VoL cxih PL 6- % 8-  Lectures on Comparative Anatomy, vol.
  t Lib. cit. fig. 7.
  X The same  observation may be made respecting the representation of  circular  and
radiated fibres in the eye of the cobitis anableps;  Phil. Trans, vol. cxii  pi 8 fio- 6   Lee
tures, vol. iv. pi 88. fig. 6. By M. Maunoir of Geneva, also, who strongly advocates the
muscularity of the ins, the structure ,s delineated in such a way as to remove all doubt on
PJriT&c YarVim^       gUr°S ^ admitlud'  ^moires sur VOrganization de
  § Untersuchungen, p. 73, 74. 
ANATOMY OF THE EYE-BALL.
55
when the healthy iris is wounded, no blood flows; free bleeding, how-
ever, occurs when it is detached from the ciliary body.
  [The recent experiments of Prof. Grimelli, of Modena, corroborate Arnold's
account of the structure of the iris.   Prof. Grimelli  found that the substances
which answer best for very fine injections of this organ are olive or walnut oil
variously coloured, Avhich penetrates into the most delicate vascular ramusculi
without transuding through their coats, and preserves for a long time  the parts
which they impregnate.  In injecting the bodies of children, Dr. Grimelli ob-
served, that from being soft and much dilated, the iris became turgid,  and con-
tracted more than half its diameter, in the same manner as when the  retina  is
affected by light during life.  This fact appears to  prove that the iris is com-
posed of a union of vessels forming a disc, in the centre of which is the pupil-
lary aperture, and the circumference of which is attached to the ciliary liga-
ment.   By the aid of the lens and microscope, we see that the very fine
vessels which constitute the iris are disposed between the pupillary and ciliary
circles, under the form of rectilinear and curvilinear radii, curved upon them-
selves and zigzag; agglomerated and united in an inextricable  manner.   We
observe also some ramifications disposed in circles between  the pupillary and
ciliary circles, more or less near each  other, and always  few in number.  It
results from this disposition of the minute vessels, fixed towards the larger cir-
cle and moveable towards the  lesser, that the  sanguineous  afflux and tumes-
cence unfold the iris and contract  the pupil, and that the  return of blood and
diminution of turgescence, fold again or wrinkle the membrane and dilate the
pupillary aperture.  Thus, contrary to the generally admitted opinion on the
muscularity of the iris, as it appears to the author, this membrane is composed
of a turgescible or erectile vascular tissue, in  which arterial vessels  predomi-
nate.]
   Membrana pupillaris.—During a considerable portion of fetal exist-
ence, the pupil is occupied by a  delicate membrane, which closes the
opening, so that  the two chambers of the aqueous humour do not com-
municate.   Arnold* states  that in  the third month, when the eyelids
and  the conjunctiva are formed, a membrane is developed behind the
cornea, and closes the  pupillary aperture, then  very considerable:  that,
so long as the spherical lens lies close on the flat cornea, there are no
chambers of the eye, but a cellular texture, in which the vessels of the
iris ramify, intervenes  between the cornea  and lens; and  that, when
the lens becomes flatter, and the cornea more  arched, a  serous mem-
brane is developed, defining the anterior chamber and continued  over
the lens and pupil.   He represents that the pupillary membrane, at first
soft, becomes gradually firmer, and attains its  full development in the
fifth  and sixth months,  when it is an extremely thin  and  delicate,  per-
fectly transparent membrane, divisible into  two  layers, of which the
anterior is part of the membrane  of  the aqueous humour, and destitute
of vessels,  while the posterior is  a  cellular production  with  numerous
vessels.  It was  observed by Rudolphi that the pupillary membrane  is
continued over the iris, and that the pupil can be  seen  behind it with a
free edge.   The separation into two layers  is easy at an early period,
but can hardly be accomplished later.  The vessels of  the iris  are not
united in the fetus into  an inner arterial circle, but run into the pupillary
membrane, converging towards the centre, but not crossing it:  they in-
osculate so as to form loops, between which a small portion of the mem-
* Untersuchungen, p. 156. 
50
ANATOMY OF THE EYE-BALL.
brane, at its centre, is free from vessels.  The iris  gradually enlarges,
and the membrana pupillaris becomes of course less considerable.  In
the seventh month its  vessels, which were previously numerous  and
large, are lessened in number and size, and there is a larger transparent
portion in the centre.  It has been generally supposed to disappear in
the seventh month, but Dr. Jacob,* who  has minutely investigated this
matter, states that it* lasts considerably longer.  He says that " at the
approach of the eighth month, a few vessels cross the pupil,  or ramify
through the membrane at a short distance from the margin, without at
all presenting the looped appearance of  the previous period, but admit-
ting a free communication between the vessels of the opposite side of
the iris.  The pupil is now still more diminished  in size, and the iris has
assumed its  characteristic  coloured  appearance;  notwithstanding the
absence of vessels, the membrane still preserves its integrity, though per-
fectly transparent.  The  period  now  approaches, when  it is to disap-
pear; this occurrence takes place, according to my observations, a short
time previous or subsequent to  birth.   In every  instance where I  have
made the examination, I have found the  membrana pupillaris existing
in a greater or less degree  of  perfection in the new-born infant;  fre-
quently perfect, without the smallest breach, sometimes presenting ragged
apertures in several places,  and, in other instances, nothing existing but
a remnant hanging across the pupil like a  cobweb.   I have  even suc-
ceeded in injecting a  single vessel in the membrana pupillaris of the
ninth month.  When I have examined it in subjects who have lived for
a week or fortnight after birth, as proved by the  umbilicus being healed,
I have uniformly found a few shreds still remaining.  It is obvious from
the preceding observations,  that the membrane  does  not disappear by
a rent taking place in  the centre, and retraction of the vessels to the
iris, as supposed by Blumenbach ; but that it at first loses its vascularity,
then becomes exceedingly thin and delicate, and is finally absorbed."
Portal| says, that it  disappears at the lime of  birth, or a little later.
ArnoldJ states, that he had frequently seen some vascular ramifications
in the pupil, remains of the pupillary  membrane in  the eyes  of newly-
born infants;  and  that he once saw, in both eyes of a child at full time,
the membrane perfect, excepting a small point in the centre, and well
supplied with  blood-vessels.
  Arachnoid  coat of the eye  [Membrana Fusca.—5. fig.  1.]  Some
anatomists have recently described a serous membrane, lining the cornea,
spread over the choroid, and bearing  the same relation  to those tunics
that the arachnoid does  to  the dura and pia mater: hence  they have
called it arachnoidea oculi.  It has been observed  that there is a fluid
between the sclerotica  and  choroid,  giving their surfaces a shining, if
not very moist appearance;  that minute injections escape here, as they
do into serous cavities, and that  morbid collections of fluid  have beeu
found in this situation.

  * Medico chirurgical Transactions, vol. xii.      t Memoires du Museum, torn. iv.
  t Lib. cit. p. 158.—The blood-vessels of the  membrana pupillaris have been repeatedly
delineated; by Blumenbach, Institutiones Physiological, tab. 2. Soemmerring, Icones Oculi
Humani, tab. 5.  J. Cloquet, Memoire sur la Membrane Pupillaire, et sur la"formation du
petit cercle arteriel de Vlris, Paris, 1818. The best representations of the subject are those
of Dr. Jacob, Medicochirurgical Transactions, vol. xii. pi. 10. und of Arnold  Iron  Anat
fasc. 2, tab. 2. fig. 19.                                           '     Anal' 
ANATOMY OF THE EYE-BALL.
57
   Zinn* expressly compares the space between the two membranes to
the serous cavities; and many  anatomists  have regarded  the external
surface  of the choroid,  or  the lining  of the sclerotica  as serous.
Schreiber says " sclerotica in  facie sua  interna naturam  membranas
serosas prce se fert, sicut chorioidea in facie sua externa."!   FraenzelJ
and Meckel§ consider the internal surface of the sclerotica to be serous,
and analogous  to the internal surface of the dura mater, while the latter
represents this  serous  layer of the  sclerotica as  derived from the
arachnoid coat of the brain.
   Although the arachnoid of the eye has  escaped the  notice of  Zinn,
of Sommerring, and of Jacob,|| ArnoldTI describes  it regularly, and in-
troduces  it in  his  view of the  vertically  divided  globe, both  in his
Untersuchungen (tab. 3, fig. 2) and  in  the  Tabula Anatomicce (tab. 2,
fig. 4.)   He says that the arachnoidea  oculi can be easily exhibited, by
careful  dissection, in the eye of the fetus, both on  the choroid and the
sclerotica;  but that it is not so  easily seen in  the  adult.  The portion
lining the sclerotica is as readily demonstrable as the arachnoid cover-
ing the  dura mater; but the difficulty is with the other part of the  mem-
brane.  The eye should be put  in spirit, and divided, when  sufficiently
hardened, into an anterior  and posterior half by a vertical incision. The
choroid is then to be drawn away from the sclerotica from within; thus
the inner layer of the arachnoid remains in contact with the outer, and
they can be easily  separated in water.   Under the  microscope, the
arachnoidea oculi exhibits  the same  arrangement of lymphatic vessels
as other serous membranes.**   The membrane is easily shown in  birds,
particularly in the falcon, where the choroid and sclerotica have a very
slight, if any cellular connexion.  In the mammalia, particularly  in the
sheep and ox, they  are closely connected by cellular texture,  so that in
detaching the sclerotica a portion of the choroid is often carried with it.
   It appears to me that the existence of this arachnoid coat in the eye
has  been rather inferred  from analogy than directly demonstrated;
while the argument from analogy is  not very  strong.   Organs, or por-
tions of organs, are insulated  by serous membranes, where they are lia-
ble to change of size, position,  or relation  to surrounding parts :  these
points are exemplified in the viscera of the abdomen, in the lungs and
heart, in the brain and spinal cord,  in the iris.  The case of the choroid
bears no resemblance to these.   The membrane is firmly  fixed  to the
sclerotica at its anterior termination, and at the entrance of the  optic
nerve.   Consider again the mutual  connexions of the tunics by soft and
short, but numerous cellular threads, and by the passage of the ciliary
arteries, veins, and  nerves.  In  these respects  the eye, instead of resem-
bling, presents  a contrast  to  the organs furnished with  serous invest-
ments.

  * Descript. Anat. Oculi Humani, p. 25.
  f Radius, Script. Ophthal. minor, vol.  lii. p.  ]28.  See also WARDRor, Morbid Anatomy
of the Human Eye, vol. ii. ch. 27 and 53.
  I Ammon's Zeitschrift, vol. i. p.  13.
  § Handbuch der Mensch. Anat. b. iv. p. 73.
  || Article Eye in the Cyclopaedia of Anatomy and Physiology.
  IT Untersuchungen, p. 33 et seq.                                      •
  **  Ibid. tab. 1, fig. 4.   fig'- 5, a and 6, are two representations of the same part, from
the eye of the falcon, under great  magnifying powers.
       ■S 
58
ANATOMY OF THE EYE-BALL.
  Retina.  [20. fig. L]   This  pulpy,  soft, and almost  mucilaginous
expansion of the optic nerve covers the globe within the choroid, ex-
tending, like that  membrane, from the  insertion of the optic nerve to
the circumference of the crystalline.   The point, at which it terminates
anteriorly, has  been and  still is a matter of dispute.   When we look
into the front section  of an eye divided vertically into an  anterior and
posterior half, the retina seems to end abruptly, by a slightly undulated
edge  (margo undulato-dentatus) at the commencement of the  ciliary
body; and the terminating margin even appears a little elevated,   lhis
has generally been  considered  the anterior end of the membrane.   It
has, however, been asserted that it continues in a thinner form, between
the ciliary processes and the zonula ciliaris to the circumference of the
crystalline capsule, and  ends there; and  this view  of the subject  is
adopted by the  most accurate modern inquirers.*
  The optic nerve  passes through a small opening in the choroid and
sclerotic coats; and here a  singular circumstance is observed.   If we
make a section of the optic  nerve at the point where  it passes through
these  tunics, we find that  it becomes suddenly constricted, and reduced
to one-third of  its previous diameter.   The  appearance is the same as
would be produced by tying  a string tightly round the nerve.  Having
passed through the  aperture of the membranes, it forms a small flattened
prominence in  the  interior of the globe, at its fundus  {papilla  conica,)
from  which the nervous  substance spreads out to form the  grayish
white pulpy membrane called the retina; which may be  considered as
a nerve expanded so as to form a membrane.  Two different parts may
be distinguished in this soft  texture, an exterior medullary pulp, and an
interior vascular membrane.  With a camel-hair pencil, after a slight
maceration, we can brush away the medullary part of the retina in the
form  of  thin flocculi  floating in  water: there will  remain a vascular
basis, of a thin and almost cobweb-lifte texture, made up of vascular
ramifications, divided, subdivided, and united  together, so as to form a
most  delicate membrane.  The latter and  the  medullary pulp are re-
spectively analogous to the pia mater and the substance of the brain; it
being understood that the nervous pulp and the vascular portion are
completely  blended, and  form  a single membrane,  not divisible into
layers.
   Dr. Jacob,! of Dublin, who has investigated the  minute structure  of
the eye  with great patience and success, has  lately described a very
thin membrane, [16. fig. 1.] thinner, softer and more delicate than the
arachnoid coat, on the outer surface of the retina, giving an external
covering to the nervous pulp, and separating it from the choroid,  while
the vascular texture of the  retina is in a  manner  interposed  between
the pulp and the vitreous humour.  The delicacy of this  structure, and
the consequent difficulty of demonstrating it, will account for differences
of opinion respecting its  nature.  Arnold does not regard it as a mem-
brane, but as a mucous stratum (schleimschichte) on the retina;  and in

   * Schneider, das Ende der  Nervenhaut. im menschlichen Auge, Miinchen, 1827 4to.
Huschke, uber einige Streitpuncte in der Anatomie des menschlichen Auges, in Ammon's
Zeitschrift, vol. iii.  Arnold's  Untersuchungen, kap. iv.
   t Account of a newly discovered Membrane in the Eye, Philos. Trans. 1819.  Inquiries
respecting the Anatomy of the Eye,  Medico Ghir. Trans, vol. xii. 
ANATOMY OF  THE EYE-BALL.
59
another place he calls it a sediment of the  pigment, which is removed
in water.*
  Nearly, if not exactly, in the axis of the eye, and  therefore on the
temporal side of the papilla conica, we find in the retina of the human
eye a fold, a bright yellow spot, and either  a hole or a thin place in the
membrane.   [21. fig. 1.]   These parts were  discovered  by Soemmer-
RiNG,f whose  name they bear.  The fold begins close to  the temporal
side of the optic nerve, and runs transversely outwards.   Some have
supposed that the fold may arise after death ;  there is, however,  a de-
pression  in  the  vitreous  humour  for lodging it.   The  yellow  spot
(macula luted) is at the same place  as the  fold, and of a bright colour
in the recent eye.   The most exact  researches render it  probable that
the retina is not perforated,  but  only thinner  in this  situation.}.   The
structure  in  question is peculiar, among the  mammalia, to those, in
whom, as  in  man, the optic axes are  parallel, viz. the  monkey and
lemur  tribes;  and it was supposed  to be  confined  to these  until the
researches of Dr.  Knox§  had demonstrated  its  existence in several
reptiles.
   In the living eye the  retina is transparent, but after death it becomes
opaque.   If we examine it in an animal recently dead, we find it trans-
parent, and we can see the choroid  coat through it, as if it were not
covered by a membrane.   Hence the colour of the pupil is determined
by that of the choroid coat, and is generally black.   In certain animals,
where a considerable portion of the choroid is otherwise  coloured, the
pupil  has a luminous or shining appearance, which is the reflection of
light from the choroid coat.  Any alteration,  which takes place in the
colour of the human pupil, must be  caused by a corresponding change
in the  choroid, the  retina, or the transparent media between the retina
and pupil.
   The retina has been represented as possessing a fibrous structure, and
as composed of the fibres of the optic nerve separated where the nerve
enters  the eye,  and then  interwoven.  In some animals this fibrous
arrangement  is distinctly  visible, but nothing of the kind can be dis-
cerned in  man,  where the retina  presents   throughout  a  soft  pulp.
Arnold found it on microscopical examination,  to consist of a congeries
of globules||  closely arranged, connected and supported  by a delicate
and transparent cellular texture, in which  the minute  ramifications of
the arteria centralis are distributed.
   The continuation of the  retina  under the  ciliary processes, called the
ciliary portion of the membrane, is  a very  thin and  delicate structure,
concealed by the pigment, and with difficulty discovered  by the naked
eye,  but  clearly seen with the aid  of the  microscope.   Arnold says
that it possesses the same granular texture as the rest of the membrane.


  » Lib. cit. p. 6 and 91.
  t De Foramine centrali, limbo luteo cincto, Retina human a, in Comment. Soc. Gotting.
t. xiii.
  X Jacob,  loc. cit. p. 508.  Ammon, de Genesi et  Usu Macula luteal in Retina  Oculi
humani obvia, 1830, 4to. Huschke, in Ammon's Zeitschrift, b. iii. p. 16. Arnold hour.
ever asserts the existence of the opening, Untersuchungen,  p. 89.
  § Transactions of the Wernerian Society.
  || Untersuehungen, pi. 2, fig. 3. 
CO
ANATOMY OF THE EYE-BALL.
  The blood-vessels of the retina are derived from the artena centralis
retinae, a branch of the ophthalmic,   it enters the optic nerve at a short
distance from the sclerotica, passes through  its centre, and ramifies on
the inner surface of the retina, forming a very minute vascular net-work
over the whole membrane;  no branches, however, can be seen in the
ciliary portion.   This artery is accompanied by a corresponding vein.
In the eyes of animals recently dead the central vessels are usually
found more or less filled with blood.   Their distribution is  beautifully
represented, on a magnified scale, in the 3rd plate of Arnold's Tabula
Anatomica, fig. 5, 6, and 7; while the first four figures exhibit the natu-
ral appearance of the  membrane.   In  the  entire globe, the retina  is
smoothly expanded over the vitreous humour ; but it soon falls into folds
on a section of the eve.
   Connexions of the" Coats.—Having explained the texture and compo-
sition of these parts, I proceed to point out the mode in which they are
connected with each other.  In the first place, the retina covers the ex-
ternal surface of the vitreous humour; the parts lie merely in contact;
nothing is interposed between them :  there is no cellular connexion, no
passage of blood-vessels.   In  front, however, the  retina is firmly  con-
nected to the corpus ciliare and the vitreous  humour;  if we consider
the dentated  and slightly elevated margin {margo  undulato-denlatus,)
which corresponds to the posterior edge of  the ciliary processes  (ora.
serrata) to be the anterior  termination of the membrane,  it adheres
firmly to the vitreous  humour.  If we adopt the now more  generally
received notion of the retina  being continued to the circumference  of
the crystalline capsule, the thin anterior or ciliary portion of the mem-
brane, placed between the ciliary body and the Zonula Zinnii, adheres
most intimately, in its whole breadth, to both these, exhibiting folds and
intervening depressions corresponding to those of the parts in question.
   The choroid  coat lies upon and covers the retina, in the same way
as the retina embraces the vitreous  humour; being merely contiguous,
not actually connected with, or adherent to it, except at the anterior or
ciliary portion of the nervous expansion.  Its internal surface adheres,
in the anterior part of the eye, to the vitreous humour, by means of the
ciliary processes.  Let me observe, in the first place, that the crystal-
line  lens occupies the middle of the anterior part of the vitreous humour,
and that on  the latter, round  the  crystalline, there is a black mark,
made by a number of impressions disposed in a radiated form.   This
mark  arises from the  adhesion of the ciliary processes, together  with
the ciliary portion of the retina, to the  vitreous humour.   If we detach
the choroid coat from the latter, we shall observe  the adhesion of the
ciliary processes giving  way,  and we  may see the defined edge by
which the retina seems to terminate.
   The external  surface of the  choroid is connected to the internal sur-
face of the sclerotica, by numerous short and soft  cellular  threads  so
loosely, that we can easily cut the sclerotic round with a pair of scis-
sors, without injuring the choroid.   The two coats adhere more firmly
in front, where they are closely united by a dense white medium called
the ciliary ligament (ligamentum sclerotico-choroidale.)  The point of
union is just behind the  cornea and the ciliary margin of the iris-  so
that this ciliary ligament, uniting the anterior edges of the sclerotic 'and 
ANATOMY OE THE EYE-BALL.
61
choroid corresponds to the boundaries of the iris and cornea.   When
the sclerotic and choroid have been detached from the front of the eye,
the ciliary ligament  forms a white circle, marking  the distinction be-
tween the choroid  and iris, and a similar circle defines the boundary of
the cornea;  hence  the expressions of orbiculus, annulus, or circulw-
ciliaris, as applied to the part in question.
   The connexion to which I have just adverted, is an important part of
the anatomy of the eye, because it will be seen, that at one and the same
point the sclerotic  and cornea are united externally, and the  choroid and
iris internally; while, at the same part, the choroid adheres internally
to the vitreous humour, by means of the ciliary processes, the ciliary
portion of the retina being included in the same adhesion.  Further,
the zonula ciliaris,  to  which these processes adhere, is  closely con-
nected to  the capsule of the lens.  We may, therefore, consider this as
a common point of union, embracing all the essential constituents of the
globe, namely, the sclerotica, cornea, choroid, iris, retina, vitreous hu-
mour, and crystalline lens.  It is a most important  part, in a patholo-
gical point of view; for example, in inflammation of the iris, or cornea,
peculiar appearances arise in the sclerotic, and the affection easily ex-
tends from  the  iris to  the  ciliary  ligament and processes, and thus
reaches the posterior and inner parts of the globe; while inflammatory
affections, beginning in  the  latter, may extend, in the  same manner, to
the anterior portion  of the globe.
   The black mark  left on the vitreous humour, after the ciliary pro-
cesses have been detached, is sometimes called the zona or corona cilia-
ris, while the ciliary ligament and  processes,  taken collectively, are
spoken  of, anatomically, under  the  denomination  of the ciliary  body,
corpus ciliare.
   To the same point, where the choroid  and sclerotic  are united by
the ligamentum ciliare,  the greater circumference, or ciliary margin of
the iris is affixed;  thus  that ligament not only connects the  former two
coats, but also joins the iris to them.  The iris seems, to use a mechani-
cal phrase, to be set in  the ciliary body; it is firmly connected to the
boundary between the  sclerotic and cornea; hence these parts, more
especially the former, almost always participate in  its morbid pheno-
mena.
   The vitreous humour appears, in  its  natural  state, like a portion of
perfectly transparent jelly.  In the living human eye it is a little more
fluid than we find  it in the dead eyes of sheep and bullocks; for  when
it escapes, as it sometimes does, in the operation for  cataract, it runs
over the patient's cheek in a continued stream, quite  pellucid, and re-
sembling in consistence the white of an egg.   We can see no fibres, no
vessels, nor any particular arrangement of parts in the vitreous humour;
it is transparent, like a lump of clear glass ; it is said to be composed of
cellular texture,  containing water in the interstices ;  if it be left to itself,
and particularly if it be pricked, the fluid drains away; it is smooth and
uniform on the surface, where it is  in contact with the retina, the  cellu-
lar substance being condensed externally into a membrane  called mem-
brana hyaloidea, or vitrea.  In bulk, it composes four-fifths of the en-
tire globe, occupying the whole cavity formed by the retina; indeed, if
we make a vertical  section of the eye, in either direction, the coats re- 
62
ANATOMY OF THE  EYE-BALL.
present a thin cup nearly filled with the tremulous vitreous jelly.  Petit
found it to weigh 104 grains in an eye, of which the entire weight was
142 grains.  Its cellular substance can be demonstrated by inflating and
drying it after the fluid  has  been allowed  to drain out;  also by freezing
the eye and then dividing it, when  the figure and size  of  the cells are
shown by the portions of  ice which  they contain.  Arnold has repre-
sented this cellular structure as it appears in a vertical section  of the
frozen vitreous body.*
  If, after removing the choroid and iris  from the front of the vitreous
humour, we wash off the pigment, we shall find a thin transparent mem-
brane, extending from  the  dentated margin of  the ciliary body  (ora
serrata) to the  crystalline capsule.   This is called zonula ciliaris, or
zonula Zinnii; it is the strahlenbldttchen of the Germans.  It forms a
ring of similar breadth to that of the corpus ciliare, and presents radiated
grooves and folds running from behind forwards, to which the  ciliary
portion of the retina and the corpus ciliare are  closely connected  by
means of corresponding folds and grooves.  The pigment remains be-
hind, after the choroid  has  been detached, forming  a regular series of
dark parallel striae, arranged in a radiated  form round the  circumfe-
rence of the lens.  The undulated edge of  the retina is attached to the
posterior or external edge of the zonula;  while the anterior, or internal
margin of the latter is firmly attached to  the crystalline capsule.  The
ciliary processes do not reach to the capsule, but leave a small interval
between it and their termination ;  this part of the zonula presents striae,
which are continued  on the anterior portion of the capsule.f   Between
the zonula ciliaris and the tunica vitrea an irregular space is left, which
can be inflated by making an opening into  the  former.   When air is
impelled,  a canal with puckered sides becomes distended, on  the  ante-
rior surface of the vitreous humour, round the circumference of the lens.
This is the canal godronne, or canal of Petit.   Some have considered
the zonula ciliaris to be a continuation of the vascular  layer of  the  re-
tina ; others have represented  that the vitreous  tunic  divides into two
layers, and that the canal godronne is left between  them.   The retina
separates easily from the zonula after a short  maceration.  The latter
differs in  structure from the tunica vitrea, being thicker,  firmer and
fibrous, and  it may be removed, leaving that tunic entire.
   The crystalline Zensf [27. fig.  1,]  which is imbedded in the cup-like
excavation of the vitreous humour (fossa hyaloidea,) is a part of firmer
consistence.  It  is retained in its situation by  a compact membrane
called its capsule, which  is closely connected  to the membrana vitrea;
but is much more firm, dense, and resisting than that membrane.   The
crystalline lens is an optical instrument for refracting the rays of  light,
and bringing them to a  focus; in its  recent state, if it be held towards the
flame of a candle, the flame will be seen inverted as with an artificial lens.
It is not perfectly spherical, but is composed of portions of two spheres, the
posterior half being more convex than the anterior.  The former is com-
  * Icones Anat. fasc. 2, tab. 3, fig. 11.
  t This appearance is described and f
 ilo-ciliaris.—Zeitschrift; vol. i. No. 1.
• See Baerens da Systemate  Lentis crystallines, and Lf.iblein de Syst, lent, crust Mam-
malium atque Avium, in Radius Script. Ophthalm. minores, vol. i.
  t This appearance is described and figured by Ammon, under the name oforbiculus cc
sulo-ciliaris.—Zeitschrift; vol. i. No. 1.                                 '    * 
ANATOMY OF THE EYE-BALL.
63
 pletely imbedded in the front of the vitreous humour, while the latter pro-
 jects on the surface of the humour, being only covered by its capsule. The
 external part is so soft, that it can only be compared in consistence to soft
 jelly; but if this be squeezed off, the centre is found to possess the firmness
 of wax slightly softened: it is, in fact, firm in the centre, and gradually
 looser in texture towards the circumference.   The firmer central portion
 is called the nucleus of the lens.
   How is  the crystalline lens, or humour, as it is also called, connected
 with the other parts?   It  seems to be  no  otherwise attached  than
 by the mere  mechanical confinement of  the capsule.  This  invest-
 ment contains, but it cannot be shown to adhere to, the lens;  we cannot
 trace any blood-vessels, any cellular connexion, or any direct adhesion.
 When the  capsule is divided, the lens immediately escapes:  if there be
 any vessels, they  are of such extreme tenuity, that we cannot demonstrate
 them, nor can we show that the crystalline lens is organically connected
 with the parts immediately surrounding it.   When an  opening is made
 into the capsule,  a minute portion of water escapes, which is called the
 aqua or aquula Morgagni, from the illustrious anatomist  who first de-
 tected it.
   The existence of this  fluid has been denied; and Dr. Jacob seems to en-
 tertain doubt on the subject.  He says, "the fluid called aqua Morgagni,
 supposed to surround the lens, and separate it from its  capsule, appears
 to me, when it does exist, to be confined to the anterior part.   I once
 met with it in the human eye, within five or six hours after death, and at
 longer periods in a few other  instances,  but how  far the product of
 disease I cannot  determine.  In the eyes of sheep and  oxen yet warm,
 1 do not perceive the least appearance of such a fluid;  after some time,
 however, has elapsed, it is found in considerable quantity, but evidently
 in consequence of that change which takes place after  death, by which
 fluids are permitted to escape into situations not formerly occupied by
 them.   Petit  found only half a grain of this fluid within the  capsule of
 the human lens, and could not obtain sufficient for analytical experiment
 from eighteen eyes; he  also says he found it in one eye and  not in the
 other."*
   Dr. Jacob f also calls in  question the commonly received opinion that
 there is no direct connexion between the lens and capsule.  He attempts
 to show that they are organically connected.   He adduces however no
 direct proof; and  the facts on which his arguments are grounded, admit
 of different explanations from those he has assigned.
   In the living animal, and within a short period after death,  the lens is
 perfectly pellucid, like  the  clearest  crystal, an attribute  obviously
necessary to the  perfect execution  of its office.  It gradually becomes
 muddy, and the loss of transparency occurs more quickly  when it is
immersed in water; hot  water, alcohol, and  acids, render it immediately
and densely opaque throughout.   The kind  of effect is seen in  the boiled
lens  of the  fish.   In its  p*ellucid state, no fibres, nor other Organic ar-
rangement  can be observed; but the opaque lens has a fibrous structure,
and exhibits some subdivisions of its substance.  The entire body is di-

  * Mem. de V Acad. Roy. des Sciences, 1730, p. 445.  Medico Chirurgical Transactions,
vol. xii. p. 501.                                      t Ibid, p. 499. 
04
ANATOMY of the eye-ball.
 videdinto three parts by an equal number of lines meeting in the centre.
 It is made  up of layers arranged concentrically like those of an onion,
 and these are found on microscopical examination to  consist of fibres
 closely aggregated. *   Arnold found these fibres to be tubular, and be-
 lieves that they are lymphatics.  But can we regard these appearances,
 thus obviously produced by powerful chemical agency on the dead lens
 as illustrating its living state ? or draw from them any inferences respect-
 ing the supposed actions or changes of the living organ?  Can we sup-
 pose the soft jelly of the lens, or its firmer nucleus, to be muscular, capable
 of contraction and relaxation,  and thus of changing the figure of the
 organ ?
   The  lens is more or less  opaque during fetal existence;  after birth
 it is large, colourless, and perfectly transparent; as age advances, it be-
 comes less, and  its  nucleus is  often amber-coloured in old  persons, in
 whom it sometimes becomes more or less opaque.
   The capsule of the lens [28, 29, fig. 1.] is a perfectly transparent tex-
 ture, not rendered opaque by maceration, or slight heat, and only slightly
 affected by  boiling water or strong acids.   It is compact, and perhaps
 cartilaginous; so firm  and tough that force is necessary to lacerate
it.   The anterior portion [28. fig. 1.] 'is thicker and  tougher than the
posterior, [29. fig.  2.]  and  almost retains  its  figure  when detached.
The membrana  vitrea  is connected  to  it at the circumference of the
 lens, but can  be easily separated;  and the two structures are so dis-
similar, that there is no ground for representing the capsule as a con-
tinuation of that  membrane.
  Although no vessels can be discerned or demonstrated in the vitreous
humour or the crystalline capsule, in their state of perfect transparency
after birth, they possess, during the  fetal  period of existence, arteries
and veins, capable of demonstration by injection, and  sufficiently large
and numerous to impart a  reddish tint to the  textures.   Arnold has
delineated the arteries  of the vitreous humour in two  beautiful figures
of his third  plate (figs. 12 and 13,) as they appeared after injection  in
a  fetus of  four months: they present an elaborate and  characteristic
net-work spread  over the whole vitreous body, forming an arterial cir-
cle round the  margin of the lens, and then covering the anterior layer
of the crystalline capsule with an  arterial plexus.   The arteries of the
crystalline capsule are represented in the 21st and 22d  figures of the
same plate from a fetus of six  months.  A branch  from the  centralis
retinae  proceeds straight through the vitreous  humour  to the centre of
the posterior  layer of  the  capsule, dividing  then, and  spreading its
branches in all directions.   It  covers not only the back, but  the sides
and front of the capsule with a beautiful and delicate arterial net-work,
which  communicates in front with the  arterial circle of the  vitreous
humour and with the arteries of the iris.

  * Soemmerring has delineated the lens as it is found at the time of birth, the age of six
years, andJn  the adult.  Tab. 5, figs. 13, 14, 15.  Arnold has figured it in the child the
adult, and the  old subject.  Tab. 3, figs. 14, 15, 16.  It is nearly spherical in  the infant
 becoming gradually flatter in the progress of age. Arnold has carefully investigated and deli'
neated the minute structure of the lens : Untersuchungen, Kap. vi. tab. 2, figs. 8 and 9Tb
Anat. tab. 3, figs. 17—20, and 23—25.  Descriptions and figures relating'to the same subicct
are given by Iluschkc in Ammon's Zeitschrift, vol. iii. Heft, 1; and by Wcrncck  ibid vol v 
anatomy of the eye-eall.
65
   Arnold* found  that  these vessels  ramify in a cellular  layer, which
can be stripped off, leaving the  capsule entire;  he  therefore regards
the latter to consist of two laminae, an external vascular, and an inter-
nal serous; the latter being destitute of blood-vessels like  other  serous
structures.
   The blood-vessels of the crystalline capsule  contain red blood in the
fetal state only, or at farthest in the lately born child.  They shrink up
quickly  after birth, so  that  they can  neither be  seen nor injected.
WaltherI says that he  succeeded  twice in injecting vessels  in both
parts of  the capsule in the adult:  they were cases of violently inflamed
eyes, and the vessels of  the cornea were at the same time successfully
filled.
   ArnoldJ found, under the microscope, a fine net-work of lymphatics
in the inner or serous portion of the capsule.
   Aqueous humour.—The last of the humours is the aqueous, consisting
of a few drops (three  to five  grains) of clear watery fluid, filling  the
interval  between  the  cornea  and the  crystalline  lens, and escaping
when the cornea is punctured.   The  space between the  cornea and
the crystalline  lens is unequally divided by the iris, into two portions,
called the anterior and posterior chambers of the eye, or of the aqueous
humour.  Of these, which communicate by the pupil, the anterior is
the most considerable, and consequently contains trie largest quantity
of fluid.'  Its boundaries are the concavity of  the cornea and the iris.
The posterior  chamber is formed by  the uvea, the front of the crystal-
line capsule, and a portion of the zonula; being  bounded  laterally by
the ciliary processes, the points  of which  project  into  it.   The uvea
seems to  be in contact  with the crystalline capsule, at  least it is sepa-
rated from it by an interval which is not distinguishable by the senses;
but if the eye be frozen, a small pellicle of ice will be found between
the uvea and the crystalline«iens.  This contiguity of the parts accounts
for the adhesions so often occurring between the  pupil or uvea, and the
capsule,  under inflammation.
  Some anatomists believe that the surfaces of the  cavity  containing
the aqueous humour, are covered by a delicate  membrane of the  serous
class, the office of  which is to secrete that fluid.  On the posterior  sur-
face of the cornea  it may be detected, but the existence of such a mem-
brane cannot be demonstrated on the iris or crystalline  capsule.   The
iris, uvea, and capsule,  forming portions of a cavity containing watery
fluid, have smooth, or we might say serous surfaces: the possession of
such  a  surface, however, and probably even  the  power of serous or
other exhalation, does not necessarily imply the existence of a distinct
membranous layer admitting of direct demonstration, as we see  in the
case of the dura mater, and the articular cartilages.^

  * Untersuchungen, p. 111.                         t De  Venis Oculi, p. 18.
  t Lib. cit. p. 113.
  § In addition to  the writings quoted in the  foregoing description, to the well-known
standard works of Zinn  and Soemmerring, and the recent  important publications of Fr.
Arnold, the following may be referred toon the anatomy of the eye.
  The article Eye in the Cyclopedia of Dr. Rees, written by Mr. Barnes of Exeter.
  Dr. Jacob's article on the Eye, in the Cyclopcedia. of Anatomy and Physiology.
  The first volume of the Handbuch der Theoretischen  und Praktischcn Augenheilkunde
of l'rofcssur Rosas. Vienna, 1830.
         9 
66
PHYSIOLOGY OF THF EYE-BALL.
                  PHYSIOLOGY OF THE  EYE-BALL.

   The science of optics, which  has for its object the investigation  of
 light and colours, and their relation to the organ of vision, is an exten-
 sive branch of natural philosophy, and would occupy a large space if
 adequately illustrated.  I cannot enter at length into such  a subject,
 and shall only make a few  remarks  respecting the physiology of the
 eye, confining myself to such topics as are most interesting in reference
 to disease.
   The nature of light has not hitherto been clearly explained;  at least
 among those who have devoted great  attention to the  subject, diversity
 of opinion still prevails.   For our present purpose it will be sufficient to
 adopt the generally received notion, that light consists of an extremely
 subtle  matter,  emanating in all  directions from  luminous bodies, or
 from such as, not being themselves luminous, are illuminated by others,
 and proceeding in straight lines, to which the name of rays  is techni-
 cally given.
   A ray of light then is to be regarded as a straight  line drawn  from
 any luminous, or  illuminated  body, to the eye of  the observer.   We
 make use of  the expression "rays  of  light," and speak of the various
 affections which these rays of light undergo so familiarly, that we bring
 ourselves at  last to believe that we are designating some material  exis-
 tence which has been clearly demonstrated.   Rays of light are to be
 considered  as emanating  in  all directions  from any luminous  body.
 Thus a candle  placed in the  centre  of a room  fills the  whole of the
 room with light, more or less intense; if we take any portion of the rays
 proceeding from it they will  represent a cone, the apex of which is "in
 the flame of the candle: from this central  point the rays  diverge, sepa-
 rating from each other more and  more wtdely as  they proceed  to  a
 greater distance.   These lines of light continue to diverge to whatever
 extent they may proceed; however, trie divergence  is greatest near the
 luminous body, becomes  less and  less as the  distance increases, and
 when the source of light is very remote, we are so  little sensible of it,
 that, for all practical calculations, the rays may be regarded as parallel ;
 hence the distinction  of divergent and parallel rays.
   The extremely subtile nature of  light, that is, of  the cause of those
phenomena and influences which form  the  subject of optics, make it so
different from the ordinary forms of grosser matter, that  it is not easy


  Dr. W. Soemmering de  Oculorum Hominis Animaliumque sectione horizontali Commen-
tat 10 ; cum. tig. Gottingae, folio, 1818,
  Doellinger, Illustralio Ichnographic.a Oculi Humani.  Wirccburgi, 1817
  —---------Ueber das  SiruhlenMdttchen, in the Acta Novissima katuia\ Curiosorum
torn. ix.                                                      v»'«»wim»,
  Salomon, Beitrage zur  Anatomie  des  Auges ; in Graefe und Walther's Journal

ch^Au \U Graefe UT>d WaIther'S Jmrnal vo1- ''•; Ueber die wichtigsten Theile im menschli.
-de Motu Iridis; 4to. 1821.
  Various Memoirs of Petit, in the Mem. de 1'Acad. des Sciences 1723—1730
  Several papers  in Ammon's Zeitschrift,  Graefe and Walther's  Journal  and  nih.r
German periodicals.                                               ,m  oiner 
PHYSIOLOGY OF THE EYE-BALL.
67
to demonstrate clearly its material nature; yet some of the affections,
which light exhibits, bear a strong analogy to what is  observed  in the
other forms of matter.   Its reflection is one of these.  Light falling, on
bodies freely permeates some, and these are called transparent.  Others,
on the contrary, do not admit it to pass through them, but reflect it, and
these are called opaque.  The light is reflected, or it rebounds from the
surface of  these opaque substances, and though the comparison may
not be scientifically accurate, the occurrence is similar  to the rebound-
ing of a ball from  a wall.   The  light strikes  against an opaque  body;
the rays rebound and come back again from the body on  which they
fell.   One of the most familiar  instances of  the reflection of light is
that of a common mirror; the metallic coating behind the glass reflects
the rays of light, which come back to the eyes of an individual standing
before it, and represent his image as if  it were behind the glass.
   Another phenomenon exhibited by light is that called refraction, which
literally means  breaking.  The rays, under certain circumstances, in-
stead of proceeding in straight lines, are turned aside, and thus, as it
were, broken or interrupted.  This takes place  whenever they pass
from one medium  into another of different density.  If they travel on
in one and the same medium, they invariably  pursue a  straight course
through whatever  extent of space they may  be transmitted to the eye
of the observer.  But there are media,  which, though they agree  in the
circumstances of being transparent, differ  very much in their density;
for instance, air, water, and  glass.  When the light passes from a rarer
into a denser medium, it deviates from  its straight course, and is drawn
towards the perpendicular, or  towards a straight line  drawn  through
the two media at right angles to their  line of contact.  On the other
hand, if the ray passes out of a denser into a rarer medium, it is turned
away from the  perpendicular.  A familiar instance of this phenomenon
is afforded by the appearance which  a straight stick exhibits, when one-
half of its length is immersed  in  water; it appears bent, or broken, at
the surface of the water; for the  immersed portion is seen through the
medium of refracted light, the rays which, on entering the air, have been
drawn away  from  the perpendicular, making the object  appear more
elevated than it really is, and causing us to see it in a  wrong position,
while the portion in the air is seen by direct rays, and  therefore  in its
true position.
   It may be stated, generally, that the deviation of light  from its straight
course is greater in proportion to the density of the medium into which
it passes; water refracts more powerfully than air, glass more than water,
and  the diamond more than glass; but in the  case  of the diamond, the
influence of another principle is observed, viz.  the more  inflammable the
nature of  the body, the greater its refraction.   Many  familiar experi-
ments may be  made to illustrate  the phenomenon of refraction; one of
the most common  is that of putting a piece of coin in  a  basin, on the
ground, and retiring to such a distance that the margin of the basin may
intercept the  direct  view of the  coin; if the  basin  be  then filled with
water, the refraction which the rays of light, proceeding from the coin
undergo in passing  from the water into the air, will bring the  coin, which
was before invisible, into view again;  we see it by refracted light, and
consequently  not in its true situation, the effect being exactly the same 
68
PHYSIOLOGY OF THE EYE-BALL.
as in the case of the stick.  Light comnig to the earth from the hea-
venly bodies is refracted by the terrestrial atmosphere, and increases the
apparent altitudes of all these bodies.   From this cause we see the  sun
before it has risen above, and after it has sunk below the horizen; thus
the day is lengthened and the night shortened, and the phenomenon of
twilight is produced.
   When the rays of light fall  on a dense,  transparent body, of a con-
vex surface, the effect of the refraction which they experienced will be
to collect and unite them  together into one point, at a certain distance
behind the medium, the  degree of refraction at  each point of the con-
vex surface  depending on mathematical rules, calculated from the na-
ture of  the curve on which the rays fall.   The most familiar instance
of this optical law  is afforded  by a convex  glass.   As there is a close
connexion between light and heat, when luminous rays are thus brought
together, considerable heat is produced, sufficient, if the sun's rays be
received upon a large convex glass, to burn substances placed at the
point  of union.  Hence  arose the first application of the Latin term
focus (fire place) to  this point; the word is now used generally, whe-
ther heat be produced or not.   A concave glass  has the opposite effect;
instead of uniting the rays of  light, it .separates and  disperses them;
hence, optically speaking, rays  of light are said to be collected  or
dispersed.
   The transparent  structures of  the eye have the effect of collecting
together the rays falling on the  surface of the organ, and bringing them
to a focus, or  point of union, on the retina.   The eye may, in this point
of view, be regarded as an optical instrument; and as the effect of dif-
ferent transparent media on the rays of light may be calculated mathe-
matically, the density and configuration of the media being previously
given, we may, in  some degree, imitate the composition of the eye arti-
ficially, and by putting  together  substances of  a  certain density and
configuration, produce  an instrument  which will  refract, collect, and
unite the rays of light into a  focus, in  a  manner nearly similar to that
of the living eye.  When we say that the  eye  can be imitated artifi-
cially, it must of course  be understood that this can be effected only
imperfectly.   It is  true that the human eye is an  optical instrument, but
it is so perfectly constructed, that  the most profound theory can scarcely
appreciate all  the wonders which it exhibits, and the most exquisite art
can only arrive at  an imperfect imitation of it.
   The business of vision  is two-fold ;  consisting, first of the mechani-
cal, or optical effect, produced by the transparent  media on which the
rays of light fall;  and secondly, of the impressions on the nerve, and
through it on the sensorium,by which the mental perception of external
objects is produced.   If the transparent media possess a given density
and a given configuration, and are situated in certain relations to each
other and to  the retina, the result will  be, that the  rays of light falling
upon the eye, from any object at  a certain distance, will be  collected
together into a focus on  the retina, and upon that part  of the retina
will be represented a miniature  picture of the  objects  placed before
the eye; but, in this representation, the objects are inverted, or upside
down.
   We can prove, by calculation, that the effects of the transparent
media of the eye on the rays of light would be such as thev are in fact 
PHYSIOLOGY OF THE EYE-BALL.
69
found to be; the results of experiment  coincide perfectly with those of
calculation, and  the proof is easily  exhibited, since the phenomena,
being purely mechanical, take place in  the dead just as  perfectly as in
the living eye.   If we take the eye of an animal recently dead, and dis-
sect away the back  parts of the  sclerotic and choroid  coats, so as to
expose, without wounding, the retina, and then hold it up at a certain
distance from the candle, we shall see a miniature representation of the
candle on the  retina, with  the apex of  the  flame downwards.   The
flame of the candle is seen inverted through the crystalline lens.  If an
eye prepared in the same way be placed  in a hole  made  in a window
shutter, an inverted miniature picture of the external objects is seen on
the retina.*
   Magendie describes more simple methods of demonstrating the images
formed at the back of the globe.   If the eye of a rabbit, pigeon, owl, or
small dog,  in which  the choroid  and  sclerotica are semitransparent,
having been cleared of fat and muscle at its posterior part, be held with
the cornea towards illuminated objects, the images of such objects will
be seen distinctly at the  back of the globe.  Mr. Magendie tried the ex-
periment with eyes of the albino variety of animals, such as the  white
rabbit, pigeon, and mouse, in whom the sclerotica and choroid are very
thin and delicate.  The  images in this case were particularly clear; and
he was hence led to make various trials  with such eyes, in order to show
how  the images at  the  fundus of the globe are  affected  by various
changes in the  stale of  the organ, such as diminished  quantity of the
aqueous humour or its entire absence, diminution of the vitreous humour,
removal of the cornea and crystalline-!
   These are the general effects of the  action of the eye, considered as
an optical instrument.  The rays of  light fall in the first instance upon
the cornea,  which, being a  convex  body, of greater density than  air,
exerts a refractive force upon  them, drawing them together, so that if
they were continued in the same direction and medium, they would meet
in a focus at a certain distance behind the retina.   All the rays falling
upon the cornea  do not  pass through it; in order to permeate it they
must strike upon the part within a certain  given angle (of about  forty-
eight degrees.)   Those which  fall upon it more obliquely, are reflected
from it, and  produce that sparkling appearance which characterizes the
living eye, and which  it is necessary  to introduce into portraits, in order
to give them a  character of life.  The  same reflection produces the
image which we see behind the cornea, as that of our own countenance,
when we are examining the eye, or that of an opposite  window.   The
light, having been refracted by the cornea, passes through the pupillary
opening, which,  however, transmits that only which is near the centre;
the lateral rays striking  upon the iris, are  reflected from it, and  hence
the peculiar brilliancy of that  part.  This is so striking in some indi-
viduals, that their eyes are literally, not  metaphorically, sparkling.   The

   * As the pictures of external objects on the retina are actually seen in these experiments
on dead eyes, the notion has been universally received, never, that I know of, having been
questioned, that such representations  are formed in the retina of the living eye.  Dr.
Fleming, as quoted by Mr. Walker, rightly observes that as the retina is transparent, the
rays of light will pass through it, and consequently no picture can be formed on  it.  On
the Nervous System, p. 186.
  + Precis elementaire de Physiologie, ed. 2d,  p. 70. 
70
PHYSIOLOGY OF THE EYE-BALL.
degree of brilliancy depends upon the nature of the surface on wh ch
the rays strike ; and this is different in different individuals.   VV hen the
iris is altered by disease, nothing  is more striking than  its cnange in
this respect; it no longer reflects  light as in the healthy state, and the
eye thus acquires a peculiarly dull and dead expression.
   The pupil is the opening through which light enters the dark chamber
of  the eye; it is analogous to the aperture by  which light is admitted
into the optical instrument called a camera obscura: the interior of the
eye is a dark chamber like the interior of such an instrument.
   The rays of light, after passing through the pupil, strike upon the crys-
talline lens, where they undergo a powerful refraction; that lens being
the principal agent of this process.  The light thus refracted is ultimately
brought to a focus on the  concave surface of the retina.  It must be
understood that I am  speaking of light proceeding from  objects placed
at a certain distance from the eye, and falling upon it in such a way as
to produce distinct vision.   The  eye is  subject, in this respect, to the
same laws which are  applicable to all optical instruments.  It can only
distinguish objects with  accuracy at a certain distance;  and though it
may  perceive nearer or more remote objects sufficiently for many pur-
poses, vision without or beyond a certain limit ceases to be distinct.
   I have stated that the crystalline lens is the principal agent of refrac-
tion ; consequently when it is lost, as after operations for cataract, the
refractive powers of the eye are greatly weakened, and it is necessary
to  substitute for the lens, which has been removed from the axis of vision
by the operation, a glass of considerable convexity, even for the ordinary
purposes of vision.  It is difficult to appreciate exactly the effect which
the crystalline lens produces on the rays of light, in consequence of its
peculiar structure, varying in  density from the centre to  the circumfe-
rence.   Opticians represent that this peculiarity renders the eye achro-
matic.   Achromatic means colourless;  and it is a great object to  con-
struct optical instruments, such as telescopes, microscopes, &c. in  such
a way, that after the various reflections and refractions which the light
may undergo, the object may be represented clear, well-defined, and un-
interrupted by any admixture of prismatic colours.  The decomposition
of light which leads to this inconvenience, takes place at the surfaces of
the glasses, through which it passes.  If the  lens  had been of uniform
density throughout, and as  firm as its central portion, there must  have
been a reflection at both its surfaces, rendering the retinal picture indis-
tinct; but, by the softness of its exterior, the density of its surfaces ap-
proximates to that of the  aqueous and vitreous humours, and it refracts
without reflecting or decomposing any of the light which  falls on it.
   The rays of light, in  passing  through the crystalline  lens, undergo
decussation; hence  the picture represented on the retina is inverted.
This is a mere optical  phenomenon, not depending on any vital action,
but arising from  the mode in which the rays cross each other in  their
passage through the lens.
   The refractive power of the vitreous humour is less than that of the
crystalline; hence it gives passage to  the  converging rays,  without
altering them.*  This structure fills out the globe to the requisite magni-

to pShB«ThirK.]h°UM Slight,y """" thClr COnVer^nCy- «d it is usually supposed 
PHYSIOLOGY OF THE EYE-BALL.
71
tude, affords a soft medium on which the retina may be expanded, and
keeps that nervous expansion at the proper distance from the lens and
other parts of the organ, distending it so as to increase its extent, and
thus enlarge the field of vision.
  The retina  is the immediate instrument of vision, its office being to
receive impressions from the rays of light, when refracted and collected
in the way already described, while the  optic nerve conveys these im-
pressions  to  the  sensorium.   To accomplish these purposes properly,
the  light must be applied  in a certain degree of strength;  when very
powerful,  as in attempting to look at the sun, a painful impression is pro-
duced ; the eyes are dazzled,  and we  see nothing.  On the other hand,
a feeble light gives us only imperfect  vision.   If we attempt  any occu-
pation requiring accurate sight, with insufficient light, an  uneasy sensa-
tion like that of fatigue will come on in the eye and brow.
  Division of the optic nerve entirely destroys sight.  Mr.  Magendie
found that the same effect was  produced by dividing the fifth pair, so
that the exercise of  the sense seems to require the combined action of
the  two nerves.  He observed, however, that the  retina  still remains
partially sensible after the  section of the fifth  nerve, so that the animal
closed  the lid, when brought  from the dark into a strong light.*
  The iris can enlarge or contract  its pupillary opening, and  thus regu-
late the quantity of light  admitted  into  the  dark interior of the eye.
When the organ is exposed to a weak light, the pupil is enlarged ; when
to a strong one, it is diminished;  so that, in the living eye, if the quan-
tity of light  be altered, corresponding changes will be observed in the
dimensions of this opening.  These alterations are effected by contrac-
tion and dilatation of the iris, the motions of which are performed from
the ciliary margin, or greater circumference, as a fixed  point.  Here
the iris is closely attached  to the ciliary body, the rest of the membrane
being loose  and moveable.   The  iris contracts, or is  rendered nar-
rower, to  dilate the pupil, the pupillary margin being drawn towards
the ciliary edge; while the contraction  of  the aperture is effected by
the pupillary margin  being   carried to a  greater distance from the
ciliary.  These phenomena may be observed by placing a person oppo-
site to a window, and putting the hand between his eye and the light;
the iris  will contract and  dilate according as  the light has free access,
or is intercepted.  If a strong light be suddenly thrown on the eye, the
pupil will be  considerably contracted;  a painful sensation  is at first
experienced, and the person  feels  dazzled;  but the pupil immediately
contracting, shuts out the offensive  quantity of light, and thus  moderates
the effect  of its sudden influence upon the organ.  When the eye, after
having  been exposed to a strong light, is suddenly submitted  to a much
weaker, the opposite changes ensue; the pupil  dilates, and the effect
upon the individual, when  he is first introduced into the  less degree of
light, is almost to blind him  for the moment; the pupil, however, gra-
dually dilates, so as to admit the quantity of light necessary to  vision
in the new situation.  The degree of motion in the iris, and  the conse-
quent amount of change in the dimensions of the pupil, vary in diffe-
rent individuals.   In some persons, although the sensibility of the optic
* Precis elementaire, p. 83. 
72
PHYSIOLOGY OF THE EYE-BALL.
nerve is unimpaired, and vision is not defective, the mobility of the ins
is very slight.                                                   ,
   The iris exhibits two kinds of motion; the independent, produced by
the direct influence of light, in its various degree  of intensity, on the
eye ;  and the associated or sympathetic, which takes place in one eye
when not exposed to change, in  harmony with the movements pro-
duced in the other iris under alterations in the quantity of light.  These
are so far distinct, that the latter often continues when the former is at
an end.  Sometimes the optic nerve  is completely  insensible in  one
eye, and light produces no effect whatever on the  iris of the diseased
eye, if the sound  organ be kept carefully closed; but if we produce
motion in the  iris of the sound eye, by varying the  quantity of light,
corresponding motion will be observed in the iris of the diseased eye.
   The changes in the state of the pupil are not produced by the imme-
diate  influence of light  upon the iris;  for, if we direct a  strong  light
upon that part, taking care that it shall not enter the pupil, no contrac-
tion of  the aperture takes place.   The iris does not move, the pupil is
not altered, unless the retina be influenced.   Fontana* bestowed great
pains in investigating this point experimentally, both in the human sub-
ject and in animals, varying his trials in  many ways so as to avoid all
sources of fallacy.  The result of his experiments clearly establishes the
position just laid down.
   We are thus led  to the conclusion that the motions of the  iris are
caused  indirectly through the influence of light upon the  retina.  The
phenomena  of disease  accord with  this  view.  When the sensibility
of the retina to light is impaired, there is a corresponding imperfection
in the  movements of  the  iris, and  they cease altogether, when  the
nervous expansion  has become  completely insensible.  Yet we  occa-
sionally meet with  exceptions in this  respect, which prevent us from
laying  down  the  rule that the action of  light upon  the retina is
absolutely necessary to the motions of the iris.  In some instances, not
merely of partial, but complete amaurosis, not only does the iris  retain
some power of motion, but  occasionally its movements are perfect.  I
have sometimes seen perfect mobility of the iris in amaurosis caused by
hydrocephalus, where the retina has been completely insensible, so that
the patient could not distinguish light from darkness.   The phenomenon
in question is  not  confined  to  cases of that description.  Farther
particulars on this subject will be found in the chapter on  amaurosis.
In amaurosis from hydrocephalus the cause of blindness is in the senso-
rium, not in the retina or optic nerve, which  retain their perfect struc-
ture.   Perhaps it may be found that the retina is not the seat of  dis-
ease  in the other instances of amaurosis accompanied by a moveable
state of the iris.
   From experiments on animals we  should  draw the inference, that
the motions of the iris are directly dependent on the effect, which varia-
tions  in the quantity of light produce  on the  retina.   Division  of the
optic nerve renders it motionless.  Magendie states that the same effect is
produced in the dog and cat by dividing the  nerve of the fifth pair.f
   Arnold explains the  associated action of the  iris by the union  that

      * Die moti delV hide, Lucca, 1765, chap. i.         t Precis elcm.p. 76. 
physiology of the eye-ball.
73
exists between  the two nerves of the third pair at their origin.   He
says that " the nervus  oculo-motorius arises  not only from the  crus
cerebri, but also from the mass between  the two crura, the substantia
perforata  media, so that several roots of the two nerves are intimately
united  at this point.   I  consider that the corresponding  and simulta-
neous movement of the two irides depends on this union, as the unity
of the visual organ is explained by the junction of the two optic nerves
in the chiasma."*
  The size of the pupil varies in some degree according to the distance
of what we look  at.  It dilates when the eye is directed to a remote
object, in  order to admit a greater quantity of light, which reaches the
organ in a less intense state; and it  contracts when a nearer object is
looked at, as the light then comes in a more powerful form.   These al-
terations, however, according to distance, are irregular and limited, and
by no  means adequate to account for the adjustment of the eye to dif-
ferent distances.  The quantity of light influences these changes as well
as the distance, for if the body, although extremely remote, be powerfully
luminous, the pupil contracts,  as in looking at  the sun.
  During sleep  the pupil is  contracted, as we may easily convince
ourselves by examining the  pupil of  a sleeping  infant.  By gently ele-
vating the upper lid, we can examine the eye, and ascertain the  state
of the pupil  without waking  the child.  Perhaps we should not  have
expected a priori what we find, namely, that,  in this quiescent  state of
the organ, accompanying the repose of  the external senses and of the
sensorium, and the relaxation of the voluntary muscles, the pupil is
contracted: it is very small, and dilates immediately if the child wakes.
This  circumstance  was  particularly noticed  by Fontana,  who made
observations on the subject, both in man  and in the cat:  in the latter he
sometimes found the pupil quite closed, and representing a mere line.f
  When the nerve of the third pair, from which, through the ophthal-
mic  ganglion, the ciliary nerves are principally derived, is paralyzed,
the iris is motionless, and the pupil is dilated.   I have  seen instances,
in which there was paralysis of all the parts supplied by the nerve of
the third pair, viz. three of the recti muscles, one of the obliqui, and the
levator palpebra? superioris, so that the upper lid could not be elevated,
and the globe was drawn outwards by the external  straight muscle; in
these cases the pupil has been largely dilated.   It might be  suspected
that the optic nerve was insensible;  but we shall find at least  in some
of these cases, that, if the patient looks through  a minute opening in a
card,  producing  what may be called  an artificial  contracted pupil,
vision is perfect.
  Belladonna, and some  other narcotics, when applied externally, or
taken internally, render the iris motionless, and largely dilate the pupil.
This condition of the part, which will be more particularly considered
hereafter  in treating of internal ophthalmic inflammation, was called
paralysis of the iris by Himly, who  first directed the attention of the
profession to the subject.
  The pupil is dilated in the complete insensiblity of cerebral compres-
sion, whether from accident or apoplexy; and it is contracted in the

     * Untersuchungen p. 80.                        t Lib. cit. chap. II,
       10 
74                  physiology of the eye-ball.
opposite condition of cerebral excitement.   In some morbid conditions
of the  alimentary canal it is enlarged; as in  certain  cases ot worms,
or of loaded intestines.  It is permanently dilated when the optic nerve
is completely insensible, in most cases; it will probably be found in the
instances which are exceptions to this rule,  that the iris had undergone
previous change, rendering it to a greater or less degree insusceptible
of dilatation.                                                     ,
  The question  has  been asked, which is  the active and-which the
passive state of the iris?  Contraction of the pupil has generally  been
referred to action of the iris;  and dilatation of the opening, taking place
under the circumstances just enumerated, has been considered to imply
a passive state of the organ.  When the motions of the iris are observed
in the living eye, we can hardlv suppose it  to be passive, either  in the
contracted or dilated  state of *the pupil; and we are inclined to agree
with those,* who have held the opinion that it is  active in both  condi-
tions of the opening;  that the contraction  is effected  by change in the
lesser circle, while dilatation is  accomplished by the  outer or radiated
portion of the membrane.   The pupil is found, after death, in the  mid-
dle state, between contraction and dilatation.
  The nature of the motions exhibited by the iris has been a subject of
controversy, which is  not yet settled; and it  is immediately connected
with the question respecting the intimate structure of the organ.   Mo-
tion is generally seen  in the animal economy as an attribute of muscu-
lar  structure:  this would  account  for the  opinion  entertained by
many  that the iris  is  muscular.  The question is, in  a  great measure,
a verbal one, and the  answer will depend on the notions we affix to the
expressions muscularity and muscular motion.  In external appearance,
and on the first view,  the iris is unlike any other muscle, whether of the
voluntary  or involuntary kind, though it presents an obvious fibrous ar-
rangement, both on its anterior and posterior surfaces.  On the  former
or  coloured surface, there are evident fibres or striae, of a  radiated dis-
position, converging  towards the pupil.  We observe  in  this anterior
surface an evident division into two parts;  an outer or larger, an  inner
or  smaller circle;  these are generally different in colour, the inner being
usually the darkest, and not  unfrequently of a different tint. The ex-
ternal circle exhibits an arrangement of radiated fibres, which, arriving
 at  the inner circle, divide into branches uniting together laterally,  so as
 to  form an undulated  line of division between the two circles: from this
 line numerous straight and delicate parallel fibres proceed to the pupil-
 lary margin.  When  the dark pigment has been washed off the uvea, it
 has a whitish or greyish colour, and the surface is composed of straight
 fibres, converging from the ciliary to the pupillary margin, quite unlike
 those  in the anterior surface.  The iris resembles  muscular organs in
 its great vascularity and large supply of nerves.   The latter, which are
 very numerous, and as abundant in proportion to the size of the iris, as
 in any organ of the body, come from the lenticular ganglion, and from
 the nasal branch of the ophthalmic, and run between the sclerotic and

       * Rudolpht, Physiologie, vol. ii. p. 217.  Arnold, Untersuchungen, p. 75. 
physiology of the eye-ball.
75
choroid coats, where we meet with them, on cutting round the former,
distinguished by the contrast of their whiteness with the dark ground of
the choroid.
  The muscularity of the iris has certainly not been established by
direct  anatomical investigation, although much  pains  have been  be-
stowed on the inquiry, and the aid of magnifying  powers has been em-
ployed.   Indeed, from  the delicacy and  minuteness  of the parts, the
subject is a  difficult one;  and, as the question turns on minute circum-
stances of colour, arrangement, and size, the observer easily succeeds
in seeing that which his previous opinions  lead him to wish.   Thus
many feel quite  certain that the anterior fibrous  arrangement is  a  ra-
diated muscle, the contractions of which contract the iris and enlarge
the pupil; and they are equally positive that the posterior  surface of
the organ has a circular or sphincter muscle, which antagonises the for-
mer.  I have already cited  the strong  negative  testimony of Arnold,
whose intimate acquaintance with minute structure, and  long habit of
microscopic observation, give  great weight  to his opinion.—See ante,
p. 54.  He finds in the iris nothing but  blood-vessels  and cellular tex-
ture, and supposes the  latter to possess  a contractile power, by means
of which the motions of the iris are effected.   We see various instances
where motion exists  independently of muscular structure, as in the in-
teguments generally, and those of the scrotum more particularly, in the
ureter, and perhaps the urethra.  In reference to  this  subject it may be
observed that the iris does not contract, like other  muscles, from  the
application of galvanism or electricity, or from mechanical or chemical
stimuli after death.  Nor have we any evidence that it possesses sensi-
bility.
   Some  have supposed that the movements  of the iris may depend on
changes  in the blood-vessels which enter so largely into its composition;
that it may  be susceptible of a kind of erection, and of collapse.  Not
a particle of conclusive and satisfactory evidence has been adduced  on
this point; while the supposed changes in the  blood-vessels are clearly
negatived by direct  observation  of the part in  the albino  and  white
rabbit.
  As the nerves of the iris are derived principally from the ophthalmic
ganglion, its movements are automatic:  some ciliary branches, how-
ever, are furnished by the nasal branch of the ophthalmic.   Certain in-
dividuals are said to'have had the power of  moving the iris voluntarily.
The influence in these cases must have been indirect,  as in the rare ex-
amples where a  similar power has been said to exist over the motions
of the heart.   Magendie mentions an experiment, which shows how the
iris may  move indirectly, and  also  exemplifies the contraction of  the
pupil caused by looking at near objects.   Having  selected a person with
very moveable iris, he places a sheet of paper at a certain  distance from
the eye, and observes the state  of the pupil.  He then directs the per-
son to read small characters written on the paper, without moving the
head or eyes: the pupil  immediately contracts, and the state of con-
traction lasts as  long as the effort is continued.*
  Distinct vision requires not only perfectly pellucid humours, and a
* Precis elemenlaire, p. 75. 
76
physiology of the eye-ball.
clear impression of the object on the retina, but also that the interior of
the eye should form  a perfectly dark chamber, to absorb all the  light
except that which contributes to form the image on the retina.   Hence
the dark colour of the choroid, ciliary processes, and uvea: hence, in
man, where the whole of these are coloured by the dark pigment, vision
requires much light,  and  he sees badly in  the dark.  Animals, on the
contrary, have part of the internal surface of the choroid (the tapetum)
light, and capable of reflecting the luminous rays.  Those rays, which
the dark human  choroid  absorbs, are reflected  by the tapetum of the
animal, and again strike the retina, thus producing a greater impression
with less light, a circumstance of great importance to those which  feed,
and pursue their prey, by night.  The herbivorous tribes, in many cases,
go on feeding in the  dark;  the carnivora are drowsy and inactive by
day, and go out  to supply themselves with  food at night.   The reflec-
tion of light, from the tapetum, gives a luminous appearance to the eyes
of animals in the dark; the pupil is dilated, and the reflected light is of
the same colour  as the tapetum.  This is a fact of familiar observation
in the cat, where the bright yellow of  the tapetum renders the pheno-
menon very conspicuous.   In  our  own species, individuals with  light
choroids see in weak  light better than those in whom the membrane is
dark.   The light of day is  too powerful for the Albino; it dazzles him
and obscures his vision.  If he  attempts to examine any object in the
full glare, he knits  and  draws down  his brows, and keeps  his lids
almost shut.   In twilight, however, he sees clearly, and he has tolera-
ble vision even  in  the dark.   The ferret, which has no  pigment, is a
kind of subterraneous animal, following  its prey under ground; and the
rabbit, in  which the same deficiency so  often occurs, requires,  from
its habits of life, a similar kind  of vision.  The Albino variety is very
common in the domestic  mouse, which passes its life almost entirely in
the dark.
   The situation  of the impression on the  retina  is  at the  intersection
of the  optic  axis with that nervous expansion.   The optic, or visual
axis  is a  straight line drawn through  the centre of the  cornea, pupil,
lens, and vitreous humour,  and consequently  meeting the  retina at the
centre of the posterior hemisphere of the globe ;  the light refracted by
the cornea and lens will come to a focus at this point.  In order to see
an object perfectly, it must be so placed that the rays proceeding from
it may be collected in this situation,  which seems  to be  more sensible
than the  rest of the  retina.   Under  other circumstances an imperfect
image is formed, and the farther the objects are placed from the direc-
tion  of the visual axis,  the greater  is  this imperfection, until at last
vision  is not affected.  The limits of its exercise around the visual axis
correspond with the  external boundaries formed  by the surrounding
parts of the face;  the greatest scope is outwards, the next downwards,
then inwards, and the most confined range is upwards;  thus  we have
the widest extent  of vision in those directions in which the  greatest
number of objects occur.  The retina is much more extensive than the
field of vision; indeed a considerable portion of it is  so placed, that the
light  going through  the transparent media of the eye  can  never be
brought to a focus on it.
   The visual axis strikes the retina externally to the termination of the 
physiology of the eye-ball.
77
optic nerve, which is placed nearer  to  the nasal than to  the temporal
side of the globe.  The entrance of the nerve through  the  choroid,
which  appears as a small, round, white spot on the interior of the globe,
is  called  porus opticus, and is said to be insensible; if it be so, we un-
derstand why the nerve did not penetrate the tunics in the  centre.  We
certainly should  not have  supposed, a priori, that this part could be
destitute of sensibility; for the nervous  matter,  which is thinly and
widely expanded  in the retina, is here concentrated into  a small spot.
Experiments, however, are cited in proof of the fact, and they  show, at
all events, that there is an insensible spot not far removed from  the
axes of vision.   Some complicated means of bringing the light to bear
on  the porus opticus of  each eye  at  the same time are  detailed in
works  on natural philosophy.  The fact may, however, be exhibited
by a more simple  process.  Stretch out your arms at full  length with
your thumbs extended and close  together; shut one eye  (say the left)
and keep the other steadfastly fixed on the left thumb; keeping the left
hand steady, and the  right eye fixed on it, move away the right hand
slowly towards the side; the right thumb will be lost for a moment, at
a certain distance, and then come  into view again.
  Calculations have been made of the size of the retinal picture; that it
must be extremely small is obvious.  A landscape, of  miles in  length
and  breadth, with its  hills, woods, rivers, houses, cattle,  and all  the
endless details belonging  to these,  and a thousand other  objects, is
painted in a membranous space not larger than the finger nail, by means
of light let in at  an aperture (the  pupil) often not larger  than a pin's
head.  No  part of the animal economy is more calculated to excite
our surprise and admiration than the contemplation of results so multi-
plied, varied, and important, produced by means so simple  and appa-
rently  trivial.  In the section of a gilt  silver wire we can  distinguish
the gold, when its thickness  does  not exceed the 110,000,000th part
of an  inch.  How shall we calculate  the size of the image on  the
retina ?
  Physiologists have been  much puzzled by the inverted image on  the
retina, and  have endeavoured to  explain how, in spite of this we see
things  in their true position.  It must be observed, that every thing we
see is  painted inverted on the retina, and the problem is, to  find  out
how we avoid the error that would apparently be produced from this
cause,  and see  all external objects in  their true relation to ourselves.
Buffon, Condillac, and others boldly assert that we actually see them in-
verted  ; that they  appear at first upside down; that touch corrects  the
mistake, and that by habit, at last  we see them  in  their true  position.
Not a single fact can be adduced in proof of this position ; on the contrary,
all our observations on infants, on persons born  blind and  restored to
sight, on the newly-hatched bird, and the newly-born calf,  foal, lamb,
and other animals, clearly prove that, in respect of relative position to
themselves, their vision leads them into no error.   If we see every thing
inverted, and have to depend merely on experience and habit for rectify-
ing so  essential an error, the correction could  apply only to objects seen
repeatedly;  but we see new objects just as correctly, in relation to our-
selves, as  those with which we are most familiar.  We judge of situa-
tion  by the direction in which the  luminous rays reach  the  eye; in 
78
TIIYSIOLOGY OF THE EYE-BALL.
obedience to  this law we  shall refer the upper  and lower  end of an
object to their real places, although the rays strike on the respectively
opposite parts of the retina.  On the same principle we often err in the
situation, and no length of experience rectifies the error.   We see our
own image behind the mirror;  we see it lengthened, shortened, inverted,
according to the form of the  mirror; and we see  the stick, which we
well know to be straight, crooked when  it is half immersed in water.
The notion  of  naturally seeing things inverted  arises from a partial
view of the subject;  as if vision were performed in the orbit; as if the
sensorium were just  behind the retina.   The impression on the retina
is only one of many  conditions belonging to vision.   Consider  the long
course of the nerve in the orbit; its  passage within the skull,  and the
junction with that of the other side; its complicated  connexion with
various cerebral parts.  The  original impression  may be modified in
many ways that we  know nothing of, before the ultimate effect is pro-
duced on the sensorium.   That an action on the retina should let into
our minds all the boundless  extent and diversity of visual perceptions,
is indeed unintelligible to us  as to the mode of accomplishment; but the
communication of a knowledge of true position by an  inverted retinal
image, is neither more nor less difficult to comprehend than the mental
perception produced  by impression on the nerves of any other  sense.
  Philosophers have  given  a  similar solution  of single vision  with the
two pictures, one in each eye.   The difficulty here has arisen from our
tracing the exact impression on the nerve, and finding it to be a picture.
Is there  not  just an equal difficulty in  single hearing with two ears 1
single thinking with a double  brain ? and the  tangible perception of a
single object with impressions on thousands of cutaneous nerves 1   Here
again  philosophers have  confidently asserted that  we  naturally see
double;  that touch gradually teaches us that objects  are single, and
habit at last makes  us see them so.  We have not a shadow of proof
to support so strange an assertion, while we collect clear evidence from
infants,  cataract cases,  and  young animals, that they naturally see
objects single from the first.  Experience is of no use when  an error
is really made; in sensorial  affections, accompanied with strabismus,
in displacement of one  globe, or by pushing one eye aside  with the
finger, double vision is produced, and  continues as long  as the cause
lasts, in spite of our perfect  knowledge that the objects  thus seen double
are  really single.
   The opinion has  been advanced, that, in the attentive exercise  of
vision, when we look at objects to examine them carefully, one eye only
is employed, although both  may be open, and  apparently  directed
towards the object thus examined.  A familiar  experiment is adduced
in proof: placing any object, for instance a pencil, between himself and
 a candle, let a person bring the pencil and  flame into  a line, with both
 eyes open; then let him close one eye:  if it is the weak eye, the flame
 and pencil are still seen in a  line  as before; if it is  the stronger, the
 flame of the candle seems to  move aside, and is now seen out of the
 line with the pencil.
   In opposition  to  this view Magendie mentions  an experiment to
 prove that an object, though it appears single, is seen at the same time
 by both eyes.  Receive the image of the sun in a darkened chamber; 
PHYSIOLOGY OF THE EYE-BALL.
79
take two thick  glasses, each of them presenting one of the prismatic
colours, and place them before your eyes.  If you have good sight, and
eyes of equal strength, the image of the sun will appear of a dirty white,
whatever may be the colour of the  glasses.  If, on the contrary, one
eye be much stronger than the other, the solar  image will be of the
same colour with the  glass before the strongest eye.*
   The concurrence of the two eyes is generally necessary for accurate
vision, and  especially for judging of  distance.  The  difficulty of snuff-
ing a candle, when we close one eye, is well known.   Magendie men-
tions  that a person whom  he knew, and who  had  lost one eye, was
obliged for  several months to proceed  slowly and in a groping manner
to take hold even of objects within his reach.   He mentions the follow-
ing experiment  in illustration of the subject: suspend a ring by a thread ;
take a long rod with a hook at the end ; place  yourself at a proper dis-
tance, and endeavour  to carry the hook through the ring.  If both eyes
are open, you will  succeed every time.   Shut  one  eye and you  will
succeed no  longer;  the  hook will go  too far, or not  far  enough, and
you will only accomplish the point  in several trials,  and with uncer-
tainty.  Persons whose eyes are of very unequal power, do not succeed
in this experiment even with both eyes open.f
   We cannot, therefore,  account for the unity of vision on the supposi-
tion that one eye only is used, although both are open.  The explana-
tion must probably be derived from  the union  of the two  optic nerves
within  the cranium, which is so arranged as to connect intimately the
nervous apparatus  of  the two organs in every  direction.   If the fibres
of the nerves are carefully  traced in  the  union or chiasma,% behind and
before it, so as to show the course which they severally take, as repre-
sented in the eleventh figure of Arnold's fourth plate, it will  be found
that three orders of fibres can  be distinguished in each  nerve, before
and behind  the united  portion, and in the chiasma itself.  Those of the
middle and largest division decussate  in the chiasma, the  fibres of the
right  tractus opticus going to the left optic nerve, and vice versa.  The
exterior fibres of each tractus pass along the corresponding sides of the
chiasma, and are continued to the outer side of their respective  nerves,
not joining together in any  way.  The posterior fibres  of the chiasma
represent an arch, of  which the" concavity is turned backwards ; they
are continued on each side along the inner margins of the tractus optici,
thus uniting the  cerebral portions of the nerves, without being connected
to the orbital parts (fibrce arcuaice cerebrales.)   The front fibres form
a similar arch, of which  the concavity is forwards, and are then con-
tinued along the inner side of the orbital portions of the nerve (fibrce
arcuatce orbitales;)  so that they unite these parts of the optic nervous
apparatus, without  going to the brain.
  [The eye has been thus far regarded, principally, as a dioptric§ instrument,

    * Pre'cis eUmentaire p. 86.                            t Ibid. p. 87, 88.
  X Xmtjux and  %t*.ir/uo; are Greek words meaning decussation ;  the term therefore
implies the fact that there is decussation at the union of the optic nerves.  On the ques-
tion of decussation see Metzger de controversa Nervorum opticorum Decussatione.  Konigs-
bcrg, 1794.
  [§ Instruments which operate on light by refraction are termed dioptric from St* through
and oTnafjitu, I  see;  those which operate on light by refraction are termed catoptric, from
Kxrct against and wroy.xt, I see.] 
80
PHYSIOLOGY OF THE EYE-BALL.
that is, in reference to its power of transmitting the rays of light to the retina
and so refracting or  collecting them as to form images  of external objects on
that part.  This is undoubtedly its especial function,—that for which it  was
designed, nevertheless all the rays of light which impinge upon these transpa-
rent textures are not transmitted, some of them are reflected, (see  p. 69.) and
these catoptric phenomena though merely incidental, are worthy of conside-
ration, inasmuch as they afford important diagnostic signs in certain affections
of the organ.
  It has been stated  (p. 67.) that when light falls upon some surfaces, instead
of passing through them, it is reflected  or rebounds from their surface.  In
such cases the angle of reflection  is always equal to  the angle of incidence,
and this is true whether the reflecting surface is plain, convex, or concave.
  Images formed by a plane reflecting surface, are equal and similar to the ob-
jects, and appear at the same distance behind the plane that the objects are be-
fore it.
  Images formed by a convex reflecting surface, always appear behind it, and
they are erect and smaller than the objects they represent.  The greater the
convexity of the mirror* the nearer and smaller appears the image. When the
object is moved laterally the image moves in the same  direction.   As the ob-
ject is approached to  the mirror, the image  approaches  also, and  vice versa;
and the nearer the object is approached to the mirror the less is the image dimi-
nished.
  Images formed by a concave reflecting surface, when  the object is placed
further from it than its  principal focus, appears before it, diminished  and in-
verted.
  The cornea, and anterior and posterior crystalline capsule reflect images  of
luminous bodies in accordance with these laws.   If a lighted candle be  held
before a healthy eye, three  images  of it are visible, two upright and one in-
verted.
  The cornea presenting a  regular, polished, convex surface, reflects an erect
and diminished  image  which moves in the same direction as the candle when
this latter is carried laterally.   A reflection takes place  from each surface  of
the cornea, but the thinness of this coat renders the interval between the images
so small, that they appear as one.   If, however, a candle  be held before a com-
mon watch glass, the two images may be readily distinguished.
  The anterior crystalline  capsule having  a surface similar to  the cornea,t
reflects  a  similar image.   This image is,  however,  larger, being magni-
fied by the aqueous humour and cornea through which it is seen.   It is also
much  paler and less distinct, owing to the manner in which the rays are re-
fracted or dispersed in passing from these denser media into the air.
  The posterior  crystalline  capsule  presents a  concave surface, the image
reflected from it is  inverted, diminished, appears before it, and  moves  in  a
direction opposite to that of the  candle when the latter  is  carried laterally in
front of the eye.   This image is the smallest of the three, being reflected  from
the surface  of smallest curvature, its radius  of curvature being about ^ths of
an  inch; whilst that of the other surfaces is \.£ths as already stated.   This image
is very bright and distinct, and appears anterior to that formed by the anterior
crystalline capsule, but posterior to the corneal image.   The position of these

  * All surfaces of a regular form which reflect images are termed mirrors.
  t According to Dr. Mackenzie (Physiology of Vision, p. 73.) the curvatures of the ante-
rior surface of the cornea and of the anterior crystalline capsule are the same, the radius of
of curvature of each being thirteen-fortieths of an inch ; other authorities consider the curva-
tures of the latter rather the smaller.  These curvatures, however, vary in  different indi-
viduals and in the same individual at different periods of life. 
ANATOMY OF THE APPENDAGES.
81
images being so regulated by the curvatures and relative position of the reflect-
ing surfaces.
  The images will  be  seen most distinctly when  the pupil is well dilated,*
the room darkened,  and the observer seated in front of the  patient so that he
may look down into the eye rather than up.   A candle should be used which
burns steadily and does not blaze much.
  When the curvatures of the reflecting surfaces becomes altered, or the trans-
parency of these or the  intervening humours are  diminished, corresponding
changes take place in these images or they become obliterated, and thus  fur-
nish most valuable diagnostic signs as  will be  more particularly pointed out in
the chapters on these affections.   To  appreciate the changes  referred to,  it is
essential that the observer should be perfectly familiar with the natural appear-
ances of the images, and for this purpose he must carefully study them  as seen
in the healthy eye.t]
           ANATOMY OF THE APPENDAGES  OF THE  EYE.

  The appendages of  the eye consist of the parts which move it,  the
muscles of the globe;  of those which cover externally and protect it,
the eyebrows, the eye-lids, and their muscles;  of the mucous membrane
which connects the globe to the eye-lids, the conjunctiva; of the organs,
which secrete, distribute, and convey away from the surface of the  eye
such fluids as lubricate it, the lachrymal organs, or apparatus.   They
are sometimes divided into the orbital and facial appendages, the eye-
lids and eye-brows forming part  of what  is  called  the face, and  the
muscles and other parts being contained  in the cavity of the orbit.

                                     [Muscles of the eye-ball, view from the outer side of
                                    the right orbit.  1. A small fragment of the sphenoid
                                    bone around the entrance of the optic nerve into
                                    the orbit.  2. Optic nerve. 3. Eye-ball.  4.  Levator
                                    palpebral.  5. Superior oblique.  6. Ita cartilaginous
                                    pulley.  7. Its reflected tendon. 8. Inferior oblique,
                                    with a fragment of the orbit from which  it  origi-
                                    nates.  9.  Superior rectus.  10. The internal rectus,
                                    partly concealed by the optic nerve. II. Part of the
                                    external rectus showing its two heads of origin.
                                    12. Do.  showing its insertion—the intermediate part
                                    has been removed.  13. Inferior rectus.  14. Tunica
                                    alhiiginea, formed by the expansion of the  tendons
                                    of the four recti and subconjunctival fascia.]

  Muscles.—The globe of  the  eye  is moved by  six  muscles, four of
which, namely, the recti or straight muscles, are nearly alike, and very
simple in their origin and arrangement.   They arise from the margin
of the foramen opticum [1. fig. 3.] at the bottom of the orbit, pursue a
straight  course, and are inserted by broad but thin and flat tendons  into
the sclerotic  coat; they closely embrace the optic nerve at their origin,
surround it more loosely in  their  progress, and include  the globe  be-
tween their tendinous  expansions, being  situated respectively above,
below, on the outside  and inside  of the  nerve and globe.   These four
muscles move the globe in the four directions of their course, or  in the
intermediate direction, when the actions  of two are combined.
  There are two oblique muscles, the superior and inferior.  These are
situated  obliquely with  respect  to the globe, and  give it a rotary  mo-
     * This may be effected by the application of belladonna,  stramonium, &c.
      t See American Journ. Med. Sc. Aug. 1838. p. 494. May, 1839. p. 255, &c.
       11
 
82
ANATOMY OF THE APPENDAGES.
tion downwards  and outwards, (obliquus superior,) or  upwards  and
inwards, (obliquus inferior,) acting together, they turn the eye-ball to-
wards the nose.
  The use of the  recti  muscles is obvious: they are voluntary agents
connected with the office of  the retina.  They can move the globe, in
obedience to the will, so as to direct the visual axes successively to the
various parts of any object which we are desirous of surveying.  They
can carry the globe into every situation, in which the surrounding bony
prominences admit of vision  being exercised.   When a greater extent
of motion is required, we direct the optical axes to the object, by turn-
ing the whole head.
  The effect of the obliqui is by no means  so apparent.  They have
been called circumagentes or  amatorii, having been probably regarded
as muscles of expression, and supposed  to be subservient to the motions
which take place  in ogling.  We find them, however, in the  eyes of
animals, which certainly do not make love in that way.
  The physiology of these muscles  has been greatly elucidated by Sir.
Charles Bell,* who has noticed and explained certain  movements of
the eye, which had hitherto nearly escaped attention.  These are in-
voluntary motions by which the globe is  rolled upwards, for the pur-
pose of clearing the cornea, or protecting and defending the eye, in ordi-
nary winking, in the closure of the lids when any thing approaches capa-
ble of injuring the eye, and in sleep. " There is a motion of the eye-ball," *
says  Sir Charles, " which from its rapidity has  escaped observation.
At the instant in which  the eye-lids are closed, the eye-ball makes a
movement which raises the cornea under the upper eye-lid.  If we fix
one eye  upon an object, and  close the other with the finger in such a
manner as to feel the convexity of the cornea through the eye-lid, when
we shut the eye that is open, we shall feel that the cornea, of the other
eye is instantly  elevated, and  that it thus rises and  falls in sympathy
with the eye that is closed and  opened.  This change of the  position
of the eye-ball takes  place during the most rapid winking motions of the
eye-lids."  Sir Charles observes that this movement takes place even
when the eye-lids cannot be closed in consequence of contraction from
burns or paralysis of the orbicularis.   In the latter cases I have re-
peatedly observed  the fact, and  pointed it out to others, although I had
not reflected, as Sir Charles  has done, on the nature and mechanism
of the phenomenon.  The use of this movement in sweeping and  clear-
ing the surface  of  the cornea is obvious.  " By the  double motion, the
descent of the eye-lid and the ascent of the cornea  at the same time,
the rapidity with which  the eye escapes  from  injury  is  increased."
The globe is rolled upwards in  the same  way during sleep, and on the
approach of death.  The fact had been observed in the  former case,
and even delineated by Soemmerring in his first plate ; but he erroneously
ascribes the movement to the rectus superior, which being a voluntary
muscle, cannot  be  in action during  sleep.  Moreover, when the  rectus
superior turns the  globe upwards, as in contemplating an object placed
higher than the  head, its action is united with that of the  levator  palpe-
brae; while, in the case  under consideration, the rolling upwards  of the

  * On Motions of the Eye ; Phil. Trans. 1823 ;  and in the Nervous System of the  Human
Body, p. 177. 
ANATOMY OP THE APPENDAGES.
83
globe is associated with descent of the upper lid.   Sir. Charles observes
further, that this involuntary action of the obliqui is seen in  oppression
of the brain, in  faintness, in debility after fever,  in  hydrocephalus, and
on the  approach of death, when  the action of the voluntary powers  is
either greatly enfeebled, or altogether suspended.
  [The muscles  of the eye and their  appendages have lately acquired such
surgical importance, that some further particulars  relative to their anatomical
relations, seems demanded.
  The  internal is the shortest and thickest of the recti muscles, whilst its anta-
gonist,  the external, is the longest and next to the former in thickness.
  The following  are the measurements of the tendons of the recti muscles,  as
given by Dr. Mackenzie,* but they must be regarded as only approximations.
  Length of the tendinous portion of inner rectus three  lines; of the other recti
one line and a-half.
  Breadth of the  tendons of the internal and  external recti  at their  insertions
about four lines;  of the superior and inferior recti about three lines and  a-half.
  Each tendon has a crescent shaped  insertion, the  convexity being towards
the cornea,  so that the centre of insertion is nearer the cornea than the  edges.
This arrangement has  doubtless mislead some careless  operators into the be-
lief that they have divided the whole of the  tendon  of  the muscle they were
operating on, when in fact they  had only divided the central part, leaving both
edges still attached.
  The  internal rectus is inserted nearer to the cornea than the external rectus.
The distance between the centre of the tendon and the cornea, being  in the
former  about two lines, and in the latter about three lines.
  The  superior and inferior recti appear to be inserted at equal distances from
the cornea, which according to Mr. Lucas is four lines; whilst Dr. Mackenzie
represents the latter muscle as inserted nearer the  cornea than the former, the
respective  distances between the centre of their tendons and the cornea  being
according to him two lines and  a-half and three lines and a-half.
  It has not yet  been satisfactorily determined whether or  not the  opponent
recti muscles are  inserted symetrically; though  it has seemed to us that such
is the case.  Dr.  Mackenzie states  that the internal  and external recti are  in-
serted in the same horizontal line, but that the superior and inferior recti are
not inserted in  the same  vertical line, the latter being  inserted considerably
nearer the nose than the middle  line of the eye-ball.   To this arrangement he
attributes  the tendency, so frequent in convergent strabismus  of the  eye  to
turn upwards and inwards.t
  According to Mr. Lucas the  internal  rectus  is inserted obliquely  to the
edge of the cornea, its inferior edge being a line more  distant  from this part
than its superior; whilst  the other recti muscles are  inserted concentrically
to the  edge of the  cornea.  Mr. Mackenzie on  the contrary states that the
internal rectus  is inserted concentrically to  the edge of  the  cornea,   as
well as the external;  but that the inferior  rectus  is  not inserted concen-
trically, and that the superior is  inserted still more obliquely in  respect to the
edge of the cornea.  It will require a very careful examination of a great num-
ber of cases to determine with precision the general rule as respects  the inser-
tion of these muscles; and  to avoid  being led  into error by exceptional cases.
  The centre of the tendon of the superior oblique is eleven lines distant from
the cornea, and that of the inferior oblique fifteen lines from the same point.J
  The eye-ball is invested with  a membranous  tunic which separates it from


      *  On the cure of Strabismus by Surgical Operation. London. 1841. p.  12.
      t  Loc. cit.
      t  Lucas. Practical Treatise on the cure of Strabismus.   London. 1840. 
84
ANATOMY OP THE APPENDAGES.
the other structures in the orbit, and forms a smooth hollow surface by'which
the motions of the eye  are  facilitated.   This investment was described by
Tenon in a paper read before the French Institute in 1804,* who styles it a new
tunic of the eye.  It has since been described by Mr. Dalrymplet as the cel-
lular capsule of the eye,  by Mr. Bonnett. of Lyons, by Mr. Ferral| of Dublin
who proposes for it the name of tunica vaginalis oculi, and by Mr. Lucas||  who
terms it the submuscu/ar fascia, each of whom seems  to  consider  himself as
the discoverer of this structure.
   Mr. Lucas^f recommends the following  method of demonstrating  this fascia.
   " 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 down-
wards.  The masses of fat, together with the loose cellular tissue  and blood-
vessels, should be carefully dissected away, and the muscles be turned forwards
towards their insertions, not  dissected as  if with a view of exposing their ap-
pearance, but merely expanded upon the surface of the plate.
   " If the neurilema of  the  optic nerve  be  now examined, it will be found
covered with a fine fascia, which can be easily raised with a forceps, and  with
little difficulty can be traced off the neurilema to the sclerotic coat at the point
where the nerve enters.   It will be now 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 mus-
cles,  and  passes backwards  along them to where they surround the optic
nerve."
   This fascia, passes from one muscle to  the  other, and  forms a strong, con-
tinuous, double circular membrane behind them; the masses of fat, enveloped
with their own proper cells, being placed between its layers.
   It offers  considerable resistance to the passage of an  instrument between
the tendons of the  muscles, and in operating  upon them  requires to be fairly
divided.
   This fascia  "possesses a high degree of elasticity, and forms rather a mem-
branous sheath for  the sclerotica, that an  expansion for the muscles;  it takes
the form of the eye-ball, and acts the part of a membranous 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  cuplike  membrane and
the eye-ball, which always  enables  the  anatomist to  separate one from the
other with the greatest facility.   That effusion to  a considerable extent some-
times takes place between this membrane and the eye-ball, there  can be little
doubt."**
   This effusion is apt to accompany rheumatic inflammation of this tunic, and
to Mr. Ferral we are indebted for first inviting the attention of practitioners to
the existence  of that pathological condition as well as  for a very interesting
account of its phenomena and mode of treatment.
   Mr. Lucas describes as a second fascia, which he names the subconjunctival^
but which Dr. Mackenzie conceives to be a continuation of the  ocular cap-
sule, a dense layer of cellular tissue which covers the external surface of the recti

   * Memoires et Observations sur 1'Anatomie, la Pathologie et la Chirurgie  et principale-
ment sur 1' Organe de 1' Oeil, p. 193.   Paris. 1816.
   t Anatomy of the Human Eye.  London. 1834.
   t Sur 1' anatomie des aponeuroses et des muscles de 1' ceil, letter addressed to the Academy
of Sciences and read at their meeting the 1st Feb. le4l. Gazette Med. de Paris, 13 Feb. 1841.
   § Dublin Journal, Med. Sc. July, 1841.      || American Journ. Med. Sc. Oct. 1841.
   IT Op. cit.                             ** Lucas, loc. cit.
   tt Dr. Gross in a paper on Strabismus (Western J. Med. & Surg., Ap. 1842) states that
this fascia is identical with  that described by him in his pathological  anatomy  published
in 1839, with the appellation of the ocular fascia. 
ANATOMY OF THE APPENDAGES.
85
muscles.   " Behind the conjunctiva," he observes, " there exists a quantity of
loose cellular tissue; upon carefully removing which, a denser layer will be
found immediately to cover the orbital aspects of the recti muscles, and to pass
along their expanded tendons to  the  sclerotica, with the anterior surface of
which it is in intimate contact, and is traceable along it to the circumference of
the cornea, becoming thinner and  more identified with the sclerotica as it gains
this point.
   " This subconjunctival fascia, although  exceedingly delicate, is sufficiently
strong to offer considerable resistance to even  a  slightly blunted instrument;
and as, in addition to its passing from all the recti muscles to the sclerotica, it
also passes from the anterior surface of one muscle to another, it is of impor-
tance to be aware of its existence  in performing an operation for the section of
the tendons of  the recti muscles.  Unless the subconjunctival fascia be  torn
through or divided, the passage of an instrument beneath any of the tendons
will be attended with difficulty."*
   This like the submuscular fascia it is less strongly developed in children than
in  adults.  It is sometimes rendered very dense  and  becomes adherent to the
conjunctiva and muscles, from inflammation; and when  this condition of the
fascia accompanies strabismus, it  is sufficient to  maintain the deformity after
the muscle has been divided, and in such cases it is necessary to freely separate
the morbid adhesions.]
   Nerves.—The orbit contains several nerves, of which the  optic, or
nerve of the second pair,  is the most considerable.   Its magnitude suffi-
ciently points  out the importance of the sense to which it is subservient.
In size it is the second of those connected with the  basis of the  brain,
being inferior  only to the nerve of the fifth pair.   The Optic nerves have
this singularity, that  they converge  within the cavity of the  skull, all
the others diverging to their respective destinations ; they meet together,
and their respective substances are united into one mass on the anterior
surface of the  sphenoid bone.   The  course, which the various compo-
nent fibres of  the two nerves take in  the chiasma or junction, as well
as before and  after it, has been already described ;  see page 79.  This
kind of arrangement is found in no other instance.   The intermixture of
their substance may account for unity  of vision,  for the  intimate sym-
pathy between the two eyes, and for various morbid phenomena.   The
nerves,  having united, separate  again, passing  each through  its  re-
spective  foramen opticum into the orbit, and terminating in the posterior
part of the eye-ball.  In the progress from the foramen opticum to the
globe, another peculiarity is observed ; the nerve is closely invested by
a  sheath of  dura mater, a  prolongation  of  the fibrous membrane
which lines the skull.
   The function of the optic  nerve  is  entirely confined to the sense of
vision.    It is even destitute in  its healthy  state of ordinary sensibility.
M. MAGENDiEf pushed the opaque lens against the retina in the operation
of depression, and not only touched, but punctured it with  the cataract
needle repeatedly, without causing pain or any sensation to the patient.
These injuries were not  followed by any inflammation,  or  impaired
vision.    The  optic nerve is  equally insensible  to  the  mechanical in-
juries of pricking, cutting, or laceration.
   The cavity of the orbit contains further the nerve of the third pair,

   * hoc. cit.
   t Sur VIusensibilitt de la Retine de I'homme;  Journal de Physiologie, t. v. p. 37. 
86
ANATOMY OF THE APPENDAGES.
which is employed in supplying  three of the recti muscles, one of the
obliqui,  and the levator palpebral superioris, besides forming the Pnnci-
pal origin of the lenticular  or  ophthalmic ganglion, from which  the
nerves of the iris proceed:  the  nerve of the fourth pair supplying the
trochlearis muscle; the ophthalmic branch of the fifth, which contributes
a small branch to  the lenticular ganglion, sends off a few small twigs
in the orbit, and then leaves the cavity at  the supra orbital i°ramJJ »
and the nerve of the sixth pair,  for the  external straight muscle.  We
cannot hesitate in concluding with Sir Charles Bell,* that the ophthal-
mic branch of the fifth gives  common  sensibility to the surface of the
eye and  the lids, and that  the destructive inflammation of the  organ,
which ensues, when the fifth nerve is destroyed by injury or disease,f
arises from the loss of this sensibility.   The third  and sixth nerves are
obviously voluntary ; Sir Charles regards the fourth as an involuntary
nerve, whithout considering the point clearly proved.
   The  cavity of the orbit contains the ophthalmic artery, the various
ramifications of which supply the globe of the eye, and the parts be-
longing to it; and the ophthalmic vein, by which  the blood is returned
from  the orbital veins into the cavernous sinus of the dura mater, through
the foramen lacerum  orbitale.   The orbit  also contains the lachrymal
gland, which has its nervous supply from the ophthalmic branch of the
fifth.   Accurate and  beautiful  delineations of these several parts are
found in the works of Soemmerring and Arnold.
   The several parts just enumerated are connected together by a copious
and particularly soft  adipous substance, which in the living  subject is
almost fluid, and therefore  readily accommodates itself to the different
motions of the eye, and to  the  various changes of position which may
occur in the globe.
   The  bony cavity is lined by a fibrous membrane, which is a direct
continuation of the dura mater, and technically called periorbita, bear-
ing the same relation to the orbit, as the pericranium does to  the skull,
or the periosteum to other  bones.  The peculiarity of the arrangement
consists in its being continuous  with the dura mater at the foramen op-
ticum, like the fibrous sheath that covers the optic nerve.
   The  eyebrow is the arched prominence which terminates the forehead
and overhangs the eye; it  consists partly of bone and partly of muscu-
lar and  other  soft parts.  The  bone is the superciliary ridge of the os
frontis, forming the superior arch of the anterior orbital aperture.   Im-
 mediately on the surface of  the bone lies the corrugator supercilii muscle,
 which is subservient to the motion of the brow.   It derives its origin
 from the nasal process of the os frontis, turns upwards and outwards in
 the  direction of the  eye-brow,  and is lost among the fibres of  the orbi-
 cularis palpebrarum and the occipito frontalis; it consists of a conside-
 rable fasciculus of  muscular  fibres.   Its  action  throws  the  eye-brow
 and  forehead into those longitudinal folds which are exhibited in frown-
 ing; it is, in fact, the muscle of frowning;  it is  more important  as an

   * On the Nerves of the Orbit; Philos.  Trans. 1823, and in the Nervous System, &c. p. 203;
  also Appendix, No viii. p.23 and  103-
   t Magendie de VInfluence de la cinquieme Paire des Nerfs sur la  nutrition et les fonc
  tions de Vail, in the Journal de Physiologie, t. iv. p. 176, and Suite des Experiences &c,
  ibid.  p. 302. 
anatomy of the appendages.
87
instrument of expression than in reference to the physiology of vision;
its indications are rather of a pathognomic than of a physiological kind,
and illustrate the state of feeling or passion in the individual.  Hence it
is peculiar to the human species, though I am  not prepared to say that
it may not be found in those of the simiae, or monkey tribe, which ap-
proach the nearest to man.
  Over the  corrugator supercilii there is a stratum of muscular fibres
forming part of the orbicularis palpebrarum; there is, further, a portion
of adipous substance, covered by integument similar to that of the face
in general, with the exception of the skin, having a number of hairs im-
planted in it.  These hairs are peculiar in their form and arrangement;
they do not  run lengthwise with respect to the  brow, but are short, and
form a double series, of which the inferior are directed upwards and
outwards, the  superior downwards and outwards, and the two orders
meet and form a kind of ridge in the middle of the brow.
  The palpebrce, or eye-lids, are a thin and moveable kind of curtain,
closing the anterior aperture of the orbit.   The boundaries of the eye-
lids are, the eye-brow above, the cheek below, the temple on the outside,
and the nose on the inside.  The palpebrae are the parts included between
these boundaries; when they are approximated to each other, they close
the bony opening of the orbit, which is seen in the skeleton.   As the eye-
lids are adapted to the front of the globe, they are concave on the pos-
terior surface, and  proportionally  convex on  the  anterior.   They are
made up  of skin, muscular fibres, cartilage,  and mucous membrane.
They are separated from each other by a horizontal slit or opening,
which is closed when they are completely approximated, and enlarged
in various degrees as they are moved apart.  The separation of the lids
from each other is termed in popular language opening the eye: it ex-
poses the previously concealed anterior surface of the organ.   The pal-
pebral aperture or slit is said generally to be  horizontal;  but it is not
strictly so, for the  outer  or temporal part  is  a little lower than the
inner or nasal portion.  The  palpebras are more firmly fixed to the bone
at the nose than towards the temple.
  Muscles of the Eye-lids.—The motions of the lids are performed  by
two muscles;  one situated in the cavity  of  the orbit, and  the other on
the face.  The former is the levator  palpebrae  superioris, arising close
to the superior rectis, from the margin of the foramen opticum, running
along the upper part of the orbit, and inserted by a broad expanded ten-
don into  the whole breadth of the upper lid.  The other muscle is the
orbicularis palpebrarum; it consists of a broad stratum of fibres, deriving
its origin from a small tendon at the  side of the nose.  This tendon  is
placed in front of the excavation which lodges  the lachrymal sac.  The
fibres, which are immediately under the skin, and arranged in a circu-
lar or elliptic form round the  eye-lids, cover the whole surface of these,
reaching to  the  ciliary margin, and  extending over the adjoining part
of the eye-brow, temple, and  cheek.
   When the eye is  shut, the levator  muscle elevates the upper lid, and
draws it away from the lower.  In  opening the eye, the  two lids are
not equally moved,  the  inferior remains  nearly at rest; it descends a
little, but the separation is chiefly accomplished by motion of the supe-
rior lid.   The two palpebrae contribute unequally to cover the globe of 
88
ANATOMY of the appendages.
the eye, the superior being by much the largest or deepest; the line of
junction between the two lids does not run along the middle of the ante-
rior surface of the eye, but is situated below the inferior margin of the
cornea; and the superior lid, in its closed state, covers the whole of the
cornea.  Soemmerring. in the  first plate of his work, gives a front and
side view of the lids as closed in sleep, and represents the line of junc-
tion between them as more than one-eighth of an inch  below the infe-
rior margin of the  cornea.  The levator then, by elevating the upper
lid, denudes the anterior surface of the globe: but its continued action
is necessary in order to keep the eye open; the weight of the upper lid
would carry it down, unless there were some cause to  counteract this
tendency.   Accordingly, when the action of this muscle is  suspended,
the lid drops of itself in front of the eye.  When persons are extremely
tired, and  incapable of continuing voluntary exertion, the lids descend,
or,  in popular  language, the eyes feel heavy.   A fortiori this effect will
be produced, when  the muscle is paralyzed ; the power of opening the
eye is either impaired or lost  according as the paralysis of  the levator
is partial or complete.   Such  affections are by no means uncommon:
indeed I know no single muscle of the body which is so frequently the
subject of paralytic affection independently of all others.  May not this
arise  from  the constant duty required from it,  and consequent  exhaus-
tion of its  power 1  The  explanation  of the  phenomenon must be
sought for  in some  cause affecting the muscle,  and not the  nervous
trunk, since the other muscles supplied by the same  nerve are very
seldom affected.
  Sir Charles Bell has shown that the levator palpebrae not only ele-
vates the upper lid,  but that, at the same time, it  depresses  the lower.
" Anatomists," he says, " have sought for a depressor of the  inferior
eye-lid, seeing that it is depressed, but such a muscle has no existence,
and is quite unnecessary.   The levator palpebrae  superioris opens wide
the eye-lid, depressing the  lower eye-lid at the same time that it  elevates
the upper one.   If we put the  finger upon the lower eye-lid so as to feel
the eye-ball when the eye is shut,  and then open the eye,  we shall feel
that during this  action the eye-ball is  pushed  outwards.  Now  the
lower eye-lid  is  so adapted as to slip off the  convex surface of the
ball in this action, and to  be depressed, whilst the upper eye-lid is ele-
vated."*
  The orbicularis palpebrarum is the antagonist of the levator;  the con-
traction of its circular fibres, according to its degree, will either diminish
the dimensions of the palpebral aperture, or completely approximate the
lids.  Sir Charles Bell has observed that the two lids do not  move in
the same direction when the eye is shut.  The upper  descends and rises
perpendicularly, while the lower plays horizontally like a  shuttle, being
moved towards the nose, when the eye is closed.  He  considers this a
part of the curious  provision for collecting offensive  particles  towards
the inner cornea  of the eye.f  When the levator is relaxed, the gradual
descent of the upper lid, by its own weight, will  slowly close the eye;
and  this may be exemplified  by elevating the lid when the muscle is
paralyzed.  Generally, however, this passive  kind of closure does not
* The Nervous System of the Human Body, p. 186.
t Ibid. p. 182. 
ANATOMY of the appendages.
89
answer the purpose; we want  to  shut  the lids more  quickly, and we
employ the active exertion of the  orbicularis; its  sudden and  forcible
contraction draws the  lids  together when a foreign body approaches,
or when the organ requires  shelter from  too strong a light.   In these
cases the muscle can contract with great force,  as we find when we
attempt to draw the lids apart, in opposition to the will of the  indivi-
dual.  Even  in a child, labouring under  intolerance of light, we can
hardly overcome the violent  and spasmodic contraction of the orbicu-
laris.  The action of this muscle not only closes the eye, but corrugates
the whole integuments of the lids, temples, and surrounding parts.   The
orbicularis in  front,  and the  orbital  muscles  behind  are  antagonist
powers,  between  which the globe  is  retained in a proper  position.
When the former is paralyzed, not  only  are the  eye-lids and the sur-
rounding integuments flabby and folded, but the globe protrudes unna-
turally, as if it were pushed forwards by a force acting  from behind.
   Component  tissues of the eye-lids.—The  lids are formed of several
different textures, which I shall enumerate in their order.  The exter-
nal surface is  skin, peculiarly thin  and  delicate, so  that,  in fair persons,
we not only see through it the ramifications of the subcutaneous ves-
sels, but can even trace their minute divisions.   In young persons, this
portion  of integument is perfectly smooth, but, as age advances, it loses
its elasticity, and falls into wrinkles.   When  the upper lid is elevated,
a deep fold is  observable between the lid and the eye-brow; there is no
corresponding fold in the lower lid.  Immediately  under the skin is the
stratum of fibres composing the orbicularis palpebrarum.  Next, in the
upper lid, is the expanded tendon  of the  levator  palpebrae superioris;
there is no corresponding part in the lower lid.
   The tarsi.—We  then  come to the part which gives  firmness to the
lid, extending  and supporting the softer textures; it is a thin and flexi-
ble, yet firm and elastic cartilage, or rather fibro-cartilage, on  which
the skin, muscular fibres, and  mucous  membrane, may be said to be
stretched.  It  can bend, and change its figure, recovering itself again
by its elasticity.   These cartilages are called tarsi, the superior and
inferior.  They are convex on the external surface, and concave on the
inside; they have a thick margin corresponding to the ciliary edges of
the lids, and a thinner turned towards the  rim of the orbit.  If we evert
the upper or lower lid, these fibro-cartilages are easily brought  into
view.  The superior is  deeper than  the inferior, in correspondence to
the difference  between  the  lids;  the proportions, in this respect, are
about as three to one.   The inferior tarsus, like  its eye-lid, is nearly of
equal breadth  throughout;  the  superior also corresponds in form to its
lid, being broadest in the middle, and  narrower towards the two ex-
tremities.  The orbital  edges  of  the tarsi  are connected by fibrous
expansions to the front of the orbit.  These, which  are sometimes called
the broad ligaments of the  tarsi, are firm, distinct fibrous layers near
the bone, with the periosteum of which  they are continuous, becoming
looser and  thinner towards  the cartilage.  The ligament is  strongest
and most firmly attached to the tarsi on the temporal side of the orbits,
where protection is most needed.
  Sebaceous glands.—A large  number of glands  disposed in parallel
longitudinal clusters, called the  Meibomian glands, is imbedded  in the
       12 
90
ANATOMY OF THE APPENDAGES.
tarsus.  The rows or clusters of glands, although principally lodged in
the substance of the cartilage, are partially seen on the internal surfaces
of the palpebrae, through the thin mucous membrane, and are even con-
spicuous by their whitish colour.   When  examined  by a magnifying
glass, each row is found to consist of a central tube with a congeries of
minute  roundish bodies arranged  round  it on all sides in  successive
groups; the-e, which have been called acini or vesiculae, are, no doubt,
so many glands, each of which pours out its secretion into the excretory
tube, running along the centre of the cluster, and terminating by an open
orifice on the ciliary margin of the lid. These openings, which, although
minute, are  distinctly visible in the living eye, corresponding in number
to that of the glandular rows, are called the ciliary ducts.   If  a single
duct with its glands be dissected out separately, it represents a slender
thread with  the minute acini hanging to it  all round,  something like a
rope of onions, except that these little glands are much more numerous,
from fifty to more than a hundred connected with each duct.   There
are two'figures in the work of Soemmerring, in  which  these minute
structures are represented, of the natural size, and magnified with great
accuracy and fidelity.  Arnold has given different  and more varied
views of the same subject;  especially one  representing a row of glands
dissected out, and another  exhibiting the mode in which they are im-
bedded in the tarsal cartilaue.*
   The whole  number  of the Meibomian  glands is very considerable.
There are between thirty and forty rows in the upper lid, but  not quite
so many in  the lower: these clusters too are much shorter in the latter
than in the former, in consequence of the different size of the two lids.
The unctuous or sebaceous  substance  which they secrete anoints the
lids, and prevents them from sticking together: after  death it congeals
into a solid form, and may be expressed from the orifices of the ciliary
ducts, like minute white threads.
   Next to this arrangement of glands is the mucous membrane or pro-
duction of conjunctiva, which gives  a  smooth and  polished surface to
the interior of the lid, and facilitates the relative motions of the eve and
lids.
   The eye-lids, although  made up  of so many distinct structures, are by
no means impervious to light.   One obvious use of them is to guard the
eye from the access of light during  sleep; however, so much  light
passes through them, that we  can readily distinguish, in the day-time,
whether the  light of a window fall on the face or be intercepted, although
the lids may be closed; and persons, who usually sleep with  their win-
dow and bed curtains drawn, adopt  the  expedient  of leaving them
open when they wish to  rise early, generally finding  the unusual  im-
pulse  of light on the organs of vision  sufficient to awaken them.
   Cellular substance of the lids.—The several textures, or strata com-
posing the lid, are connected  together by a rather abundant  cellular
tissue, which contains no fat;  the eyes  would, in  many instances, be
permanently closed if the lids were liable,  like other parts of the body,
to deposition of adipous substance.  On the other hand, the cellular tex-

  * Tab. Anat. fasc. 2, tab. I, fig. 9—12.  This plate  exhibits the entire anatomy of the
eye lids and lachrymal organs in a series of beautiful figures. 
ANATOMY OF THE APPENDAGES.
91
ture of the lids is often the seat of inflammation, in erysipelas and other
affections: serous effusion takes place, enlarging and  distending them
so as  completely to close the eyes, with  great inconvenience and  de-
formity.   A similar effect is produced  by ecchymosis from blows.   In-
flammation, when more  violent, causes effusion of lymph or formation
of pus, with the  same effect of closing the lids.
   Ciliary margins of the eye-lids.—Surgeons should attend  closely to
the ciliary  margins of the lids, and  make  themselves  well acquainted
with their form,  structure, and appearances.  Here the  common integu-
ment  and the mucous membrane of the eye are continuous.   The very
edge of the lid is formed by a kind  of covering intermediate between
the two  structures;  it is not exactly  a  mucous membrane, like that
which lines the  palpebrae, nor  integument like the common skin: it is
red, thin, yet compact and dense, and adheres closely to the  cartilage:
this delicate  integument has a  covering  of epithelium.   The ciliary
margin is the  thickest part of the lid: it is a  flat surface coming into
contact with that of the other lid when the eye is closed; yet the inner
edge,  or  that turned towards the globe, is a little sloped, so that a small
channel is  formed, in the closed state, between the palpebrae and  the
globe, for the passage of the tears.
   Cilia.—At the outer edge of the ciliary margin are a  number of pores
in the integument, in which the cilia or eye-lashes are implanted.   The
hairs  which form the cilia, like those of  the supercilia, are peculiar in
their  form  and arrangement; each hair arises from a  bulb, like the hairs
in other parts of  the body ; it is slender at  the origin, increases gradually
in thickness, and then tapers off to a fine point; they are all curved, the
convexity  of the superior cilia being directed downwards, and that of
the inferior upwards, so that  they cross when the lids are closed.   The
superior  are stronger and longer than the inferior;  the middle are the
largest and strongest, and they diminish gradually in length and strength
towards  the angles of the eye.
   Just behind the eye-lashes  are seen the apertures of the ciliary ducts.
Where the series of these openings  ends towards the  nose, and at the
very  inner or  nasal extremity of the tarsus, there is a slightly prominent
kind of papilla,  of whitish colour, with a round aperture  in the centre,
called the  punctum lacrymale.
   The lids, though separated by a transverse  slit, are united towards
the temple and the nose, and the points  of junction are termed the angles,
or  canlhi, of the eye; the internal and external, or  the greater and
smaller.   The internal, or greater angle, is rather rounded ; the external,
or smaller, is acute.   By the tendon of  the orbicularis, the internal angle
is closely fixed to the side of the nose; the external  is  more loosely at-
tached to the orbit by the broad ligament of the tarsi.
   The size of the palpebral aperture is  different in different individuals;
in some persons  a greater portion of the globe is habitually exposed than
in others, and hence persons are popularly said to have large or small
eyes,  for the size of the globe varies but little.   The organization of the
eye-lids,  as now described, enables  them to execute their various useful
purposes, of protecting the eye from violence and accident, of shielding
it during sleep, of shutting out the light  when it is too powerful, or when
disease renders  it offensive;  of keeping the cornea  smooth, moist, and 
92
ANATOMY OF THE APPENDAGES.
free from impurities, and of disseminating the lachrymal fluids ovet  he
organ.   The cartilage gives to the lid its uniform smooth surface; the
Meibomian secretion anoints  their edges, and prevents them irom ad-
hering during sleep, or occasional contact;  their rapid motion in wink-
ing, with the concurrent rolling upwards of the globe, and approximation
of the eye-lashes, shuts out extraneous substances, and preserves the cor-
nea constantly clear  for the  transmission of light, whilst the polished
mucous surface glides without the smallest friction over the equally po-
lished globe.
   Conjunctiva.*—The name denotes that it joins or unites the globe to
the lid's; it is sometimes called adnata, from its growing or adhering to
the surface of the eye.  Indeed, it adheres so  closely to the front of the
organ, that it ought, strictly speaking, to be  enumerated  among the
tunics belonging to the globe.   The lii.e of the cilia, in each lid, may be
considered the boundary between  the skin and the mucous membrane,
the point of union of the two structures.  The conjunctiva, then, is per-
forated  at the ciliary margin of the upper  lid, by the ciliary ducts; it
lines the posterior or inner surface of that lid, extending a little  way
above the upper or orbital edge of the tarsus; from the lid it turns  over
the globe, covering two-thirds of the eye, viz. the anterior portion of the
sclerotica, and the cornea; it is reflected from the inferior portion of the
globe to the posterior surface  of the under lid, which it lines: reaching
the ciliary margin of the lower lid, it is perforated by the ciliary ducts,
and again becomes continuous with  the skin.
  Thus the membrane is reflected from the palpebrae to the whole cir-
cumference of the globe, forming a circular fold, which, at the point of
reflexion, corresponds to the fat of the orbit.  This angle of reflexion is
the boundary between the external surface  and the orbital contents; it
opposes the passage of an instrument, or any extraneous substance.  It
is a loose fold, and loosely connected to the surrounding parts, yielding
to  the motions of the globe with perfect facility, drawn smoothly  over
the convexity  of  the sclerotic,  when the eye is moved in a contrary di-
rection, and forming two or three loose folds on the opposite side, or that
towards which the eye is turned.
  The conjunctiva is not only connected with, but constitutes part of the
external surface of the body;  it is actually exposed to the air when the
 lalpebraa are open, though it is completely shut up when they are closed.
 t  is a mucous membrane,  having a polished  surface lubricated  by a
mucous exhalation, and a cellular surface adhering to the parts which
it  covers.   It  is  one uninterrupted  membrane, differing, however, in
structure and appearance in  its different parts.  Hence anatomists have
designated that portion which  lines the lids as the conjunctiva palpebra-
lis; that which covers the eye as the c. oculi: the latter  part has been
further  subdivided into  the c. cornece, and c. sclerotica:.   All these,
however, agree in the circumstance of having a smooth and polished
surface.
  The c. palpebralis is  a thin vascular  membrane, of reddish colour

 * Eble, uber den Bau und die Krankheiten der Bindehaut des Auges, with coloured
plates. Vienna, 1828, 8vo. Arnold, Untersuchungen,  Kap. I, § 2.  Roemer Bemerkun-
gen uber die arteriellen Gefdsse der Bindehaut des Auges, in Ammon's Zeitschrift vol v
F, 
ANATOMY OF THE APPENDAGES.
93
from numerous visible vascular ramifications, and semi-transparent, so
that you may see through it the cartilage, and the parallel rows of Mei-
bomian glands;  it is  consolidated to the ciliary  margin of the tarsus,
and it  adheres  closely, but  less  firmly, to the  rest of the  cartilage.
Soemmerring, who has represented the palpebral conjunctiva in the 15th
fig. of his second plate, mentions in the  description its silky and as it
were warty structure.   Mueller* says that a  great  number of  mucous
glands is scattered over the surface, and  that  they give to it a some-
what velvety appearance.  Eble| considers that  this part of the mem-
brane has a papillary structure, analogous to that of the tongue or the
Schneiderian  membrane; that this structure is more obvious after death
with congestion in  the vessels of the  head; and  that it  secretes the
mucous which lubricates the surface of the eye.   He has  given excel-
lent figures of this corpus papillare, as he  calls it, both of the natural
size and under various degrees of microscopic enlargement.   The same
parts, and particularly  the villous or papillary portion of the conjunc-
tiva, both in its  natural appearance  and magnified, are beautifully de-
lineated by Arnold.J
   The  c. scleroticcB  is of a white colour, thick and pulpy in its texture,
and, in conjunction with the dead white  sclerotica, gives to this part of
the eye that appearance which is designated by the popular expression,
white of the eye.   It is remarkable for the  almost  entire absence of
vessels carrying red blood; in its  natural state we see merely a  few
small red vessels creeping on its circumference from the lid.  It is con-
nected  to the parts on which it lies by a loose cellular texture; thus it
easily falls into  folds, and  permits  the globe of the eye to be moved in
all directions.   These folds  become the seat of  serous effusion in cer-
tain inflammatory affections of the eye.
   The c. cornece  differs remarkably from both  portions of  the  mem-
brane just described, so  much so, that one doubts, at first, whether it
really is a part of the same structure^   No vascular ramifications are
visible in it, and it is so closely connected to the  corneal substance, that
it cannot be separated by dissection in the recent eye; we are satisfied,
however, that the cornea is  covered by a continuation of  conjunctiva.
In the first place, the anterior surface of the cornea possesses the same
acute sensibility as the rest of the conjunctiva.   In fact, the  sensibility
is greater in this than  in any other part  of  the  eye, while the proper
corneal laminae appear insensible.   Secondly, the vessels  of the con-
junctiva are continued  to the anterior surface of  the cornea: this fact,
which is difficulty demonstrable in the normal state of the eye, is proved
daily by the effects of disease.  Changes produced by disease are often

   * Erfahrungssatze, pp. 5 and  6.
   f  Ueber den Bau und, die Krankheilen der Bindehaut des Auges, p. 19—29. pi. 1 and 2.
   X Tab. 1, fig. 13—18.
   § The continuation of the conjunctiva over the cornea is doubted by Eble, (lib. cit. p.
60 ;) and denied by Meckel, (Handbuch, b. iv. p. 59.)
   In a work recently published on purulent ophthalmia (die  sogennante contao-iiise, oder
 Aegyptische Augenentziindung, mit 9 colorirten Abbildungen, Stuttgart, 1839) Eble has
given at considerable length the result  of his recent inquiries, especially with the aid of
the microscope, into the structure of the conjunctiva, p. 124—132.  He expresses himself
perfectly convinced that the cornea has a conjunctival covering, particularly from  finding
that its surface presents, under the microscope, appearances analogous to those observed in
other parts of the membrane, p. 124. 
94
anatomy of the appendages.
continued from the conjunctiva scleroticae to  the cornea.  The Prol°"-
gation of red vessels, the loosening and thickening of texture, and  the
loss  of transparency from  interstitial  deposition, bring the c°rnea t0
such an identity of character with the conjunctiva, that the boundary
between them is sometimes hardly distinguishable.
  In certain animals a strong proof is afforded that the front of the cor-
nea is  formed by a continuation of the  palpebral lining.   In  the serpent
tribe, which annually shed their epidermis, the front of the cornea comes
off with the rest of the external surface of the body.   In the eel the an-
terior surface of  the cornea is  often drawn off, when it is skinned.   A
subterraneous animal (zemni, slepez, mus  typhlus, Lin.) whose habits
and manner of living are analogous to those of the mole, has the eye
covered with hairy integument hke the common skin of the  body.
  The conjunctival layer cannot be dissected off the  cornea in the per-
fectly fresh eye;  but, if the organ be previously  placed  for  some time
in warm water, or macerated in water for some days, and the conjunc-
tiva be then raised from  the  sclerotica, the dissection being carefully
pursued by small and repeated strokes  of the knife, it may be detached
sufficiently from the corneal substance to show the continuity of  the
membrane.  Arnold represents that the separation  is effected more
easily  in the sheep, pig, and calf, than in the human subject.
  In the normal state of the membrane, the conjunctiva palpebralis has
a reddish colour, while the conjunctiva oculi is of pearly whiteness with
a few  slender straggling red vessels towards the angles of the  lids.
After successful injection, the palpebral linings are deep red and villous,
while the conjunctiva scleroticae has a rose tint:  the latter terminates at
the border of the  cornea, but under favourable circumstances vessels
are seen to pass on to that membrane.
  I have called the conjunctiva a mucous membrane;  and this view of
its nature is  supported by its analogies of structure  and office  in  the
normal state, by the  changes which  it  undergoes in  disease, and  par-
ticularly by the remarkable alterations, which its secreted fluid then  un-
dergoes.  Some have been  inclined to place the conjunctiva, especially
where  it covers the cornea, among the  epidermoid structures, in  favour
of which its  separation with the  cuticle in animals  which cast their
skins may be alleged.  Arnold states that the corneal  layer of the mem-
brane is most abundantly supplied with  lymphatics, while the epidermis
possesses no vessels of any  kind.   Eble considers that the nature of the
conjunctiva differs in its different portions; that it  is  integumental,
where  it lines the tarsi; mucous in the  angle of reflection from the lids
to the  globe; and serous in the latter. There are remarkable differences
of structure between these  three  parts: the  palpebral lining is distin-
guished by its corpus papillare.  Roemer states that the mucous portion
is abundantly supplied with mucous glands, which are easily seen after
minute injections.  In the conjunctiva  oculi there is  no appearance of
villi, papillae, or mucous glands.  The  opinion of Eble on this point is
adopted by Arnold and Roemer.
  Lachrymal organs.—Under particular circumstances the surface of
the eye is washed by a more copious  secretion, of different character
from the mucous conjunctival exhalation, which, not being conveyed
away fast enough by the ordinary excretory apparatus, is poured over 
                    anatomy of the appendages.                  95

the lid, taking the name of tears.   This fluid is secreted by the lachry-
mal gland, \k. I. fig. 2.] which is a small body of conglomerate texture,
seated in the orbit, within the  external angular process of the frontal
bone.   Its excretory ducts  open on  the  surface of the  conjunctiva,
above the external angle of the eye; there are about seven ducts, which
are scarcely to be seen in the human eye, except under favourable cir-
cumstances.   In the eye of the horse  or  bullock they are of sufficient
magnitude to admit a small  probe.  The secretion  of the lachrymal
gland is a watery fluid, containing a considerable saline impregnation,
hence saltish or brackish to the taste,  and, when copiously poured out,
it produces a  temporary irritation and redness.  Its discharge is ex-
cited by the direct irritation of foreign bodies, particularly those of acrid
properties; by various inflammatory affections, especially by strumous
ophthalmia, by recent conjunctival inflammation, but more strongly by in-
flammation of the external proper tunics, and by mental emotion.  The
fluid  which moistens the eye, whether conjunctival or lachrymal, is ab-
sorbed by the excretory apparatus, and conveyed into the nose.  The
puncta lacrymalia [a, fig. 2.] already described are the external com-
mencements of two small tubes, which go towards the internal angle of the
eye, and there terminate in the lachrymal sac.  These tubes are called the
lachrymal canals, or ducts; [a, b, c, d, fig. 2.] they converge, the superior
passing inwards and downwards, and the inferior inwards  and upwards;
they are about a quarter of an inch in length, and open at one and  the
same point into the lachrymal sac. [e,f, g, fig. 2.]   This  bag, about the
size of a small horsebean, and oval, is seated in the bony excavation on the
inner side of the anterior orbital aperture.   Its superior end [e, fig. 2.] is
rounded ; the inferior, slightly contracted, forms a tube half an inch long,
and larger than a crow quill, called the nasal duct, \h,  i.] which descends
into the nose.  The lachrymal bag closely adheres to the bony excavation
which lodges it, being covered, on its anterior or exposed surface, by a
firm fibrous layer attached to the edges of the bony groove. This anterior
surface is further covered by the fibres of the orbicularis and the skin ; the
tendon of the  former  crosses it transversely a little above  its  middle, so
that one-third of the bag is above, and two-thirds below the line of the
tendon.   The lachrymal canals open just behind this tendon, on the
outer or ocular  side of the  bag.   The communication with the nasal
duct is  the inferior extremity of the sac, a slight constriction  [g, fig. 2.]
marking the distinction between the bag and  duct.   The latter passes
from above obliquely  downwards, and a little backwards, enclosed in a
bony canal, and opens in the inferior meatus  narium, on  the outer side
of the inferior turbinate  bone, which must  be cut  away in the dead
body to expose the  aperture;  the  latter is then seen  as an oblique slit.
 [i. fig. 2.]
   The lachrymal sac and the nasal duct are lined by a thick pulpy mu-
cous membrane, resembling in its structure the Schneiderian membrane
of the nose, and containing, like that, numerous small mucous cryptas.
The lachrymal canals, and the puncta lacrymalia, are lined by a thin-
ner and  more compact  membrane continuous with the conjunctiva.
Thus these lacrymal passages establish a connexion, by continuity of
surface, between the  eye and nose.   The fluid  taken up  by the puncta
lacrymalia is  conveyed into the sac, and  it then descends into the nose. 
90
PATHOLOGY OF THE EYE.
 We do not exactly understand the mode in which the circular orifices
 of the lachrymal canals suck up the fluid.   A small space is seen in the
 inner angle of the eye, between  the two lids, towards which the tears
 flow,  and at which the small  triangular canal  formed  between  the
 closed lids terminates; this is called  lacus lacrymarum, and the  pro-
 minent papillae, in which  the  puncta lacrymalia  are perforated,  are
 turned towards this space.   When the  secretion of tears is much in-
 creased by any of the  exciting  causes  which  I have mentioned,  the
 fluid is poured out faster than it can be absorbed by the puncta, and it
 flows over the surface of the cheeks.
   In  the  internal  angle of the  eye, near the puncta lacrymalia, is a
 small  prominent  body of a reddish  colour,  called the  caruncula
 lachrymalis  this part may be  better  appreciated  by looking at it in
 the living  eye,  than by examining it  in the collapsed and  shrivelled
 state which it exhibits in the dead subject, and in preparations.   It is a
 congeries of glandular  bodies, similar  in structure to the  Meibomian
 glands.  Between the caruncula lacrymalis and the globe of the eye, is
a small fold of conjunctiva, called the  semilunar fold, [extending from
a to a fig. 2.] which  appears to be a rudiment or  imperfect exhibition
of that structure which in quadrupeds  constitutes what has been termed
a third eye-lid;  it  is situated vertically between  the upper and  lower
lid.
CHAPTER. I.
Pathology  of the Eye—Inflammation— Classification  of Ophthalmic
                              Diseases.
SECTION I.--PATHOLOGY OF THE EYE.
   Within the small compass of the  visual apparatus, we meet with a
greater variety of  structure  than in any other part of the bod v.   We
have seen, indeed, in the  preceding description, that  the  eye with its
appendages  exhibits specimens of every animal tissue  in  the  body.*
We find in it bone, cellular and adipous substance, and  blood-vessels;
mucous, fibrous, and serous membranes;  the conjunctiva exemplifying

  * I conclude that Brer means  to express this circumstance in the singular paragraph,
with which he begins his work on Diseases of the Eye.                   piragidp.i,
  "As man, in relation  to the universe, must be regarded as a little  world (microcosmns,)
so mus  we consider the eye, in relation to the individual man, as a microcosmus  in which
his soul and body are reflected."—hehre vol. i. p. 1.            microcosmus, in wlncn
  The same view is given, in nearly  the same words, by Professor Rosas
  "By its intimate connexion with the rest of the organization, and their con«eauent mn.
tual influence, the eye may justly be regarded as the mirror of the soufa^ he bodj
1 urther, as it exh.bits in miniature a repitition of the whole bodily structure it mav be eon
sidered to bear to the latter the same relation that the body, as a little world Ss 'o tlie
universe."—Handbuch, i. s. 48o.                                 "U| Dears io me 
PATHOLOGY OF  THE EYE.
97
the first; the sclerotica, the sheath of the optic nerve, and the lining of the
orbit  (periorbita,)  the  second ;  the  surfaces  containing the aqueous
humour the third ;  muscular,  nervous, and glandular  parts; common
integument and hairs.  Besides these it contains several tissues of pecu-
liar nature, to which there is nothing strictly analogous in other parts;
these are the iris, the ciliary body, the choroid coat, and the transpa-
rent media.  Each of the latter has its own  characteristic structure;
the cornea, the crystalline lens, and its capsule, the hyaloid membrane,
and the vitreous humour, resemble each other only in being transparent.
Most of these parts are highly  organized,  copiously  supplied  with
blood-vessels and nerves.
   By the nature of its organization, by its office  and its situation, and
by its connexions with other parts of the system,  the organ of vision is
exposed to numerous external and internal sources of disease.  The
aid of this sense is required on most  occasions; hence the eyes are in-
cessantly exercised during our waking hours.   In many  instances they
are excessively exerted, as by the  numerous persons engaged in the va-
rious mechanical occupations  requiring close  attention, by artists, stu-
dents, and literary characters. The situation of the eye lays it open, not
only to accidental  injury,  but to  various external influences.
   As there is a common  source of  nutrition  and circulation, and one
centre of nervous  energy, pathological principles must be the same for
the whole body.   In addition  to the  mutual dependence  and influence
resulting from this  arrangement, there are numerous and  important
relations between the  organ of vision and other parts of the animal
ceconomy.   The fifth pair of nerves and the excretory part of the lachry-
mal apparatus  connect it  with the nose.   A close, reciprocal influence
is established between this organ and the  brain with  its membranes, by
means of the nerves which enter the orbit, by the fibrous sheath of the
optic nerve, and the periorbita.  By the connexions of its blood-vessels,
it must participate in the determinations  of blood to  the  head.   The
communications between  the great sympathetic and the third, fifth, and
sixth cerebral  nerves, as well  as the  continuity of mucous surface,
establish a  connexion between the abdominal viscera and the eye, capa-
ble of explaining many points in pathology and treatment.   Again, the
eye is a part of the  external surface of the body, connected  with  the
integuments through the medium of  the conjunctiva, which  may be re-
garded  as a modified cutaneous  covering.  Hence it participates in the
various diseases of  the skin, not  only in  the acute affections, such  as
smallpox, scarlatina, and measles, but also  in the more chronic disorders.
Hence, too, perhaps, we may explain the  advantageous effect, in  oph-
thalmic disease, of cutaneous irritation, and of attention to the condition
of the skin  generally.
   It will be clear, from the preceding considerations, that the affections
of the eye, as a part of  the organic system,  come  under the general
laws of disease and treatment.   We must, however,  not lose sight of
its peculiar tissues, and of the modifications which fit  the organ for its
especial office.  It would  be  a most fatal error to insulate the diseases
of the eye from the rest of pathology, to consider them as merely local
ailments, and treat them  only by remedies applied to the part.  It would
also be a mistake, though much  less serious, to overlook the peculiarities
       13 
98
INFLAMMATION.
of ophthalmic disease, and, trusting entirely to general means, to neglect
all applications to the part.
   When we consider that  the component parts of the eye are  so
numerous and diversified in organization, and that each  of these is sub-
ject to the same diseases, and  consequent  changes,  which are incident
to analogous structures  in other parts ; that they are not only liable to
common disease with its various results, but that they exhibit important
modifications of diseased action, dependent on peculiarity in the exciting
causes, or on specific states of constitution, whether original or acquired;
and that this complex and delicate organization is exposed to numerous
and  powerful causes of disturbance, we can  easily account for  the
numerous distinguishable forms of ophthalmic disease.  If each of these
should be regarded and  named as a distinct affection, we need  not be
surprised at the long catalogue, which ophthalmic nosology would thus
exhibit;  that Taylor should  have  given  an "Exact Account of Two
Hundred and Forty-three different Diseases to which the Eye and its
Coverings are exposed,"* and  that Dr. Rowley should have written " A
Treatise on  One Hundred and Eighteen principal Diseases of the Eyes
and  Eyelids."-\   We shall find, however, on  closer  inquiry,  that this
numerous offspring belongs,  nearly all, to one family ; that,  although
designated by distinct appellations, they are not distinct  diseases, but
that  the  great majority are merely forms and results of one morbid
affection, viz. inflammation.

                     SECTION II.--INFLAMMATION.

   The question then presents itself, what is  inflammation ?  There ought
to be no difficulty in answering it.  We are continually talking of inflam-
mation ; almost constantly occupied in observing  and  treating  what we
call inflammations.   The existence of this  morbid affection is more and
more generally recognised as the source of disease;  and it seems likely,
in the end, to spread itself over nearly the whole  field of nosology.  It
has been carefully investigated  by pathologists and practitioners, and
much has been written  on it;  but the real nature of the  process is as
yet imperfectly known.  If we should ask a surgeon, or look  into a
book for an explanation, we  should learn that inflammation exists when
the following  changes are seen in a part; viz. redness, heat,  swelling,
pain,  altered secretion,  and impaired function.   The word inflamma-
tion, from injlammo, denotes  the most  striking character of external
inflammations; that is, the increased heat  of the part.   The other items
in the nosological description are drawn from the same source, and by
no means derived from a general survey of the process as it occurs in all
structures.   As a mere description, it is not applicable to  the  eye in
many cases.  In  some  conditions of the cornea,  the iris, and  the crys-
talline capsule, which are regarded as inflammations, there is no visible
swelling, no redness, nor can  we detect the existence of heat or pain
Again, in parts removed by their situation from  direct  observation  as
the retina and hyaloid membrane, or the various internal organs of 'the
body,  we cannot determine whether  the circumstances regarded as
criteria of inflammation are  present or not.                 D

           * 8v«- Edinburgh, 1759.               t London, 1790. 
INFLAMMATION.
99
   The question, however, what  is inflammation 1 is not satisfactorily
answered by enumerating these changes, even if we admit that  their
assemblage generally characterizes the process.   Redness,  swelling,
heat, and pain, are the symptoms of the disease, the external signs that
denote its presence.   We  must inquire, therefore, what is the internal
change that produces these external signs? what is the alteration in the
capillary circulation, that gives rise  to redness, swelling, heat, and pain?
This is not yet known.  We understand something of particular inflam-
mations, as those of  the skin, cellular tissue, serous  and mucous mem-
branes, &c, because  we can both observe their progress, and examine
the parts affected ; but, when we attempt to explain the nature of inflam-
mation generally, we are investigating an abstract term.   In  this  point
of view it is a creation  of the mind, not conveying  any sensible ideas;
its  acceptation, therefore, cannot be defined  or limited  by reference to
nature, our only safe guide.
   The most general  notion that we  can form of inflammation, is that of
increased activity in the  capillary circulation, whether evinced by
increased size of vessels and redness, by increased or altered secretions,
or by deposition of new matter and  consequent visible changes, such as
thickening, consolidation, opacity, preternatural adhesions.
   The phenomena of inflammation, when it  is seated in an external
part of some size, as the hand and fore-arm, for example, show  that an
increased quantity of blood enters the  inflamed part, and circulates
through it.  The  throbbing  and the increased size  of  the arteries, the
distention of the venous trunks, with the  fulness of the small vessels, as
evinced by the externa]  redness, and by the unusual red  colour of all the
textures  of the inflamed member, with the obvious increase in the num-
ber and  size of their capillaries, proves  that an increased  quantity of
blood enters the  part.  It  seems to me equally evident that a larger
quantity  circulates through it.  Blood flows much more freely from an
incision into an inflamed part than into a  sound one.   This is strikingly
exemplified in  the division of the integuments and cellular membrane in
phlegmonous erysipelas ; both arteries and veins bleed so freely on  such
occasions, that twenty or thirty ounces of blood are often lost in a few
minutes.   When  an  operation is performed on an inflamed part, or in
its immediate  neighbourhood, the blood is thrown more  forcibly  from
the divided vessels, and we find it necessary to tie a  much greater num-
ber than  under other circumstances.  The fulness of the veins in an in-
flamed limb is another unequivocal proof of the same point: these ves-
sels could not be distended, if the blood sent to the inflamed part stagnated
in it, as some have supposed. In a case of inflamed  hand and fore-arm,
requiring general depletion, I have tried the experiment of opening a vein
in each arm at the same moment.   Three times more blood flowed  from
the vein of the inflamed limb, than from that of the sound one, in the same
time.  We are thus led  to regard the phenomena of inflammation, that
is, the changes which occur in the  part itself, as  dependent on an in-
creased activity in the  circulating  system.   But  it is  not  merely in-
creased activity, that  would produce increased nutrition, augmentation
of bulk, as in the growth of the stag's horn, the enlargement of the ute-
rus and the mammary glands in pregnancy; there must be an alteration 
100
VARIETIES OF INFLAMMATION.
in the mode of action ; but in what that alteration consists we have hither-
to been unable to determine.
  The agents of inflammation are the capillary vessels, which carry on
the  active business of the animal economy, performing the various pro-
cesses  of nutrition, growth, secretion, and excretion.  We  do not yet
know the differences of arrangement or action which lead to the various
results of vascular exertion; we cannot tell how it is that the capillaries
of one  part deposite bone, those of another muscle, of a third membrane;
how some secrete bile, others urine or saliva.  As we know nothing of
the  causes which produce these striking differences, it is not surprising
that the exact nature of the process called inflammation should still be
a mystery to us.
  The various inquirers who have  investigated  the  subject experimen-
tally, endeavouring to found a theory of inflammation on observation of
the'process in living animals, especially with the aid of the microscope,
have come to very different, indeed opposite conclusions.   Some have
seen in inflammation an increased flow of blood to the part, and a more
active transmission of it through the vessels; others assert that the cir-
culation is obstructed.   That there is increased activity of the capillaries
has been generally believed; yet elaborate attempts have been made to
show from microscopical observations that these vessels are  in a state
of debility, and do not exert themselves so much  as in the natural condi-
tion.   These and other similar contradictions must convince us, that the
exact nature of that deviation from  the normal  or  healthy state of the
capillary circulation, which constitutes inflammation, is as yet unknown;
and will save us  the trouble of examining the speculations which have
been founded on microscopical  observations of the circulation  in the
transparent parts of living animals.
   Varieties of inflammation; acute and  chronic.—Inflammation is not
one and  the same process under all circumstances; if it  were, pathology
and treatment would be very simple.  The phenomena, which it exhi-
bits, vary considerably, and the eye, from its position, and peculiar or-
ganization, affords the most favourable opportunity in the  body for the
study  of these varieties.  In the first place, the affection differs in de-
gree ;  there may be more or less of the inflammatory disturbance.  This
distinction is denoted by the terms acute and chronic.  Severity of symp-
toms and rapidity of progress characterize the former; the  opposite at-
tributes  of mildness and slowness belong to the latter.   I do not mean
 to  represent that there are  two degrees and no more: we  may have
 every gradation of the affection, from that in which we barely  recog-
 nise the existence of increased  action, to  the violent unnatural exertion,
 in  which all  the ordinary functions are perverted or interrupted, and even
 the very structure changed  or destroyed.  These diversities are only
 pointed  out in a general way by the epithets  acute and  chronic, the
 shades of difference between the two extremes  being numerous and in-
 definite.   The terms themselves are not precisely contrasted in meaning;
 the epithet acute marks the violence of  the symptoms; while chronic,
 which is equivalent to lasting or enduring (from  xntvor, time,) denotes
 their  duration: it is this violence that particularly  attracts notice in the
 former case, while the continuance of disease is the most striking circum-
  stance in the latter.  Acute inflammation is also  called active, violent, 
VARIETIES OF INFLAMMATION.
101
or phlegmonous; the latter term being derived from the Greek <p*eyi*.w,
the name given to that active inflammation of the cellular  texture and
skin, which generally terminates in abscess.  Thus acute inflammation
is a violent disturbance which  cannot last long; unless cut short by pro-
per treatment, it soon produces  mortification, suppuration, or effusion ;
like fire, it soon burns itself out.  Chronic inflammation is  also called
languid, slow, or indolent.   Its characteristics differ in several  impor-
tant points  from those of the acute  kind.  The vascular distention and
disturbance are not so considerable; the redness much less, often hardly
perceptible; the pain is slight  or absent.   Hence it may arise and pro-
ceed for some time, without  the patient being aware  of its existence.
Although in these respects chronic seems a less  alarming  disturbance
than acute  inflammation, it is more serious in another  point  of view: it
produces interstitial deposition, and consequent  change of structure,
which  often impair or destroy the functions of the affected part.
   Some  are of opinion that there is a difference, not only in  degree, but
in kind, between acute and chronic inflammation.  They admit preter-
natural excitement, and consequently increased exertion, as the essence
of the  former;  but they suppose the latter to be the result of debility,
and to consist of a weakened or atonic state  of  the capillaries.   Thus
we read and hear of  active  and passive or atonic, of sthenic and
asthenic inflammations.  Believing inflammation to be increased activity
or exertion of the capillaries, I consider the expressions, passive, atonic,
and asthenic inflammation, as applied to the state of the inflamed part,
to be contradictory in terms.   It is true  that inflammation  may occur
in weak  as well as in strong states  of body, and  that the local pheno-
mena, the  sympathetic disturbance of other parts, and  the treatment
will differ  materially in  the two instances.  Moreover, an unhealthy,
and consequently, in a certain  sense, weak state of the constitution, may
remotely cause many inflammations; but I cannot trace the disturbance,
under  these circumstances, to  weakness of the part, and still less can I
refer the phenomena to a weakened or passive state of the vessels.  On
the contrary, when we observe inflammations occurring in weak  indivi-
duals,  as in the advanced period of typhus, when the patient is  in  the
lowest condition of debility, we still find the  local changes and  results,
which under  other circumstances  we refer, without hesitation, to in-
creased vascular action.  If there are any inflammations in which  the
capillaries  are less active than in the healthy condition, I am not  ac-
quainted with them.
   The same observation is equally applicable to the expressions, arte-
rial and  venous inflammation, or congestion.   If we trace  the arteries
and veins  of  a part,  we soon come to a point, at which  we  can no
longer distinguish them.   The capillary system,  in which inflammation
resides, is a net-work of minute ramifications, which we cannot unravel.
How then  can we ascertain whether arteries or veins  are  exclusively
affected?   Can we suppose such exclusive affection  probable, or even
possible?
   The acute and chronic stages of inflammation are  often spoken of.
If we  survey attentively any  particular case, we do not find that it is
one and the same process  throughout: there is a succession of pheno-
mena.  The disturbance commences insensibly,  gradually increases till 
102
VARIETIES OF INFLAMMATION.
it acquires a certain development, remains for a time at that point, and
then gradually recedes, till the part recovers  its healthy state.  The
whole of this course passes under the name of inflammation, though the
various parts of it differ considerably from each other.  If we were to
divide each inflammation into three periods, of formation, in which the
symptoms arise and proceed to a  certain extent, of full development,
and of decline, we should find that the first two are nearly of equal
length in most  cases of active inflammation; but  that the  portion of
time, between the point at which  the  symptoms begin  to lessen and
complete  recovery, varies  much  in its length  in  different instances.
When inflammation has been violent, and allowed to pursue its progress
uncontrolled, more particularly if the exciting causes have continued to
act, the disturbance lasts in a  greater  or  less degree for a long time,
although the  more urgent  symptoms may have been lessened.  The
part is still inflamed, but the redness and pain are less, the interruption
of function is not  so great.  This minor degree of inflammation, which
may continue for  a long time, is called the chronic stage, while the for-
mer period, in which the symptoms were  violent is termed the acute
stage of an inflammation.  If the disease be actively treated, if its pro-
gress  be  arrested by judicious means, the part  recovers quickly, and
we can  hardly say that any chronic stage  occurs.
  Besides employing these  terms to designate the different  portions of
one and the same inflammation, some have contended that the  two pe-
riods are totally different in their nature; that increased exertion is the
essence of one, weakness of the other; and that a  corresponding dif-
ference of treatment is necessary, the chronic stage requiring, as  they
represent, tonic and stimulant  means.  These  views seem  to me alto-
gether erroneous.   Without asserting that there is no difference between
acute and chronic inflammation in general, I have no hesitation in af-
firming that  the acute and chronic stages of one and  the same inflam-
mation do not differ in their essential nature.  Thus we  find that the
acute form passes into  the chronic, and that the latter may relapse into
the  acute.  When inflammation  of the eye has reached  the  chronic
stage, all the phenomena of acute inflammation may be re-produced by
exertion of the organ, imprudence  in  diet, or other causes.  Finding
that, within  a short period, one form can pass into  the other, and vice
versa, how can we admit the notion that the two are opposite in their
nature  and in the  treatment they require?
  In a large proportion of cases, the chronic stage  of inflammation is
merely the continuance, under  milder  symptoms, of  a disorder essen-
tially the same as that which  existed  in the earlier or  acute  period.
The disease  is protracted  by the  causes just alluded to, and requires
treatment similar  in principle to that which we employ in its more active
state.  In other cases inflammation is obstinate and tedious, often be-
coming confirmed or chronic, from an unhealthy state of constitution,
whether  original, as  in those of  delicate frame,  and especially the
strumous, or brought on by unwholesome habits, by the various depres-
sing influences, or by the advance of age.   Under such circumstances,
we  adopt a treatment both local and general, different from that em-
ployed in the first kind of cases, often finding it necessary to raise and
support the  general  powers by medicines, generous  diet, stimuli, and 
VARIETIES OF INFLAMNAT10N.
103
the various invigorating  influences.   Hence probably has arisen the
notion that these  chronic  inflammations  are maintained by weakness,
which is correct in the sense thus explained.
   Various effects.—Inflammations differ in their effects; these differ-
ences depending principally, though not entirely, on differences in the
degree of disturbance.  Irritation  and congestion or determination of
blood, may denote the early stages in the deviation from health, before
the disturbance has attained such a degree as to warrant us in calling
it inflammation.  Then come hemorrhage, effusion of serum, of lymph,
or of pus, ulceration, and mortification.   Loss of transparency, preter-
natural adhesion, thickening, and induration, are changes dependent on
effusion, and are  observed for  the  most part, as more remote conse-
quences  of inflammation.   Softening may occur  as  a  primary  or
secondary effect of the inflammatory process.  On the  other hand, the
disturbance often passes away  without any ill consequence to the  part,
the symptoms either ceasing suddenly, or subsiding more gradually: both
these events are called resolution, which may therefore be distinguished
as sudden, or gradual; the former is called by the French,  delitescence.
   So much hardness is sometimes  produced  by interstitial deposition
in the inflamed part and  its subsequent organization, that the  part is
said  to  become  scirrhous.   The  production of  scirrhus,  and its sub-
sequent ulceration which  constitutes cancer, are mentioned as common
consequences of inflammation, even in the modern surgical works of
France and Germany.*   This  seems to me an erroneous view of the
subject.   The  consequence of  inflammation is simply induration,  often
with enlargement: in the part  thus altered we can  always discern the
characters of the natural structure. In  scirrhus the natural  structure
is quite lost, and a new organization substituted.   Confining  the  term
scirrhus  to that  induration which  precedes cancer, and  terminates in
the destruction of the part and  of life,  I have never seen it as the result
of inflammation,  either in the eye or any other organ.
   Common and  specific.—That the state of the constitution should
modify  inflammation is  a  circumstance  which might  be expected.
When it occurs in a healthy  individual, from an ordinary cause  it is
called common inflammation; this may exemplified by the  effect of
a wound on a person in good health.   The terms, true, proper, simple,
idiopathic inflammation are used in the same sense.   If the patient be
young, strong, and of full habit, the inflammation will be acute, active,
or phlegmonous in its character.   The terms, specific, sympathetic, spu-
rious, mixed, are applied to   those modifications which inflammation
 assumes in various  states of constitution, more  or  less different  from
the healthy condition.  A peculiar character will be  given to the in-
 flammatory process by certain differences of organization, or natural
defects of constitution, such as the scrofulous and rheumatic, by ac-
quired conditions of a morbid  kind, as in  gout and syphilis,  or by the
 specific  influence of the exciting cause, as in smallpox, measles, scarla-
 tina, malignant pustule, and all other  contagious diseases. In the  in-


   * Andral, Precis d?Anat. pathol. t. i. p.  501; Broussais, Examen des doctrines. Pro-
 positions  de  Medecine, prop.  196. Dictionnaire de Mdd. et Chir.  Pratiques, t. iv. p.
 444.  Langknbeck, Nosologic, b. i. p. 316—318. 
104
VARIETIES OF INFAMMATION.
 stances last mentioned, the disease is produced by one particular cause,
 and no other.  The specific character of the inflammation, therefore,
 arises from the cause in these instances, while in the others it has its
 source in peculiarity of constitution in the affected individual.    Under
 these various conditions, the appearances of inflammation will differ very
 much from those which it exhibits in persons of good natural constitu-
 tion, and in sound health.   Frequently, however, specific is so much like
 common inflammation, that the distinction  is difficult.  The extremes
 are  well marked, but  they are  connected by numerous  intermediate
 gradations.
   Varieties from difference of texture.—Inflammations differ according
 to the texture of the affected  part.  When we find  that inflammation
 is an  increased  action of the blood-vessels, that  its seat is in the ca-
 pillaries of a part; when we know, at the same time, that the arrange-
 ment of these  is peculiar in each tissue and  organ,  we naturally con-
 clude  that the inflammatory process will  have its peculiar characters
 in each structure.  From this source  we  deduce  differences, not only
 in the characters of inflammation, but also in its effects.  Hemorrhage
 occurs frequently in the inflammation of mucous membranes, rarely in
 other parts; effusion of lymph, adventitious membranes, and adhesions
 are  common in the serous, hardly ever observed in the mucous mem-
 branes.  Ulceration, which is  a frequent result in the skin, the mucous
 membranes,  the  articular  cartilages, and  the cornea, is  hardly seen
elsewhere.
   No organ in the body presents  so favourable an opportunity as the
eye, for observing the varieties of the inflammatory process, which de-
pend on difference of structure.  It contains specimens of all the animal
tissues, and these are, for  the  most part, immediately open  to our ob-
servation, so that the study of ophthalmic diseases constitutes an epitome
of general pathology.   In this  point of view nothing  can be more inte-
resting and instructive  than an observation of the varieties presented by
inflammation of the  conjunctiva, sclerotica, cornea, iris, and retina.
 ^ Other modifications.—Inflammation  is also modified by many other
circumstances, which influence the body more or less powerfully, such
as temperament, age,  sex; individual constitution;  mode  of  life, as
respects  air, diet, clothing, exercise, sleep, and  other habits; season,
climate, state of the weather and  atmosphere, and  the unknown agen-
cies  which produce  endemic or epidemic disease.
   When we consider the numerous distinct component parts of the eye,
the several circumstances which  modify the inflammatory process in
those structures, and the varied results  which it may produce in each,
we shall  be enabled to account  for the great number of ophthalmic
diseases,  if the length of the list  should frighten the student, he must
remember that these various affections  may, for the  most part, be re-
ferred  to a common origin, that they partake of a common nature, and
that, as they are nearly all the offspring of inflammation, so the treat-
ment of them is, in essential circumstances, similar.   The more atten-
tively we observe the phenomena  of disease, and consider the effects of
remedies, the more we  shall be led to adopt simplicity of treatment, and
the less confidence shall  we place in  complicated plans, or  great di-
versity of remedial means.                                  e 
VARIETIES OF INFLAMMATION.
105
         SECTION III.—ARRANGEMENT OF THE  SUBJECT.

  The arrangement adopted by Beer in his large work, is a simple one.
He treats, in the first place, of inflammations, and then of their conse-
quences.  However, we cannot refer all the affections of the eve to one
or the other of these heads;  and thus Beer is obliged to adopt a third,
a catalogue of undefined affections, which do not come under  either
of the preceding divisions.  As we do not know the  exact nature of the
inflammatory process, as the pathology of some parts of the eye is yet
in an imperfect state; and as we have seldom  an opportunity of ex-
amining the results of ophthalmic diseases after death, we are unable to
present  a classification of  them founded on clear and unequivocal prin-
ciples, and in all respects  satisfactory.  If it were required to give  an
arrangement of all diseases and defects of the  eye,  that is, of all  those
matters upon which our professional opinion may be required,  I should
be inclined to  adopt a greater number of divisions than Beer has  done.
  Injuries might be considered first; inflammations would occupy the
second division, and they  might be  conveniently distributed, according
to their seat, into those of the orbit, lids,  and globe;  those of the  latter
being subdivided  into the internal and external.  This head would of
itself embrace a long catalogue of diseases.  Thirdly, I should speak of
the consequences and concomitants of inflammation, as they appear in
the individual  parts of the apparatus; fourthly of tumours in the lids, in
the globe, and in the orbit; fifthly, of malignant affections, such as scir-
rhus, cancer, fungus  haematodes, melanosis; sixthly, of affections not
referrible to inflammation; and the seventh head  might comprise con-
genital  peculiarities or defects.  Under these divisions we  might con-
veniently enough arrange every thing which can  be the subject of pro-
fessional consideration respecting the eye.
  I propose, in the, following sheets, to treat of all these subjects, though
not under the same arrangement.  I shall consider successively the af-
fections of  the eye-lids  and eye-brows;  of the  globe; the  orbit; the
lachrymal organs.  Under the first division, chapters will be devoted to
wounds, inflammations and their consequences, ulcerations, changes of
figure and position, morbid connexions, tumours.   Under the second,
after a general view  of the causes and treatment of ophthalmic inflam-
mation, I shall describe the inflammations and other changes incidental
to each  of the  parts belonging to the eye-ball;  the operation for artifi-
cial  pupil, cataract,  amaurosis, and other defects of sight,  malignant
affections of the eye, dropsy, and atrophy of the globe will come under
this head.
14 
(  106  )
                        CHAPTER  II.

                     Affections of the Eye-lids.

                        SECTION I.--INJURIES.

   Wounds of the eye-brows and eye-lids.—The ordinary principles of
treatment are applicable to wounds of these parts, whether incised, lace-
rated or contused ; the only difference being that it is here more urgently
necessary to bring together the sides accurately, and to prevent inflam-
mation in order to attain that  speedy and perfect union, which affords
the best  security against subsequent deformity.  From negligence in
this point I have seen  in a longitudinal  wound of the eye-lid, a perma-
nent slit in the shape of the letter V, like  the fissure of  hare-lip.   Such
a fissure  has been called coloboma.   Inversion or eversion of the palpe-
brae may take place from similar neglect, occasioning serious inconve-
nience in various ways,  as well as great and conspicuous deformity.  I
saw  a case of horizontal wound in the upper lid, which had been grossly
neglected; the edges, not having been brought together, had cicatrized
separately, so as to form a slit in the lid like a button-hole.  The wound
had no doubt affected the eye; for the surface  of  the  lid had become
preternaturally connected to the globe, so that  it could not be raised,
but constantly covered  the cornea, rendering  the  eye, of which the
vision was perfect, nearly useless.
  I was consulted some time ago by a  gentleman who had been thrown
from  his horse, and received a wound  of the eye-brow, so that about
one-third of it, being  the middle portion, was detached and torn down
towards the lid.   From  inattention to the management of the accident,
the detached part of the brow healed below the level of the rest; pro-
ducing a remarkable  and by  no means becoming  appearance.  This
gentleman, who was handsome, rejected my advice  of letting it remain
as it was, and wished me to adopt some proceeding for removing the
deformtiy.   I made a vertical  incision on  each side of the displaced
part, united the incisions transversely above, and dissected off the por-
tion  from its new situation, leaving it adherent below.  Of the flap
thus  made I cutoff the upper portion, corresponding to the depth of the
eye-brow; and then secured the remainder in  its  proper position by
sutures.   It  adhered  readily, and the  operation seemed to have suc-
ceeded perfectly, when the patient left  England for a long absence on
the continent.
  Accurate union can  scarcely be accomplished  in  these  cases by
means of adhesive plaster, especially  in  the eye-lids.  At  all  events
sutures answer the purpose much better.   We employ small thin sharp
needles, with single silk  threads, and place as many sutures as may be
necessary to unite the parts in their proper relation to each other. Lay
over the part a soft linen rag or a portion of lint dipped in cold water;
use this application frequently; keep the patient quiet, and  attend to his
bowels.   Plasters, compresses, and bandages, are not only entirely use- 
WOUNDS OF THE EYE.
107
 less, but by heating the parts, must be injurious.  The sutures may be
 cut out  in  twelve, eighteen, or  twenty-four hours; in that  time the
 edges of the wound will have become agglutinated either by coagulated
 blood or coagulable lymph, so as to remain subsequently in proper ap-
 position.  We thus avoid all irritation  from the sutures;  it does not
 come on in so short a time.   By these measures the union  of  the parts
 is effected speedily and completely.  This mode of proceeding is par-
 ticularly necessary in wounds of the lid,  in which it is more difficult to
 preserve an accurate  adjustment than in those of  the brow.   After
 wounds in this neighbourhood, the  lids are often considerably swelled
 by serous effusion, which  is of no consequence.  Greater care is neces-
 sary to avert inflammation  in lacerated wounds  of the  brow or lid.
 They should  be  united by a sufficient  number of  sutures, and  then
 covered with  a soft wet rag, or  with  the water-dressing according to
 the plan of Dr. Macartney, or with a soft bread poultice.
   In punctured wounds, with trivial external mischief, injury may ex-
 tend deeply, into  the  orbit, to the bone, through the thin roof of the
 orbital cavity to the  brain.   In  some instances, where no alarming
 symptoms  have  appeared at first, inflammation within the skull  has
 come on in  a  few days, and has speedily proved fatal.  Suppuration in
 the orbit, although less dangerous, would be a serious occurrence.   In-
 juries of this description should be attentively and cautiously examined
 in the first instance, to ascertain  the extent  and nature of the injury.
 If we find or suspect that  the bone  has been  penetrated, every precau-
 tion calculated to keep off inflammation must be adopted, such as quiet,
 low diet, purgative medicine, and free depletion, if syrnptoms of cere-
 bral affection  or constitutional excitement should arise.
   Poisoned  wounds.—The eye-lids inflame and swell from the stings
 of bees and  wasps, the bites of knats and other insects.  Beer* men-
 tions that he saw in two cases, where the  stings of bees had  been left
 in the wounds, mortification, with danger of life, in a day  and a-half.f
 It would be proper therefore, to  extract  the sting, and to  employ  cold
 applications, as saturnine lotion,  or  vinegar and water.
   I once saw  malignant pustule on  the lower eye-lid,  and  the  contigu-
 ous part of the cheek.   It  occurred in a man  about  fifty, who had been
 employed in Leadenhall-market in handling and moving hides brought
 from South America.   They were in a very bad  state, one  of them
 accidentally came in contact with his face, but  he  hardly  noticed  the
 circumstance, and  did  not think it necessary to wipe himself.    He
 came to St. Bartholomew's hospital,  with a portion of integument, nearly
 equal in size to a crown  piece,  slightly  swelled, red, with some heat
 and pain.   The appearance was  just like that of incipient  erysipelas.
 The skin thus  affected  soon became livid, and then  mortified.    In the
process of separation,  which  went on favourably, it  became evident
that the soft textures beneath had suffered as  well as the skin, and thus
a large chasm was left below  the eye-lid, when  the eschar had sepa-
rated.  Excepting the sloughing, there were no severe local symptoms,


  * hehre, v. i. p. 234.
  [t Dr. Mease has recorded in the American Journ. Med. Sc. Nov. 1836. p. 265, a case in
which the sting of a bee on the eye brow, proved fatal in twenty minutes.] 
108
WOUNDS OF THE EYE.
nor was there any material constitutional disturbance.   The  affection
of the skin did not extend  beyond the part which was  red at the time
of admission.  The only local application was a  bread  poultice, under
which the slough separated, and healthy granulation and cicatrization
ensued, with the effect of  producing  slight eversion of the lower lid.
Bark was administered at first, but  soon discontinued, because it pro-
duced fulness of pulse, thirst, and headach.  Simple  saline medicines
were substituted.
   In scalds of the eye-lids we use the local  means best calculated to
lessen inflammation, and recovery takes place without deformity.   But
in burns, with destruction of the integuments, especially if it  be exten-
sive, cicatrization is likely to be followed by changes in the figure and
position of the palpebrae, with more or less of deformity.  The ciliary
edges of the palpebral may be drawn  towards the cheek or the  fore-
head and fixed there by the cicatrix, so that the conjunctival surface of
the lids is exposed (eversion or ectropium;) the upper lid may be drawn
towards the edge of the orbit, so as to denude the eye partially or  com-
pletely (lagophthalmus;) or the lids may be drawn out of place laterally,
towards the  temple or the nose.    These  cases must be carefully
watched during  granulation and cicatrization, and we must employ all
means in our power to prevent changes of figure or position in the lids,
Slow healing is favourable, as well as the abundant granulation which
generally follows burns where the integument has been entirely destroyed.
   Amaurosis from wounds of the eye-brow.—Wounds of the  eye-brow,
and neighbouring frontal region, are  sometimes  attended with  more
serious  consequences  than mere alterations  in  form, and the conse-
quent effect on personal appearance.  A violent blow in this situation,
with or without  wound, may affect  the  globe, as well as  the  external
soft parts;  may  cause serious injury  by concussion,  without  external
wound,  and thus sight may be impaired or entirely destroyed.  I shall
speak subsequently of concussion of the retina.
  The  bone may be fractured, and the anterior cerebral lobes injured:
or the fracture may extend along the thin, brittle, orbital process of the
frontal bone, reaching  to the optic  nerve, or to  the union of  the two
nerves.  In such cases injury to sight, in various degrees, will probably
accompany the external wound, but the state of vision is here a subordi-
nate point; our attention is called to the danger of life,  and the means
we resort to  for averting it will  probably  be  equally advantageous
to the  eye.   It  is obviously necessary, in  all such accidents, for the
surgeon to examine the globe carefully, and to ascertain, as soon as the
circumstances will allow, whether vision is injured or lost.
   Other cases have been  mentioned, where the  direct injury has been
confined to the soft parts of the brow, without anv fracture of the skull,
or any concussion of  the  globe, and yet amaurotic weakness of  sight
or actual  blindness, has supervened sooner or later.  Hippocrates has
made the remark, that  wounds of the eye-brows often cause blindness;
several learned men have commented on this remark, but have not at-
tempted to illustrate the point  by facts.   Beer, however, states that he
has had frequent opportunities of  accurately observing and curing
amblyopia (weakness of sight) and amaurosis (loss of sight) occurring 
WOUNDS OF THE EYE.
109
in consequence  of wounds of  the eye-brows:  Mr.  Wardrop,*  too,
speaks as if he  had seen such cases.  The amaurosis  or amblyopia,
according to Beer, may immediately  follow the injury, or come on
soon after; it may occur during the healing, that is, during the process,
of cicatrization,  or some time after the cicatrix has been completed ;  or
it may be  the consequence of simple bruise without wound.   The affec-
tion may be developed  rapidly or  slowly.f   The  instances referred to
are incised  or lacerated  wounds, embracing the trunk  or  principal
branches of the frontal  nerve, and  Beer regards the injury of this nerve,
as the determining  cause of the  amaurotic affection.   However,  he
applies this explanation to what he represents as the most frequent case,
viz. that of the impaired vision  coming  on  during the cicatrization, or
after its  completion.  He says, that where such wounds  are judiciously
managed and speedily healed by adhesion, no bad consequence  ensues;
but that when suppuration occurs, followed  by the granulating process
necessary for secondary union, the divided  nerves are  involved in the
inflammation,  and subsequently included in the  hard cicatrix, and, as
he conceives, compressed and irritated.  He observes, that among the
numerous cases  which  he has seen of such wounds, only two instances
have occurred of complete amaurotic blindness, in both  of which it did
not appear till some length of time after the healing  of the wound. His
treatment, founded on this  view of the cause, consists  in dividing the
nerves included in the  cicatrix.  He states, that  in  the two  cases just
mentioned,  the  patients were  completely restored to sight by cutting
down to the bone, close to the supraorbital  foramen, so as to divide all
the branches of the frontal nerve.
   The following case is related by Mr. Middlemore.
   " A person received a wound just above the right eye-brow, from a piece of glass,
which  was removed  immediately  after the  accident, by the patient himself;  the
wound was then dressed with simple dressing.  It healed  in  a  few days, but to  the
patient's  great surprise, the sight of the right eye  was very nearly lost;  he  had  a
painful sensation in the neighbourhood of the cicatrix, and a singular sense of creep-
ing, pritching, and quivering of the upper eye-lid,  and the integuments of the fore-
head.  The eye was perfectly natural in appearance, except that the action  of the iris
 was sluggish, the pupil dilated, and slightly drawn towards the nose.  I made a free
incision of the parts in the site of the cicatrix quite down to the bone, and all uneasi-
ness at once ceased, the eye shortly afterwards assumed  its healthy character and
functions, and vision was permanently restored.''^
   Some years ago  I saw a gentleman, about twenty years of age, ten weeks after he
 had received a violent blow on the left eye-brow.  The skin was divided, but the pa-
tient was not stunned, nor did he experience the slightest headach, either at  the time
or afterwards.  The lids were greatly swollen after the injury,  probably from ecchy,
 mosis, so  that he could not  open the  eye. When he did open  it, at the end of  a few
days, he could see  nothing,  although the surgeon informed  him that there was no per.
ceptible change in  the eye.   He was bled, purged, and confined  to low diet. I found
the appearance of the eye quite natural.   The pupil contracted and dilated  in sympa-
thy with  the other, but the independent  motion of the iris  was completely lost.  The
pupil dilated when the opposite eye was closed, and remained motionless in  that state.
Vision was extinct, so that  the difference between light and darkness could not be dis-
 tinguished.  There was a small cicatrix on  the eye-brow,  near the external angle of
 the eye.
   About the same time I was  consulted by a young lady, in whom  the

      * Essays, vol. ii. p. 179.                        t hehre, vol. i, § 195.
      X Treatise, vol. ii. p. 364. 
110
WOUNDS OF THE EYE.
 eye-brow and lid had been  much  lacerated in  consequence of a  fall
 from her horse.  There was imperfect amaurosis of the eye, which did
 not seem to have experienced direct injury.  The pupil was moderately
 dilated.
   In some cases, it is doubtful whether  the amaurosis following blows
 on the  head is determined by the particular nature or sympathies of the
 organ or texture immediately injured.
   In October 1827, I saw a gentleman, thirty-two years of age, who had been thrown
 from his gig seven weeks before, and had fallen  on  the head.  He  was  completely
 stunned, and remained insensible for some hours.   According to  the account of the
 surgeon  who attended him after the accident, there  were appearances indicating that
 the head had come in contact with the ground above the right eye-brow, where  the
 skin afterwards exhibited the discoloration of a slight bruise; there was neither bruise,
 ecchymosis, nor any direct injury to the globe, conjunctiva,  upper eyelid, or eye-brow.
 The eye, in which vision  had before been perfect, was totally blind, and had continued
 so in spite of the treatment adopted for the accident, as well as  in reference to this
 particular affection.   When I saw the patient, there was  no trace of  injury to  the
 part which had been struck.  If both eyes were open, no difference could be observed
 between them : the pupils were perfectly alike in size, colour, and movement.  When
 the left eye was closed, the ri<rht pupil dilated moderately,  and remained fixed in that
 state under every variation of light.  When the left eye was opened again, the right
 pupil contracted.   When both eyes were open, the  right pupil dilated and contracted
just as the left.  The right eye was absolutely insensible to light; the left suffered a
little sympathetically.
  A lady was thrown out of a gig, and came to the  ground on the head  and side; she
was stunned, but soon recovered.   Bruise and ecchymosis of the right temple and eye-
lids were observed; but the latter were not closed.   She was confined to bed in con-
sequence of the injury to  the side, for five weeks, at the end of which time she found
the sight of the right eye affected.   I saw her three months after the accident, when
the pupil of the right eye was twice as large as that of the left;  she  said  that it had
been still more dilated at first.  It  did  not contract  on exposure  to light;  there was
confusion of vision.
   The blindness occasioned  in Magendie's  experiment of dividing the
nerve of the fifth pair (see ante, p.  86,) may be cited in support of the
opinion, that the imperfection of sight in the cases  now under conside-
ration, arises from injury of  the  frontal  nerve.   The influence which
morbid  conditions  of  this nerve may exert  on the eye, is strikingly evi-
denced  in a case now under my care.  It is that  of a gentleman with a
large cancerous ulcer of the  forehead, occupying the right eye-brow in
its whole  breadth from the root of the nose  to the temple, and  the right
frontal region for about two  inches above the brow.  In the extent just
mentioned, the soft parts have been completely changed in structure by
the ulceration, which has been going on for some years, and  even the
bone has participated in the disease, small fragments having come away
from time to time.  The eye has lately become the seat of inflamma-
tion, with destructive ulceration of  the cornea, as in the cases of dis-
ease affecting the trunk of the fifth pair.
   It is still a matter of doubt, whether injury of  the frontal  nerve may
cause amaurosis.  In some of the cases I have mentioned, the external
injury was not in the situation of the nerve; while there is  no clear evi-
dence  of the  nerve having really  suffered  in any instance.   Again, I
have seen amaurosis  of one eye following severe injury of the head,
where the frontal region had  suffered no direct violence.
   During the revision of these sheets I have been consulted by a lady
labouring under amaurosis of the right eye, consequent on an  injury of
the  head  not involving the  superciliary or frontal region.    She was 
WOUNDS OF THE EYE.
Ill
thrown from her horse in September, 1839, and  the back part of the
head towards the right side came to the ground.   She rose, remounted,
and rode home, a distance of twelve  miles.   She became ill, and was
confined to  her room for  ten or twelve  days.  When she came down
stairs, the  sight was imperfect: it soon recovered in the left eye, but was
quite gone in the right.  When I saw her (in June, 1840) she could not
dislinguish objects with the  right eye, although it was sensible to light
and darkness.   The appearance of the organ was perfectly natural, and
the movements of the iris both independent and associated, if not in all
respects equal to those of the left eye, were very little different.
   Beer has  strongly recommended a complete division of the nerve by
a transverse cut down to the bone, where impaired vision is supposed to
arise from injury inflicted on it, and states that he had found the pro-
ceeding  uniformly successful in restoring sight.   It failed  invariably
with Dr. Hennen*  and Mr. Guthrie,f who tried it in several instances.
   If sight  may be  thus injured or lost by wounds of the frontal  nerve,
we should infer that similar  consequences would  arise from injuries of
the infra-orbital nerve.  Beer says that  this is the case, but he does not
cite any  facts.J  The latter nerve, however,  is  more effectually pro-
tected than the former, and hence it is rarely wounded.
   [Electricity, galvanism, moxas, repeated small blisters, and strychnine, ap-
pear to us  to  be worthy of trial in many cases of this form of amaurosis, before
resorting to the division of the supra orbitar nerve, as recommended by Beer.
   In several  cases we have found much benefit from the application of galvan-
ism, one or two of which we will relate.
   Imperfect Amaurosis from a blow—Partial recovery.—Abraham  Corbit, setat. 41,
native of England; married; scissor grinder; admitted  into Wills Hospital, October
5th, 1839.   Nine days ago, whilst splitting wood, a piece flew up and struck him over
the right eye.  He experienced little or no pain from the blow  at the time, nor did he suf-
fer from any subsequently.  But three days after he found that the sight of the right eye
began to fail, and by the seventh day after the accident, he was quite blind in it. Per-
son spare, medium height; irides  gray, pupil of right eye  rather larger than that of
left; in other  respects  appearance of this  eye perfectly natural; health good.   Has
been blistered  over right brow and purged.  Can now tell  when objects are placed
before his right eye, but cannot distinguish their form.  Ordered  him to be purged
every alternate night,  with Mass. hydrarg. cum. extr. colocynth comp. aa. gr. iv.
The following collyrium to be dropped in  his eye daily. & Strychnin gr. ij; Acid.
acet. 3j. Aq : Pur:e. %].
   October 7th.  Sight has improved ; can distinguish the sashes of the windows; sees
better at midday than in the evening, and  near objects better than remote ones.  Con-
tinue treatment.
   9lh.  Sight continues to improve; can tell how many fingers are held before right
eye, and can distinguish a silver pencil case.
   11th.  Sees distant objects better; distinguishes the window sash  distinctly and a
pencil case at the distance of two yards; continue treatment, with addition of mustard
pediluvia at bed-time.
   14*^.  Can distinguish some of the large capitals in a primer.
   16th.  Complains of rheumatic pains in  his lower limbs; &. pulv. Doveri, gr. x, and
mustard pediluvium at bed-time.
   17th.  Sight diminished.  Has headach ; rheumatic pains continue.  Ordered viu.
rad. colchic. gtt. xx. ter. d.; mustard pediluv. at bed-time.
   18lh.  Sight diminishing; rheumatic pains rather less severe; cups to spine; con-
tinue colchicum and pediluvium.
  19th.  Vision improved ; rheumatic pains lessened ; prevented sleeping by tooth-
ach; extract tooth ;§ continue treatment.
  * Observations on some points in Military  Surgery, p. 366.
  t On the Operative Surgery of the Eye, p. 102.
  t hehre, vol. i. § 205.                         § This was neglected. 
112
WOUNDS OF THE EYE.
  21st.  Sight improving; can distinguish large letters; says objects "appear clearer
and more distinct;" continue treatment.                                   _,
  23d.   Sight better;  rheumatic pains  less; bowels costive; sleeps well.   Cups to
back;  senna and salts.
  27th.  Sees distant objects better;  has required purgatives occasionally to remove
costiveness; rheumatic pains diminished.  Continue  treatment; apply galvanism, one
pole of the  instrument to right brow, the other to mastoid process of same side.
  29th.  Sight has improved he thinks since application of galvanism; sees objects
at the end  of the ward  ; rheumatic pains pretty severe.
  31st.  Sight about the same;  rheumatism much better;  sleeps well; bowels regu-
lar; galvanism was applied yesterday, but without  any perceptible benefit; ordered
moxa to  brow.
  November 3d.  No improvement in vision; free from rheumatism; repeat moxa.
  6th.   No improvement in sight within the last week;  sees, however, well enough,
he thinks, to  weave, which  has been  his occupation recently, and  being desirous of
finishing some work for an order, as he has a family  to support, he requests to be dis-
charged as  an in patient, and to be placed on the out door list.  His wishes were gra-
tified, and he was furnished with a box of purgative pills (blue  mass and  extr. colo-
cynth comp.) and a bottle of Henderson's collyrium.
  23d.   The patient was again admitted into the house.   During the interval he  had
several  times  received  advice, but no change  in the  treatment  worthy of note was
made.  He  had been weaving and the premature use of the eye had impaired its power,
and he could not now see sufficiently  well to continue his work.  The treatment to
which he was now subjected, consisted in the frequent use of galvanism, with the ad-
dition after a few days  of strychnine  conveyed into  the system  by the  galvanic cur-
rent ;  with  mustard pediluvia and tincture of capsicum in frictions to the feet and legs,
(the patient suffering much during the first three weeks in  December from coldness
of extremities,) and a due  regulation of  the bowels.   By these  means  his sight im-
proved.  At night the  patient stated that he could see considerably better than pre-
viously;  though he maintained, contrary, however, to our impressions, that he saw no
better by daylight.   When my tour of duty expired he was still in the house, and I
find by the  register that he was discharged February 10, 1840, relieved.
  Observations.  Whether the  amaurosis in the present instance was the result of
concussion  of the retina, or of injury of the supra orbitar branch  of the fifth pair can-
not  positively be determined, as it was impossible to learn from the patient whether the
blow was directly on the eye or on the brow, the  injury being so slight as not to have
attracted much attention at the time, and the blow had left no mark.
  The remedy which  was most useful  in this  case was  unquestionably  galvanism.
We have an evidence of this not only  in the improvement which followed its applica-
tion, but in the still more striking fact, that the patient actually saw better whilst subjected
to the galvanic action.  On the 6th of  December, whilst the galvanic current was
passing from the mastoid process to the superciliary  ridge, I  requested my  intelligent
friend, Dr. John Neill, to hold before the patient some letters; and 1 asked him if he could
distinguish  them: he replied, " I see better than I could."  The  galvanic current was
then interrupted by disconnecting one of the wires from the plates, and which was accom-
plished without the patient's knowing it.  The letters being still held up, the patient
in a minute or two requested the letters to be held nearer, then farther off,  and finally
he observed, " I do not  see as well as I did just  now."  The connexion being again
made, the patient almost immediately, and with  apparent surprise exclaimed, "I see
better  now."   The patient was not  aware of  our object  in  this experiment, and
though of course he must have been  sensible of a difference  in the effect, still he did
not know, as the poles were all  the  time applied to his head, that he  was  at times
freed from  the action of the apparatus.
  In a case of a similar kind, that of Jos, M. Sutter,  a  carpenter, setat. 43,  admitted
October  18, 1836, a complete cure was effected by galvanism.  This man trod upon a
log, which  tilted up and struck him over one eye.  When admitted he  had complete
amaurosis of that eye.   Various remedies were employed, among others moxas, with
little benefit.  I then resorted to galvanism, the  very  first application  of which was
productive  of marked  improvement, and  its employment for an hour, two or three
times a week, for five weeks, effected a  complete cure.  He was discharged January
3, 1837, well.                                                      b          3
  In Sutter's case, and also for Corbit when he was the first time in the  house, the 
WOUNDS OF THE EYE.
113
 galvanic apparatus employed was a Cruickshank's battery of twenty pairs of plates one
 and a-half inches square.  Subsequently for Corbit we  used one with fifty pairs of
 plates three inches square.   When this was in full activity it was too powerful for our
 purpose, and only one-half or two-thirds of the plates were then used.  The connexion
 was made by means of leaden wire conductors, to one end of each of which  was sol-
 dered a slip of copper; and to the other a hemisphere of brass, the  flat surface  of
 which was tiled into grooves crossing at right angles, so as to form a number  of sharp
 points.  Over these were tied thin discs of sponge, which  were  kept moist with a
 solution of common salt.  When we desired to introduce the strychnine into the sys-
 tem we moistened the sponge attached to the negative polo, and sometimes both, with
 a solution of this substance.  That the  strychnine may readily be conveyed  into the
 system by this means would appear to  be  shown  by the experiments of M. Fabre-
 Palaprat,* and also by the fact that  usuilly much greater twitchings of  the muscles
 were observed when the solution of this substance was employed, that when the sponge
 was wet merely with the solution of common silt.  When  the whole  force of the
 battery was not  wanted, instead of placing  the slips in  the extreme cells, they were
 placed  in cells more or less remote, according to the power required : thus the force
 was easily regulated.
   Mr. Hey narrates (Med. Obs. Sf  Inquiries, v.  i.)  a case  of  amaurosis fol-
 lowing a wound of the forehead caused by the patient falling  against, a chest of
 drawers, which was cured by Electricity; and Dr. Lichtenstadtt another which
 seemed to have originated in a  wound of the infra-orbitary nerve in which the
 same application had an equally happy effect.]
   Ecchymosis of the eye-lids.—The eye-lids, the eye-brows, and the an-
 terior surface of the eye, are  liable to ecchymosis.   Effusion of blood
 into the texture of the part produces those livid, blackish, or  bluish marks
 in the palpebrae and  surrounding skin  commonly termed  a black eye.
 Much loose cellular texture enters into  the composition of the lids,  and
 the effusion which takes place  is sometimes considerable.   The palpe-
 brae may be distended by a projecting convex swelling, and in pugilistic
 contests  the eyes of  the combatants become  in this way completely
 closed.   On such occasions  the seconds are in the habit of performing a
 kind of chirurgical operation, without having received any diploma from
 the college: they make an opening in the skin with a lancet, and squeeze
 out the blood,  by which expedient they enable the combatant  to  see his
 wayr a little longer.  Ecchymosis is often occasioned by the application
 of leeches.   In whatever way these  external marks are produced, indi-
 viduals are generally desirous of getting rid of them, and surgical assist-
 ance is sometimes sought for that purpose.  The external application of
 cold is usually  resorted to in the first instance.  The question is, whether
 we can adopt  any means to hasten the removal of this  discolouration 1
 Absorption will  accomplish  the  business in  a  certain  time,  and it is
 doubtful whether we can abridge  the period by using any of the articles
 termed discutients.  The  muriate of ammonia, dissolved in a mixture
 of vinegar,  spirit, and water, is employed for this purpose,  and will do
 as much good as any thing.   The liquor ammonias acetatis may be
 used, alone or  mixed with rose-water;  or the liquor ammonias,  mixed
with soap liniment, may be rubbed on the part after two or three days,
as such stimulating applications are supposed to be capable of accele-
rating the process of absorption.  There is  a quack preparation,  called
" pommade divine," composed apparently of unctuous and aromatic in-
gredients, which  is used for this  purpose; it is  an  agreeable sort of

       * See American Journal of the Medical Sciences, for Feb. 1834. p. 561.
       t Mackenzie, Treatise, &c, from Graefe und  Walthers Journal.
       15 
114
INFLAMMATIONS OF THE EYE-LIDS.
salve, and  unexceptionable as an application.  I have fancied that the
discolouration of ecchymosis has disappeared sooner under its use.
  Mr. Tyrrell recommends a poultice made with the root of the black
bryony, finely scraped after being deprived of its external bark, and
mixed with crumbs of bread.  It  should be enclosed in a muslin bag, and
renewed every six or eight hours until  the absorption of the effused
blood is completed, which will take place  in forty-eight  hours or a little
more, even when the ecchymosis is considerable.   He adds, " I became
acquainted with this remedy, from noticing that some of our celebrated
pugilists appeared, a few days after severe encounters, without any dis-
figuration from ecchymosis; and, on inquiring the reason of this, I found
they employed the bryony root, in the manner I  have described, to re-
move such evidence of their occupation."*
  [We have known common tallow, thickly  applied, over the contused part,
employed with the same view, and apparently with the desired result.]
  SECTION II.--INFLAMMATIONS OF THE EYE-LIDS AND THEIR CONSEQUENCES.

  Inflammation of the cellular texture of the lids; abscess.—The cellular
texture  is liable here, as in other parts, to inflammation,! which may
proceed to suppuration.  There is nothing peculiar in the abscess thus
formed, nor in the essential points of  treatment.  The matter may ap-
proach to the surface on either aspect of the lid; or it may be present in
both situations  at once.  In order  to avoid subsequent deformity, we
should endeavour to limit the extent of suppuration as much as possible.
An early opening of the  abscess is necessary  for this purpose; the inci-
sion should be transverse, that is, parallel to the natural folds of the in-
tegument.  If the integuments of the upper lid should be detached from
the subjacent parts,  and  distended by a large collection of matter, the
consolidation of the abscess may cause the tarsus to become unnaturally
fixed to the superciliary ridge, and  lagophthalmus, or ectropium with
great deformity may ensue.  This point is still more important in scro-
fulous than in common suppuration, because the matter extends laterally,
with little disposition to approach the surface; and consequently, if left
alone, will occupy the whole lid.  I have seen about half a dozen in-
stances, in which distressing deformity from lagophthalmus, either alone,
or in company with  eversion of the superior  tarsus, has resulted  from
this cause; the external convexity, or the very ciliary margin  of the
tarsal cartilage, having become closely attached to the edge of the orbit.
In one case, of a young gentleman from Scotland, where the appearance
was so very disagreeable that he kept the eye constantly covered by a
close green shade, and consequently was prevented from using the organ,
I succeeded, by a painful Operation, and much subsequent trouble, in re-
moving the deformity entirely, and in restoring the eye.   In another in-
stance of a highly scrofulous subject, an abscess was allowed to burst
in each upper eye-lid, producing ectropium on both sides, which greatly


   *  Practical Work, vol. i. p. 436.
  t Blepharophthalmitis  idiopathica, Beer, vol. i. §291.  Blepharitis idiopathica  Jueng-
ken, p. 144. 
INFLAMMATIONS OF THE EYE-LIDS.
115
disfigured the individual, and could be only partially remedied.  Fistu-
lous excavations sometimes remain after palpebral abscesses.
   [A case, in which inflammation  of  the cellular tissue of the upper lid ter-
minating in abscess, was mistaken for purulent ophthalmia, and the patient
subjected to much alarm and  very  unnecessarily harsh treatment, came under
our observation which we will briefly  notice as a caution to practitioners.
   We were requested by a medical friend to visit with him a young lady who
he stated was labouring under violent  purulent ophthalmia which had resisted
several large bleedings, and the most  active antiphlogistic measures, and he
feared that she would lose her eye.
   We found the affected lid of a  dark  red colour, greatly swollen, hot, and
painful;  the lids encrusted with matter and the  patient unable to separate them
to the smallest extent. At this period there certainly was a sufficient resemblance
to purulent ophthalmia to mislead an incautious  practitioner.  Upon examining
the lid, however, fluctuation,  was  at once detected.   An incision Avas made
with a bistoury, about two  drachms of pus evacuated, and in  a few minutes
the patient was able to separate her lids, and to her great delight assure herself
of the safety of her eye.  With the exception of slight redness,  this organ was
entirely  unaffected.  In a few days the abscess healed, and a cure was effected
without the least deformity.3
   Erysipelatous inflammation of the eye-lids.—In erysipelas the palpe-
bral suffer in common with the rest  of the face; the disease indeed often
begins about the eye.   The integuments are more or less reddened, and
the lids are swelled from serous effusion into the sub-cutaneous cellular
tissue.  As that tissue is  abundant, the  swelling is often considerable, so
as to close the eyes, with great inconvenience and sometimes  alarm to
the patient.   The disease goes through its  course and ends in resolution,
with or without the previous formation of bullae from effusion under the
cuticle.   The inflammation may be more violent and proceed to suppu-
ration and mortification of the cellular tissue.   The purulent fluid, which
is sometimes white  and thin,  sometimes yellowish and thicker, is infil-
trated in  the cellular  tissue,  which turns  yellow  and then  loses its
vitality.
   In ordinary cases of erysipelas no local treatment is necessary for the
palpebras; at least cool or  tepid ablution will suffice.  If the inflamma-
tion should be  considerable, with  much heat and  burning  pain, blood
may be abstracted locally by minute lancet punctures, the bleeding being
encouraged by tepid sponging.  The vessels are thus unloaded with con-
siderable relief of the local  distress, and the danger of suppuration and
mortification is  averted.  The latter changes, which are attended with
great suffering in  the  part, throbbing pain, and  generally considerable
constitutional disorder, are  best remedied  by free transverse  incision
through the affected textures, which not only immediately arrests the
local disturbance, but  prevent the extension of mischief by providing a
free outlet for matter and slough.
   Simple  abscess of the eye-lids, which is not unfrequent in the decline
of erysipelas, should be opened early by a  transverse incision.
  [Carbuncle, of the eye-lids.—>" This circumscribed,  gangrenous inflamma-
tion of the  cellular membrane," Dr. Mackenzie remarks, " is occasionally met
with in the eye-lids.   The  swelling is of a dark red, or purple colour, ex-
tremely hard, and attended by severe burning pain.  Vesicles rise on its sur-
face, occasioning  intolerable itching.  Ichorous  matter is discharged, and  the 
116
INFLAMMATION OF THE EYE-LIDS.
affected cellular membrane and skin becoming black and sloughy, at length fall
out.  The cavity left by the separation of the slough granulates and heals up.
  Carbuncle occurs principally in old persons, whose constitutions have suf-
fered from irregularities in diet.
  Opium to relieve the  pain; bark and  wine, to  support the strength; laxa-
tives, and gentle diaphoretics, make up the  general treatment.
  An early and  free  incision into the  tumour, most effectually relieves the
pain, allows the  matter to escape, and promotes the separation of the slough.
An emollient poultice is  to be applied  after the incision has been made, and
continued till the cavity left by the slough  has been filled up  by gianulation.
The sore is then to be dressed with simple  cerate."]
  (Edema.—Serous effusion takes place into the cellular texture of the
eye-lids, when  inflammation  exists in the neighbourhood, either from
accident or disease, especially if it proceed to  suppuration.   The lids
sometimes swell  considerably from trivial  causes, such as the irritation
of hordeolum, the bites or stings of insects, and the bites of leeches ap-
plied in the neighbourhood.   They are often enormously enlarged in in-
flammation of  the lachrymal sac : the eyes are closed, as in erysipelas;
and patients are  sometimes alarmed  by the fear of blindness, until the
nature of the  case is explained.  This  swelling, which constitutes the
oedema palpebrarum, calidum or inflammatorium, goes away as the cause
which  produced it subsides.  The lids are swelled, but not so considera-
bly, in anasarca  of the face  (oedema frigidum or  chronicum.)   If this
kind of swelling or the preceding were troublesome, especially by closing
the lids, the serous fluid might be let out by a  small puncture.
  Emphysema  of the eye-lids may arise  from injury of the lachrymal
sac, or from fracture of the bony parietes of the nose  or nasal sinuses
in the vicinity  of the orbit.  The swelling  has not been considerable  in
any case within my observation, and has soon disappeared.
  Ophthalmia, tarsi.—In the cases hitherto described, the  integuments and
cellular texture of the palpebrae are the seat of disease: in catarrhal inflam-
mation of the lids, which will be next spoken of, the mucous membrane is
affected.  There is another inflammatory  affection of  these organs, in
which  the mucous membrane, the tarsal cartilage and glands, and  the
ciliary margin  are involved, to which the old name of ophthalmia tarsi
is not inappropriate.   The edge and the neighbouring part of the lid are
swelled, bright red, and extremely painful; the palpebral conjunctiva is
of a scarlet colour and villous.   If the lids are moved, an acute pricking
sensation is experienced, with a sensation as if  there were sand in the
eye; hence they are  kept  closed and at rest.  There is lachrymation,
with more or less intolerance  of light, and feverish disturbance of the
system.   The  ciliary  margins,  at first dry, become moistened  by in-
creased mucous secretion, and are more or less firmly agglutinated in
the morning.   In a severe attack of  this disorder,  especially if it affect
both eyes, active antiphlogistic treatment may be required.  I have
found  cupping, and even venesection,  necessary  under such circum-
stances.   In the  early stage, cold lotions  with  mild unctuous applica-
tions to the ciliary margins are best; sometimes tepid ablution, or steam-
ing the eyes, is found  most agreeable.  When the active inflammation
is subdued, the case must be treated in  the same way as lippitudo.
  Repeated attacks of this inflammation seriously affect the tarsal car- 
                    INFLAMMATION OF THE EYE-LIDS.                 117

tilages, causing them to contract and turn inwards, and thus sometimes
producing trichiasis or entropium.
  Catarrhal inflammation of the eye-lids.*—The propriety of describing
this as a distinct  affection  from the preceding  may be doubted.   The
seat of disease and the symptoms  are partly the same in the two cases.
In the former, the textures of the lid are more generally involved ; while
in this affection the disorder is confined to the  ciliary margin and  the
mucous lining.
  In its active form, the catarrhal affection begins with dryness, soreness,
smarting, burning of the ciliary margins, which are red, a little swelled,
and painful, sometimes acutely so.  The angles are generally affected
first, or principally; they may suffer alone, or the whole margin may be
inflamed, the palpebral conjunctiva is red, perhaps a little thickened and
villous.  Uneasiness is experienced on motion, with a sense of stiffness
or dryness, and the feeling of a foreign  body in the eye; hence, in an
acute attack, the  lids are kept closed and  quiet.  Employment of the
eye, as in reading or writing,  particularly before the fire, and exposure
to strong light and heat, bring on pain with  lachrymation and confusion
of sight.   Mucous discharge soon takes place  from the inflamed mem-
brane, and the pain is  then  succeeded  by itching.   The  Meibomian
glands participate in the affection, which begins on  the ciliary margin
of the lids, in the thin and delicate skin perforated by the  ducts of these
glands, which are themselves in close contact with the inflamed mem-
brane. They no longer pour out the mild unctuous matter, which usually
smears and softens the edges of the lids, but their secretion is suspended,
so that in the morning the  ciliary  margins are stuck  together by the in-
creased conjunctival discharge, which  has become incrusted by  the
evaporation of its watery part during the  night.   In this way the  lids
are often so firmly agglutinated as to require bathing with warm water
before they can be parted.   When the Meibomian secretion is renewed,
it is altered in quality, being viscid, and  thus assisting in  causing  the
palpebras to stick together.   This  morbid secretion, spread over  the
cornea, affects its polish and transparency,  as glass is rendered dull by
extraneous impurities; hence vision is impaired, and often considerably,
alarming patients for their  sight, and making them ask for something to
clear  it.   Hence frequent  attempts are made to  clear the cornea by
moving the lids; hence, too, when vision becomes worse in the evening,
exacerbation of the symptoms, rings, haloes, and the irides, are seen
round the candle, or its flame splits into  stars.  At the same time  the
uneasiness, smarting, or  itching, the stiffness, redness, and  mucous  se-
cretion are increased.
  The ciliary margins lose their cuticular covering, and  become  raw,
with  further changes of the  Meibomian and  conjunctival secretions.
These irritate the lids and excoriate them externally, particularly to-
wards the  angles, and the lower  lid more especially, which is  often
entirely deprived  of its cuticle, and even ulcerated.   This, which is  the
chronic form of the complaint, and called lippitudo, often lasts for many

  * Beer calls this affection Blepharophthalmitis glandulosa idiopathica, that is, idiopathic
inflammation of the glands of the eye-lids, hehre, vol. i. p. 284.  It appears to me that
the mucous membrane is the primary seat  of disease, and that the Meibomian glands are
affected secondarily. 
118
INFLAMMATION OF THE EYE-LIDS.
 weeks, months, or even years; recurring on  the application of slight
 causes, whether  external or internal; often originating insensibly and
 advancing slowly, without any marked acute stage; leading to thick-
 ening of the lids, especially of the mucous lining of the lower, and con-
 sequent ectropium of that lid, and  to loss  of the cilia.   The affection
 commonly begins, and is  usually most conspicuous towards the angles
 of the  eye:  hence the expression lippitudo angularis.  The affection
 presents no peculiarity of character in elderly persons to justify the ap-
 pellation of lippitudo senilis.
   The lower lid suffers more than the  upper, especially in  the chronic
 stage; its edge and  cutaneous surface being irritated and excoriated by
 the increased and morbid secretions.
   Causes.—Catarrhal  affections of  the lids  are frequent, and easily ex-
 plicable ; beginning in  the ciliary margin, where the thin and vascular
 membrane  is constantly exposed to atmospheric influence, and to the
 irritation of unhealthy secretions lodging and incrusting  about  the eye.
 According to Beer,  catarrhal inflammation of the lids  appears occa-
 sionally at  Vienna, almost in an epidemic form, under the prevalence of
 cold drying winds at a particular season of the  year.*  Although we
 do not see cases here in such abundance  as  he speaks of, they occur in
 so much greater number in cold and wet weather, particularly in the
 long prevalence of cold winds, as to indicate their atmospherical origin.
   But inflammation  of the lids, (ophthalmia tarsi,) not essentially dis-
 tinguishable from the catarrhal, is often produced by other causes; by
 any irritation applied to  the  ciliary margins,  especially in persons of
 fair complexion, thin skin, and what is called a lax fibre.  Thus it may
 be  caused  by residence in close  confined  air and  smoky  apartments;
 by sitting up at night in close  chambers; by confinement in-doors; by
 much employment of the organ by candle-light; by exposure of  it to
vapour, smoke, and  other irritants.   The operation of  such  causes is
aided and increased by neglect of personal cleanliness, indulgence in
fermented liquors, particularly of the  stronger kind, by other impru-
dences in regimen, and by inattention to the  state of the bowels.  Hence
it is common in nurses, washerwomen, and  many of the middling and
lower classes, becoming  at last, from long exposure  to the exciting
causes, inveterate and  habitual.
   The  treatment, in the acute or incipient stage, must be of a  mild an-
tiphlogistic  character.  Leeches may be necessary to the lids, with tepid
lotions, mild ointments, and active aperients: afterwards alteratives and
 mild purgatives may be administered.  The organ must be rested, and
 the exciting causes removed.
   As soon as the active symptoms are  removed, astringents and stimu-
 lants are not only advantageous but necessary.   Scarification is most
applicable to this form of complaint; the lid should be inverted, and the
shoulder of the lancet drawn along  at a single stroke, from one end to
the other.  The vinum  opii, and the  metallic salts in  solution may be
employed.  One grain of the oxymuriate  of  mercury in eight ounces of
 rose-water, makes a  useful mild collyrium.   The  liquor aluminis  com-
posite of the London Pharmacopoeia, diluted with six, five, or  four
* hehre, vol. i. p. 301. 
INFLAMMATION OF THE EYE-LIDS.
119
times its quantity of rose-water;  or a solution of  the  acetate  of zinc
may be used for the same purpose; but the greatest benefit is derived from
stimulating ointments applied to the ciliary margins of the lids.   When
thus used, they correct the Meibomian secretion, and relieve the patient
from the very troublesome agglutination of the lids.  The unguentum
hydrargyri nitratis, or the citrine ointment, as it is  called from  its yel-
low colour, is the best of these.  Having gently melted  it in the  flame
of a candle, take up  a little of it with a small camel-hair pencil;  carry
the pencil two or three times  through the flame of the candle that the
ointment  may be perfectly liquid; then draw it once along the  edge of
each lid, taking  care that the application shall be confined to the ciliary
margin.   When applied in this way, the ointment  causes a sensation of
heat or even  burning, with smarting or  pain, and a  copious  flow of
tears.  The patient cannot open the eye; and he should keep it  closed
till the effect has completely gone off: he will then feel much relieved.
 Sometimes it may be advisable  to  introduce a drop of the  vinum  opii
 between  the lids previously.   The red precipitate ointment (ung. hy-
 drargyri  nitrico-oxydi)  may be used in  the same way.  In  its mild
 form, that is  with one grain to one dram of spermaceti cerate, this oint-
 ment may be applied at night, from the commencement of the affection.
 If the patient or an ordinary attendant should apply either the citrine or
 red precipitate ointment,  the strength should be  reduced one-half, two-
 thirds, or three-quarters.*   Much more benefit however, is derived from
 the citrine ointment of  full strength, when used in the way above  de-
 scribed by the surgeon, or a person properly instructed.   The ointment
 of Janin, so much recommended by Scarpa and other foreign writers,
 is a composition of  inferior efficacy; it  is  made  of  white precipitate,
 3ss; armenian  bole and tutty, of each 3j; lard,  3ij.  The active ingre-
 dient in  Singleton's, or the golden ointment, is stated by Dr. Paris! to
 be orpiment (auripigmenlum, sulphuret of arsenic.)
    [Todine and kreasote ointments are useful in some cases but we have found
 the Ung. hydr: rub. of the London Pharmacopia? of 1787 the most efficacious.]
    These  stimulating local applications must not  be  used in  an early
 period of the complaint;  they would aggravate the inflammation;  nor
 should they be employed when the eye is inflamed, however  long the
 affection  may have lasted.  The antiphlogistic treatment must precede
 in such a case.  If our  stimuli  irritate, they should  be laid aside,  and
 mild local applications should be substituted.
    The complaint is often tedious, lasting  for months, or  even years,
 sometimes better and sometimes worse.   It is aggravated  by cold  and
 damp weather, and by cold winds;  by excessive  exertion of the organ,
 as in reading small print, in writing, particularly by candle-light.   They

   * The red precipitate ointment of the London Pharmacopoeia, containing1 one dram of
 the precipitate to one ounce  of the  vehicle, is too strong for the eyes. Mr. Mackenzie
 allows only twelve grains to the ounce, increasing it in some cases to twenty.  (Practical
  Treatise, p. ]38.)  Juengken considers from one to two grains to  two drams of ointment
 strong enough, when it is to be introduced into the eye; one or two grains may be added,
 when it is used to the lids only.—hehre von den Augenkrankheiten;  p. 936.
    The German writers direct the red precipitate to be mixed  with fresh butter, which is
  unfit for the purpose from its soft consistence, and soon turning rancid. Juengken advises
  a mixture of hog's lard and wax, similar to that directed in the London Pharmacopoeia.
  Ibid. p. 903.
    t  Pharmacologia, vol, ii. p, 99. 
120
INFLAMMATION OF THE EYE-LIDS.
 who suffer  from it should avoid  costiveness, take fermented liquors
 sparingly, avoid hot rooms, and not expose the eyes to strong lights or
 large fires.                                        .    ...  ,         ,
   Inflammation of the eye-lids is  sometimes seen in  mild  degree and
 chronic form from  the commencement.   The redness  and swelling are
 inconsiderable;  vet there is troublesome tingling and itching, more  or
 less uneasiness, perhaps with redness and watering when the eyes are
 used at night, and agglutination  of the margins in the morning.   Mr.
 Ware called the affection in this form psorophthalmia; it has also been
 called lippitudo pruriginosa.  The same local treatment must be em-
 ployed as in lippitudo; and we use the same  means  when there  is a
 sense of dryness and stiffness in the eye, with uneasiness of the lids  at
 their margin, although there should be neither swelling nor redness.
   Scrofulous inflammation  of the eye-lids.—Thickening and redness  of
 the ciliary margins are common in the scrofulous, and are habitual  in
 some subjects,  so  that they are not regarded  as disease.   Strumous
 ophthalmia frequently begins with inflammation of the lids; and the lat-
 ter affection, in a more or less active form, characterized by the symp-
 toms already described,  accompanied  by the frequent occurrence of
 hordeola, and  often causing, when neglected, ulceration, enlargement,
 induration,  and irregularity in the figure of the affected part, with par-
 tial or general loss  of the  cilia, is common  in the scrofulous.   It must
 be treated, locally  and generally, according  to trie principles already
 explained as applicable to common inflammation  of the  lids, and stru-
 mous ophthalmia.
   Inflammation of the eye-lids with ulceration; blepharophthalmia ulce-
 rosa;  ophthalmia psorica ; tinea of the eye-lids.—The edges of the lids
 swell and become red in  children, with great pain and itching.  Pus-
 tules like those of tinea  form on the inflamed part, particularly about
 the roots of the cilia.  These break and pour out a yellowish  matter,
 concreting into more or less firm yellow or brownish scabs, which mat
 together the cilia,  and sometimes  adhere  very closely to the surface.
 As this affection is seated along the roots of the cilia, it affects their
 growth, altering their form and direction.   The  ulcerations extend
 deeper and deeper,  and at last destroy the bulbs of the cilia, which come
 away with the scabs.*
  The  Germans regard this disease as  itch of the eye-lids, and they
employ the terms psorophihalmy and ophthalmia psorica] in that sense.
 They consider that  it may be produced  by immediately  applying  the
contents of the vesicles or pustules of itch to the eye-lids, or that it may
come on when itch  has been suddenly cured.   I do not consider that
there is any connexion between this disease and scabies,  or that there
is any analogy between them,  except in the circumstance of itching,


  *  When the ciliary margins are considerably swelled, and numerous  pustules have
formed on them, the appearance has been compared to that presented bV  the section of a
fig.: hence the terms sycosis, palpebra Jicosa.                     J
  t Beer, hehre, vol. i. p. 565.  Benedict, Handbuch, vol. ii. p 131   ROSA„  Handbuch
vol. ii. p. 242.  He calls it conjunctivitis psorica. Juengken, p. 298  ' He savs » it is true
itch of the eye-lids, fixing its seat particularly in their external surface and characterized
by scabious pustules and  ulcers.  It is rare, and only seen in the lowest class • in Poland
and Lithuania it is more frequent."                           c "- Ciass » m *oia,lu 
INFLAMMATIONS OF THE EYE-LIDS.
121
which is common to both.   I have seen innumerable  cases of  itch in
its most aggravated form, but have never met with inflammation either
of the eye or lids in such instances, either during or subsequent to the erup*
tion.  When the bodyhas been covered with scabies to the greatest degree*
I never saw any kind of  ophthalmic disease  attributable to this  cause ;
indeed it is well  known that the head and face are nearly exempt from
this loathsome disorder.   Nor  has the  rapid cure of itch by suitable
treatment, in instances of its most extensive prevalence,  had any in-
jurious effect within my experience.
   Treatment.—Antiphlogistic  means  and  mild local applications  are
necessary  in the first instance; astringents and stimulating ointments,
particularly  in the latter, are proper subsequenily<
  [Inflammation of the eye-lids, producing that state termed blear eyes, when
from neglect or improper treatment  it has been  allowed to run on until the
conjunctiva has become thickened, the edges of the lids ulcerated and thick-
ened,  the eye-lashes inverted and misplaced; and  especially when it occurs in
strumous children and is complicated with  Porrigo furvalis  or favosa, is
among the most troublesome  and  obstinate affections which the practitioner
has to treat.
  Simple inflammation of the lids, without any disorganization, yields promptly
to laxatives,  a  light, nutritious diet, and  the application to the lids of the red
precipitate ointment prepared according to the London Pharmacopoeia of 1787.
The laxative which we have found to answer best, is a mixture of equal parts
of rhubarb and prepared oyster shells, given night and morning or every night,
in doses sufficient to produce two stools daily.  Equal parts of cream of Tar-
tar and milk  of Sulphur, forms also in excellent laxative, and we often pre-
scribe this and the former combination alternately, each being continued for a
week or two  at  a time.  Under  this treatment, cases have been cured  in a
few weeks  which had run on for years, in one case nineteen years.
  When the conjunctiva is thickened, the lids  ulcerated  and their margins
swollen and rounded off instead  of being  angular (tylosis,) the Meibomian
apertures obliterated, the eye-lashes  inverted (trichiasis) or misplaced (disti-
chiasis,) other remedies are required, and  in addition to those recommended
by Mr. Lawrence we invite attention to  the following measures which we
conceive to  be of great importance.
  1st. The lids, if possible, should be prevented becoming agglutinated during
the night, or if this cannot be accomplished, they  should never be separated in
the morning until  the matter by which they are glued together is completely
softened.  By forcing the lids open, the  irritation is  kept up  and the  dis-
ease perpetuated and daily aggravated.  The first indication may  be  generally
fulfilled by carefully applying to the  roots of the  eye-lashes at bed-time some
mild ointment, as  a little spermaceti  cerate or weak ung. plumbi; and  at the
proper stage by the red precipitate or some of the other stimulant ointments.
Should these fail,  the agglutinating matter ought to be softened irt the morning
by tepid milk and  water, or as recommended  by Dr. Mackenzie by gently
smearing for some minutes the agglutinated eye-lashes with milk in which a bit
of fresh butter has been melted, and  then holding to the eye-lids a piece of soft
sponge wrung out of warm water.  The crusts should then be carefully removed;
  2d.  If the vessels of the thickened  conjunctiva are much engorged, occasional
scarifications will be useful.  After they have been relieved  by this treatment,
or by  leeches to the temples, or behind the ears ,not to the lids as usually re-
commended, the" application every four or five days of the sulphate of cop-
per in substance will be found highly useful.
  3rd. The lids should be carefully  examined  every few days with a magmV
       16 
122
INFLAMMATIONS OF THE EYE-LIDS.
fying glass and all inverted hairs removed.   The best method of accomplish-
ing this will be described under the head of Trichiasis.  These hairs are a
source of great  distress  to the patient, they keep  up  irritation, and  if not
removed they ultimately induce inflammation and opacity of the cornea.
  4th. When the lids  are ulcerated, touching  them occasionally with solid
nitrate of silver promotes the healing of the ulcers.   Quadri of Naples recom-
mends, when the lids aie greatly thickened and indurated, their edges  much
incrusted and the roots of the eye-lashes ulcerated, that  the eye-lashes  be  all
extracted,  and  the whole diseased  surface then lightly touched with a  pencil
of lunar caustic.   He repeats the caustic in a few  days, and in the interval
bathes the parts with brandy at first diluted and then  undiluted.*
  5th. Counter-irritation to the back of the neck, behind the ears, or  to the
arm, will often be found of great value.  It may be effected by repeated blis-
ters, an issue or seton, croton oil, or tartar emetic ointment.
  6th. In strumous patients tonics and alteratives are often demanded.   The
best are the sulphate of quinine alone or combined with the carbonate of iron,
the mineral acids, and what we have used with particular advantage the  sirup
of hydriodate of iron.
  7th. Pure air.  This is a most important tonic, and with proper exercise is
often essential to a cure.  A large and cool sleeping apartment is also of the
first importance.  The atmosphere of rooms in which  many persons are as-
sembled is extremely injurious, and patients should therefore  never go to large
parties,  to the theatre,  or similar places, whilst labouring under this  affec-
tion ^
  8th. Bathing, warm or cold, as may best agree with the patient, and  espe-
cially salt  baths are very useful.
  9th. The diet should be strictly regulated; and should consist of milk with
eggs, and the more easily digestible meats once a-day, and care must be taken
that the evening meal be very  light so that the stomach may not be overloaded
at bed-time.
  10th. The clothing should be attended to and so  regulated as to protect  the
patient from the impression of cold.
  Meibomian Calculus.—Calcareous matter is sometimes deposited in the Mei-
bomian glands, forming calculi, which elevate the palpebral conjunctiva,  some-
times penetrate it and rubbing against the eye cause inflammation.  They may
easily be removed by laying open the gland with a knife, and then lifting  out
the calculus with a probe or cataract needle.t]
  Hordeolum, or  stye, is  a  small,  rather firm,  inflammatory tumour,
bright red,  and  generally very  painful, formed  in the ciliary margin of
the lid.  It may be situated more towards the external or internal sur-
face, and hence the distinction of external and internal  hordeolum.   A
small conical elevation takes place, which, after a time, shows a whitish
point in the centre; suppuration has occurred; and  the  contained mat-
ter makes its way out.  This inflammation is generally attended with
the formation of a small slough; it  is a boil in miniature.   The density
of the texture explains the acute pain attendant on this form of disease,
and the extension of the redness in some cases over  the whole lid.  The
process of suppuration is not quick, and when it has taken place, ulce-
ration slowly follows, and  the  slough gradually makes its  way out.
Some hordeola  form  more quickly, with greater suppuration and  no
slough; but,  generally speaking, they are  slow, and several occur in
succession in scrofulous individuals (hordeolum  scrofulosum.)   In such

        *  Mackenzie's Treatise, p. 145.                     t Ibid n 150 
INFLAMMATIONS OF THE EYE-LIDS.
123
constitutions the inflammatory process is sometimes  very chronic, and
leads to enlargement and induration, rather than suppuration.
   Treatment.—We may perhaps  prevent suppuration in the very out-
set by the use of purgatives and cold  lotions to the part.  In general,
however, the boil goes through its regular course.   Tepid fomentation,
or the softest bread and milk  poultice,  will suit  best while matter is
forming and coming to the surface.   Leeches and active aperients may
be necessary if the inflammation runs  high.  If suppuration has  de-
cidedly occurred,  and the local  uneasiness continues, relief may be
afforded by puncturing the part.   A premature puncture is injurious, as
in case of boils; and in general it  is best to leave the disease to its natu-
ral course.   When the inflammation has  subsided, a  mild course of
alterative and aperient  medicine,  with  attention to  diet, and the local
employment of  the citrine or red precipitate ointment, will be advisa^
ble in scrofulous subjects, as measures of prevention.  If the inflamma-
tion  is stationary,  the  removal of the  swelling  may  be hastened  by
touching it with the nitrate of silver.
   Beer mentions  that  the  prognosis  is always  very unfavourable in
scrofulous hordeolum;  that it may lead to true carbuncle  or anthrax,
and  thus to destruction of the eyelid, or to scirrhous  induration  and _
cancer.*  I never saw such effects, and consider these  dangers  purely
imaginary.
   Secondary inflammations of the palpebrce.—The eyelids are involved
in external inflammation of  the globe;  that is, in common, catarrhal,
purulent and strumous  ophthalmias.   We do  not  see a severe case of
these affections, particularly of the first  three, without more or less  in-
flammation of the lids, while in many cases, the  redness, swelling,  and
pain of the latter.   Hence, from the condition of the lids we may derive
information respecting the state of the eye, where we cannot actually see
the latter are considerable.   This influence is not  reciprocal: the more
important organ acts on the  subordinate  parts,  but  the latter  do not
react on it.   The conjunctiva is only a  little reddened  in erysipelatous
inflammation of the lids, although they are  often enormously swollen, or
bright red, with the cellular tissue in a state of purulent infiltration  and
mortification.   The same observation holds good in  most cases of va-
riolous and  traumatic inflammations of  the lids.   They do not become
inflamed in the internal ophthalmias; that is, if the disorder is confined
to the internal tunics.
   Thickening and induration of the palpebral margins; tylosis.]—The
ciliary margins, after long continued slow  inflammation, become thick-;
ened, indurated, and knotty, especially in the scrofulous.   They ulcerate
irregularly, and incrustations  form about the  lashes, which are often
partially or generally detached.   This  swollen and knotty  state of  the
lids, in which their margin often loses altogether  its  natural figure  and
appearance has been technically called  tylosis.  In this state, or in ag-
gravated  cases of tinea, where  the eye-lashes  are loosened, and  the

  * Lehre, vol. i. § 585, 586.
  t This word is formed from tokos, callosity.  The words pachyblepharosis, pachea, ble.
phara, and pachytes, denote the enlarged and thickened state of the lids.  Ptilosis, which
originally means the moulting of birds, has been applied to this disease, which is attended
with loss of the cilia. 
124
ULCERATIONS OF THE EYE-LIDS.
ulcerated margins of the lids are covered by hard incrustations, which,
together with the cilia, prevent the application  of remedies to the seat
of disease, the best plan  of  treatment is to extract all the cilia, with a
pair of broad forceps, and then touch the thickened and irregular ulce-
rated surface  lightly with a pencil of lunar caustic.   This has a great
effect in healing  the ulcerations  and  dispersing the swelling.   The
citrine ointment  should  be used afterwards, and the caustic may be
repeated in a few days, if necessary; a single application, however, is
often sufficient,
  Loss of the eye-lashes, (ptilosis, madarosis, alopecia.)—Destruction of
the bulbs by ulceration or by injury  causes permanent loss of the cilia,
which may be  either total or partial.  It is a  frequent result of small-
pox, the pustules  of which, besides partially destroying the lashes, leave
reddish  marks of unpleasant appearance on  the margin of the lids, with
disposition to inflammation,  The loss  is irremediable; but when the
disorder which caused it has completely ceased, the effect on personal
appearance  is  much less than would  have been expected, especially
when it has been total:  the  partial loss  is more conspicuous.   The en-
tire  absence of   cilia   is  sometimes  hardly  observed, especially  in
those of light hair; while, at least in many instances, it is not attended
with the slightest inconvenience.   The  latter observation was exempli-
fied in a lady, in whom  the eye-lashes had fallen out without disease of
the lids, the hair having  at the same time disappeared from all parts of
the body without any apparent cause.
  I saw a young lady in whom the lashes  of one  upper eye-lid had
dropped out without previous inflammation, or any other ascertainable
change in the part.  My opinion was that  they would not be repro-
duced;  but 1 recommended  the trial of  a stimulating ointment, and the
ung. hydrarg.  nitrat. in a  dilute form was consequently  employed,
After the lapse  of some  months the hair again appeared, and were ulti-
mately restored, of natural size, colour,  and number.
  The cilia  are  reproduced after  being plucked out, and that very
speedily; a  circumstance which is  found  very inconvenient by those
affected with  trichiasis.  We  may  therefore  safely remove  them  in
ulcerative affections of the lids.  Such  removal  indeed, by facilitating
the application  of suitable  remedies to  the ulcerations, prevents them
from proceeding to destruction of the bulbs, and consequent permanent
Joss of the cilia.
                     SECTION III.--ULCERATIONS,

  Syphilitic diseases of the palpebral.—As integument and  mucous
membrane, the most frequent seats of syphilitic disease, enter into the
composition of the  eye-lids, we  may expect to  find these parts often
suffering in syphilis.  Syphilitic  eruptions, particularly the scaly and
tubercular, frequently appear on the external surface, and on the ciliary
margins of the lids; and the latter are almost  ahvavs red, excoriated,
and sore (lippitudo syphilitica  neonatorum,) in that" form of syphilis
which is imparted to the infant by a  diseased mother  or nurse where
the disease is almost confined to the skin. 
ULCERATIONS OF THE EYE-LIDS.
125
  The  mucous lining  of the palpebrae  sometimes participates in the
syphilitic eruptions, which affect  the surface generally; but this  does
not happen so often as  we might have expected from observing the cor-
respondence in  diseased  action between  the conjunctiva  and integu-
ments.   In a case of syphilitic iritis, where there was papular eruption,
papula? were observed  on the internal surface of the eye-lids.  A gentle-
man was under my  care some years ago with papular eruption over the
whole body, following  chancre.   The pimples were large, bright red,
and proceeded to suppuration on  their summits, then dried up, leaving
red marks, which were conspicuous for a long time.  There was great
feverishness, with pain in the side.   The eruption extended to the mu-
cous lining of the palpebrae, in which there  were several pustules  as
large as pins' heads, with swelling and  redness  of  the palpebrae, and
considerable local uneasiness.  The affection of the lids required merely
cooling and tepid lotions.   The  eruption, which  occurred in  March,
lasted six weeks.  The marks of the papula were still very visible in the
face in August; at which  time some scaly eruptions appeared on the legs,
with considerable inflammation.   The left upper lid  was still  red, and
rather swelled, the conjunctival lining red and thickened, and the marks
of the former papulae very evident.  No other means were employed
in this case except active antiphlogistic treatment, including two vene-
sections.  This gentleman has continued well to the  present time.
  In  a patient, who was  twice in St. Bartholomew's  Hospital under my
care, first  for primary phagedenic  ulceration of the  labia,  and one
nympha, and subsequently for tubercular eruption  chiefly affecting the
face, and node of the tibia, the upper eye-lid  of one eye became swelled
on the second occasion.  It is stated in notes which I have of the  case,
that an " eruption of small pustules was observed  upon  the  lining of the
upper eye-lid, which was swollen."   I cannot describe the appearances
exactly, not recollecting  the particulars of the case, which occurred in
1825 and 1826.  She took calomel  and opium freely, under which  all
her symptoms quickly  disappeared, and she was discharged cured.
  Syphilitic ulceration of the eye-lids.—Although this is not of  very
rare occurrence, it is not particularly noticed in  any of the works  on
syphilis with which I am acquainted.  As it sometimes proceeds to the
destruction of the lid, it is of consequence that the character, progress,
and treatment of the affection should be  understood.
  My attention was first attracted  to the subject many years ago, by a
case which came under my care  in St. Bathojomew's Hospital.
  A stout red-faced woman, of full habit, who had been long on the town, was admitted
on account of an ulcer,  which had nearly destroyed the lower  eye-lid.  The surface
was greyish with bloody points, and the  edge towards the  cheek livid and sloughy;
the discharge ichorous.   The  neighbouring integument to a considerable distance was
highly inflamed, and the side of  the face  was generally swelled.  The sore and the
surrounding parts were  acutely painful, so as entirely to prevent  rest.  No eruption
or ulceration existed in  any other part of the body, nor was there any other local affec-
tion.   Having neither heard nor read of such cases, I did not entertain any suspicion
of the disease being venereal, and attempted to arrest its progress by leeches, fomenta-
tion, poultice, and opium.  During the employment of these measures, which were
altogether ineffectual, the destruction of the lid  was completed. I now had recourse
to the free administration of calomel with opium, which quickly affected the mouth.
The pain  immediately ceased, the inflammation of  the ulcer and of the surrounding
parts was arrested : in two or three days the sore acquired a  healthy surface, and cica- 
126
ULCERATIONS OF THE EYE-LIDS.
trization soon followed.  Although this patient had no other venereal disease at the
time, and said she h id not recently been affected with syphilis, I entertain no doubt at
present that the ulceration of the eye-lid was syphilitic.
  Soon afterwards I had under my care, at the Eye Infirmary, in Charterhouse bquare,
a youth under twenty years of age, in whom a chronic ulceration had slowly destroyed
about one-half of one  lower eye-lid, the other being affected on its margin by a smaller
superficial ulceration  of similar character.   In this case there was an excavated ulcer
with tawny surface, and  no  surrounding inflammation, in each tonsil.  The charac-
ters of the disease were here so strongly marked, that  I could  give no credit  to the
representation of the patient that  he had never  had venereal  disease.  The com-
pound decoction of sarsaparilla, with the oxymuriate of mercury,  was administered in
this case.  The ulcerations of the throat soon disappeared; but those of  the eye-lids
were more obstinate,  and did not yield till the mouth was affected, when they slowly
cicatrized.  A relapse of the palpebral affection occurred in this  patient, who was a
tailor; the use of mercury was again required, and proved effectual.
  In the last few  years I have met with several instances of syphilitic
ulceration affecting the eye-lids, and have  thus learned that the charac-
ter and progress of such sores are  various in this as in other parts of
the body.
  The ulcer, commencing on  the ciliary margin, where it is  generally
described as beginning with a small hardness, supposed  to be a stye,
may occupy the  whole thickness of  the  lid, involving all its textures.
It may have the same origin,  and be confined to the  external surface of
the lid;  or  it may arise on  the mucous surface, and never extend  be-
yond that.  In a patient who  had syphilitic ulcers in  several parts of the
body,  with  periosteal swellings, I observed that the left upper eye-lid
was red and swollen, and proceeded to  evert it, when I discovered on
the inner surface  a sore as large as  a sixpence, with a tawny surface:
it did not reach the edge of the lid.   1  have also  seen several smaller
sores at  the same time in the mucous lining of both upper lids.
  The ulceration  is sometimes acute, attended  with inflammation and
great pain ; and it rapidly destroys the affected part.   In  a case, where
the eye-lids were  twice affected, two-thirds of  the  lower lid were  de-
stroyed on  the second occasion in about five days.   On the contrary, in
another instance,  there was but little inflammation or pain, and although
the disease had existed for two months before treatment was begun, the
cure was accomplished almost without loss of substance.   The charac-
ters of the sore will of course be very  different in  the  two  instances.
The acute ulceration is of the phagedenic  character,  with red margin,
sharp  edge, foul unequal surface, on which bloody points are seen, and
severe pain.  In  the chronic, there is swelling and some  hardness of
the basis of the sore, with expansion of the cutaneous texture  instead of
loss of substance, and little or  no pain.
   Ulceration of the eye-lid generally occurs  in  conjunction with other
syphilitic symptoms, such  as ulcers in other  parts of the  body,  and
swelling of the bones or periosteum.  In one patient the affection of the
lid  was the only secondary symptom for about  two months,  at the  end
of which time  scaly eruption  appeared.   In  two  other instances, the
eye-lid was the only part affected.   I was consulted some years ago by
a gentleman, of whose  case I did not make any notes.  He had a large
ulcer, with dirty  whitish surface,  on the  lining of the  upper eye-lid.
The character of the sore, and the circumstance of  his being otherwise
in excellent health, made  me conclude that it was venereal, though he 
CANCER OF THE LOWER EYE-LID.
127
had no other symptom, and stated that he had not been affected with
syphilis for a long time; if my memory is correct, not for three or four
years.  The sore healed under the use of mercury and sarsaparilla.
  In some instances of entire destruction of the lower eye-lid there has
been no conspicuous deformity, and the patients  have experienced no
inconvenience after cicatrization was completed.  The loss  could not
be discovered without  close inspection ; and  when the  eye  was shut,
the descent of the upper lid covered the globe.
  No other  ulcerative affection of the palpebrae can be confounded
with that now described  by any  person  who pays  even slight atten-
tion to the character and  progress of the  disease.  The ulcers called
cancerous begin, at least in the great majority of instances, in the in-
tegument, and are for a long time confined to it, not reaching the ciliary
margin  or mucous surface until the disease has  made some progress.
The affection has  two stages, the  tubercular and  the ulcerative.,  It
begins with the formation of small, hard, and scarcely discoloured tuber-
cles in the skin; ulceration  does  not take place till  these have existed
many months or even  some years; it proceeds slowly, the edge of the
ulcer being hard, and tuberculated, and several years will elapse with-
out any great progress.   The ulcer  is superficial, producing in  small
quantity a thin discharge  which forms an adherent scale on the surface.
These cancerous ulcerations do not occur until the middle period of life,
or after it. Besides the difference of age, and the entirely different origin,
development, character, and progress of  syphilitic ulceration, the his-
tory of the case and the concomitant existence of other syphilitic symp-
toms would remove all doubt respecting the nature of the affection.
   Treatment.—I have found the free  use of mercury to be the quickest
and most effectual  mode  of arresting  and curing the disease.  This
remedy has been employed with the best effect in all the cases which have
come under my observation.  As soon  as  its influence on the system
has been  produced, the sores have lost their syphilitic character and
then quickly healed.   Having found the desired purpose so completely
answered by this plan of  treatment, I have not been willing to make
the experiment, which has been tried with  other syphilitic ulcerations,
of leaving them to their own progress, or trusting to sarsaparilla and
other remedies.   The loss of substance which might occur under this
mode of proceeding, would be attended with serious deformity in the
case of the upper eye-lid.
                CANCER OF THE LOWER EYE-LID.

  The skin of the face, more particularly of the lower eye-lid, cheek,
nose, and lips, is not unfrequently the seat of cancerous disease, which
exhibits in this, as in other textures, the successive occurrence and com-
bination of two morbid  changes; namely, induration and ulceration,
the latter being intractable, and little affected by externa]  and internal
remedies, if not absolutely incurable by such  means.  This  affection,
like others of similar nature, seldom shows itself before the middle pe-
riod of life.   I have seen it affecting the  eye-lid only in the male sex: 
128
CANCER OF THE LOWER EYE-LID.
in two out of three  cases mentioned  by Dr. Jacob, the  patients were
females.* The same affection, in other parts of the face, has been much
less frequent in the female than in the male, within my experience.
   A hard knot at first forms in  the  skin, not discoloured, and rising a
little above the surface.   The patient calls it a wart, but the entire and
natural state of the cuticle obviously distinguishes this scirrhous tubercle
from warts, of which the cuticular covering is thick, rough, and fissured.
The first tubercle is  slowly followed by others, which make with it a
single small group or  mass; they are equal  in  size  to  small peas or
large pins' heads.  The portion  of skin, on which they are situated, is
somewhat swelled and hard: a  few red  vessels are sometimes seen on
it and on the tubercles, which in other respects present the natural ap-
pearance of  skin.   After some time, superficial  ulceration occurs, the
denuded surface appears  as  a mere excoriation, producing a thin yel-
low fluid in small quantity, which dries into a thin scale.  If this is not
disturbed, the part will remain for a long  time  without any apparent
change.   The disease spreads in the same manner, by the formation of
cutaneous  tubercles  and ulceration, the process being so  extremely
slow, that  many years often elapse  without the ulcer  exceeding the
magnitude of a sixpence or a shilling.   In this state it presents a super-
ficial ulceration, smooth, and without granulations, with an irregular
knotted margin.  It is at first confined to the cutaneous  surface of the
eye-lid, and it often remains so  for  several  years; in other instances,
when it  has reached the ciliary margin, it  slowly destroys the whole
thickness of the lid by ulceration, and makes its way into the orbit be-
tween the globe and the bone.   In its early period, and  indolent state,
it  causes little or no paim  When the ulcerative process is more active,
the complaint is painful; there  is often  considerable uneasiness from
irritation of the globe by  the edge of the ulcer when it is destroying the
lid.  The health does not suffer, being often unimpaired even when the
ulcer has attained  considerable magnitude.
   The lymphatic  glands are not  affected; nor  have I ever seen se-
condary cancerous affection of other parts.
   Although the progress  of the  disease,  taken generally, may be called
destructive, there  is  sometimes partial  reparation and cicatrization.
The surface thus restored is  generally irregular, and  not like a healthy
cicatrix:  and, while cicatrization is proceeding in one part, the disease
extends in other directions.   I had a patient, about forty years of age,
with  an ulcer of this kind  about one inch and  a-half  in  length, and
three-quarters of an inch wide, on  the cheek, at  the side of the nose.
The complaint, which  had  lasted six years, began on the  ala nasi, of
which it bad destroyed a considerable portion.   The  part first affected
had  cicatrized soundly, and the sore still had a healing edge  on the
side next the nose.   The margin in other parts was indurated and irre-
gularly elevated; the surface was not deep;  it was smooth, red, with-
out granulations, and it produced, in small quantity, a thin  yellow mat-
ter, without any offensive odour.  When I  had extirpated this  disease,

  * Observations respecting an Ulcer of peculiar character, which attacks the Eye-lids and
other parts of the face ; in  Dublin Hospital Reports, vol. v. p. 232. 
CANCER OF THE LOWER EYE-LID.
129
I found that the  basis of the ulcer was  the  cutaneous  texture about
twice its ordinary thickness; firm, of greyish colour, and with the semi-
transparency belonging to  scirrhous induration.
  There can be no danger of confounding this complaint with syphilitic
ulceration of the  palpebrae, which I have  described  at p. 125.  It  is
easily distinguished from lupus, which does not affect the eye-lids. The
tubercles of lupus are larger, red, and  scattered ; sometimes the cuticle
covering them becomes scaly.  In carcinoma, the  tubercle is  at first
single, and subsequently only a  single group, unaltered in colour, and
without change of the cuticle.  The ulceration of  lupus has a tawny
surface, often with bloody points or streaks secreting a yellow matter
which forms yellow scabs;  the  margin is sharp and  ragged, and the
surrounding skin bright red.   The  carcinomatous ulcer has a smooth,
red surface, and  a knotted  edge; and  the  surrounding skin is  of the
natural colour.
  Dr. Jacob, who, in a paper already quoted, has described this disease
as he had seen it in three  instances, considers that it " is peculiar in its
nature, and not to be confounded with genuine carcinoma ;" from which,
he says, " it is distinguished by the absence of lancinating pain, fungous
growth, fetor, slough, hemorrhage, or contamination  of lymphatics."*
If, by genuine carcinoma, Dr. Jacob means that of the female mam-
mary gland, the  correctness of his opinion will  be allowed, though
all  the circumstances he  has mentioned  are  not found in every case
and stage of that disease.   The present  affection appears to me to  be
genuine carcinoma of the skin, and not to  differ from the progress of
the disease so called in  other textures, more than the differences of or-
ganization  will explain.   The phenomena and progress of the affection
are even modified in different parts of the integuments; it is different in
the hands and in the organs of generation from the  course which I have
described it to  pursue in the face, though it every  where exhibits the
same leading features of primary  scirrhous induration and subsequent
intractable ulceration.
  Mr. MiDDLEMOREf has described this disease under the name of pecu-
liar ulceration of the eye-lids, and  has detailed  some cases.  Like Dr.
Jacob, he regards it as distinct cancer.
  The causes  of this affection are involved in the same obscurity  as
those of  cancerous diseases generally; we  are altogether  ignorant of
the  circumstances which either immediately or remotely give to mor-
bid  affections  this  peculiar character.   Within my experience it has
always occurred  spontaneously in healthy  subjects, and almost exclu-
sively in males.  Juengken,J on the contrary, states that it is more fre-
quent in women than in men ; that it is seldom seen as  a pure idiopathic
affection  in individuals otherwise  healthy; and  in general it  occurs
only in cachectic subjects, and that a strong predisposition to the com-
plaint is produced by certain cachexias and dyscrasia?, particularly by
scrophulosis, arthritis, and  syphilis larvata.   According to the repre-
sentations  of   Beer,§  with  whom Juengken,||  Rosas,*!!  and  other

  *  Lib. cit. p. 236, 237.                     t Treatise, vol. ii. p. 744—755.
  t hehre von den Augenkrankheiten, p. 603.
  §  hehre, vol. ii. p. 50 ard 140.                  II Loc. cit.
  If  Common warts may  become cancerous from the supervention of a morbid state of
       17 
130
AFFECTIONS OF THE EYE-LIDS.
writers* agree, scirrhus of the eye-lids  may proceed from the chronic
swelling consequent  on scrofulous inflammation, (tylosis, see p.  123,)
or from the induration  remaining after hordeolum, especially when in-
judiciously treated, in scrofulous  persons ; while this  scirrhous  indura-
tion may degenerate  into cancer  when the scrofulous subjects labouring
under it suffer from other  causes, such as syphilis, itch, gout, or scurvy,
or when irritating applications are made to the part.   He states further,
that in individuals who have long been highly scrofulous, destructive can-
cerous ulceration may attack the eye-lids from the repeated irritation of
an encysted  tumour by stimulating applications, or  from the develop-
ment and  improper  treatment of an inflamed, painful, and wart-like
tubercle on the ciliary margin, (papula maligna.])
  If the causes assigned by  these  writers were capable of producing
cancer of  the eye  and lids, it ought  to occur frequently; it is, on  the
contrary, a rare affection.   To account  for the wide difference between
their statements and  my own experience, I must conclude, either that
scirrhus and cancer are much more common on the continent than in
this  country,  or that  they  employ the terms in a more  comprehensive
sense than we do.
   Treatment.—I consider excision to be the  proper  treatment, when-
ever the situation and extent  of the  disease will admit of its complete
removal; and that  it  should  embrace, not only  all the parts altered  in
structure, but also,  if possible, a portion  of the surrounding healthy sub-
stance.  As the health is undisturbed, no benefit can be expected  from
internal remedies.   External  irritating applications often bring on pain,
and  render ulceration more active.  When the disease is of small extent, it
may be destroyed  by  an  escharotic  sufficiently powerful  to kill  the
whole affected  texture; but this process is less  satisfactory than exci-
sion, as I found in an instance where I destroyed  a small  growth of
this  kind on the ala nasi, by means of arsenic.
  Dr. Jacob's experience  on  this point  seems to coincide very nearly
with my own.  " It remains," he says, " to be determined whether this
disease can be removed by any other means than the knife or powerful
escharotics;  and from the experience I have had in those cases, I am
inclined to conclude that it bids defiance to all remedies short of extir-
pation.  I  have  tried internally alterative mercurials, antimony, sarsa-
parilla, acids, cicuta, arsenic, iron, and  other remedies; and locally,

constitution, (dyscrasia,) or from  mechanical and chemical irritation.  Handbuch, vol. ii.
p. 118.  In another place he says, that cancerous ulcers of the lids depend on some hitherto
imperfectly known malignant modification of scrofula, gout, or other dyscrasiae; that they
appear as consequences  of encysted tumours, warts, or  more frequently of scirrhus;  and
that the occasional  causes are accidental, mechanical, or chemical injuries of the lids, or
curative attempts with stimulating escharotic or even mechanical means. He adds, that
in many cases no such immediate cause can be assigned.  Ibid. p. 139.
  *  According to Sabatier, cancer of the lids and  globe may arise from scirrhous tuber-
cles, from pimples of dartrous character, from fungous excrescences, and from obstinate
ophthalmia, terminating in partial or  local abscesses.  It is excited by the imprudent use
of acrid and  irritating local applications, especially caustics,  but it depends on an internal
disposition, which can neither be prevented nor corrected.  De la Medecine operatoire, 1824;
vol. iii. p. 346.  Analogous opinions  respecting  cancer of the eyes are delivered 'in  the
Dictionaire de Med. et  de Chir. pratiques, torn. iv. p. 536, 537.  The writer assigns as
causes of cander  of the eye, chronic inflammations, whether external or internal  and pro-
trusions of the globe consequent on disease of the orbit or surrounding' Darts
  t  Lib. cit. p. 140-143.                                   S *   ' 
CANCER OF THE LOWER EYE-LID.
131
simple and compound poultices, ointments, and washes containing mer-
cury, lead, zinc, copper, arsenic, sulphur, tar, cicuta, opium, belladonna,
nitrate of silver, and acids, without arresting for a moment the progress
of the disease.  I have indeed observed  that one of these cases which
is  completely neglected, and  left  without any other  dressing than a
piece of rag, is slower in its progress than another which has  had all
the resources of surgery exhausted upon  it.   The success even of pow-
erful escharotics is doubtful.   Mary  Sherlock, the old woman who has
laboured under the disease for twenty-three years, and who is now in
the incurable hospital, says that " a burning cancer plaster" was applied
several times, seventeen years ago; and she has lately  had the arsenical
composition, called Plunkett's  powder, applied without any good effect.
The gentleman to whose case I have alluded, had the sore healed, when
it was very  small, by the free application of  lunar caustic  under the
care of Mr. Travers ; it however broke out again and spread without
interruption, until it destroyed the  lids  and globe of the eye, under
which  circumstances, he,"in despair,  submitted  himself to  a popu-
lar charlatan, who, bold and  fearless from ignorance, gave a  full  trial
to escharotics;  he repeatedly  applied what I understood  to  have been
a solution  of muriate of mercury in  strong nitic acid,  and in a short
time excavated a hideous cavern, extending from the orbitar plate of
the frontal bone above, to the floor  of the  maxillary sinus below, and
from the ear on the outside of the  septum  narium within; yet the un-
fortunate gentleman survived, but the disease preserved in every respect
its  original  character.   Mr.  Colles,  however, tells me,  that in a  case
which came under his care, before the disease  had extended to the lids,
he  succeeded in establishing a permanent cure by the application of a
powerful escharotic, covering up the eye, during the operation of the
remedy, with goldbeater's leaf."*
   We possess, however, some means of relief, even in the unfortunate
cases, where the extent of mischief  precludes  the effectual remedy of
extirpation.   Mild antiphlogistic  and soothing measures not only alle-
viate suflerini, but sometimes  induce restorative efforts more considera-
ble than we could have  expected, as  will  appear from  a case subse-
quently related.   (See Case IV.)   The observations on  the  local and
internal  employment  of narcotics, when there  is  severe pain, in the
treatment of carcinoma of the eye, are equally applicable to this  affec-
tion.   The following histories are  selected  to  exemplify the foregoing
description and remarks.
  Case I.  Carcinoma of the lower eye-lid, of seventeen years duration: extirpation
of the disease, and permanent cure.—A  gentleman, between fifty and sixty years of
ao-e, employed in p:untin<r and drawing, had a disease of the lower eye-lid, which be-
gan seventeen years befiTre I saw him, with what he called a small wart.  It gave
him no trouble, so that he paid  little attention  to it.  Caustic was  once applied; it
produced a scab, and the surface afterwards became clear again. It had increased,
and became troublesome in using the eye.  The disease, when I first saw the patient,
was about equal to half a large filbert, and occupied the inner two-thirds of the eye-
lid.  It reached at the internal angle to the root of the nose; the upper edge extended
to the margin of the lid, where it seemed inseparably connected  to the tarsus; below,
it was moveable on the subjacent parts.  It was a swelling of the skin, knotty at the
edge, with a few red vessels ramifying on it, and two or three small  smooth ulcerated

                           * Lib. cit. p. 237, 238. 
132
AFFECTIONS OF THE EYE-LIDS.
 surfaces towards the centre, producing a clear  yellowish  fluid, which formed a thin
 adhering scab.  1 removed it in April, lSJS, and found it easily separable from the
 tarsus, though they had appeared so closely  united; the  latter was denuded in  its
 whole depth.  The disease was strictly cutaneous, with  a regularly defined circumfe-
 rence, not extending  into the surrounding textures.  Two small smooth cysts were
 found near the surface of the tumour.  The wound was soundly healed in three weeks,
 without any other inconvenience than a slight degree of ectropium, which continues
 to the present time, (1840,) the cure in other respects being perfect.
   Case II. Carcinoma of the lower eyelid, which had existed five years: extirpation,
 and permanent cure.—The patient was a gentleman  about fifty-five years of age, of
 sound  constitution, and good health.  The disease occupied  the ciliary margin and
 the external surface of the lid.   It began with the formation of small hard  knots, on
 which a  kw red  vessels  ramified ;  superficial ulceration ensued, without much dis-
 charge.   It had proceeded very slowly, so that  at the end of  five years it did not oc-
 cupy the whole eye-lid.   Various local and  general means, employed  at different
 times, had no effect in checking the progress of the complaint.   He had used calamine
 cerate spread  on thin rag, to cover the ulceration.  Carbonate of iron, made into a
 paste with water, and applied with a fine  brush, seemed to have afforded  some relief.
 When I  saw him,  the disease occupied rather more than the inner two-thirds of the
 lid, reaching quite to the side of the nose; the inferior punctum lachrymale could not
 be discovered.  The  lid, more than  twice  its natural thickness,  was knotted exter-
 nally and ulcerated; the irregular inner margin of the  ulceration occasionally irritated
 the globe.  This was the only inconvenience, for the  disease  had never given much
 pain.   I  removed  the parts in  December, 1825, cutting  quite clear of  the disease
 below, and externally.  It was so close,  to the bone, on the inside, that I could not feel
 equally confident of having removed  the whole morbid  growth.  A soft  rag  doubled
 and dipped in  water was placed  over the  eye.   The  wound, although large, healed
 rapidly;  and the patient was able to leave town in  ten days.  In February, 1826, the
 cicatrix  was firm.  Although the lower  eye-lid, with  its  punctum  lachrymale, had
 been removed, there was no deformity, nor any inconvenience from  watering of the
 eye.  This gentleman whom  I have since seen at various times is perfectly well at
 present (1840.)  No deformity, nor any other unpleasant result,  remains from the ope-
 ration.
  Case III. Carcinomatous ulceration of the lower eyelid;  extirpation: return of
 the disease.—G. S. fifty-five years of age, came under my care, in St. Bartholomew's
 Hospital, in January, 1829.   The  complaint, which was an ulceration of the lower
 eye-lid, with indurated  margin, had  begun seven  years before, in what  the patient
 called a small  pimple.   The disease extended to the internal  anglp, where the indu-
 rated mass adhered firmly to the bone, and it occupied also the  whole external angle
 of the lids.  It had been generally easy, but occasionally painful;  various means  had
 been employed without benefit.   I removed the  whole  lower eye-lid with a small por-
 tion of the upper at each angle.   The disease adhered  so closely to  the nose on  the
 inside, that I could not  feel certain  of having  removed it effectually.   The wound
 proceeded very favourably.  Some inflammation of the conjunctiva occurred, but soon
 went off leaving the cornea quite clear.   The cicatrix caused contraction of the pal-
 pebral slit; but a sufficient opening remained, when he left the  hospital, for tolerable
 use of the eye.   The patient remained well until the be<rinnino-of 1832, when uneasi-
 ness began to be felt in the internal  angle of the eye.  This gradually increased,  and
 he came  to town in the beginning of the summer.  There was  return of the complaint
 along the cicatrix, more particularly towards  the internal  angle.  The  conjunctiva
 between the scar and  the globe seemed  to participate  in  the affection;  it was thick-
 ened, preternaturally red,  and exhibited  granular  masses advancing on  the cornea,
 which in  other respects was healthy.   It appeared  to  my colleagues~and  myself that
 the disease could not be satisfactorily removed without including the elobe in the ope-
 ration ; the patient being averse to this proceeding returned to the country
  Case IV. Carcinomatous ulceration of the lower eye-lid and cheek, healing under
the application of leeches.—A man of spare habit, sixty-four years  of aSe was for a
long time an out-patient of  St. Bartholomew's  Hospital,  on account of  a  lar^e ulcer
 with unequal  surface, knotted and  irregular margin, which  had  commenced about
twenty-four years previously.   The boundaries of the  ulceration were  the bridge of
the nose and the left ala nasi, the left angle of the mouth, the left inferior naloehra
which had been nearly destroyed, and the left temple.   The eye had been occaeionally 
CHANGES OF FIGURE AND POSITION.
133
inflamed, but had not suffered materially.  For some months it was dressed with a lotion
of distilled water, and liquor opii sedativus, the latter being in the proportion of one-
third or one-half.  This eased the pain, which had been considerable : the health was
perfectly good.  The discharge from the sore was so sparing, that the lint, by means
of which the lotion was applied, adhered firmly.  The surface used tobleed  freely on
its removal, which suggested the idea of taking blood by leeches.  Six were accord-
ingly applied, and with so much benefit  that they were repeated.  The  progressive
improvement in the sore led to two or three further repetitions.  In the course of a
short time, nearly the whole of this extensive ulcer cicatrized; the surface continuing
unequal, and the edge knotted.  The only part which did  not heal was towards the
external angle of the eye, where a portion  of skin  formed an  uneven tuberculated
mnss vvith  small  superficial ulcerations.   The neighbouring integuments  were
strongly drawn towards the lower part of the orbit by the contraction of the cicatrix.
The opiate lotion was still applied  to the part which had  not healed.  The patient
was free from pain and in perfect health.   He continued well for about a twelvemonth,
when he died, as 1 was informed, after a short illness, from erysipelas of the head.
   While the preceding case   was  under observation, an old man be-
came my patient in the hospital, with a cancerous sore at the angle of
the mouth, of many years  duration.   It was  so considerable, that ex-
cision would  have  been hardly practicable, even if there had not  existed
a  considerable  indurated  enlargement of  the  submaxillary  absorbent
glands.  Erysipelas of the face came on, and was severe.  As he was
recovering, the  sore lessened, and its  raised edge sunk considerably.
It. seemed in a fair way for  healing  when he  left the hospital on his
return to the country.
             SECTION IV. — CHANGES OF FIGURE AND POSITION.

  Ptosis; Blepharo-ptosis; lapsus palpebrcc superioris.—By these names
is  designated  a falling of  the  upper  eye-lid, with  a partial or com-
plete want of power to elevate it.   Such a state may exist for a time
with enlargement of the part, in consequence of inflammation or injury.
It gradually disappears without any local treatment.  There seems to
be no difference between this state and that which Beer* has spoken
of, under the name of relaxation of the eye-lids, (alonia palpebrarum;
atoniaton blepharon.)
  Juengken distinguishes four kinds of blepharo-ptosis; viz. 1st, senilis,
generally leading  to entropium; 2d, traumatica,  from  wounds;  3d,
symptomatica, from  abscess or tumours; 4th, congenita.   The latter, he
says, sometimes appears in several members of a family.f
  I have seen a few instances of this congenital  imperfection.   In the
case of  a gentleman,  who  consulted me for it, the lids could  not be
opened, on  either side, by voluntary effort, to more than one-third of
the usual extent; and when this was accomplished, the upper palpebra
was quite smooth, without any fold between it  and the eye-brow.  It
was necessary to throw back the head, in order to see  objects above
the level of the eye.  There was striking peculiarity  in the expression
of the countenance.   This  patient derived  great advantage from the
removal of a portion of skin, as in  the operation for entropium.   He
informed me that he had a sister, in whom the imperfection was greater
than in himself.  1 saw a young girl with one eye in a similar  state.
* hehre, vol. ii. p. 15.
t Handbuch, p. 701—704. 
134
AFFECTIONS OF THE EYE-LIDS.
   The name ptosis is sometimes applied to the falling of the lid, conse-
quent on paralysis of its  levator muscle, the ophthalmoplegia of  some
authors.   Sometimes the want of power over this muscle is the only
disease; the other muscles, supplied by the nerve of the third pair may
be also involved; or there may be squinting, double vision, or amauro-
sis.  If the eye-lid be lifted, it  slowly falls down  again, over the eye,
and the patient either is  unable to move  it by voluntary exertion, or can
raise it only partially.   This affection, which is  not uncommon, is pro-
duced by disease within the  head, and hence it is sometimes the pre-
cursor of apoplexy.  It must be treated in the same way as other para-
lyses consequent  on  disease of the  brain;  that  is, by abstraction  of
blood,  aperients, low diet, and the  administration  of  mercury.   After
the former measures, and in conjunction with the  latter, counter-irrita-
tion is  of great service, by blisters to  the nape, behind the ear, on the
temple or forehead, by the tartar emetic ointment, or  by seton.   Some
have particularly recommended the application  of  caustic,* or moxa,
between  the  angle  of the jaw, and  the  mastoid  process;  but I have
never found it necessary to have recourse to that measure.  To ensure
a  successful  result, it  is  sometimes necessary to  persevere for a long
time  in the plan of treatment now recommended.   If  the power of the
levator should  not return in a few weeks, electricity may be tried.
   I subjoin the following case to illustrate the nature and treatment  of
the affection.
  Case.—E. B., forty years of age, came under my care at St. Bartholomew's on the
11th of July, 1827.  She was a short thin woman, whose habits of drinking porter and
spirits had given her'a very  sallow,  unhealthy countenance.   A week before, and
three days after having been  intoxicated, she felt pain in the head, and giddiness, im-
mediately succeeded by dimness and confusion of vision, which continued to the time
of her admission.   July 11th. The upper lids hang loosely over the eyes, and she has
no power of elevating them.  The  irides are motionless, the  pupils contracted, with a
dull and muddy appearance.  Vision is dull; best in a weak light.  She can make
out a large print by looking steadily at it for  some  time, not otherwise.  There are
constant pains in the head, and giddiness.  The  pulse is full, hard, and increased  in
frequency; the  tongue  white.  (Venesection and an active purgative.)  12th. The
patient fainted when six ounces of blood had flowed from  the arm ; six leeches were
therefore applied to each eye.  Pain and giddiness lessened ;  vision improved.  Pulse
still frequent and hard.  Venesection was repeated to twelve  ounces, and  fainting took
place.  The patient said that she could see objects more distinctly while the blood was
flowing, and that the giddiness had  ceased.  13th. Return of pain.  (Cupping on the
back to fourteen  ounces.  Pil. hydrarg.  g. v. nocte maneque quotidie.)  15th. The
levatores palpebrarum have nearly regained their full power.  Vision is distinct in a
weak light, hut rather confused in the middle of the day;  pulse natural, slight pain  in
the head.   (Twelve leeches to the temples;  opening medicine.)  19th. The mouth
is  sore.  (Continue the pill  at night only.)   30th.  Relapse of  disease from drink-
ing wine, which had been clandestinely brought by friends.   Pulse frequent and hard;
tongue white ; severe headach ; levatores completely paralyzed, and vision indistinct.
(Leeches to the temples, blisters to the nape, opening medicine.) Aug. 20th. Dis-
charged quite well, leeches having been applied again to the temples, and an abscess
of considerable size having been formed  in the  axilla, punctured and healed.  She
came to the hospital in September in excellent health, and  without a trace of the
former symptoms.
   The position of the lids in  respect  to the globe may be altered by
  * On a new Method of treating Paralysis and permanent Spasm of the Eye-lidi
roplegia and blepharospasms tonicus,) by J. A. Schmidt, in the Abhandlungen
Chir. Josephs Akademie, vol. ii.; also in the Ophthalmol. Bibliothek, vol. ii. stT 3 
CHANGES OF FIGURE AND POSITION.
135
disease;  they  may be  either turned outwards, so as to expose  their
mucous  lining, or inwards, when the cutaneous  surface  is directed
against the eye.   There may be simply this unnatural direction;  or it
may be accompanied by other alterations in the structure and figure of
the upper part.
  Permanent  elevation of the upper lid  (lagophthalmus, oculus lepori-
nus.)—The upper lid may be so shortened, as not to cover the globe pro-
perly,  in consequence  of  wounds, from  the cicatrices  consequent  on
ulceration, or from other causes.  It does not descend sufficiently, and
thus a  portion  of the eye-ball is exposed, even during sleep.   This state
may exist with or without ectropium.   The  operative  proceedings
necessary to remedy this condition of the part are considered under the
head of ectropium.
  Paralysis of the orbicularis palpebrarum.—The upper eye-lid is some-
times in an opposite condition to that of ptosis: it does not descend  so as
to meet the lower, and the patient cannot close the lids by voluntary
effort.   This arises from  palsy of the orbicularis palpebrarum,  which,
with a similar affection of the  eye-brow, usually accompanies para-
lysis of the face.  The levator palpebrae is sometimes paralyzed alone:
I have not seen  a corresponding affection of the orbicularis  singly.
What  we observe in the majority of these cases is that  the lids  do not
come together when the patient attempts  to shut the eye; the upper lid
does not descend in the usual way;  we notice no change in the state of
the lower.  When  the palsy  is complete,  especially in old persons,
where  it is of long standing, the lower  eye-lid is loose and falls away
from the globe.  Less  inconvenience is experienced from this paralysis
of the  orbicularis  than  might have been expected : for, although the lids
do not come together, the cornea is not exposed.   When the  patient
attempts to close the eye, the globe is involuntarily rolled upwards, so as
to place  the cornea behind the upper lid.
  In the  greater number of instances paralysis of the face depends  on
sensorial affection, and requires  the same treatment  as  the  analogous
affection of the levator palpebrae.  Sometimes it is produced by causes
acting  on the  facial nerve, such as cold, disease of the bony canals
through  which it passes,  pressure on  it by  morbid growths, injury or
division  of  its trunk  by accidental  wounds or surgical  operations.
Hence  the affection sometimes admits of relief, sometimes  is irreme-
diable.
  Spasm of the eye-lids (Blepharo-spasmus) generally depends on causes
affecting the eyes, such as external irritants, or inflammations.   It  may
occasionally be seen as an obscure nervous affection.
  Winking of  the lids is  produced by external irritations, such  as a
foreign body in the eye, or a lash turned inwards.  This, however, and
a quivering motion of the palpebrae may become habitual as an involun-
tary habit.
  Ectropium.—The turning outwards of the lids, which is most fre-
quent in  the  lower, has  both a Latin  and Greek name, ectropium
(ex.r?07rtei, from tM^u,  to turn out) and eversion.  It is either temporary
or permanent.
  Temporary ectropium occurs in some inflammations,  particularly in
the  purulent, and is  most frequent in the purulent ophthalmia of infants. 
136
AFFECTIONS OF THE EYE-LIDS.
In the chapter on that subject, the mode in which eversion is produced
and the treatment are considered.
  Permanent eversion may arise from various causes, and requires cor-
responding variety of treatment.  It is frequent in the lower lid as the
result of lippitudo.   The palpebral conjunctiva is thickened by repeated
inflammations, while the skin, excoriated,  or even ulcerated, by the dis-
charge, shrinks, becomes shortened, and thus draws the edge of the lid
outwards.  The exposure of the mucous membrane to the air and other
sources of irritation, increases the inflammation and thickening, until it
degenerates at last into  a more or less considerable red swelling, the
surface of which assumes ultimately a smooth cuticular aspect near the
edge of the lid: the case is  then called fleshy ectropium (e. sarcomato-
sum,) in contradistinction to the earlier state, before the conjunctiva is
swelled, when it is called ectropium simplex.   It is necessary to remove
chronic lippitudo, if it  should still exist, and to  re-establish a  healthy
stale of the palpebral margin, and Meibomian secretion.  No  applica-
tion answers this purpose better than the red precipiate ointment, which
may be freely  applied to the everted  and  thickened surface, as well as
to the ciliary margin of the  lid; it reduces the swelling of the conjunc-
tiva, and rectifies the secretion of the tarsal glands.  Ectropium, even
when accompanied with much thickening of  the  conjunctiva, may be
remedied in this manner.  If the latter affection should be obstinate, the
membrane may be lightly  touched  with the nitrate  of silver.   The
shrinking thus produced on  the internal surface draws the edge of the
lid into its natural situation.   If the sarcomatous growth of the conjunc-
tiva should be too considerable to be reduced  by the means just speci-
fied, it will be necessary to shave off the thickened membrane; the con-
traction produced by the cicatrization of the surface will draw the edge
of the lid into  its proper position.
   When the eversion is  considerable  and of long standing, the tarsus
becomes changed in figure, and elongated, so that it is no longer adapted
to the convexity of the globe, even if the lid were restored to its proper
situation.   It may be brought to the  proper length  by removing a por-
tion of the whole thickness shaped like  the letter V; the two oblique
incisions beginning at the ciliary margin,  will unite in an angle at the
orbital edge of the lid.   This may be done with a pair of sharp scissors
or a knife: the wedge-shaped portion, which is to  be removed, having
been previously seized,  so that it can be  held  firmly, with Assalini's
tenaculum-forceps, or a hook.  The sides of  the artificial fissure thus
made must be accurately united by suturos, which may be removed at
the end of twenty-four or forty-eight hours.
   Either lid may be everted by the cicatrization of ulcers, consequent
on injuries with loss of substance, particularly burns; or after the heal-
ing of abscesses, especially when complicated  with disease of the bone.
In bad cases of this kind, we sometimes see the lower lid drawn away
from the globe, and the entire tarsus firmly fixed to the cheek.  These
are troublesome cases, and  we have no effectual  remedy for some of
them : if  the cicatrix be cut through, the  healing of the wound repro-
duces  the displacement  of the lid.  It has  been proposed, after liberating
by incision the confined lid,  to dress  the surface of the  sore with irri-
tating ointments, such as the unguentum lyttae, or  the yellow basilicon, 
ECTROPIUM.
137
in order to produce abundant granulations, in the hope of supplying the
lost substance.
  [Dr. Mackenzie* recommends that the  wedged shaped portion should be re-
moved from near the temporal extremity of the lid (see fig. 4.) as the scar is here
less apparent  and produces less interruption  to the  motion of the part, than
when it is cut out of the middle of the lid.   The size of the piece to be removed
must be proportioned to the degree of the transverse elongation of the everted
eye-lid.  If too large the'lid will be so shortened that the edges of the wound
will not be brought into contact without stretching them so as to produce ulce-
ration, thereby detaching the stitches before union is accomplished ;  and if too
small the deformity will not be entirely removed.
  By the speedy  union of the edges of the  wound left by the excision of the
wedged-shaped portion, the eye-lid, will be
retained in its  place, and the danger of the
integuments  re-adhering to the orbit be,  in
a measure, prevented.   To aid, however,  in
the cure, Dr.  Mackenzie! recommends the
eye-lid to be covered with a spread pledget,
and supported, against the eye-ball, by a
compress and roller. The opposite eye should
be closed and covered, so that it may be kept
at rest.
  A useful  modification of this operation
in some  cases of eversion  of the lower
lid  has  been  devised  and  performed by
Professor Graefe.   He first cut out a wedge-
shaped portion of the eyelid, and united the
edges  of the  wound  by means of the hare-
lip suture; but just before twisting the thread
round the pins, he divided the skin of the cheek to the extent of 1 ]  inch by an
incision concentric with the edge of the  orbit.  He then twisted the threads,
drew the ends of them upwards, and fixed them to the forehead by sticking
plaster, so that the edge of the lower eye-lid might be raised sufficiently.  The
incision through the skin of the cheek was thus made to gape, and in order to
heal it with a broad scar, the edges  were  kept separate by a crescentric plate of
lead, which was pressed in between the lips of the wound, and retained by strips
of plaster. The wound of the eye-lid was quite united  on the third day, and
that into which the plate of lead was inserted was cicatrized in the fourth week,
the size and situation of the eye-lid appearing natural.J]
   Juengken§ mentions a proceeding as having been employed by Jaeger,
of Vienna, and subsequently by himself, with advantage.   It consists in
detaching the everted  lid from the  cheek or superciliary ridge, leaving
it connected  at  the angles only.  This  is accomplished in the lower lid
by entering a sharp-pointed  double-edged knife through the conjunctival
surface, near the inner angle, and bringing it  out through the skin  on
the cheek;  it must then be carried  on transversely to  the  outer angle.
A sarcomatous growth of the conjunctiva may  be previously dissected
off, if necessary; and  a triangular portion of the lid may be removed
after  the above-mentioned incision, if such a proceeding be  advisable.
The detached lid must now be fixed, accurately and firmly, in contact
with the globe and the integuments of the cheek must be drawn up  to-

  * Treatise, p. 197.    t Op. citat. p.  197.    * Ibid.     § Handbuch, p. 696—700.
        18
Fig. 4.
 
138
AFFECTIONS OF THE EYE-LIDS.
wards the eye, and maintained in that position by adhesive straps, com-
presses and bandage.  An analogous  proceeding is applicable  in the
upper lid.
   Professor Dieffeneach, of Berlin, performs the following operation for
ectropium.   He makes  an incision  through  the skin and  orbicularis,
nearly parallel to the edge of the lower  lid.   It  begins  two  or three
lines from one angle, and ends at  the same distance from  the other.  It
is one line from the edge  of the  lid at its two ends, and two or three
lines in the middle.   He turns up  the small flap of skin thus made, and
dissects through the lid to  the conjunctiva, which he divides to the ex-
tent of the external wound.   With forceps he draws the  external edge
of the divided conjunctiva  into the wound of the integuments, and unites
by sutures, which pass through the conjunctiva as well as the skin.*  A
force is thus applied to the ciliary margin of the everted lid, drawing it
inwards.
   Another proceeding has been employed by DiEFFENBACHin ectropium
         Fig. 5.              Fig. 6.      of the lower lid.   He removes
                                       the cicatrix by an incision of
                                       triangular  shape,  the  basis,
                                       of which [see fig. 5. c.  c] is
                                       towards the  ciliary  margin,
                                       the apex downwards.  He then
                                       extends  the  incision  which
                                       forms the basis of the triangle
                                       on each side, [c. a.] and  raises
                                       the lateral  portions, forming
                                       the sides of  the  triangle, a
                                       little from the subjacent  parts.
He is thus enabled to bring together  the two sides into a perpendicular
union, while, by the lateral extensions  of  the  incision above, they can
be fastened to the base of the triangular space  formed by the removal of
the cicatrix.-)-
   [The sides b. b. of the triangle are  approximated and the two cut margins
a. c, c. a. are connected to the corresponding margin of the lower lid, included
between c. c. and the edges  maintained in contact by sutures as  shown in
fig. 6.]
   Ectropium of either lid may be consequent  on the healing of an ab-
scess,  especially if it be scrofulous or connected with disease of  the
bone.  In the latter case the integument is drawn in and fixed to  the
bone at one point.  Shortening of the lid is generally  combined with the
eversion.   This shortening, in  the case of the  upper  lid, constitutes the
lagophthalmos or oculus leporinus. The combined shortening and eversion
were  exemplified in the cases alluded to at p. 114.  It has been  the
practice in such cases to expose,  by  a transverse  incision,  the indura-
tion extending  from the cicatrix  to  the  orbit, to  dissect  it awav, and
then to unite the wound.  The eye-lid and neighbouring integuments
must  be  retained in  a  suitable position by adhesive strips, compress,

  * Rust's Magazin vol. xxx. p. 438.  Ammon's Zeitschrift, vol. i  No 33
  T Zeis, Handbuch der Plastichen Chiruririe Berlin  18^8   An =.,.„„„.,» 'c.u    i   -ii
be found in the British and Foreign Medicfl Review, April', 1839       °  ^ WWk WI"
 
ECTROPIUM.
139
 and bandage.  I adopted this proceeding, together with excision of a
 triangular portion of the lid in the instances just referred to.  Professor
 Ammon* detached the  indurated portion from the  integument and  sur-
 rounding soft parts, leaving it adherent  to the bone, and  closed the ex-
 ternal wound over it.
   Professor Jaeger of Vienna has employed, in bad cases of lagophthal-
 mos and ectropium  an  operation, in which he reduces the transverse
 elongation of the tarsus  by  taking out a portion of it, and attempts to
 remedy the  shortening  of  the lid  in its  perpendicular dimension by
 bringing down or upwards  the integuments of the forehead or cheek.
 He  cuts through the everted  or  shortened lid  in  its  whole  thick-
 ness by a transverse incision including  its  whole  thickness ;  he takes
 out  a piece, so as to bring the lid to its proper width;  he then loosens
 the  integuments  of the forehead or  cheek  with  a double-edged knife
 carried between  the orbicularis  muscle and the bone, so that they can
 be drawn downwards  or upwards to a  sufficient  extent.  The perpen-
 dicular wound is first united by sutures, and then the transverse wound,
 an assistant  drawing  downwards the  detached  integuments  so as to
 approximate the sides of the wound.  The parts  are to  be  supported in
 their position by adhesive strips, compresses, and  bandage.j-
   In bad cases of lagophthalmos and ectropium, where  the superficial
 textures of the lid have been extensively destroyed, with great displace-
 ment and deformity, or where the lid has been altogether lost, repara-
 tion may be effected, to  a  certain extent, by transplanting the neigh-
 bouring sound skin of the cheek or temple.   With this may be combined,
 in cases of the first description, according to circumstances, the neces-
 sary proceedings for detaching adhesions, for shortening the lid when
 its tarsal edge has become elongated, for removing thickened  conjunc-
 tiva, and for saving such portion of the membrane, as may be useful in
 affording a mucous  covering to the  new lid.  This method seems to
 have been first practised by Dr. FrickeJ of Hamburg, who calls it Blepha-
 roplastick, and who  seems  to have transplanted a  portion of skin from
 the forehead or  cheek, probably twisting it to bring it into place, as in
 the operation of making  a new nose  from the forehead.   Two trials of
 the method,  made by Juengken§ failed entirely.
   Greater success has been obtained by following the plan suggested

  * Ueber hagophthalmos und Ectropium a carie marginis orbitalis; Zeitschrift, vol. i.
 No. 3.
  f This proceeding is described by Dreyf.r, in an inaugural dissertation, de nova Blepha-
 roplastices Methodo, c. tab. 2.  Vienna, 1831.  An account of the method is given, as an
analysis of this dissertation, in  Froiuep's Notizen,  vol. xxx. No. 16.
  A detailed account of Jaeger's operation is  given in the hondon Medical Gazette, vail.
xvii. p. 271, by Dr. Brown, of Glasgow, who speaks of it as having been successfully per-
formed.
  In  the 18th vol. of the Gazette, at p. 223. Mr. T. W. Jones offers objections to this  pro-
ceeding, and proposes another method.  The plan  of Mr. Jones, which is simple, is illus.
truted by two figures in Mr. Mackenzie's work, p. 196.  Mr. Jones makes an incision on
each side of the cicatrix or contracted portion; these incisions meet together at an acute
angle about an inch and a  half above the orbit.  He expects to obtain the necessary elon-
gation of the contracted part by the stretching of the cellular tissue uniting the triangular
flap of skin to the subjacent parts.  A short reply of Dr. Brown to Mr. Jones will be found
in the same volume at p. 485.
  t Die Bildung neuer Augenlieder; Blepharoplastick.  Hamburg, 1829.
  \ hehre von den Augen-operationen, p. 267.  Ibid. Preface, p. 9, 10. 
140
AFFECTIONS OF THE EYE-LIDS.
by  Dieffenbach for  certain  autoplastic operations;  namely, that of
transplanting the sound skin laterally without twisting  its root, instead
of moving it perpendicularly,  as in forming a new nose from the fore-
head, when the portion by which the flap  remains attached, is  neces-
sarily twisted.   Thus, in the lower eye-lid, the cicatrix  is removed, and
the lid  liberated by incisions, which  leave  a triangular wound.   The
basis of the triangle is parallel to the tarsal edge of the  lid, and the two
sides meet at an acute angle on the cheek.   An incision is then carried
in the same  direction with the  basis, from  its external angle towards
the zygoma, while, from the end of this another  incision is continued
downwards and forwards towards the apex of the triangle. The flap thus
marked out is raised from the subjacent parts, except at its lower por-
tion, and moved into the space  already prepared under the eye-lid, where
it is secured by sutures in the  usual manner, while the space left vacant
by  its removal is dressed  as an open wound.   The  same proceeding,
mutatis mutandis, is applicable to the upper eye-lid.  This method may
be  employed either  in bad cases  of lagophthalmos or ectropium, or
where the lid has been entirely destroyed, care being taken in the latter
instance to preserve  the  conjunctiva,  if possible, and  to  unite  it by
sutures  to the edge of the transplanted  integument, so  as to give it a
mucous lining.
  Professor Ammon of Dresden has performed this operation successfully
in two instances, one  of these  was a cancerous disease, occupying two-
thirds of the lower, and a small  portion  of  the  upper lid.  Integuments
were transplanted to cover the loss of substance occasioned by extirpa-
tion of  the disease.*   The  other was  an  entire loss  of the upper lid
from syphilitic ulceration.f
  [In this case Dr. Ammon began  his operation  by insulating and separating
from the temple the flap  of skin, (b, c, d, e, Fig. 7.) by which the defective
Fig. 7.                                 Fig. 8.
upper eye-lid was to be supplied; he then divided all the adhesions of the old
eye-lid, and prepared the place (a, b, c,) for the reception of the new one.  He

  * Dr. Dieffenbach's neue Methode der Blepharoplastik ; Ammon's Zeitschrift, vol. iv. p.
428; with five figures to illustrate the mode of proceeding, which is minutely described.
  t Bildung einesoberen Augenhdes aus  der Schlafenhaut, mil gleich zeitiger Restaura-
tion der unteren; Zeitschrift, vol. y.  p. 312.  Professor Ammon states that the operation
had been successfully performed in  the lower eye-lid by Fricke of Hamburg and Von
EkstrOm of Stockholm; and that Dieffenbach had lately done it in the upper lid but that
the newly-formed part, which he calls a beautiful production of art (schoner kunstproductl
perished by hospital gangrene.                                        r     ' 
ECTROPIUM.
141
formed the flap by a horizontal incision (c, d,) two inches and a-half in length,
to which he joined the perpendicular one,  (d, e,) and then dissected it off.   He
reduced the shrunken remains of the old eye-lid with the bistoury; but unfortu-
nately found it impossible to separate enough of conjunctiva from it, to form a
lining membrane for the new eye-lid.
   As soon as the bleeding had ceased, the flag forming the new eye-lid having
been brought into such a position that it covered the eye, it  was secured along
its inner edge (b,  c, Fig. 9.) by Dieffenbach's suture;  and thus ended the for-
mation of the upper eye-lid.*]
   Mr. TvRRELL-f states that he has succeeded in  several operations for
ectropium, which I  conclude  were  performed  on the plan  now  de-
scribed.
   [My friend Professor Horner, of the University of Pennsylvania, has succeeded
in relieving a case of ectropium of the lower lid by an operation founded on the
same principle.  The subject of his case was a man forty-two years of age, in whom
the disease had resulted from a burn two years  previously.   The whole tarsus
was permanently everted, the conjunctiva of the lid exposed nearly half an inch in
breadth and inflamed, ulcered and thickened : " An incision, two inches in length
and down to the bone was made parallel  with and at the inferior margin of the
orbicularis muscle.  The whole thickness of the eye-lid was then dissected up
from the adjoining bones.   From  about the  middle  of that incision started
Fig. 9.
Fig. 10.
another, of an inch in length, downwards
towards the angle of the jaw.  From the
termination of the latter another incision
of the same length was directed towards
the root of the  nose.   The  last two
incisions consequently defined  an an-
gle of integuments, which, being  dis-
sected up as  far as its base, was then
turned into  beginning of the first inci-
sion.   Diagram fig. 9. will illustrate the
operation.
  "The angle  a, Fig. 9, taken from the
cheek, was inserted into  the lower eye-
lid, as seen in Fig. 10, and
a pin fixed at b, and another
at c, so as to keep the parts
in place.   An almost imme-
diate correction of the de-
formity ensued.  Common
dressings were put on, and
at the end of two weeks the
cure was accomplished, with
the exception that the mar-
gin of the lid was  rather
loose, but still leaving the
prospect of  that being cor-
rected by a natural process
of shortening in due time.  He, in fact, was so far well, that he was discharged
from the wards a week or two afterwards.*"]
* Mackenzie's Treatise, p. 202.
t Practical Work, vol, i. p. 456—459.
t American Journal of the Medical Sciences.
Nov. 1837. 
142
AFFECTIONS OF THE EYE-LIDS.
   Entropium (urgon-ie*, Gr. from tnerxu, to turn in) or inversion of the
 lids, which may be either temporary or permanent, partial or complete,
 is more injurious to the eye than  ectropium, being often  accompanied
 with great mechanical irritation, from the rubbing of the lashes  against
 the globe of the eye, which produces severe inflammation, with  ulcera-
 tion and opacity of the cornea.
   Temporary inversion, particularly  of  the lower lid, will  occur in
 chronic external ophthalmia, and sometimes even in more acute cases.
 The ciliary margin  is  drawn  inwards by a spasmodic  action of the
 orbicularis, occasioning constant winking, particularly when attempts
 are  made to use the irritable organ; while the contraction  of this
 muscle forces the eye-lid inwards, and retains it in its unnatural position,
 the swelling of the inflamed conjunctiva between the globe and the pal-
pebra pushes the opposite  margin of the  tarsus outwards.   The eye-
lashes  and the cutaneous surface of the lid are directed against the ball
 with great aggravation of the  inflammation.   By drawing  the skin
 gently downwards, the lid, which retains its natural figure, may be  re-
 stored to its proper  position, but the patient  presently  winks, and the
 orbicularis turns it in again.
   Treatment.—We  must remove the morbid condition of the conjunc-
 tiva ;  and we shall derive assistance in respect to  the inversion by me-
 chanical means.  It is sometimes sufficient to  put a  small compress
 against the lower portion of the lower lid, and retain it  there by a strip
 or two of sticking plaster placed transversely over it.*   Pressure in this
 situation restores the ciliary edge to its right position, and if it be retained
 there for twelve or twenty-four hours, the inversion will  not be repro-
 duced.  It is, however, difficult to retain  the compress, on account of
 the tears flowing over the lid, and loosening the plaster; we may then
 succeed by employing a piece of double twisted wire, bent into the form
 of spectacles, so as  to fit on the nose, and made to press upon the lower
 lid.  This  is  easily fastened  on the face, and may be used with the
 addition of a compress, if it should be necessary.
   We are  more frequently called  on to remedy permanent  inversions,
 accompanied with serious irritation of the eye from the  pressure of the
cilia against the globe.
   There is sometimes in elderly persons*a relaxation of the  integuments;
the skin of the lid loses  its elasticity, falls into wrinkles; the fat is ab-
sorbed from the surrounding parts; and thus loose folds are formed in
the lid.  The balance between the  external surface and the mucous
lining of the lid is lost, and inversion is the consequence.  (Entropium
senile.)  The entire lid forms a round roll, the cilia lying in its interior;
 the essential form is  not altered, and  there is  little or  no  irritation.  I
have seen this inversion in the lower lid of both eyes without the patient
being aware of its existence.  If we take up a fold of integument with
the finger and thumb, or with a forceps,  and draw it  out a little, we
 shall restore the lid to its proper situation.  The surgical remedy for
 the disorder consists in removing a portion of skin close to the edge of

  [* A plan, which we have found to answer very well, is to apply one end of a strip of ad-
 hesive plaster to near the edge of the ower lid, and then to draw down the lid and apply the
other portion to the cheek. This will rarely require adjusting more than  once a-duy, and
often only once every three or four days.]                               J' 
ENTROPIUM.
143
 the  lid, of  such breadth as may be  sufficient, when  the  cicatrix has
 formed, to  bring the part back to its natural direction.
   The superfluous portion of integument may be got rid of by the appli-
 cation of a strong  escharotic; the  concentrated  sulphuric  acid  will
 answer the purpose.*  A small bit of smooth hard wood should be cut
 flat, and almost  brought to a point, then dipped in  the acid and drawn
 gently and  repeatedly over the surface of the skin which it is wished to
 destroy.  The greatest caution is  necessary to prevent the  contact of
 the acid with the ciliary margin, or the globe.  The  application must
 be continued until the proposed object is accomplished, which will gene-
 rally require about ten minutes or a quarter of an hour.   The acid turns
 the skin at  first white and then brown; the skin contracts, shrivels up,
 and thus draws the ciliary margin of the lid outward.   The portion of
 the integument  thus destroyed  soon separates and leaves a  cicatrix,
 which is not conspicuous, although it answers the purpose of preventing
 the lid from rolling inwards.
   The most effective mode of proceeding, however, is to remove a por-
 tion of skin by  the knife or scissors.  A fold  of integument  is to be
 taken up with  a forceps, having small horizontal blades corresponding
 in length to that of the lid.  Before making the incision, it is necessary
 to ascertain exactly how much skin ought to be removed;  this is easily
 accomplished by taking up a fold with the  forceps, and observing  the
 effect on the position of the lid.   If too  much be removed, eversion is
 caused; if  too little,  inversion remains.  The integument is  sometimes
 so loose and redundant, that a broad piece must be removed; I have
 sometimes  found it  necessary to take  away  an  inch.  The incision
 should be as near as possible to  the ciliary margin, just leaving room
 for the sutures.  By this proceeding an elliptical portion of the skin is
 removed ; the  broadest part should be at the point of greatest inversion.
 The forceps are sometimes made with a spring between the handles, so
 that having opened  the extremities and  taken  hold of skin,  the sprino-
 retains that hold.  I  prefer  those  without  a spring, because  we  can
 apply with  the hand  exactly the requisite degree of force.   The  pres-
 sure of the  spring is  sometimes insufficient, and the fold  of skin conse-
 quently escapes.  After having cut off the fold of skin, the  edges should
 be united by two or three fine sHk sutures, which should be  cut out in
 about  twenty-four hours; I never allow them to  remain longer, the
 degree of adhesion being then sufficient to retain the edges of the wound
 in apposition.   The cicatrization produces  a permanent  contraction of
 the part, and consequent restoration of the lid  to  its  natural position.
 When it has been long inverted, and there is change of figure in the
 tarsus, with a tumid  state of the lid and strong contraction of the orbi-
 cularis, it is not sufficient merely to remove a  portion of skin.   This
 proceeding  remedies  the inconvenience for a time, but it is soon repro-
 duced.  Therefore,  after excising the fold of integument, take  up a
 portion of the orbicularis, and remove it by the scissors.  The contrac-

  * This proceeding was proposed by Helling.  Heilungsart d. unkehrung d. Augenlieder
 nach mnen mit concentrirter Schwefelsdure ; in  Hufelanu's Journal, 1815. st. 4 p. 98 vol
 xl. See also hisprakt. Handbuch, 1821, vol. i. p. 302. It has also been employed by Quadri'
 Annot. praliche sulle  Malattie degli Occhi, 1818, p. 69. tav. i. iii.
  Bekr speaks of it in terms of strong commendation, having, as he says, employed it with
 complete success in cases that appeared almost desperate.  Medicinische  Jahrbucher  der
kaiserl. kbmgl.  (Esterreichischen slaaten, band. 4. stuck. 4. p. 166 
144
AFFECTIONS OF THE EYE'LIDS.
tion of this muscle, which has so much influence  in causing and keep-
ing up the entropium, is thus  weakened;  and the subsequent cicatriza-
tion, being deeper and firmer, affords a greater security against relapse.
   Another form of inversion, of which the cause is found in the tarsus,
occurs when the lid has been long the seat of chronic inflammation, or
when it has been frequently the subject of inflammatory attacks.  The
consequence is, that the tarsus becomes corrugated and shortened, the
ciliary margin is contracted and presses  inwards, and the cilia turned
against the globe cause insupportable irritation  by rubbing against the
cornea, whenever the eye is moved:  hence the  eye is kept closed, and
the patient is nearly deprived of sight, if the disease exists on both sides.
The same cause excites and maintains external  inflammation of the eye
with  vascularity and opacity of the cornea,- ultimately changing the
texture of the latter by  rendering it vascular, and converting its mucous
surface into a tough, opaque, and almost insensible covering.
   In an incipient case it may be sufficient to excise  a portion of skin;
this remedy will at least answer the purpose  for some time.  To make
the operation more effectual, a portion of the orbicularis should be re-
moved also, that a firm cicatrix may be produced ; or the acid may be
employed, using it  more freely, so that its action may extend deeper,
and a solid scar be the  result.
  If the entropium should be again produced, other means must be resorted
to.   A mode of operation has been recommended by Mr. CRAMPTON,*of
Dublin, and followed with a little modification by Mr. Guthrie ;f it con-
sists in a perpendicular  division of the lid near to each angle, or on each
side of the inverted portion, cutting through  its textures longitudinally,
when it maybe turned up and brought into a state of complete eversion.
The whole thickness of the lid is cut through by a strong  pair of scis-
sors, so that when you  lift it, the mucous  or concave surface is  fully
exposed.  The contracted ciliary margin being thus set at liberty, the
inversion is remedied at the moment, but  in  bad cases the tarsus still
remains a little bent inwards.   A portion  of  the external skin must  be
cut out, as in the operation  already described, taking up the necessary
fold with the forceps, measuring it, removing it  with  the knife or scis-
sors, and  then uniting with two small sutures.   A little cut,  or nick,
should then be made in  each edge of the curved  tarsal cartilage, so that
it may more easily bend outwards in its proper direction.  Then, having
left the threads of the external sutures of proper length, carry them up-
wards, and  confine  them on  the  brow by  sticking  plaster, elevating
them sufficiently to evert completely the liberated upper  eye-lid, and to
maintain it everted, with its mucous surface completely exposed.  Thus
the parts are to be left till the sutures come through by ulceration, and
till the granulation of the two longitudinal cuts draws the lids gradually
into its natural position.  The inverted  lid is to be covered by a piece
of thin linen spread with spermaceti cerate.  The object  of the pro-
ceeding is to liberate  the contracted tarsus, to destroy its unnatural
curvature, and thus  to  prevent renewed inversions.   Mr.  Guthrie re-
presents that it accomplishes these  points completely; that it is a per-
fect remedy for the severe sufferings  caused  by  habitual entropium.

  * Essay on the Entropion,  London, 1806.
  t hectures on the operative Surgery of the Eye, 1823, p. 31—41. 
ENTROriUM.
145
Fig. 11.
  [Fig. 11 represents an eye the upper lid of which has been operated on for inver-
sion, a, the inner incision, close to the punctum lachrymale, which is marked by
a black  spot, and which incision need never exceed one-third of  an inch in
length;  b, the outer incision, of the same length, close to the external canthus;
c, the ligatures supporting the  lid against the eye-brow, and more particularly
the inner one, which is passed through  the edge of the lid; d, strips of adhesive
plaster affixing the ligatures to the forehead;  e, line of incision, in a case of in-
version  of low lid.]
  There are objections to this complicated proceeding, in which great
liberties are taken with the part; and I believe that the object may be
attained more  simply.   Mr. Tyrrell makes  a perpendicular  section of
the whole substance of the  lid, near its centre, which in some cases is
followed by a rapid  removal of the  inversion, while in other instances
it is  necessary in addition to cut out a portion of integument.   The sec-
tion  of  the  lid  makes a wound shaped like the letter V, which is after-
wards filled by granulations, so that little deformity results.   Mr. Tyr-
rell has found this method  invariably successful.*
  There is another operation, which is certainly effectual in removing
the immediate cause of evil, viz. the irritation caused by the inverted
cilia.  This is  the excision of the inverted cilia with that portion of the
edge of the lid containing their bulbs, proposed  by Professor  Jaeger,!
of Vienna.   In a case of complete  inversion, it is difficult,  if not impos-
sible, to accomplish a perfect  cure; that is, to restore the edge of the
lid, with its lashes, to its natural state; the excision of the bulbs sacri-
fices the lashes, but has the advantage of removing effectually  all source
of irritation from  the eye.
  A smooth slightly concave  piece of horn, adapted  to  the size of the
lid, is introduced under it as a means of extension and support in the ope-
  f Vol. i. p. 447.
  t Hosr. diss. med. chir. sis tens Diagnosin, et Curam radxcnUm Trichiasis, Distichiasis,
nccnon Entropii, Viennee; also in Radius, Script, ophthalm. minor, vol. i.
       19 
146
AFFECTIONS OF THE EYE-LIDS.
tion:  this however is not  indispensable.   A horizontal incision is then
carried through the skin and  orbicularis,  a  line and a-half from the
ciliary margin, and continued to that margin at each extremity of the
inverted portion.  The part thus marked out is to be dissected carefully
off by repeated short strokes of the knife  carried obliquely, so as to in-
clude the bulbs of the inverted lashes, and leave  the mucous surface
entire.   As the integument is redundant,  it may sometimes be advan-
tageous to make the first incision further from the margin of the lid than
I have mentioned; but in  the subsequent dissection, we must not remove
more than a line and  a-half, which will  include the complete ciliary
bulbs.  The portion to be removed may be held and drawn outwards
with forceps; or it  may  be more completely  and  conveniently com-
manded by means of  a ligature passed under the skin with a curved
needle.  A soft rag dipped in cold water may be laid on the eye  after
the operation, and occasionally renewed.   I have adopted this mode of
proceeding in many instances with a completely satisfactory result.
The patient is immediately relieved from the intolerable irritation caused
by the rubbing of the cilia; the eyes and lids can now be moved freely,
and thus the use of these important organs is  restored.  The  chronic
ophthalmia ceases, the vascularity of the  cornea disappears, and opaci-
ties are  either removed entirely, or  greatly lessened  in extent  and in-
tensity.   When the wounded surface  of the lid has  cicatrized, no
deformity remains.
   The excision of the whole tarsus, proposed by  Mr. Saunders* is an
unnecessarily extensive and severe measure, and  is  now, I believe, en-
tirely abandoned.  Dr. Jacob")- cuts away the  cilia and their bulbs with
scissors, making repeated small incisions until the whole of the inverted
portion is removed.
   Trichiasis (from Tew?, genitive of Sf <£, hair.)—This word  denotes
an unnatural direction of the cilia, in which they turn inwards, so as to
press  against the  eye-ball.   It  generally attends entropium, but not
necessarily so; for  the lid, when  inverted, sometimes forms a  roll, the
interior of which is occupied by the lashes.  On the other  hand, the lid
retaining its natural direction and position, one or more  of the cilia may
be turned in so as to press against the globe of the  eye.   This wrong
 direction of the cilia is called trichiasis.  The changes which the form
 and direction of the ciliary margin  undergo  in the  worst  forms  of en-
 tropium, cause trichiasis, which is then  combined with  the inversion.
 Cicatrices of the ciliary margin, or tarsal surface  of the lid, will cause
 partial trichiasis; thus it happens after  wounds, injuries from  caustic
 substances,  or ulceration from various causes.   The trichiasis may be
 complete, involving the whole row of eye-lashes;  there may be  only a
 single hair; or it may exist in any intermediate degree.  I have seen
 patients in whom the entire series in both  lids  of both  eyes has been
 inverted; so that they have not only been deprived of all useful vision,
 but  rendered miserable by inflammation  and  pain for many  years.
 When the form of the ciliary margin has been altered by long continued
 disease, the cilia, instead of projecting nearly  horizontally, are  placed

   * On the cure of the Inversion of the upper Eye-lid by excision of the tarsus, in his pos-
 thumous work, p. 74.
   t Dublin Hospital Reports, vol. v. p. 392. 
TRICHIASIS.
147
almost perpendicularly, so that their convexity brushes against the globe.
Their points are directed towards the eye, when the inversion proceeds
further.   Sometimes one or two hairs are inverted without any appa-
rent cause, the lid and the  other cilia  being quite natural; in this case
the wrongly directed hair is usually slender and light coloured, so that
close examination is necessary to  detect the inconvenience.   The sen-
sations  of the patient, however, are very  accurate; the feeling of a
foreign  body rubbing the eye is  almost invariably expressed.   This me-
chanical irritation of the organ produces different effects according to
its degree, and other circumstances.  Sometimes there  is a slight un-
easiness without inflammation ; and this may exist for a long time with-
out the  cause being discovered when there is only a single inverted
lash.  Inflammation may be caused, with ulceration and*opacity of the
cornea, severe pain, with intolerance of light and the greatest irritabi-
lity.   Sight may be destroyed  by the  effects of repeated acute inflam-
mation of the cornea, but the patient's sufferings are not at an end; they
are only alleviated by keeping the  eye absolutely at rest; the motion
required in using it renews the pain.
   Treatment.—The cure of trichiasis is either palliative or radical.  The
former consists in plucking out the cilia;  for  which purpose we  use
forceps  with broad  ends.   The  lashes  soon grow again, and must  be
extracted as often as they are reproduced.   If the case requires a more
effectual remedy, we must have recourse to the operation of extirpating
the bulbs of the inverted cilia, as described for entropium.
   There is a  modification of the affection,  called distichiasis,* a Greek
word meaning double row; not that there is properly a double row,but
there is a partial series of cilia produced on the inner margin of the lid,
in addition to the natural row.
  These pseudo-cilia, which  are produced  not  unfrequently where  the
lids have long been  the seat of irritation, generally turn  in against  the
globe.  The palliative measure of eradication must be adopted ; its fre-
quent repetition in this, as in  other cases, sometimes proves a radical
remedy.   If this should be insufficient,  we must resort to  excision.
  A triangular portion of the eye-lid has been removed in the case of a
small partial trichiasis.  I have  found excision of the bulbs  a sufficient
remedy  in similar instances.
  [The amount of serious injury to the eye and of distress to the patient, often
caused by inverted cilia, can scarcely be realized by any one who has not had
extensive experience.  I have known  cases in which inflammation of the eyes
was kept up for years by them, and one instance in which the eye was lost from
the irritation of a single hair.   This occurred in a young gentleman favourably
convalescing from an extremely severe attack of purulent conjunctivitis; and
who  had several times suffered from inversion of his eye-lashes.  The hair
could not be discovered by the friend whom he requested  to extract it, and  he
was persuaded that the sensation he experienced was delusive.   On my visit I
readily discovered and extracted the eye-lash, but the eye never recovered  the
effects of the re-excitement of inflammation in it.
  The inverted cilia are sometimes so extremely delicate, and light coloured
that it is very difficult  to detect them.  The plan we adopt is to place the patient

  * Distichia and distichiasis, are from <f/c, bis, and o-t^oc, ordo.  Districhiasis is from (f«
and S-pig. 
142
AFFECTIONS OF THE EYE-LIDS.
sideways to the light and to "use a magnifying glass of about an inch and
a-quarter focus.   The best instrument for extracting them is  a pair of forceps
about two  lines broad, and square at  their ends, ground flat that  their oppo-
site blades  may accurately correspond so as to prevent the hairs from slipping
out, and without teeth.  The hair should be  seized  near the root and  slowly
drawn out  in a straight direction, by which means they are  usually extracted
by the roots.  When drawn out with a jerk they almost invariably are broken
off, and the short portion  left, irritates like  a short bristle. When the ex-
traction of the hairs does not  prove  sufficiently efficacious, the application  of
an irritant  to the hair bulbs to  destroy  their  reproductive functior,  as recom-
mended by Dr. James Hunter,  appears  to us a much better procedure than the
operation for excision.   Dr. Hunter's method of proceeding is as follows:—
  " 1.  To  ascertain the  presence  anil position  of  the inverted  eye-lashes.
When they are white coloured, and of  extreme delicacy, not  exceeding T^7  of
an inch in diameter, as is often  the case, it is very difficult to  distinguish them;
the edge of the lid should be brought in contact with the  cornea,  so that the
pupil  or iris may form a good contrasting background, and  though they may
not be visible at once, the surgeon should look  from a variety of positions, and
alter the direction  of the light till he sees them.  A convex  lens of two  inches
focus, and not less than an inch in diameter, should  be held by an assistant so
as to condense the light on the parts, which is  a much better plan than using  it
as a magnifier.  If, in order to  make the puncture, the edge of the lid is to  be
removed from the cornea, it is well  first of all  to blacken the pale and delicate
eye-lashes  with any dark  extract, such as belladonna, to render  them visible,
when  contrasted  with the  white sclerotic coat.  2.  The puncturing  of the
bulbs.—This should be done with a lancet, or iris knife, entered close  to the base
of the inverted hairs, in the direction of their growth, to the depth of an eighth
of an inch, and moved about a little, so as to  widen the bottom of the w7ound,
and cut the bulbs.   In doing this, it is  sometimes advantageous to stretch the
part either  with a  small hook, or over a convex black horn spatula,  such as  is
usually attached to the German wire  speculum.   3. The  inoculation.—This
must be deferred till the bleeding has wholly ceased, when the lid  being wiped
very dry, the drilled end of a  darning-needle  slightly damped, and  dipped  in
powdered tartrate of antimony, or what answers far  better, the tartar  emetic
point made in the  manner to be afterwards described, is  to be inserted in the
puncture, and held there for a few seconds.  4. The evulsion of the inverted
eye-lashes is the last  step.—They should be seized lengthways  close to their
roots, and drawn  with  a  slight jerk.   When  common  dissecting forceps are
used, they should be held below their  shoulder, and close to their points, which
are apt to separate a little when the fingers  are placed higher up.   The best
forceps are those made without teeth; the holding part being merely rough
polished, so as not to cut hairs.   When the eye-lashes are exquisitely fine, and
slip through even the best made forceps, I have found it an infallible plan  to
damp their points  with a saturated solution of  shell-lac in alcohol,  and to grasp
the hairs for a second or two before pulling them.*  A momentary, though sharp
pain follows the  inoculation, and more or less inflammation ; but the latter
generally subsides in the course of twenty-four hours, and if the  operation has
been properly done, it recurs in a day or two,  in a subacute form, producing a
slight pustulation,  which, however, is of very limited extent, causing almost no
annoyance, but is sufficient to destroy the functions of the bulbs."f
   Pseudo-cilia  are sometimes  met with growing from  different  parts  of the
conjunctiva, even, according to Dr. Mackenzie, the conjunctiva corneae.J  Dr.

  * [This is an excellent  expedient.]
  + Am. J. Med.  Sciences, Oct. 1841, from Ed. Month. J. Med. Sc. 1841.
  \ Treatise p. 210. 
ANCYLOBLEPHARON.   SYMBLEPHARON.
149
Monteith* mentions a case in which one exceedingly strong hair grew from the
inner surface  of the lower lid.  It was directed perpendicularly towards  the
eye-ball, and irritated.   The natural cilia were of a light colour, the pseudo-
cilium jet black, and double the length of the common cilia.  We have met with
one case in which a long delicate cilium grew from the surface of the upper lid;
it was light coloured whilst the natural  cilia were black.
  Dr. Mackenzie has seen  an eye-lash fully an inch in length, soft, and woolly,
in a patient who had long suffered from ophthalmia.!]
                   SECTION V.--MORBID CONNEXIONS.

  Ancyloblepharon is a preternatural union of the two lids.   They have
been found thus united in some instances, as a congenital malformation;
but I have not seen such an  occurrence.!   It  is usually the result of
ulceration:  if the opposed margins are both ulcerated at the same time,
they may grow together.  In this way partial union  may be produced
at the external angle,  in old cases of lippitudo, where there have been
frequent inflammation and excoriation, shortening the palpebral slit, and
inconvenient in the operation of extraction, by preventing a sufficient
exposure of the globe.   This  state cannot be remedied ;  indeed, I never
saw it existing to a degree requiring any remedy.  If there were con-
genital  union  of the  lids, as we sometimes find in the  anus and labia
pudendi, with no other defect, they  ought to be separated by incision,
taking the necessary care not to wound the globe.
  The term symblepharon denotes a connexion of the lid  to the globe
of the eye.  This  is generally the  consequence of accidents, in  which
caustic substances, such as lime or mortar, are brought into contact with
the surfaces of the  lid and the globe; it may take place  whenever ulce-
ration of the two opposed conjunctival surfaces takes  place, from what-
ever cause.  The granulations, which shoot  up from  the globe  and lid,
inosculate, and a permanent adhesion is produced.   When  the surfaces
are extensive, it is  impossible to prevent their accretion, even if we see
the case from  the  beginning; at  least I failed completely  in a case
where the lower lid and globe were thus injured by mortar, and where
I took every pains  to prevent the parts growing together.  The accre-
tion varies in  extent and firmness; there may be a close and firm union
of the entire lid and  globe, or merely slender and loose  bridles of con-
nexion ;  or any intermediate degree between these.   The slender frsena
may be divided and dissected off, if there be any useful purpose  to be
accomplished; and there would be no difficulty in separating the more
extensive and close connexion;  but the  constant apposition of  the raw
surfaces reproduces the  union, so that the inconvenience may be con-
sidered  irremediable.^

  * Translation of VVeller's Manual, vol. i. p 115.           t Treatise, p. 210.
  t Beer says, that the very rare affection, congenital ancyloblepharon, had come under
his observation, and that he had operated both with and without successful result,  hehre,
vol. ii. p. 123, note.
  § In a case of total symblepharon of both eyes  from ill-treated catarrhal blennorrhcea,
Blkr separated the lids  from the globes, and found the latter natural, excepting the opacity
ot the cornea.  The adhesion was partially renewed while Dr. Juengken, who mentions the 
150
EPICANTHUS.
   Epicanthus.—The present seems the only convenient opportunity for
mentioning a congenital peculiarity of structure, which I have seen a few
times in infants, consisting of a fold of skin at the side of the nose pro-
jecting from one to two lines, covering the  internal  canthus, and appa-
rently limiting the separation of the lids.   The prominent edge  of the
fold is nearly  perpendicular, or  it may be  a very little concave.   The
effect on the movement of the lids has not been sufficient in the cases I
have seen to require remedy by operation.   Professor Anmon,* who has
described the  case under the name of  epicanthus, has proposed an ope-
ration for it;  and Graefe")- seems also to have operated in a case.
   [Epicanthus consists in a fold of skin projecting in such a way from the side
of the root of the nose, over the inner angle of the eye, as  to cover the caruncula
lachrymalis and inner portion of the globe of the eye.   The free edge of the fold
                        Fig, 12.                     is somewhat crescentic,
                                                    and its extremities are
                                                    continued into the skin
                                                    of the upper and lower
                                                    eye-lids.  (See fig. 12.)
                                                    It prevents the eye-lids
                                                    from being completely
                                                    opened, and thus inter-
                                                    feres with vision.  This
                                                    conformation  has been
                                                    supposed always to be
                                                    congenital and to exist
                                                    on both sides  at  the
                                                    same time, but M. Car-
                                                    ron du Villardsf asserts
                                                    that he has three times
                                                    seen  it spontaneously
                                                    developed  at  an  ad-
vanced age, where  there was  no  congenital trace of it,—twice as a sequel of
scrofulous and  once of variolous ophthalmia^—and that he has  also seen it on
one side only.   How those diseases, however, can possibly give rise to  this de-
formity, we must confess ourselves unable to conceive.  In the only two examples
we have met with of it,—a lady and her child,—it  was  congenital and  existed
on both sides.
   When this deformity is sufficiently great to impede the opening of the lids, it
may be removed by pinching up a longitudinal fold of skin of sufficient size to
efface the epecanthis, including this fold in two elliptical incisions, removing it
and then bringing together the edges of the wound by harelip suture.  (See fig.
 12.)  Dr. Ammon calls this operation Rhinoraphy.

case in a letter, had the opportunity of seeing the patient.—Graefe und Walther's Jour-
nat, vol. i. p. 521.
   " Quant a. l'adherence des paupieres  an globe," says Demour's, " je l'ai vu  plusieurs fois
plutot augmenlee que diminnee, apres une operation  tentee pour la detruire."  " Au rap-
port de M. Richerand, M. Boyek a vu  trois fois cette adherence se renouveler."—Traite
des Maladies des  Yeux, torn. i. p. 113.]
   [In all the cases which have come under our observation in which an attempt was made to
separate the adherent lid from the ball  of the eye, the result  was unfavourable.   See Am.
Journ. Med. Sc. Aug. 1839, p. 279.]
   * Zeitschrift, vol. i. No. 34, plate 5.
   t  Ibid. vol. ii.  No. 4, plate 1, fig. 8.
   t  Bulletin  General de Therapeutique.  July, 1838, p. 45, 47.
   §  Ibid.
 
TUMOURS OF THE EYE-LIDS.
151
  Another operation has been tried, which consists in dividing the fold of skin
itself transversely and trying to prevent its immediate reunion, but with little or
no benefit.
  Dr. Mackenzie says if the folds do not exist in any great extent, the rising of
the nose, as the person advances in age, may perhaps have the effect of oblite-
rating them.*]
                       SECTION VI.--TUMOURS.

  There is a great variety of these, some of them being  analogous to
what we meet with in other parts, while  others are  peculiar  to  this
situation.
  JVcevi materni occur not unfrequently on  the eye-brow or upper lid.
In a large one  occupying the latter situation, the employment of the
knife would be  inadmissible, not only on  account of  dangerous hemor-
rhage, but also because the cicatrization of the wound  might cause
shortening or eversion of the lid.   In such a case I lately  employed the
ligature with perfect success; the basis of the growth was so large, that
I found it necessary to tie it in three portions.
  In an infant of six months, there was a subcutaneous naevus as large
as a filbert, occupying the inner half  of the  upper lid, and  its entire
thickness.  It formed on the conjunctival surface  a  soft purple pro-
minence,  marked by superficial sulci.   Through   the centre of  this
growth I passed a seton, which was followed by profuse arterial hemor-
rhage : pressure soon stopped it.   The seton was taken out at the  end
of a week.  The increase of the nasvus  was arrested; but  when  the
patient left town  at the end of five or  six weeks its  size was not dimi-
nished.  This operation was performed in the spring  of 1832, and I saw
the patient again last  autumn (1839.)   The disease  had entirely disap-
peared, and the only trace of the operation was a slight tuck  of the in-
tegument  not noticeable on superficial  inspection.
  In newly born  children I have frequently seen red marks, sometimes
of considerable extent, on the lower part of the forehead, eye-brows,
and eye-lids.  The skin  deviates  from its normal state, merely in  this
circumstance of redness, which is owing to an unusual development of
its minute vessels.  Sometimes the colour becomes faint, or even disap-
pears,  while it is  augmented to a bright  scarlet tint  on crying or hold-
ing the breath.   No surgical treatment is required as the  preternatural
colour gradually goes off.  Still, for some years, the original situation
of these marks  is rendered visible when the vessels are distended, as by
crying.  If  it  should be  necessary to adopt some   local  treatment, to
satisfy the minds of parents, the red  parts may be occasionally wetted
with an evaporating lotion of rose water with some  alcohol;  or an as-
tringent might be tried, such as a solution of alum.
  Encysted tumours are met with not unfrequently in  the neighbourhood
of the  eye-brow and lids.   They may  be situated under the skin, as in
other parts of the body, and may be removed by operation in  the usual
way.
  Another description of these swellings is found, in  infants and young
* Treatise, p. 185. 
152
TUMOURS OF THE EYE-LIDS.
 children, most commonly near the external  canthus, on the neighbour-
 ing surface of the frontal bones; less frequently at the internal or nasal
 end of the  eye-brow.  The history given by the mother, leads to the
 opinion that they are congenital.   The swelling, about the size of a pea
 or a horse bean, is a colourless elevation, with the  integuments cover-
 ing it loosely, so that they can be pinched up into a fold. They increase
 in size, without attaining considerable magnitude; I have, however, seen
 in the adult a tumour of this kind, at least an inch in diameter.  They
 must be removed if they  cause, or are likely to produce  conspicuous
 deformity.  On this  account their excision is commonly desired in fe-
 males.  They are sometimes stationary, when, if the swelling be of mo-
 derate size, there is no necessity for operation.   I am  acquainted with
 a gentleman, who has had through life a larger growth of this kind: it
 causes an unnatural fulness  near the external angle of the eye, and has
 never been attended with the slightest uneasiness.   Unless examined by
 the hand, it might be taken for an  unusual  development  of the skull.
 The disease consists of a thin  but compact  cyst, with white glistening
 surface, containing fat, sometimes of oily consistence, sometimes firmer,
 and short hairs mixed with it in various proportions.  Is this admixture
 of hairs,  which resemble those of the eye-brow in length, to be regard-
 ed as an exemplification of the principle so frequently observed in ad-
 ventitious structures; viz. that they resemble in nature that  of the tex-
 tures in which they grow, or that of the parts in their immediate vicinity?
 These  cysts, although they seem  loose  on  external examination, are
 placed under the orbicularis, and adhere more or less firmly to the bone,
 which is sometimes indented : the smooth lining of the cyst and the hairs,
 would lead us to consider these cysts as cuticular: we should not have
 expected to find such a structure under the muscles.
  In all operations on this region, the external incision, if circumstances
 admit, should be parallel to the fibres of the orbicularis.  In the case of
 these cysts, it should  also be  free, that we may  have room enough to
 expose the cyst clearly, and to dissect  it away from the bone, without
 cutting or breaking it.  The removal of the whole cyst must be accom-
 plished, and especially care  must be taken to effect  this, where  it ad-
 heres to the bone.  If  a portion of the bag  is left, the wound will not
 close; such an occurrence being annoying to the patient, and discredit-
 able to the operator.   I saw a young lady, in whom such  a tumour as
 those I have described had been removed  from the root of the nose, at
 the interval of the eye-brows.  She was  a handsome person, and  had
 submitted to the operation for  the removal of what she deemed a blem-
 ish, though it must have been slight, as the tumour was inconsiderable.
 She was  much worse off after the operation than before; for the wound
did not heal; at least it  sometimes scabbed over, and sometimes  dis-
charged.   A probe introduced into the opening went down apparently
to the bone.  Having learned  the nature of  the swelling, and that the
operator had experienced unexpected difficulty in separating it from the
bone I concluded that a bit of the cyst had been left behind, and to as-
certain that point, I proposed an incision, to which the  patient readily
assented.  I found, closely adhering to the frontal  bone, a small strip of
the cyst, conspicuous by its white glistening surface, and having a  few 
TUMOURS OF THE EYE-LIDS.
153
 short  hairs on  it; this  was  easily removed, and  sound cicatrization
•quickly followed.
   Mr. Tyrrell*  recommends that  these encysted tumours should not
 be meddled with, when they are attached  to  the  bone, having  seen
 inflammation  with sloughing,  exposure, and exfoliation of the bone
 resulting  from such operations.  I  have never witnessed any thing of
 this kind.
   The lids are subject to the formation of tumours, which may be called
 half-encysted,f containing a small quantity of white milky matter, in an
 imperfectly formed cavity.  They appear first as a small smooth promi-
 nence, with a flatlened surface, and  a small pin-hole in its centre;  they
 gradually increase in size to that of a pea, a horsebean, or the end of the
 finger.  Pressure  will  squeeze out a little soft  white matter from the
 central opening.   They  sometimes inflame;  the aperture enlarges, and
 the cavity of  the cyst is exposed, as an  irregular fibrous surface, pro-
 ducing a copious discharge, with  surrounding inflammation and excori-
 ation.   Theie is generally more than one, and often they are numerous
 in both lids; they are  also seen in other parts of the face, but less fre-
 quently.   The  easiest  mode of removing them is to  split them in  two
 with a small sharp knife; we  may then with  a forceps take hold of the
 divided halves, and pull  them  gently out; very little force  is sufficient
 to separate the loose cellular adhesions of the  tumour to the surrounding
 parts.   The tumour is lobulated and granulated on the surface, soft and
 whitish, and has a small cavity  in the centre.   In this mode  of pro-
 ceeding, no skin is removed.  Lay a soft rag dipped in cold water over
 the eye and keep it damp;  the part heals  readily, and no mark is  left.
 If it should have begun  to ulcerate,  it will be sufficient to take  a caus-
 tic pencil and touch the exposed surface;  the tumour  then drops out in
 a  day or two.  Sometimes it  is  spontaneously detached under the in-
 flammatory action, and the surface heals.
   Tarsal tumours.—These, which  are of frequent occurrence, grow
 from  the  tarsus, to which they firmly adhere, and form small external
 swellings, sometimes  reddish   coloured, on  the  lids.  They are  co-
 vered  externally by the integuments and  the fibres of the orbicularis.
 They seldom grow larger than a  pea or bean, and do not give much
 trouble, except  producing  a  sense  of heaviness in the  lid.   By  in-
 verting the lid, more particularly the  upper,  the  part of  the tarsus
 from which  the tumour  rises  may be distinctly seen: the  cartilage is
 rendered thin at that part, so  as  to show the. size and situation of the
 base of the tumour.  The contents are various; sometimes there is  ob-
 vious redness, and  the production  is inflammatory; pus is contained, and
 the case may be considered  as chronic abscess of the lid.   Sometimes
 there is a glairy fluid ;  sometimes a soft vascular tissue breaking down
 under the probe.  These swellings  may probably be diseased Meibomian
glands. The general rule given for operating on tumours of the lids, is
to cut down  through the skin and orbicularis, and dissect them out. This
is a painful operation, and cannot  be strictly executed, as the basis can-

  • Vol. i. p. 180.
 t These growths arc called albuminous tumours by Mr. Mackenzie, p. 151; glandiform
tumours  bv Mr. Tiukel, vol. i. p. lti'J.
       20 
154
TUMOURS OF THE EYE-LIDS.
not be insulated from the tarsus; to separate the tumour entire,it would
be necessary to cut through the cartilage, and thus make a button-holo
in the lid.   However, this external incision and dissection are unneces-
sary ; it is sufficient to invert the lid, and to puncture  the thinned por-
tion  of  the tarsus, with a sharp-pointed double-edged  knife: the pus,
glairy fluid, or whatever else it may contain, escapes;  nothing more is
necessary, the cavity contracts, and the place soon heals.   Supposing
the tumour not to contain fluid, but to be of a vascular texture, then a
second incision should be made at an acute angle to the former, so that
a little triangular flap is produced, which may be cut out with the scis-
sors; then break down the soft texture with a probe.  In a few days
a soft kind of fungus projects, which we cut off with the scissors, and
the part heals.
  Tumours sometimes form upon the inner surface of  the eye-lid, just
at its orbital edge, where they are merely covered by  the conjunctiva.
If we invert the lid, we can remove them very easily, transfixing them
with a hook and drawing them out.   It is better to do these little ope-
rations on the inside than on the outside, if we can; there is  less to be
cut through, and less risk of unpleasant  scar.
  An indurated tumour of undefined  margin, occupying the edge of the
lid, is described under the name of chalazion, or grando, which are the
Greek and Latin terms for hail: the German gives it the corresponding
name of hagelkorn.   It  is said to be the indurated remains of a stye,
which has not suppurated regularly: Hence it has been called hordeo-
lum induratum.  Beer's  chapter* on this subject is a  most unfortunate
specimen of pathology and treatment. He says, that this indurated stye
may assume a scirrhous  character in scrofulous subjects, and that  if
such persons should  become affected by any other kind  of dyscrasia or
cachexia, such as syphilis, itch, gout, scurvy, the complaint may go on
to carcinomatous ulceration.  RosAsf give's a similar  representation.
If the complaint should not  be  removed by the farrago of applications
recommended, extirpation is advised.   I  have never seen the remains of
a stye become troublesome, nor found it necessary to cut away such
substances as those described by the name of grando.    I am quite at  a
loss  to account for the strange notion that hordeola may be  metamor-
phosed into scirrhus  and  cancer.
  Milium and Phlyctenule—Small white tumours are sometimes seen
on the margin of the lids.  They are about equal to the head of a  large
pin,  or they may be rather larger.  They consist of  a  thin but dense
membrane, containing a soft white substance like boiled rice.   They are
called milta; and generally  occur in elderly persons.   They cause no
inconvenience, when they remain  stationary, and  attain only a limited
size.   When it is wished to get rid of them, they are easily removed by
transfixing them with a hook,  and cutting them out with  scissors.   If
 hey  are deeply imbedded, a little  nick may be made on each side with
the knile, before using the scissors.
  The same observations are applicable  to watery vesicles of the cili-

  * hehre, vol. ii. p. 139.
  + Handbuch, vol.  ii. §  209.  Juengxen states that earwr „f tu.    ij
from chalazion or  warts badly treated.-Z/aX^ p 6oT          *      "^ '"" 
TUMOURS OF THE EYE-LIDS.
155
ary margin (phlyctenule.)   I  have seen the edges of both lids on each
side studded with a mixture of these milia and phlyctenulae without any
inconvenience to the individual.  If patients should object to the use of
knife or scissors, these cysts might be got  rid of  by puncturing  them
freely, removing the contents, and touching  the  internal surface with
nitrate of silver.
   Verrucce.—Warts are seen  occasionally, but not frequently, on the
edge  of the eyelid.  They may be confined  to the ciliary margin, or the
integument; or they may occupy both.   They are rough or fissured on
the surface; sometimes of brownish colour, with short stiff hairs: they
may be pedunculated, or have a broad basis.  They  may be snipped off
with scissors, or  removed by ligature; and the part from which they
have  grown, may be touched, if necessary,  with the  nitrate of silver or
a particle of strong acid.
  Pediculi ciliorum, phtheiriasis.—Foreign writers speak of lice found
an the cilia, and  occasioning  ulceration  of the  lids, or even external
ophthalmia.   A child came  to the London  Ophthalmic Infirmary  com-
plaining of the eyes being sore, and that they itched.   I looked at the
eye, which did not appear diseased ; but  I  thought that the  cilia  were
thick, and  I found, on a closer examination, that  there was  an infinite
number of pediculi sticking  over the hairs.  I ordered the free applica-
tion of the citrine ointment,  and wished to see its effect; but the mother,
who came with the child was not pleased at learning the nature of the
complaint  and did not bring  the  child  back again.  The mother and
child  were clean in person and dress, and of respectable appearance.  I
have  seen  these vermin on the eye-lashes in one other instance only. In
general appearance  they resemble the crab-lice {pediculi pubis)  more
than those of the head.*
  Loss of the eye-lashes may  uccur spontaneously; at least without in-
flammation.   1 have already alluded to the  subject at p. 124.

  * Demours states that neither he nor his father had ever seen lice on the cilia.   Traite
des Maladies des Yeux;  torn. i. p. 81.  Scarpa says that he had seen one instance,
and  that the pediculi  were only discovered by examining the roots of the eye-lashes
with a powerful lens  They had occasioned an obstinate affection of the eye,  which
was speedily removed  by applying  mercurial ointment to the  eye-lids and eye-brow.
He observes that  a case of the same sort is mentioned at the end of Guillemeau's Trea-
tise on diseases  of the Eyes, and that similar  cases are related in the twenty fourth
volume of Cokvisart's Journul, August, 1812.   Treatise, &.c. translated by Briggs. Ed.
9, p. 173.
.« 
(   156  )
CHAPTER  III.
                      Injuries of the Eye-ball.

                 SECTION I.--WOUNDS OF THE GLOBE.

  The general principles of treatment are the same for all  wounds.
They comprise the removal of extraneous substances, keeping the edges
of the wound in apposition, and the employment of such local and gene-
ral  means as are best calculated to prevent or  lessen inflammation.
These are repose of the injured part, and the protection  of it from all
causes of excitement;  rest of the body generally, when the  organ is
important, or the  mischief considerable; evacuation of the  alimentary
canal in the first instance, and  maintaining  its regular  action subse-
quently ;  a mild and unexciting diet.  The great importance of the part,
and  its susceptibility of inflammation, require that these circumstances
should be attended to, in wounds of the  eye and its appendages, more
carefully than in many other instances.
  Conjunctiva.—Slight injuries of the membrane, such as rubbing by
the end of a finger or the edge of a hat, the wounds of scarification, or
in removing a pterygium, are unimportant, and require only the simplest
management.   A considerable laceration of the membrane, if accompa-
nied with separation of the edges, might require a  fine  ligature, and
greater care to guard against the occurrence of inflammation.
  Ecchymosis  of the conjunctiva, accidental and spontaneous.—Ex-
ternal violence may occasion rupture of vessels and consequent effusion
of blood into the submucous cellular tissue.   The  membrane presents a
discolouration, of lighter or deeper lint, as if blood were injected into its
texture;  and the quantity may be sufficient to raise it from the subjacent
parts.  The tint is at first a bright red, and it gradually becomes a deep
brownish red: the more superficial the effusion, and the smaller in quan-
tity, the more vivid is the colour; when it  is deeper-seated and abun-
dant, the part has a dark liver colour.
  This conjunctival ecchymosis may be produced by violent efforts,  as
in coughing, and it sometimes comes on spontaneously.   The  patient
is frightened when he sees the eye discoloured; and the appearance may
puzzle a  surgeon  not conversant with the phenomenon.
   Ecchymosis is distinguished from inflammation  of the conjunctiva by
the entire absence of distended vessels, of pain, and all other inflamma-
tory symptoms; and by the uniform dark reddish brown tint of the dis-
colouration, which continues  to the edge of the cornea, and there termi-
nates abruptly.  The absorbents will remove the  effused blood in a week
or two;  and I am not aware that its appearance can be materially ac-
celerated by surgical  treatment.  The application of cold  may be re-
sorted to at first; and then a  weak solution of sulphate of zinc may be
us%4 as a collyrium.  I never saw the discolouration last  long, nor lead
to unpleasant  consequences.   It  may occur in  conjunction with more 
INJURIES OF THE EYE-BALL.
157
serious injury of the globe; but when it exists alone, it requires no fur-
ther treatment than what 1 have specified.
   Wounds of the globe.—Its delicate organization, vascular and nervous
structure, and  great sensibility, render it liable to inflammation; conse-
quently  wounds inflicted  on it  are  dangerous.   Surgical operations,
which are executed with the  sharpest and smoothest instruments, and
performed with the greatest care and gentleness on persons carefully
prepared by previous  attention  to diet and  medicine, often excites se-
rious  inflammation ; we cannot therefore be surprised at the violent and
destructive disturbance caused by wounds made  with rough, ragged, or
blunt  bodies, inflicted  with violence, and on subjects in a state of body
favourable to inflammation.
   The extent of the wound, the  amount of violence, and the state of the
constitution, are the circumstances of chief importance in determining
the degree of inflammatory re-action.  Small wounds gently inflicted are
not dangerous; such  as the wound of the cornea in kerato-nyxis, and
in the evacuation of the aqueous humour, and the puncture of the tunics
in depression.   Larger wounds, such as the section, of the cornea in ex-
traction, when gently  inflicted, often cause no inflammation.  The very
smallest, when violent, are attended with great danger, from laceration
of the delicately organized parts, and concussion of the nervous struc-
ture.   I saw complete amaurosis caused by a single small shot, which
struck the sclerotic obliquely and did not enter.   The state of health at
the time of the occurrence is, however, in most cases, a matter of more
consequence than the extent or manner of the injury : in an individual
of full habit, or one whose circulation is habitually excited by indulgence
in the enjoyments of the table, or whose health is disturbed by disorder
of the digestive functions, slight injuries may excite considerable inflam-
mation;  while under opposite circumstances, we  are  sometimes sur-
prised to  see how much violence is inflicted with impunity on this deli-
cate organization.
   In  consequence of  the serious inflammation they so often excite, in-
flammation affecting the interior of the organ, penetrating wounds of the
globe, that is,  such  as pass through the cornea  or  sclerotica, must al-
ways be deemed important  cases.  The patient should remain quiet,
and the wounded organ must be kept perfectly at rest; the  alimentary
canal should be effectually cleared, and  low diet strictly enjoined.  If
the individual be young and  robust, or of full habit, or if, from any other
circumstances,considerable inflammation  maybe expected,a full bleed-
 ing from the arm  should take place;  supposing the propriety of  this
treatment to be doubtful, it will be safer to bleed than to omit it, taking
a moderate quantity, and observing the effect on the circulation.   In a
child, leeches  should be applied to the eye-lids; from four to six or eight.
 If blood should not be taken  soon after the accident, the patient must be
closely watched, and  bleeding, cupping  on the temple, or leeching be
 resorted to, as soon as  pain comes on in the  part.  The  cupping or
 leeches must be repeated  until all uneasy sensation  shall have subsided.
   Extraneous substances are to be removed, if there should be any such
 in the wound.   This  rule, however, is not  absolute.  The  point of a
 cataract  knife was broken off in the operation, and  remained in the an- 
158
INJURIES OF THE EYE-BALL.
 terior chambervfrom which it soon disappeared without  any injurious
 consequences to the organ.   I  have  seen  this take place, and think
 it better to leave a minute particle of steel  in the anterior chamber,
 than to persevere in attempts at removing it, if it  should not come
 out easily.
   Cornea.—I saw considerable uneasiness, which lasted for two or three
 days, from a small and just perceptible  scratch of the cornea, by the
 sharp finger nail of an infant.
   A cab driver received a smart blow on the eye, with  the lash of a
 whip, and came to me  at St. Bartholomew's a day or two after, with
 slight redness of the sclerotica,  partial  nebulous  opacity of the cor-
 nea, and  impaired   vision.   By  bleeding, leeching, and  blistering,
 the opacity was dissipated, and  sight  completely  restored in a  week.
   Walther mentions, in his interesting tract on hypopyon, the nume-
 rous cases of that affection, which occur every year in Bavaria, during
 harvest, in consequence of wounds of  the cornea.  The reapers, who
 pursue their occupation with the  body bent forwards, often receive in-
juries in the eye from the ears or blades of the corn.  They are robust
 men, and  generally predisposed  to inflammation by their laborious ex-
 ertions under a hot sun, and the fuller  diet and greater supply of beer
 and brandy which they are enabled to procure at  that time.  The in-
jury in general,  is merely a slight scratch of the cornea.   They pursue
their labours, and eat and drink as usual, either neglecting the eye, or
irritating it by some  popular and  inappropriate remedy.   In the early
part of the season patients were seen with  small abscesses of the cornea;
then they  came  with matter in the anterior chamber; and after a still
longer time, others presented themselves  with the cornea  destroyed
by suppuration,  with  the chambers full of matter, or the globe burst.
Walther found  that in the Isar  district alone from fifty to sixty eyes
are annually lost in this way during the harvest.*
  Wounds of the cornea  produced by particles  of metal,  or other
minute substances, cause different degrees of inflammation in different
individuals.   In  some cases there is neither local disturbance nor uneasi-
ness; at least nothing more than mechanical irritation  on motion ; while
in others, where the person is of full habit, or continues laborious exer-
tion, especially under exposure to  heat, and combined with free drink-
ing, severe inflammation of the cornea, sclerotica, and anterior chamber
generally, with hypopyon, may be the  result.   When such inflamma-
tion begins, a pink zone is first seen in  the sclerotic, round the cornea;
this redness becomes deeper and more  extensive;  the cornea loses its
transparency, often becoming quite dull and turbid; it ulcerates round
the foreign particle, which is loosened  and drops out.  This  state will
require vigorous antiphlogistic measures, and unless they are of decided
character, and actively pursued,  suppuration of the cornea, and exten-
sion  of inflammation to the  chambers of the aqueous  humour, will
result.
  Foreign bodies in the anterior chamber.—Wounds of the cornea may
be complicated by the passage of extraneous substances into the ante-
rior chamber.   Such substances  may pierce the cornea, without pass-

      * Merkwiirdige Heilung eines Eiterauges, &c, second edition, p. 25—27. 
INJURIES OF THE F.YE-BALL.
159
ing through it, and project into the chamber; they may enter the latter
completely, and lie in the bottom of it;  or they may stick in the  iris.
Serious inflammation is excited and maintained by their presence.  The
removal of the foreign body, which seems  to be  urgently indicated, is
not easy, especially in the inflamed state of the organ, and  requires in-
cisions with other manipulations, likely to aggravate the inflammation,
and lead to loss  of sight.   Thus we have  to choose between the  two
evils, of continued inflammation  from the  presence of  the irritating
cause, or danger to the organ from the operation of removing it.  It
would be right to remove the foreign body, if its presence should keep
up  inflammation, and we  are  confident that  we  can accomplish the
object.   If doubt exists on the latter point,  the attempt should  not be
made; and we must be satisfied with taking the necessary  measures to
keep  down inflammation; for foreign substances sometimes become
enclosed by a covering of lymph, and remain quietly in the eye.
  A small  shot penetrated the  upper lid and entered the globe.  The
anterior chamber was  full of blood.   Violent inflammation ensued.
When the  blood had been absorbed, the shot was seen in the lower part
of the anterior chamber, where it became partially enclosed by a whitish
deposite.   Cataract took place in this case, and  the opaque lens  was
subsequently absorbed.   Vision was nearly lost.   When the case  was
described,  the shot had been in the eye for six years, without exciting
any further mischief after the cessation of the original inflammation.*
   Mr. Tyrrell saw  a small particle of granite,  and in  two instances
minute portions of copper cap  thus encysted.f
   By making a small incision  near the circumference of the cornea,
Mr. Mackenzie was enabled to remove a fragment of brass, which had
been  struck off by a workman  in chipping that metal, and  had entered
the anterior chamber twelve days before.J
   [By the same method we removed a small fragment of trap rock, which had
been projected by a blast through the cornea,  and had lodged in the anterior
chamber, where it had remained eleven days.]
   Professor Ammon opened the cornea in two cases, removing a piece
of slate which had been  driven  into the iris, in  one instance;  in the
other, a piece of sandy matter.   Vision was entirely lost  in the latter
case.§
   A  piece of glass, two lines in length, was removed from the anterior
chamber at the  end of  six years by Dr. C.  Jaeger of Vienna.  Great
and almost constant suffering had been caused by its presence, and the
cornea had once been opened for its removal unsuccessfully.   After the
removal of the foreign body, vision is said to have been nearly perfect.||
  [When the foreign body lodged in the anterior chamber is very small, it  is
sometimes sufficient, for its removal, to make  an incision of the cornea as for
the extraction of cataract, though smaller, when it will be washed  out by the
gush of aqueous humour which takes place the moment the incision is completed.

  * Salomon in Graefe und Walther's Journal, vol. xiv. p. 457, and tab. 4, fig.  1.
  t Vol. i. p. 367.                          t Practical Treatise, p. 366.
  § Beobachtungen uber das Eindringen fremder Korper in die vordere Augenkammer, in
die Iris, Cornea und  Conjunctiva Cornea; in the same  Journal, vol. xiii. with figures
representing the eyes and  the foreign  bodies.  Coloured representations of the first case
are also given in the Klinische Darslellungen ; p. 1, tab. 14, fig. 1—3.
  || Ammon's Zeitschrift, vol. iii. p. 103. 
160
WOUNDS OF THE EVE.
  More generally, however, especially if of any size, it  remains, and its removal
  with the least possible  injury to the  surrounding delicate structures, is of the
  utmost importance.  If the body is very flat, it may be seized with a pair of deli-
  cate forceps, but if cubical or round, it will slip from the grasp of such an instru-
  ment, and a curette or  what we have found to answer extremely well, a small
  Anel's probe with one end bent in the form of a small hook, should be used.]
    Gun-shot injuries of the eye are generally attended  with the passage
  of a foreign body into the organ.  If a small shot, penetrating the ex-
  ternal  coverings, passes  deeply into  the  globe, loss  of sight  may be
  expected.  Serious  concussion is produced at the time, usually  with
  instant loss of sight;  severe internal inflammation follows.
    A gentleman  received a shot  in the left eye-ball, causing instant
  blindness.   Severe neuralgic  pains came on in a fortnight, affecting the
  left eye and head, and influencing the right eye  so  seriously as to inter-
  fere greatly with the employment of it, and to make  him fear that loss
  of sight would ensue.  At the end of  six years, the  severity and  con-
  tinuance of his sufferings induced him to have the globe  extirpated, which
  was done by  Dr. Butter of Plymouth.  A duck-shot  was found in the
  optic nerve close to the retina.*
    Injuries of  the eye by portions of exploded  percussion caps are not
  unfrequent.   The metallic particle is sometimes imbedded in the cornea,
  when it causes inflammation and  ulceration.  It thus becomes loosened,
• and is  brought into view if it  should  have been previously concealed.
  It should be immediately extracted.
    Frequently it passes into the anterior chamber  or  more deeply, and
  excites inflammation which proves destructive to vision.f
    Mr. WatsoxJ mentions two  cases, in  which  blindness  followed im-
  mediately on accidents  of that  kind, though  there  was no  apparent
  wound of the eye.
    Mr. Crompton has described the effects  of these injuries from cases
  which he had the opportunity of  observing in the practice of Mr.  Bar-
  ton of Manchester.  He preserved  notes of seven  cases, in each of
  which the injured eye was destroyed; while in one of  them the vision
  of the  other eye was nearly lost from sympathetic inflammation.  In
  these cases  the fragment of the cap was driven into the posterior cham-
  ber of the eye;  the wound was a clean one and healed readily, so that
  the entrance of the foreign body was not known at the  time.   The case3
  seemed to proceed favourably for a length of time, varying from a few
  days to a month, when violent inflammation came on with acute  pain,
  chemosis and haziness of  the  cornea.  The pain would  subside and
  recur, the eye continuing in a  state of chronic inflammation, with loss
  of  vision, injured health, and sympathetic affection  of the other eye.
  The latter consisted, in one instance, of iritis with closed  pupil.  The
  treatment adopted by Mr. Barton, in  order to remove the painful affec-
  tion of the wounded  eye, and to relieve the other from injurious sympa-

    * hondon Medical Gazette, vol. xiii. p.  868.
    [t Au interesting case in which a fragment of percussion cap which had penetrated the
  cornea and entered the iris, was removed  by Prof. N.  R. Smith, and  the sight preserved, is
   recorded by Prof. Sewall in the American Journ. Med. Sc. for Aug. 1839.  We have met
   with several accidents ot this description, but they are so common and the treatment is so
   well established, that it is unnecessary to dwell upon  their details.]
     } Edinburgh Medical and Surgical Journal, vol. xliv. p. 106. 
wounds of The eye.
161
thetic influence, consisted in making a free incision of the cornea, as in
the operation of extraction, cutting off the flap with scissors, and cover-
ing the eye with a poultice; within a few days after the operation, the
foreign substance was, in all cases, discharged from the eye.*
  When the cornea is penetrated, as it is not unfrequently by sharp or
blunt  cutting or pointed  instruments,  or other bodies,  the  aqueous
humour escapes, the cornea and iris coming in contact; but this fluid is
soon re-produced, and the  corneal wound unites by adhesion.  When
the wound is  large, prolapsus of the iris often follows; the portion which
thus escapes cannot be replaced by direct pressure with probe, director,
or other similar instrument; at least, I never saw replacement effected.
When  we consider the irritable condition of  a wounded eye, and  the
spasmodic action of its muscles even on mere exposure by opening  the
lids, we might expect increased suffering with risk of  augmented  pro-
trusion from such attempts, which, if made at all, must be  conducted
most gently  and cautiously.   If the prolapsus embraced the pupillary
margin or adjoining portion, the effect of belladonna applied on the brow
might  be tried; the action  of this narcotic on the pupil might  liberate
the iris, if the prolapsed portion were small, and not  tightly embraced
by the margin of the wound.   When the iris protrudes in the operation
of extraction, we can replace it  by gentle pressure and slight  rubbing
with the  end  of the  fore-finger through the closed lids, followed by ex-
posing the organ to light, in order to Cause  Contraction of the pupil.
This plan might be tried in the prolapsus from wound.  We must treat
such cases on the  general  principles already explained.   1 shall more
particularly consider prolapsus iridis afterwards.
  The cornea, and  the surface of the eye generally, may be injured by
the ignition of gunpowder.   Unexploded grains are driven into the con-
junctiva and  cornea,-and are visible by  their dark colour.   The advice
usually given,  of picking  them  out, may be followed, if they can be
removed easily.  I  have seen a  few grains sticking  in the cornea at
some length of time after an accident, not exciting the mischief, which
they are  said to cause, nor injuring sight. Not long ago I saw a youth,
in whom one globe  was burst, and the other eye much hurt by a gun-
powder explosion.  On the side most seriously injured, collapse of the
eye-ball,  and complete symblepharon of both  lids took place.   Violent
inflammation occurred in the other eye, with so  much swelling of the
lids, that at the end of a few days, when 1 first saw the patient, I could
not ascertain  the condition of the cornea.   When the  lids could be
opened, there appeared little irregularities on the surface of the cornea
which  I supposed to be from grains of the powder.   The inflammation
and irritability of the eye, would have entirely precluded all attempts at
removal, if I had thought of making such an attempt.  When  the eye
had recovered,- slight nebulous opacities remained in the cornea ;• but I
could not see any gunpowder grains.  The conjunctiva oculi was  par-
tially discoloured, and presented at its upper part a considerable cica-
trix.  From the violence of the explosion, I feared that amaurosis from
concussion of the  retina  would  be found to have occurred.   Vision,
however,  was nearly perfect.

                 *  hondon Medical Gazette, vol. xxi. p. 175.
       21 
162
wounds of the eye.
  Mr. Mackenzie* says, "I have repeatedly seen grains of powder pro-
pelled through the cornea into the lens, so as  to cause  cataract.   In
one case, a grain of powder, propelled through  the  cornea, traversed
also the lower part of  the  iris, in  which it left  a  considerable opening,
and, striking  the lens, produced cataract.   Gradually the opaque sub-
stance cleared away behind the false  pupil, and vision  was restored.
The natural pupil remained much longer cataractous, but at  length it
cleared also.   The patient saw well with a cataract glass."
  Metallic and other bodies driven with considerable force may be im-
bedded in the substance of the cornea, and excite more or less serious
inflammation, their presence not being discovered  till some time after
the injury.  Careful  examination  of  the  organ is  therefore  necessary
where obstinate inflammation follows such  an occurrence.   Mr. War-
DROpf extracted a portion of gold  wire, which had pierced  the cornea
and reached the  iris, fourteen weeks after  the accident.   Serious and
obstinate inflammation had continued  for  five  weeks in  this case, and
pain had been kept up since.  Complete recovery quickly followed  the
removal of the irritating cause.   M. J. CloquetJ removed a considera-
ble splinter of iron from the cornea at the end of two months.
  [I have extracted a number of chestnut-bur spines, which had penetrated the
cornea, six or eight weeks after the accident.  The subject of this  case was a
lad twelve years of age admitted into  Wills Hospital, November 10, 1838.  He
stated that about six weeks previously, he had been engaged  with  another boy
in obtaining chestnuts, and whilst looking up, a bur fell from the tree and struck
his eye;  some inflammation followed, which not yielding entirely  to domestic
remedies, and the vision of the eye being impaired, his mother  brought him to
the hospital.   Fourteen or fifteen spines of the chestnut bur were observable in
the cornea, through which coat several of them had  penetrated.   There was
slight conjunctival  redness, but much less than might be supposed from the pre-
sence of so many irritating bodies.  With the point of a cataract needle, three
of the spines were extracted; the eye then became  so irritable, and  filled with
tears, and the blood vessels injected, that I thought it best to desist, for the pre-
sent, from further efforts.  He was ordered sal. Epsom 3j; half to be taken at
once, and the remainder the next morning.  Two days afterwards, the redness
and irritability had subsided, and I extracted two more spines;  when I thought
it prudent to again desist, and salts were prescribed  as before.   By pursuing
this course, all the spines were ultimately extracted.  One of these  spines pene-
trated the cornea, and seemed to enter the iris; its extraction was  difficult, and
I only succeeded after several trials.   When removed, a portion of  the aqueous
humour followed.   The wound healed as kindly as any of the others, and  it is
difficult to discover the points where the spines had penetrated.   He was dis-
charged October 29th, 1838, quite well,]
   Sclerotica.—Wounds of the sclerotica are not of consequence in them-
selves, but  they  become important from  the force which  must have
been required to effect them, and  from the almost  inevitable participa-
tion of the immediately adjoining internal tunics.   A violent  blow some-
times burst the  sclerotic  coat, without dividing the conjunctiva;  the
hard external covering of the eye is cracked by  the injury,  and we  see
the fissure of the sclerotic through the conjunctiva.   Concussion of  the

   *  Practical Treatise, p. 348.               f Lancet, vol. x. p. 475.
                   t Pathologie Chirurg. p. 4-1. 
WOUNDS OF THE EYE.
163
retina, internal extravasation of blood, and amaurosis, are  the almost
invariable concomitants of such an injury.   The prognosis, therefore, is
doubtful, if  not absolutely unfavourable  in such cases.   The result is
sometimes more fortunate than we anticipate.
  Case.—Penetrating wound of the sclerotica ;  recovery without injury to vision.—
In the month of February, 18:29, a boy, ten years old, was brought to me from a dis-
tance of fourteen or fifteen miles within three  or  four hours after meeting with a
wound of the eye.  It  had been  inflicted by a wooden arrow, armed with an iron nail,
which being square, had been ground to a point,  not very sharp.   It had been  thrown
against the eye, not shot from a bow. The sclerotica was punctured just, where the
needle is  entered in couching; there were two small divisions of the membrane, meet-
ing at an  obtuse angle.  The schoolmaster, who accompanied the patient, informed
me that immediately after the accident the pupil had been largely dilated, and that
the boy could not see.   The pupil was still dilated, and vision very confused. I directed
antiphlogistic treatment, with rest; and, suspecting either that the retina had suffered
by concussion, or that  inflammation of the internal tunics would ensue, I gave an un-
favourable opinion of the probable result.  The  patient was brought to me again, at
the end of a fortnight; he had been  kept on low diet in a darkened room, and  leeches
had been applied once.  There had been no inflammation,  nor pain.  The pupil was of
its natural size, the iris acted perfectly, and vision was good.  There was a small trans-
parent vesicle in the situation of the wound.  I saw the case again in another fortnight,
when vision was perfect:  the vesicle remained.
  Case.—Rupture of the sclerotica, with injury of the iris ; complete recovery.—In
the summer of 1837, a child, about five years old, was  brought to me at St. Bartho-
lomew's,  and attended as an out-patient, having  received  a severe blow on the right
eye with  a stick.  The sclerotica was ruptured  near the margin of the cornea, the
wound being about one-eighth of an inch in length.  The corresponding portion of the
iris had disappeared, so that the  pupil, opposite to  the  wound in the sclerotica, was
continued to the margin of the cornea.  The conjunctiva was slightly elevated, appa-
rently from protrusion of the missing portion of the iris.  The accident  had occurred
three or four days before the case was seen, and  nothing had been done for it.  There
was no inflammation or pain of the eye;  the pupil was clear, the iris natural,  except-
ing the changes already mentioned, and vision seemed unaffected.   The case required
nothing further than care,  with a little medicine and cold lotion.  The eye remained
in the state described; and we ascertained, at some distance of time from the accident,
that vision was unimpaired.
   Wounds of the  sclerotica do  not unite;  the fissure in the cases just
described, is permanent, and the punctured  opening made in depression
of the  cataract is equally so.
   Iris.—A wound  of the  iris is  generally an  important case;  it is  a
penetrating  wound, and usually inflicted  with  violence.   It may  be cut
or torn; these  injuries  being generally complicated,  not  only with
wound of the cornea,  but also with injury of the crystalline.   A  simple
division  of  this part is,  however, in itself unimportant.   Although  the
iris,  when  examined  microscopically after a successful minute injec-
tion, seems  to be  entirely composed of a vascular net-work, it does
not bleed on being cut,* nor does a simple division of it lead to any inju-
rious consequences.   On the other hand, it  is greatly irritated by pres-
sure.   In  the natural  state  it  is  unconfined,  freely  moving  in  the
aqueous humour;  in the  condition of  prolapsus, the  hard  edge  of the
cornea embraces and presses on the neck of the prolapsed portion, while
the external tumour is constantly undergoing  friction from the eye-lids;
thus irritation is produced, which may extend to the whole globe, greatly
aggravating- the sufferings of the patient.
* [This does not accord with our observations.] 
164
WOUNDS OF THE EYE-
   The  iris may be detached by accidental  violence at its ciliary mar-
gin, thus producing an  artificial pupil;' according to the extent of the
detachment, an alteration of figure in the natural  pupil, a diminution, or
complete closure of it may ensue.   This kind of accident is  accompa-
nied with effusion of blood  into the anterior  chamber.
   Case.—John O'Brian, forty years of age, a blacksmith, of robust frame and accus-
tomed to live  freely, was admitted into St. Bartholomew's under my  care, on the
1st of December, 1839.  Two days before, as he was breaking an iron  rod  with a
large hammer, a portion of it about an  inch long was detached, and struck him a
violent blow in the eye.  He experienced great pain in the part after the accident, but
was relieved by keeping in bed the following day, applying fomentations, and taking
salts, which  acted briskly.  I found the globe pushed forwards, the conjunctival and
sclerotic  vessels distended j the anterior chamber  more than half full of blood; the iris
detached from  the  corpus ciliare, at the  upper and outer  part, to  the extent  of
three lines, so as to  form  an artificial pupil  of elliptical  figure; no pain, nor
intolerance of light; incomplete  amaurosis, so that the divisions of a window ora  hand
held near to the  eye  could be  seen, although the letters even of large print could
not be distinguished.   I ordered a large venesection, an active purge, cold lotion to
the eye,  confinement to bed,  and  low diet.  Dec. 2. The pupil, who performed the
bleeding, finding the blood came very freely, allowed it to flow, until fifty ounces had
been taken: faintness was not produced.  The bowels were freely opened.  The pa-
tient slept well and feels much better to day. The vascularity of the eye is diminished;
vision is  improved; the pulse is eighty, and soft; the tongue  moist and clean.  3rd.
Progressive improvement.  The natural pupil has assumed an oval shape from the
falling down  of the detached portion of the iris.   The blood is completely removed
from the anterior chamber.  6th. Some pain with slight lachrymation and intolerance
of light:  the vascularity of the conjunctiva is increased. Ten ounces of blood from the
temple by cupping.  10th. He feels the  eye quite well; the vision is much improved,
though not so good as before the accident.  The protrusion of the globe has disappeared,
and the  iris has nearly resumed  its natural situation.   He left  the  hospital a few
days afterwards.   I saw this person in the spring of 1832.   His vision was good, and
the separation of the iris was marked by a very  narrow fissure, which could only  be
detected by close inspection.
   Other instances,  in which partial separation of the iris  from  the
ciliary ligament, with  formation  of a  new  pupillary  aperture, was
caused  by externa] injury, are rn.enti.onpd  in  Chapter XVIII.,  Sec-
tion  iv.
  Case;—Effusion of blood into  the anterior chamber from a blow.—A boy, ten yeara
of age, came under my care at St. Bartholomew's on the 18th of July, 1831, in con-
sequence of injury to  the  right eye from a blow with a small whip.  He was brought
to the hospital  two hours after the accident, when  the anterior chamber  was filled
with blood, ajid there was some redness of the eye.  Twelve leeches were applied, and
the antiphlogistic  treatment was adopted in other respects.   The blood  had nearly
disappeared on the evening of the 20th.  On the 21st the vascularity of the globe had
increased, and  the anterior chamber was again filled with blood.   (Twelve leeches;
aperient medicine.)   22nd.  Twelve leeches; absorption proceeding rapidly.  23rd.
The effused blood entirely absorbed and vision perfect.  He was kept  in the hospital
till the 1st of August, and was then discharged quite well.
   A  severe blow on the eye may occasion excessive  partial dilatation
of the pupil, the iris being withdrawn and disappearing to a greater or
less extent.   Such accidents are attended by effusion of blood and  im-
paired sight.*
  Discolouration afthejris or aqueous humour 1—with slight concussion of the retina
from a blow.—On the 7th of January,  1^28, a gentleman received a severe blow on
  * Such an opening, caused by the blow of a whip, is represented by Vo* Ammon in his
Klimsche Darstellungen; pt. 1, tab 14, fig 5.  The iris had assumed a lilac colour since
 he accident and the vision was but shelly injured.  A similar opening, also caused by
the stroke of a whip, is delineated by Mr. Wardrop, Essays, pi.  10, fi«r  2  Siahi wa, „nt
injured in this case.                                           "'  *  "'fc>,1L waa "Ul
  t An instance of the kind has been figured by Mr. Wardrop, pi  10 fig 3 
WOUNDS OF THE EYE.
165
the left eye from a piece of wood projected forcibly by the sudden explosion of a fire-
work:  he paid but little attention to the circumstance, which did not prevent him from
joining in the festivities of the occasion—the celebration of a birth-day.   He merely
used 6ome lotion and took a  purgative on the following day, although sight  was im-
paired, and a globe of red appeared before the eye.   Finding that he grew worse in-
stead of better, he returned to town, where I saw him on the 11th.  There was ecchy-
mosis of  the conjunctiva scleroticae  in its whole extent.  The iris, which  is naturally
blue, was of a  bright  yellow,  or  rather yellowish green;  the pupil just  like the
other,  and moving with  it.  No  pain in the eye or  head.  No increased vascu-
larity of  the conjunctiva;  no  inflammation, either of it, the cornea, or the iris. No
inflammation of the sclerotica, which was carefully examined on account of the
ecchymosis of the conjunctiva. He could see objects and recognise  persons but
could  not read ordinary  print.  (Cupping on the  left  temple; active aperients;
light diet, with exclusion of fermented  liquors; rest of the eye.)   14th.  Cupping re-
peated ; two grains of calomel night and morning.  26th. The calomel has been con-
tinued to this day, with occasional aperients, rest, and low diet.  The mouth has not
been effected in the slightest  degree.  The discolouration of the iris has gradually dis-
appeared, and it moves just as well as the other.  He can read the smallest print with
ease, and is sensible merely of a slightdimness, as if he looked through a  thin fog.
The ecchymosed  blood  is nearly absorbed from the  conjunctiva.  September, 1828.
The appearance of the eye is  natural; vision is nearly, if not quite perfect.
  Was the cause of the phenomena, in  this case, a  change  in the iris,
in the aqueous  humour,  or in  the  cornea?   Mr. Wardkop, to whom  I
mentioned the case, said that he  had seen the occurrence,  and had eva-
cuated  the aqueous  humour, when  the natural appearance of the  iris re-
turned.   The only circumstance which renders this explanation doubt-
ful, is, that the  chamber  cleared  first at the centre, and  then  gradually
towards the circumference.   When the principal portion of the iris had
appeared of its natural colour for some days, a little yellowness  was
still visible  towards each  angle  of the eye.  In a similar case, which
was  under my care  in  St.  Bartholomew's, the  discolouration disap-
peared  spontaneously.
   Wounds  of the choroid  and ciliary body—hemorrhage.—If  a pene-
trating  wound of the globe takes place behind the  cornea, the  ciliary
body or choroid coat will probably suffer, wounds of those  parts will be
attended with extravasation of blood into the chambers of the eye, both
anterior and posterior.   It has been recommended to open the anterior
chamber in order to let out the coagulated blood, and prevent further effu-
sion.  This is totally unnecessary, since absorption is very  active in this
chamber and the blood will be removed in  a few days.  I have  seen it
disappear in twenty-four hours.  Such a wound in the cornea is not only
altogether unnecessary, but must be injurious, adding to the local injury,
already considerable, and increasing the chances of inflammation by the
exposure of the chambers.  The blood does not mix with the aqueous hu-
mour or render it turbid, but it sinks to the bottom of the anterior cham-
ber and there remains, and in two instances I found  that it retained its
fluidity, so that the level  was  altered on inclining the head to one  side;
but whether this  is always the case I  do  not  know.   This effusion of
blood into the anterior chamber is  not in itself a matter of consequence;
but it shows that considerable violence has been inflicted  on important
textures.
  We sometimes see effusion of blood behind the iris; altering the colour of
the pupil and making it visibly red  in a good light; this must  always be
regarded as a very unfavourable appearance, indicating that the injury
extends to the central and  most important parts of the eye.   Rest, cold
applications, and antiphlogistic treatment  are  proper where blood has 
166
WOUNDS OF THE EYE.
been effused either before or behind the iris.  After it had been speedily
and completely absorbed under such management, I have seen a renew-
al of effusion in consequence of premature exertion.
   When the ciliary body, or choroid coat is injured, as is usually the
case when the  sclerotica is ruptured, the pupil exhibits a remarkable
change, which must be referred to the partial injury of the ciliary nerves
necessarily attendant on such an accident.  As these nerves, which sup-
ply the iris, run  between the sclerotic coat and choroid, they must suf-
fer when those tunics are injured.  Thus the  iris is partially paralyzed,
the  portion supplied  by  the  injured  nerves being  contracted to  the ut-
most, and sometimes even disappearing, and the pupil exhibiting a cor-
responding partial dilatation.
   When the sclerotica has been  injured  near the  ciliary body the dis-
appearance of the iris is attended with a dark coloured bulging  of the
former membrane under the conjunctiva, probably produced by a  pro-
lapsus  iridis in  that  situation.  Such a case  has been figured by Von
Ammon.*
   The  lens and its capsule are frequently injured, when  the cornea and
iris are punctured by sharp instruments.   As  the wound is penetrating,
and necessarily inflicted with more or less violence, the  case  is always
important.
   Mr. Travers saw. after a severe blow  on the eye,  suppuration within
the capsule, which projected through the  pupil in a globular form, filled
with pus.  Absorption took place under the use of mercury, and the case
ended in a contracted pupil closed by opaque capsule, and adhesion of
the iris to the cornea.f
   We find  invariably that the lens becomes opaque when it or its cap-
sule is wounded,  and the slightest mechanical injury is sufficient to pro-
duce that effect, such as a puncture of the part with the finest needle.
By introducing such a needle through the centre of the cornea and the
pupil, cataract might be  artificially produced  without any other  injury
to the  organ, without inflammation, and  possibly  without any appear-
ances from which the manoeuvre could be discovered.  It has been said,
that soldiers have had recourse  to this   proceeding in  order to obtain
their  discharge  from  the  army.   We  cannot explain  how  or why
wounds of  the lens and  capsule should thus  invariably  produce cata-
ract.J  We can trace no vessels into the lens  from its capsule; its ordi-
nary  nutrition is a problem to us, and we are equally in the dark respect-
ing its changes from accident or disease.   The alteration in question is
independent of inflammation;  for it will  occur  before  inflammation
comes on, or even when it does not take  place at all.

  * Klinische Darstellungen, pt. 1, tab. 14, fig. 7.               t Synopsis, p. 206.
  t From trials on animals, made by Dr. Dieterich, it seems probable that the statement
in the  text respecting the invariable occurrence of cataract after wounds of the lens and
capsule, is not correct. He instituted an extensive series of experiments on dogs, in com-
petition for a prize offered by the medical faculty of Tubingen, and published the results as
his inaugural dissertation, in 1824: of this there is a copious abstract in the Archives gene-
rales de Medecine, October 1S26.  He wounded the anterior portion of the crystalline cap-
sule with a cataract needle, in various manners, thirty-six  times.  Opacity of the lens fol.
lowed in one case only, probably from its having been unintentionally wounded. The cap-
sule also retained its complete transparency, and the wounds in it healed, even when it had
been divided transversely, without leaving a cicatrix.
  He punctured the posterior portion: of the capsule seven  times; lenticular cataract result-
ed only in one instance: but the last-mentioned effect took place in eleven out of twelve ex- 
WOUNDS OF THE EYE.
167
   Traumatic  cataract as it is  technically called, takes  place under
various circumstances;  1st.  Simple puncture  of the lens  through the
cornea and the pupil;  2dly.  Laceration of the capsule, with protrusion
through the opening of  the  exterior  soft  substance of  the lens, in the
form of a bluish white jelly ;*  a  portion of this jelly may drop off into


periments of incision of the capsule.   Wounds of the posterior  capsule were not followed
by opacity of that membrane.  The punctures healed with difficulty, and incisions did not
unite at all.
  In seventeen experiments the anterior portion of the lens was punctured.  No visible
change occurred in the eye in twelve of these; in three,lenticular cataractoccurred; and  in two
violent internal ophthalmia.  Of nine instances, in which  incision was made into the inte-
rior part of the lens, four were not followed by any morbid change, while in the five others,
where the wounds were deeper, cataract ensued. Superficial injuries of the lens, on its pos-
terior surface,  were not  followed by cataract.   Such wounds whether of the anterior  or
posterior part,  when not accompanied with displacement, produced no change in the eye.  In
a few days they were completely healed.  Wounds extending to  the centre of the lens were
constantly followed by cataract, iritis,  and inflammation of the  globe.  Of eleven experi-
ments in which the lens was displaced,  three  were not followed by cataract, while in the
others opacity  of the crystalline  and violent internal ophthalmia  ensued.
  What I have said  in the  text  respecting the effect  of wounds on the lens and capsule,
has been deduced from the  observation of such injuries in the  human subject.  Hitherto
I have  found  no reason to alter the statement; nor have I seen in man that union of
wounds of the  capsule, which Dietericu observed so uniformly in  his experiments on ani-
mals.
  Since the preceding rcrrarks were  written, I have found in the Handbuch of Professor
Rosas, analogous observations on the experiments of Dietericu.  "The result," says he,
" of my experience in the human subject have led me to draw opposite conclusions to those
which  Dietericu deduced from  his experiments on animals.  I have  seen many cases in
which  capsulo lenticular  cataract has  proceeded from inconsiderable  wounds of the ante-
rior capsule, although immediately subjected to antiphlogistic treatment.   I remember two
instances in particular, which occurred  in the time of Beer: the anterior capsule was slight-
ly wounded in puncturing the cornea  to evacuate the aqueous  humour, and cataract fol-
lowed in both.  I have since seen the same result repeatedly from accidental  wounds, both
in healthy and  diseased eyes."—Vol. i.  §  421.
  [Our own experience is in entire conformity with that of Mr. Lawrence and Prof. Rosas.
We do not remember to have seen a single case of wound  of the  lens and capsule, in  which
opacity of these parts did not follow.]
  *  Dr. Dietericu* noticed the  appearance of a white flocculent substance on the wounds
of the capsule  in his experiments, in. which it soon disappeared by absorption.  He observes
that this may proceed  from the aqua  Morgagni, from the exterior semi-fluid stratum of
the crystalline, or from  the effusion of coagulablc lymph; and he is in favour of the first
explanation.   Mr. Watson+ ascribes the  appearance  in question to the "effusion of 3emi-
transparent albuminous matter." Mr.  Wardrop! has given a good figure of it in his ninth
plate, over which he  has  placed the  following description, "Albumen  effused from a
wound of the  capsule of the lens."  In  his  description of the plate,  he speaks of it as a
protrusion of the lenticular  substance.   " An opaque white matter, resembling  a flake of
snow, extends  from the  lens, which  is also opaque, through the pupil,  and  comes nearly in
contact with the cornea."   "It  is prob'iblc," he adds, "that in  this case, the bristle had
penetrated not only the cornea, but  also the capsule of the lens,  thus allowing the thinner
parts of the lens to come through the wound into the anterior chamber."
  Having repeatedly observed and carefully inspected these protrusions  of bluish white
gelatinous substance, not only in accidental injuries of the capsule, but  also in wounds
made in operations for cataract,  I feel quite satisfied that the explanation of the appearance
given in the text is the true one. In the human subject it occurs only in conjunction with
opacity  of the lens, and the  flocculent matter protruding through the wound of the capsule
is continuous with the opaque lens.   In colour and consistence  it perfectly resembles the
fragments of lens, which arc sometimes seen in the anterior chamber after operations for
  * Archives, vol. xii. p. 299.
  t Edinb. Med. and Surg. Journal, vol. xxvi. p. 265, fig. 3. Compendium of the Diseases
of the Human Eye, p. 126, pi. 8, fig. 4.
  t Essays, vol. ii. pi. 9, p. 254. 
168
WOUNDS OF THE EYE.
the anterior chamber, and be  succeeded by a  fresh  protrusion.   3dly.
Puncture or  laceration  of  the capsule, with  dislocation  of the lens,
which may press against the iris, or be wedged into the pupil, or push
the iris into close contact with the cornea.  4thly. Passage of the entire
lens through the opening of  the capsule and  the pupil.  It may either
retain its transparency or become opaque; it may remain in the anterior
chamber, or pass backwards and forwards  through the pupil.  It may
pass in the same way into the anterior chamber, still surrounded by its
capsule.  5thly. Either of the above circumstances may be combined
with wound of  the cornea, or  of  the  ciliary body, or with  wound or
prolapsus of the iris.  When the lens is dislocated, and presses against
the iris, great irritation and severe inflammation ensue.  6thly. The lens
may become opaque, in consequence of a blow or concussion of the eye,
without any  solution of continuity.   I  have seen many such instances.
   In a patient who had received a violent blow on  the eye from the fist,
seen by Beer in twenty-four hours after the accident,  the  capsule was
torn, the lens split in two, and quite  opaque;  there was  slight effusion
of blood into the anterior chamber, and considerable ecchymosis  of the
conjunctiva.*
   Mr. Billard  saw a patient brought to the Wpital de la  Petie  for a
wound of the eye from a blow of the fist.  The  lower part of the
cornea was lacerated, and the crystalline, which had  escaped through
the opening,  was found in the patient's  pocket-handkerchief, f
   The dislocated lens may retain  its transparency and remain behind
the pupil, exhibiting a tremulous motion when the eye is moved.   More
commonly the lens and capsule become opaque, the latter sometimes
assuming the yellow  colour which denotes its  conversion into a creta-
ceous substance.  In this state it constitutes a floating cataract, gene-
rally sinking below the edge of the pupil  when the eye is at rest, but
rising more or less  considerably when it is moved.J
   The dislocated lens has sometimes  been  forced through the choroid
and sclerotica,  so  as to lie  under the conjunctiva.   Mr. Mackenzie
mentions such a case, and delineates the appearance.   The patient had
recently fallen on the  corner of a chair.   There was  a tumour under
the conjunctiva  at the upper part of  the globe, advancing  on the edge
of the  cornea.   On  laying  open  the  conjunctiva the crystalline was
easily withdrawn.  The aperture in the tunics, by which it had escaped,
was already closed.   The patient was able to  read with a cataract
glass.§   Mr. Mackenzie has seen two  other cases,  in one of  which the

cataract, while it is totally different in these respects, from  any of the effusions of lymph
which are seen in this part of the eye.  Lastly, it may take place when no inflammation
whatever has occurred in the chambers of the eye; and Dietericu, who mentions  it as a
consequence of puncturing the capsale, expressly states that the  capsule never inflames
after such punctures. I never saw lymph effused from1 the surfaee of the crystalline cap.
sule under any circumstances.
  * hehre, vol. i. p. 218, note.
  f The French translation of my lectures, under the title, » Traite  Pratique,'" &c. p.
138, note.
  t Dislocation and opacity of the lens and capsule, which had sunk in the vitreous humour,
so that  the upper edge only was visible in the  pupil, are represented by Von Ammon;
the anterior chamber was filled with blood up to the lower edge of the pupil.  Klinische
Darstellungen, pt. 1, tab. 9, fig. 20.
  § Practical Treatise, p. 343. 
WOUNDS OF THE EYE.
169
eye was partially, in  the other totally amaurotic*   Mr. Middlemore|
has seen this kind of displacement in five instances.  The subject of the
first received a severe blow on the eye, followed  by pain and  a swell-
ing behind the edge of the cornea.  After a few  days he was seen by
Mr. M. who found the iris drawn towards  the tumour  at  the edge of
the cornea, so that it had disappeared in that situation.   The pupil was
unusually clear, the eye inflamed.  The tumour,  situated  towards the
inner  canthus, was convex and of yellowish colour.  On  dividing the
conjunctiva, a moderately firm lens escaped.   A slight degree  of vision
was restored.
   When the lens  has  been rendered  opaque  by wounds, under any of
these  circumstances, it begins  to be  absorbed, and this process of ab-
sorption will go on in  many cases to the complete removal of the opaque
body, leaving the pupil entirely  clear, so  that the  wound is  both the
cause and the remedy of the cataract.  That portion of lens that may
be squeezed through the opening  in the capsule into the anterior cham-
ber undergoes absorption readily, while that which remains within the
capsule is absorbed much more  slowly.  When the lens has been  thus
removed, a  membranous cataract  is generally  left.   In  almost all
cases of penetrating wounds, considerable inflammation supervenes, in
which the capsule  participates,  being rendered opaque and  sometimes
thickened, so that when the  lens is quite  absorbed, a membranous or
capsular cataract is seen occupying more or less of the pupil, and some-
times completely filling the opening.   The iris is involved in the inflam-
mation, and hence arise adhesions of the pupil.
   The treatment of these cases, immediately after the accident, must
be managed according  to the general rules  applicable to  penetrating
wounds of the globe; we must institute the antiphlogistic pTan without
delay, and follow it up  actively, either until inflammation shall be re-
moved, or the period for its recurrence shall have gone by.   It will be
right  to dilate the pupil  by the use of belladonna, and thus expose the
lens more freely to the action of the aqueous humour, in order  to facili-
tate its absorption.  When the eye has acquired  its natural state, ex-
cepting the presence of the opaque body in the pupil, the treatment  falls
under the rules applicable to cataract, which  will be considered here-
after.
   The opaque capsule does not undergo absorption like the lens; it will
remain  in the pupil  unchanged  for  any number of years.  I doubt
whether it is ever absorbed.   Beer mentions  a case in which the  lens
had been in  the anterior chamber for twenty-six years  unreduced in
size.J  It had been displaced by a violent blow upon the eye.  A patient
occasionally visited the  London Ophthalmic  Infirmary, with  the  lens
surrounded by its capsule in the anterior chamber, where it had been
twenty-eight years.
   When the dislocated  lens has passed into the anterior  chamber, it
acts as a foreign body, irritating the surrounding  parts, causing inflam-
mation of the eye, and severe pain in  the organ, brow, and head.   The

  * Ibid. p. 344.  Other cases are recorded in  Edmonston's Treatise, p. 195,  and in the
hondon Medical Gazette, vol. ix. p. 178.
  t Treatise, vol. ii. p. 44, note.
  } hehre, vol. i. p. 220 note.
       22 
170
WOUNDS OF THE EYE.
inflammation and pain which continue in  spite of  antiphlogistic treat-
ment, may be most speedily and effectually relieved by removing  the
irritating cause;  that is, by extracting the dislocated lens through an
opening made in the cornea with a cataract knife.  Sight is not usually
restored, the retina having suffered by the  original injury, or, in con-
junction with the iris and  internal parts generally, from the inflamma-
tion consequent on the accident.  The dislocated and injured lens may
remain behind  the iris, being  pushed  against it, or protruded into  the
pupil, and  against the cornea.   Serious internal inflammation and great
pain commonly ensue.  Here extraction of the  lens is strongly recom-
mended by Mr. Barton,*  of Manchester, as  the best way,  when  per-
formed early, of preventing the inflammatory and painful consequences
of the injury, or of removing them when it has been  delayed to a later
period.  The result, as regards vision, is  rendered doubtful here by the
same circumstances as in the preceding case.  The  removal of  the
lens, which is  usually soft, and sometimes broken  up,  is accomplished
in these cases by a smaller incision than that of extraction.  It will be
sufficient to divide the cornea  in one-fourth, or  one-sixth of its circum-
ference : the lens sometimes  escapes on the knife, or it may be removed
with the scoop.
   It must  be a serious injury to reach the vitreous humour, and occa-
sion any loss of it; we  may  expect as the result, not only blindness, but
change of figure in the globe.   The escape  of this humour, in the ope-
ration of extraction will be considered under the head of cataract.
   [Rupture of the capsule with  dislocation of  the lens, is a more frequent result
of blows on the eye than is generally supposed, if we may judge from the num-
ber that have come under our observation, and it is of importance to be aware
of this fact,  as when the patient  is not seen until some time after the accident,
and the lens and capsule are absorbed, the cause of the imperfection of vision
which results, may not  be understood.  The  only method  by which the real
condition of things can be determined is by the catoptric examination.
   The following cases illustrate the nature of this accident and the value of the
catoptric examination.
   Case I. Mr. T. a  farmer, set. 30, whilst feeding a threshing  machine, was
struck in his left eye by a grain of wheat projected from the machine, which made
a small wound in the cornea  near its nasal margin.  Severe inflammation fol-
lowed, with loss  of vision in the injured  eye.   The  former was  subdued  by a
rigid antiphlogistic treatment, followed by an alterative mercurial course, and some
time afterwards vision  in the eye began  to return, and continued  to improve
until he could distinguish large  objects.   His  vision  remaining then stationary
and he being unable to  read large print he came to the city to consult us.
   When we first saw him, which  was six months after the accident, the eye was
entirely free from inflammation, and  the  only abnormal appearance we could
detect by the ordinary method  of examination was a small  cicatrix near the
nasal margin of the cornea, to which a minute portion of the iris  was adherent,
with consequently, a slight irregularity of the pupil.  This was not sufficient,
however, to account for his imperfect  vision;  and  we were at first inclined to

  •On the treatment of certain injuries of the Eye in the hondon Medical Gazette, vol. v.
PM18»-rT,RAP°rt °£ tht a/e«B'«ff"  °/ extracting the lens in severe injuries of the eve bv
Mr.R. T Hunt, North of England  Medical and Surgical Journal, vol. i. p 481 • Tool
tains the details of nine cases. In the London Medical Gazette, vol. ix. p  l-4  fivP raseg
advan^cl three!'* rep°r   '   ' MaCKENZ,E'   Extract'°« ™s performed'with grS 
WOUNDS OF THE EYE.
171
attribute that defect to some  disorganization of the internal tissues of the eye
produced by the injury or the subsequent inflammation.
   On making a catoptric examination, we found that but a single image of the
candle could be detected; and after the  pupil was completely dilated, a small
fragment of opaque capsule became apparent.   We did not hesitate, on  this
evidence to assure the patient, that his  lens had been injured and afterwards
absorbed, and that he  required a lens on the outside of his eye to replace that
which had  been removed.  I accordingly accompanied him to an optician's, and
having provided him with a suitable glass, he found to his great delight that  he
could read  with perfect facility small print.
   Case II.  George Haines, set. 13, was admitted into Wills Hospital, November
2d, 1839.  This lad stated that in  chopping brush, seven weeks before, a frag-
ment flew  up and struck him in his left eye; considerable  pain and  inflam-
mation followed.   He  had taken a dose of physic and been blistered by direction
of a country practitioner, and his parents finding that he could not see with the
eye,  he was brought to town  and placed under  my care.  At this time there
was  still considerable vascular injection of the eye, without much pain, however;
there was a dense cicatrix towards  the lower and inner margin of the cornea,
and the remainder of  this coat was so nebulous, that  it could merely be per-
ceived that the pupil was filled with an opaque  whitish substance, but whether
lymph or the capsule  or lens  became  opaque,  it was impossible, to determine.
The  patient was ordered to be actively purged, and  to be strictly dieted;  an
ointment composed of equal parts of extract of belladonna, and mercurial oint-
ment to be applied daily around the eye, and when the inflammation was sub-
dued, a collyrium of sulphate of zinc (one grain to the ounce) was employed; under
these means, the pupil became dilated, the dense mass  which  filled this opening
diminished, and in two weeks the cornea had become sufficiently clear to enable
us to see distinctly portions of lymph, some floating  in the  anterior, others in
the posterior chamber, and adherent to the iris.  The perfectly natural appear-
ance of the iris indicated that this lymph was not the  result  of iritis; and the
inference then was, that it consisted of  portions of  opaque capsule, which
had  been  ruptured  by  the  fragment  of brush.   The  catoptric  examina-
tion made  at this time,  (November 16th,)  confirmed this view.   But a single
image of a candle was reflected;  the lens  doubtless had been  absorbed.
The  treatment was continued, with the omission of the purgatives, and on the
22d of November, the  pupil was sufficiently free of lymph for the patient to read
in a testament through a pin hole made in a pill  box.  Without this aid he could
not read, except large  capital letters.
   On the 21st of December he was discharged cured.   At this period his pupil
was perfectly clear, as was also the cornea, except a small cicatrix where this
coat  had been wounded.  The perfect  regular convexity of the  cornea was
somewhat impaired, however, by the manner in which  the wound had united,
but not so much  so  as materially to affect vision.  The pupil is a little irre-
gular, in consequence  of the adhesion of the inner edge of the  iris to the cornea
at the cicatrix.   With  the aid of a cataract glass the boy could see pretty well,
and with such assistance will no doubt in time have nearly perfect  vision.
   Some weeks after his discharge we  saw this lad, at which  period the irregu-
larity of the cornea had entirely disappeared.   The cicatrix in the cornea had
further diminished, and his sight had much improved.  With a magnifying glass
he read with facility.
   In an interesting case communicated to us by Dr. James W. Kerr the patient
a stone mason had been struck in his left eye by a fragment  of stone or of the
instrument  which he was using, after which he was deprived of useful  vision.
This continued for  eighteen years without the real cause of the defective sight
being suspected, when it was discovered  by Dr. K. by a catoptric examination 
172
WOUNDS OF THE EYE.
of the eye.   The details of the case were published in the American Journal of
the Medical Sciences for May, 1840, p. 245.]
  Retina.—A simple puncture of the retina is not attended with dan-
ger ; in fact, this membrane must be frequently wounded in the opera-
tion  of depression, yet such punctures do not impair its powers; a larger
division will cause amaurosis.
  The kind of violence most  injurious to the retina  is the concussion
which  it suffers from a  blow on the eye, and the danger is in a direct
ratio to the degree of force.  The affection of this membrane, as evinced
by the diminution, or loss of sight, is not commensurate  with the appa-
rent  amount of injury to the organ.  The nervous structure of the eye
suffers in  these cases, as the brain  does  in  many injuries  of the head;
and  the term concussion would be equally applicable to both.  The em-
ployment  of this word does not exclude the  notion of actual laceration,
or "vascular rupture in either case;  we merely employ it to denote the
accidents  in which, although the symptoms  show the brain or retina to
be affected, there is no visible wound.  When the sclerotica is ruptured,
there is either  actual laceration, or concussion of the retina; but the
latter kind of  injury sometimes occurs from accidents of a more trivial
character, in which the degree of violence might have been deemed too
inconsiderable for the effect.  This  injurious influence on  the retina is
generallv  produced by blows on the naked  globe; the interposition of
the eve-lids is sufficient to protect the eye even from  great violence, as
the  pugilistic  contests teach  us.  The diminution, or loss of sight, is
immediately consequent on the accident, and usually accompanied with
a fixed state of the  pupil,  perhaps with some enlargement or change of
figure  in the  opening, and with excessive partial  dilatation, where the
ciliary nerves are divided or contused.  There may be effusion of blood
into  the anterior chamber, or behind the  pupil.
   When we first see such a case,  we should inquire minutely into the
circumstances of the accident;  ascertain the nature,  degree, and exact
situation of the injury;  observe the  condition of  the  iris and the pupil,
and  satisfy ourselves clearly respecting the state  of vision.  We  shall
thus be prepared to speak  decidedly, not only on the present state of
vision,  but on the important question  of  its ultimate  loss or recovery.
If there be mere concussion of  the retina,  without other  injury of the
globe, and if sight be only partially injured, recovery  may be expected
under  prudent management; that is, if the patient and  the organ be kept
in repose, and the access of inflammation be prevented.   Total amau-
rosis immediately following the  injury, is  an unfavourable symptom,
but  does not  preclude the chance of recovery under proper treatment,
if it  be not complicated with other injury to the organ.   The addition
of considerable change in the pupil, extravasation  of  blood, and indica-
tions of actual laceration of the retina, make the  case absolutely hope-
less.  Under  the latter  unfavourable circumstances, there is, at the time
of the  accident, no great pain in the part, nor increased redness, but in
a few  days the eye becomes painful, and grows red ; the pain increases,
inflammation  commences in the internal tunics, and spreads to the ex-
terior,  the sclerotic and  conjunctiva  becoming  red, with pain in the
head,  intolerance of light, increased lachrymal discharge.   The neces-
 sity of antiphlogistic treatment is  obvious.   As  the  violent symptoms 
WOUNDS OF THE EVE.
173
subside, the eye goes  into a state of  atrophy, the  globe becomes soft,
diminishes  in size, and shrinks into the orbit.
  This concussion of the retina, and  consequent blindness, sometimes
take place  from accidents, that we should hardly deem adequate to pro-
duce such an effect.   I was consulted  in the case of a young gentleman
in the country, who had merely struck the eye with a pocket knife,
when cutting a piece of whipcord; the blade of the knife, which  was
quite blunt, wounded the lower part of the cornea.  The  lad was treated
very judiciously; the practitioner on the spot applied  leeches, and did
all that could be done in such a case, but when the eye was opened, after a
certain time, the friends were alarmed to find that  the patient could not
see; and he was consequently brought to town.  The pupil was dilated
and fixed, but  not discoloured.   The wound seemed to have penetrated
the cornea  and reached the  iris, which adhered to the  cicatrix, but it
had not extended to the lens; the eye, however, was quite insensible to
light.  I considered the eye to be lost, and indeed it did not appear  to
me that any thing could be done. As  the parents of the child were very
anxious about him, a consultation was held  on the case, which termi-
nated in the same opinion.  After three or four months, he was brought
again to town, when  the process of absorption had not only begun, but
considerably advanced, so that  the bulk of the globe was already  con-
siderably reduced.
   Not long ago, I  had occasion to see another lad from the  country,
who had received a blow upon the eye with  a small stick from one of
his companions.   It appeared that the eye had been struck on its inner
side, but although the injury had produced at the time no visible mark,
or external redness, amaurosis followed, and was permanent.  After the
lapse of a few  weeks, the sight of the  other eye became impaired sym-
pathetically, and I was afraid that it would be entirely lost; the retina,
however, recovered.
   The influence of one eye upon the  other is not  confined to cases  of
disease.  When an eye has been lost by accident, the other often be-
comes diseased sooner or later, without any imprudence, or any exter-
nal influence  that would be injurious under ordinary  circumstances.
This kind of occurrence is so  common, that is necessary to warn those
who have lost an eye of their danger, and to point out the necessary
precautions for avoiding it.  For this  affection of the sound eye, if it is
not noticed and properly treated in the early stage, often destroys sight.
Its most common form is slow inflammation,  which may affect the iris,
the retina,  or the internal tunics generally.   Rest  of the eye, antiphlo-
gistic means and the  use of mercury,  are the principal  points of treat-
ment.
   Our only chance for restoring sight, when the retina has been injured
by concussion, is in keeping the  organ quiet, in taking  blood from the
neighbourhood by cupping  or  leeches, and  in  the general  treatment
called antiphlogistic.   After evacuations, blistering may be  resorted to
advantageously.
  Case.—A  boy about six years old was brought to the London Ophthalmic Infirmary,
with injury of the eye from the explosion of gunpowder. There was a small extra-
vasation of blood into the anterior  chamber, some enlargement of the pupil, which
was motionless, and apparently displaced towards the upper part of the eye, and loss 
174
WOUNDS OF THE EYE.
 of vision.   The  prognosis was unfavourable; but sight was perfectly restored, the
 change of figure  in the  pupil remaining.
   Case.—Effusion of blood into the anterior chamber, and complete amaurosis, from
 a severe blow :  recovery and perfect  sight.—William Kitt, aged eight, was admit-
 ted into St. Bartholomew's Hospital  on the evening of May 1, 1833, having received
 a few minutes previously a blow on the right eye from a pellet of clay thrown from a
 sling.  The following symptoms were observed ; viz. considerable swelling of the up-
 per lid; great pain in the eye-ball and  over the orbit; a small quantity of blood effused
 into the anterior  chamber, at its lower  part; complete loss of vision ; pupil dilated, and
 elongated vertically; iris  motionless.  (Thirty leeches round the eye; opening  mix-
 ture.)  The pain was relieved by the loss of blood, but it returned after a few hours,
 with  violent throbbing ;  eight ounces of blood were taken from the arm.  The patient
 fainted and  the pain  was diminished.—May 2; the patient could distinguish light from
 darkness, or if an object obstructed the light he could detect a change without know-
 ing its cause; blood  much diminished in the anterior chamber;  other symptoms as in
 the evening.— May 3; return of throbbing pain ; no improvement in the sight; pupil
 less elongated.   (Seven leeches; blisters to the nape.)  May 4;  sight much improved;
 the effused  blood  completely removed; pupil less distorted.   From this day, until the
 14th  of May, when he left the hospital, the vision  gradually improved; and  with it
 the pupil acquired its normal shape, size, and motion ; the  only defect of which  the
 patient complained  being an  inability to detect a very definite  outline of any object.
 The functions of the left eye were at  no time impaired.
   I  subjoin  the  following  cases  to  illustrate the nature, treatment,
 and  prognosis of the  amaurosis consequent on blows inflicted  on  the
 eye,  the  shrinking  of  the  globe consequent  on internal inflammation
 after such accidents, and the sympathetic effects produced  on the other
 eye.
   Incomplete amaurosis of the left eye from concussion of the retina ; same affection
 of the right from chronic internal inflammation.—A gentleman thirty-eight years of
 age, whom  I saw in January 1829, had lost the sight of the left eye from a blow on
 the front of the organ with a stick, nine years previously.   The right eye began to
 fail four years ago; he  employed no treatment, and was nearly blind with that eye.
 The pupil of the  left eye is  large, fixed, and irregular in figure, the iris having been
 contracted to its utmost  on the nasal side.   He can discern large objects with this eye,
 but cannot make  out even capital letters.   The pupil of the  right eye is contracted
 and partially adherent; vision is about  the same as on the other side.
   Amaurosis nearly complete from a blow.—A boy eight years old, was struck in  the
 eye with a  cricket-bat; there was great  swelling  of the lids.   Leeches and other
 suitable means were  employed.   When I saw him some weeks after the accident, all
 the immediate effects of the injury had  disappeared.   The pupil was dilated, and capi-
 tal letters could not be distinguished.
   Inflammation  and complete amaurosis from a blow.—A boy, twelve years  old,
 whom I saw in April 1828,  had been struck on the  eye, four weeks previously, by a
 stone  thrown by  a companion in play.  He was running away, and was struck as he
 looked round to see whether his pursuer was reaching him ; the blow  must therefore
 have been oblique.  Sight  was impaired, but there were no  external appearances of
 inflammation; and the proper means were  employed to prevent its occurrence.  There
 came  on, in  a few days,  pain and redness of the eye, with pain in the head, and com-
 atous  symptoms, for which active  treatment was necessary.  When I saw the patient,
 there  was external redness from fulness of the sclerotic vessels, extreme dilatation of
 the pupil, and complete amaurosis.  A small opaque mark observed on the cornea, near
 its margin, towards the external angle of the eye, was supposed to be the effect of the
 injury, the other  eye had  not suffered.
  Partial amaurosis from  concussion of the retina ;  partial recovery.—A boy, eight
 years  old, received, on the 8th of May,  1828, a violent contusion on the right eye from
 falling against the end of the handle of a cricket-bat, which was placed  perpendicular-
 ly.  The accident was followed by great swelling of the lids and surrounding parts,
and severe pain.   Proper treatment was  adopted; and when the  subsidence of  the
swelling allowed the eye to be examined, there was no  evidence of direct injury to
the globe;  but the boy said he was blind.  I saw him on the 20th of June, when I
found  a scar on the under lid, evincing  that the accident had  been serious.   The  pu- 
WOUNDS OF THE EYE.
175
pil was dilated, not fully;  and vision was very imperfect, but the  patient's age did
not allow the kind and degree of imperfection to be exactly appreciated.  I prescribed
the hydrarg. c. creta, with mild aperients, and a succession of blisters.   On the 26th
of July vision had much improved; the small  capitals in the title-page of an octavo
book could  be  readily distinguished.   Partial dilatation of the pupil remains.  As this
patient, who lived between twenty and thirty miles from London, was not  brought to
me again, I think it probable that sifjht was restored.
  Amaurosis from concussion of the retina;  internal inflammation; recovery.—A
youth of eighteen received a blow on the  cornea, of which a mark remained.  The
symptoms were slight redness of the sclerotica, discolouration of  the iris, dilatation of
the pupil, which had assumed an oblong figure,and amaurosis nearly complete. Leeches,
which were applied three limes, aperients, low  diet, and repose of the affected organ,
were the  means employed, under which the patient got well in  a month, the colour
and motions of the  iris, the figure of the pupil,  and the sensibility of the retina being
completely restored.
  Atrophy of the globe from a penetrating wound.—In October, 1827,  I saw a
child in arms,  in whom the eye-ball had  been  wounded by a fork three months pre-
viously.  The cornea was not more than one-fourth its natural size, and  the globe was
quite flaccid.
  Atrophy  of  both  globes.—A healthy boy seven or eight years  of age, was brought
to me in June, 1829, with  complete  atrophy of both globes.  There was  in  each a
clear cornea, about the size and figure of a barleycorn placed  horizontally.  About
fifteen months before one eye had been lost by a penetrating wound.  Internal inflam-
mation came on in the other, which seemed to  have been incautiously worked.   This
was stopped, and vision restored;  but the eye was again inconsiderately used, and in-
flammation returned.  Afterwards the globe shrunk.
  Shrinking  of the left  eye from a wound ; subsequent loss  of the right by in-
ternal inflammation.—A person, near seventy,  who had been  accustomed to exert the
eyes considerably, as a worker in  metal, received a wound of the left cornea in Jan-
uary, 1831, from a  particle of metal.  It was followed  by violent,  inflammation, sup-
puration of the globe, and  collapse of  the tunics.  The  inflammation subsided in about
six weeks.  Soon after the right eye  became inflamed, with diminution of sight.  Un-
der active treatment vision was improved, but not completely restored, and  he had
not been able  to resume his occupation.   1 saw the patient in September, four or five
days after the  relapse of the inflammation.  There was external  redness, particularly
round the cornea, which was somewhat nebulous in its lower half;  the pupil contract-
ed and irregular in figure; pain over the brow, vision very imperfect; he could see
the hand, but could not distinguish whether the  finders were open.  In  spite of ac-
tive treatment, by cupping, leeching,  blistering, and  salivation, maintained for  some
weeks, the inflammation  proceeded accompanied with severe pain, and vision was
completely lost.
  Atrophy from  penetrating wound; internal  inflammation, and cataract of the
other eye.—A boy ten years old had lost one eye from a wound of the globe, followed
by atrophy.  Slow internal inflammation occurred in the other, and produced change
of colour in the iris, opacity of the lens and capsule, and general adhesion of the pupil.
The operation  for cataract was performed, the  lens were quite  soft and nearly  fluid.
The pupil became clear, but vision was  not improved.
  Atrophy  of the  right eye ; iritis in the left.—In December, 1826,  I was consult-
ed by a  gentleman, who had received a wound  of the  right cornea, six or eight years
before.  The eye  was now  flaccid;  the iris altered in colour and texture, and the
pupil obliterated.   A violent attack of iritis had occurred in the left eye ;  it had been
arrested by antiphlogistic means and mercury;  and then relapsed.  The eye was now
slowly recovering.
   SECTION II.--INJURIES  OF  THE EYE FROM FOREIGN SUBSTANCES PASSING
                             BETWEEN THE LIDS.


   Extraneous substances getting into the  eye irritate the organ, and
quickly produce redness of the  conjunctiva with  increased  lachrymal 
176
FOREIGN SUBSTANCES IN THE EYE.
discharge,  which is sometimes sufficient  to  remedy the mischief, as
where it is caused by substances  in fine powder, or  by  acid  mat-
ters, such as snuff, pepper, salt, mustard, smoke, ammoniacal and other
vapours.
  Chemical agents  are generally found to have produced their full ef-
fect before  we see the patient.   Nitrate of silver destroys the surface it
touches, but it is so quickly decomposed by the moisture of the organ,
that its caustic action is quite superficial.  I have seen external inflam-
mation, requiring active antiphlogistic treatment, from a small particle
flying into the eye, as-a person was  scraping a stick of lunar caustic to
a point.  The introduction  into the eye of the lunar  caustic ointment
often causes active inflammation, while its continued use may give rise
to chronic ophthalmia  of the most obstinate kind.  Similar  results are
not unfrequently observed  from  applying  to  the conjunctiva  the sul-
phate of copper, or  other acrid and escharotic substances.
  A person employed in a soap  manufactory came  under my care at
St. Barthlomew's for acute external ophthalmia, caused by some strong
alkaline liquor which spurted into the eye.  The conjunctiva  scleroti-
ca3, with which  it came in  contact, was thickened, elevated, and dis-
coloured, and a  superficial eschar  was separated.  The patient was
young, robust, and of full habit: a high degree of external  inflamma-
tion was excited, requiring free depletion,  and three weeks elapsed be-
fore the organ recovered.
  Strong lavender-water thrown incautiously over the  face of a  gen-
tleman who had  fainted, passed into the eyes.  When he recovered, he
experienced intense burning pain, with redness and spasmodic closure
of the lids,  and copious lachrymal discharge, especially on any attempt
to open them.   I found merely general redness of the conjunctiva with-
out any .damage of  the cornea.   The  symptoms soon disappeared un-
der leeches and the  application of cold.
  A gentleman received an alarming injury from the  explosion near
his face of some  fulminating chemical substances.  I saw him  soon af-
ter the accident; he was in great agony from a sensation as  if some
burning fluid was between the lids and the eye-ball.  The eye-lids and
neighbouring skin were reddened, the former forcibly closed, and any
attempt at moving the  eye, or exposure to light was attended  with in-
tolerable pain.   On the temporal side of  the cornea, the conjunctiva
presented in a small space, a slight greyish discolouration in the shape
of small irregular spots.  There was general, but not considerable red-
ness of the eye, and  profuse lachrymation.  Concluding the force of the
explosion to have been great, and* likely to cause concussion  of the re-
tina and amaurosis, I was  anxious to ascertain the state  of vision.  Al-
though the  extreme  irritability of  the organ and its impatience of light
prevented me from doing this satisfactorily, I  found that  vision.was not
materially impaired.  The application of eighteen leeches, followed by
an evaporating lotion, relieved the pain considerably; it  was necessary
to put on twelve more leeches at night, and the patient slept  well.  On
the  next day the organ admitted of examination  so as to  show that
vision was uninjured.   Confinement to bed,  exclusion  of light, open-
ing medicine and light diet restored  the  organ completely in a few
days. 
FOREIGN SUBSTANCES IN THE EYE.
177
   Hot water, and heat in other shapes, act on the conjunctiva in the
 same way as on the integuments.   Such  injuries are rare, the rapid
 contraction of  the  palpebras preventing  the mischief or limiting  its
 extent.   I had a patient  in  St. Bartholomew's, in whom  melted lead
 had passed  into the  eye.    A  thin  concave  portion  of the  metal
 was removed, which obviously owed its figure to having been in con-
 tact while liquid with the eye-ball.  The organ sustained  no material
 injury.
   Pure lime applied to the cornea turns it of a dead white, and  at the
 same time decomposes the texture, reducing it to a powder, which may
 be brushed off with a camel-hair pencil.  The effect of mortar, which
 gets into the eye more frequently than lime, is less injurious in  degree;
 it turns  the cornea white,  but does not decompose it.  Lime and mortar
 exercise a destructive action on the surface of the conjunctiva; the
 membrane swells and is elevated, with a pulpy coagulated  appearance;
 the portion deprived of vitality is of a dead white, and as  the effect is
 usually  partial, the  injured surface appears marbled.*  If any particles
 of these or any other irritating  substances should remain  in the eye,
 they should be immediately removed ; and if it should seem probable
 that the caustic action of  the lime is not at an end, vinegar and  water
 may be applied to the eye.
  The cornea loses  its vitality throughout when pure lime is freely ap-
 plied to it; hence vision is  generally lost, as the whole cornea, or the
 greatest part of it suffers in most cases.  When the injury is superficial,
 the dead part  slowly separates, and the transparency of the texture  is
 partially restored.   In the  case mentioned  by Mr. Wardrop,! tw°-
 thirds of the cornea were  rendered so obscure by the application of lime,
 as entirely to destroy sight.  At the  end of five months " the whole  of
 the slough had separated,  except some small ragged portions towards
 the centre of the cornea.   There was a degree of obscurity, apparently
 seated deep in the cornea; but the patient's sight  was so  much  reco-
 vered, that with  this eye  he  could distinguish large objects."  Where
 the action of the lime has  been superficial,  and not intense  in de-
 gree, I  have seen  the transparency of the  cornea  completely re-
 stored.
  In a person who  had  contrived to dip his head in a  pailful of the
 liquid used to  whiten the  walls of a house,  there was severe burning
 pain, with closure of the lids, lachrymation and redness of the conjunc-
 tiva.  Leeches and cold lotion soon removed these symptoms, and the
 eyes were not injured.
  A detached eye-lash under the upper or lower lid produces an annoy-
 ing uneasiness.  To remove it from the former situation, eversion of the
 lid is necessary.
  The most common cases requiring our assistance are those in which
 minute particles of dust and other matters are blown  into the eye, and
 either lodge on the external surface of the globe, or stick in the mucous
 lining of the palpebrae.  In either case  the organ experiences  conside-
 rable irritation, for whenever the globe or lids are moved the foreign

  * Mr. Wardrop has delineated very faithfully the effect of lime on the cornea and con-
junctiva, in his Essays on the Morbid Anatomy of the Eye, vol. i. pi. 5, fig. 5.
  t Ibid. p. 161,16U.
      23 
178
FOREIGN SUBSTANCES IN THE EYE.
 substance scratches the opposed sensible surface, and causes acute pain;
 so long as the eye is at rest, the  patient does  not suffer.  In order to
 discover and  remove any minute substance of this kind, we  must first
 look attentively at the exposed surface of  the organ  in a good light; if
 we discover  nothing there  we should proceed to depress the under lid,
 and bring the lower surface of the globe into view by desiring  the pa-
 tient to look  up to the ceiling.   If we still find nothing we must direct
 the patient to look in  the opposite direction, and raise  the  upper lid,
 so as to bring into view the superior  surface of the globe.   In most in-
 stances these substances stick in the concavity of  the  upper lid, and
 cause exquisite  pain by scratching the very sensible surface of the cor-
 nea, whenever the lid is moved; the suffering  is much greater than
 when  the substance adheres to the cornea, since the  mucous membrane
 of the lid, which is the suffering part in the latter instance, is not so
 acutely sensitive as  the surface of the cornea.  In order to discover and
 remove them, when thus situated, we must evert the lid, which  is very
 easily accomplished.  We  take the cilia between the finger and thumb
 and draw the lid downwards and forwards; press with a probe steadily
 against its upper part; then carry the ciliary margin  upwards and back-
 wards ;  we thus turn  the  lid inside  out, and immediately see whether
 any extraneous  body lodges there.  We usually find a small black par-
 ticle not larger  than the point of a pin, and remove  it readily with the
 blunt end of a probe.  This is a  simple and perfectly easy mode of ex-
 amining the lid  under  various circumstances; it can generally  be  ac-
 complished without giving pain.  When we let go the lid returns of it-
 self; if it should not, we immediately replace it  by drawing the ciliary
 margin downwards.*
  The small metallic  particles, particularly of iron,  which get into the
 eye in striking a light, in the operations of smi;hs,  cutlers, and  other
 workers in metals, either stick close to the surface, or are imbedded in
 the substance of the cornea,  presenting the appearance of a small shining
 black or dark point, which cannot be detached with  a probe, and is of-
 ten so small that it might escape notice unless  the eye were minutely
 examined.   These particles do  not penetrate the cornea  by the direct
 force  of the motion; they areignited and appear  as sparks ; "consequent-
 ly they burn where they touch, and stick close to the burnt part.  We
 must remove  them with the  point of a cataract needle.   Let the patient
 sit down opposite a window  ; then standing behind him, we separate the
 lids with the fingers of one hand, while we use the needle with the other.
 When we have a clear view of  the particle, we direct  the  patient to
 look steadily at one object, so as  to fix the eve  in that exact position,
 then bring the point of  the needle to the edge  of the  substance, and
 passing it under, lift the foreign body  out.  Sometimes we succeed bet-
 ter with the patient standing, placing ourselves in front.  Particles of
 steel or iron leave a light brown  stain on the cornea, which disappears
 in a day or two.  The  proceeding enjoined by Beer, of scraping  off the

  * [Travellers in steam-boats and  on rail-roads often suffer much inconvenience, from par-
 ticles of cinder blown into their eyes, and frequently still more from the awkward attempts
made to discover and remove them. Not  a few examples of this have come under our ob-
 servations; where a careful attention to the  directions  given by Mr. Lawrence would
 have saved much suffering to the patient,  and great mortification to the practitioner 1 
FOREIGN SUBSTANCES IN THE EYE.
179
 stained part with the cataract needle, is quite unnecessary; and fortunate-
 ly so for the patient, as it could not be executed without a greater in-
jury to the eye than that of the  original accident.   He seems to  con-
 template the employment of considerable  force, as he adds a caution
 against penetrating the cornea with the  instrument! !   When such sub-
 stances are deeply sunk in the cornea, it is no easy matter to detach
 them,  and the difficulty is increased by irritability of the eye,  which is
 turned away involuntarily when the patient sees an instrument approach.
 More  injury may be produced by persevering  in our attempts  than by
 suffering the substance to remain.  If it is left, ulceration will take place,
 loosening and  ultimately detaching it.   This event is accelerated by
 the oxydation which the metal undergoes in consequence of which its
 texture is loosened, and  it is partially  converted into a powder of a
 rusty colour.
   Sometimes foreign substances, particularly  if small  and  smooth on
their exposed surface, stick in the cornea for many days, even for weeks
or months, without exciting inflammation, or causing much uneasiness.
 In other instances they bring  on  inflammation  very  quickly; ulceration
 soon occurs, and the irritant  is thus removed.
   Sometimes  foreign bodies of  some size  get entangled  in the  loose
 folds which connect the conjunctiva to the globe, and remain there for
a considerable time.  I recollect removing a bit of twig, from the bough
 of a tree, which had lodged  in  this situation, and  remained there for
 several weeks.  The patient  was  not aware of the existence of any
 foreign substance in the eye.  Swelling of the conjunctiva  and some-
 thing  like  a  fungous growth from the  membrane have sometimes  oc-
curred from such  causes.  A gentleman consulted me on  account of
 uneasiness in the eye; he stated that he had been on a  journey three or
 four weeks before, and that in travelling on the road a small insect flew
 into his eye;  he was not, however, disposed to attribute his present suf-
fering  to that  circumstance.   On  everting the  lower  lid, I found  the
 wing  cover of a  minute species of beetle lying on its inner surface.
After this had been removed, he said he  still felt something in the upper
lid, and upon everting  that also, I found the  other  wing cover of the
same  insect.   We should  therefore examine  carefully in all  doubtful
cases,  extending our investigation  to the reflexions  of  the conjunctiva
from the lids to the globe.
  The directions given in books  respecting extraneous substances in
the eye are in general of little use.   Beer, is tediously minute in describing
every variety of matter by which the eye can  be injured, and in laying
down rules of treatment;  but he does not even mention the simple pro-
ceeding of everting the upper eye-lid, which enables us  to  give the
necessary relief in the great majority of cases.  Injections of water,
milk and water, and mucilaginous fluids under  the lids, and over  the
surface of the eye, are recommended; these are of no use, and indeed
can only add to the  irritation which  already  exists.  If any injection
could   remove.the  foreign  body, the flow of tears  which  its presence
excites would be sufficient; when it sticks to the concavity of the upper
lid, injections are wholly ineffective.
  Many other proceedings advised by Beer, such as the use of variously-
shaped forceps and spatulae, and the introduction under the lids of camel- 
180
CAUSES OF OPHTHALMIC INFLAMMATION.
hair pencils dipped in oil or butter, or of common pins or hair-pins bent
near the head, with the view of entangling  or  hooking  out extraneous
bodies, seem to me well calculated to give pain and cause inflammation,
without the possibility of doing good.*
  Removal of the cause, even when of a mechanical description, does
not always put a stop to inflammatory action; this, when  once begun,
often pursues its regular course after the  exciting cause has ceased to
act; and it must be  controlled by the means which  will be explained
afterwards.
CHAPTER  IV.
                CAUSES OF OPHTHALMIC  INFLAMMATION.

  In investigating the origin of disease, inquirers could not fail to dis-
tinguish, from the  earliest times, those circumstances which produce  a
state of body favourable to the occurrence of disease, from such as im-
mediately precede and directly excite the morbid phenomena.   Hence
in medical works causes of disease have been  always divided into two
classes, the remote or predisposing, and the immediate or exciting.
  The organization of the body is  in relation to the influences, which
surround it, and these do not affect it while in a healthy state;  but the
least of them  is capable of  producing  disease, when the body  is pre-
pared  for their  action  by certain  previous  changes, which,  although
produced almost insensibly, are of great importance, as constituting the
first links in the chain of morbid phenomena, the first steps in the tran-
sition from health  to  disease.  A person  in sound health  encounters
wind and weather, not only without  harm, but with benefit; he is not
injured  by atmospherical  vicissitudes, by cold, heat, rain, draughts  of
air; while a little damp or  a puff of easterly wind will bring on serious
disease in sickly persons.   The necessity of closely investigating these
predisposing agencies in reference to the important object of preserving
or restoring health, and thus preventing  disease, is too obvious to require
further explanation.
  As the eyes are  parts of a general organic  system, connected  with
the rest by vessels  and supply of blood, by nerves, and by the reciprocal
sympathetic influence in health and disease, the remote or predisposing
causes must be the same for them, as for the rest of the body, and some
of the immediate causes are  at all events analogous.   I shall first con-
sider the latter, as  their agency is the most obvious.
  Immediate or exciting causes.—In the  first place, inflammation of
the eye may be produced by direct injury, such as accidental wounds,
* hehre, b. i. §1.",S. 
                CAUSES OF OPHTHALMIC INFLAMMATION.             181

or intentional violence inflicted in surgical  operations.   Such  causes
always excite inflammation, which will vary in degree  according  to
other concomitant circumstances.   This liability to inflammation, after
surgical operations, requires  our serious consideration in the previous
preparation and subsequent management of the patient.
  Direct injury to  the organ may be produced by various extraneous
substances coming in  contact with it, or, in  popular language, getting
into  the eye.   Minute bodies of all kinds may  pass  between the  lids,
and remaining fixed either to them, or to some part of the external sur-
face  of the globe, become a source of irritation and inflammation. Some
of these may irritate the organ mechanically, as particles of dust, sand,
or stone; some may act chemically, such as various acrid  substances,
particles of snuff, pepper, salt, acrid fumes, and  different chemical sub-
stances; others may affect the organ both mechanically and chemically,
as portions of heated  metal.
  Under the head of chemical stimuli, or irritants, it would not be pro-
per to omit the mention of numerous matters applied to the eye under
the name of remedies.   It would seem  as if  the most delicate and sen-
sible organ of the body had been selected for trying the most violent
applications.   Powdered glass and sugar, wine and tincture of  opium,
electricity and galvanism, spirituous  and ammoniacal vapours, are the
mildest of the ordinary local stimuli.  Subacetate of lead, white and
red precipitate, nitrate of mercury, oxide of zinc, alum, the sulphates of
zinc  and  copper, nitrate  of silver, and oxymuriate of  mercury, are
applied  daily to the eye, in  the form  of  solution,  and  various other
shapes.   The more active escharotics are sometimes resorted to, as the
nitrate of silver in substance, and we read even of the kali purum having
been used.  Pretty  strong and almost concentrated  nitric and muriatic
acid, and  the muriate  of  antimony, have been occasionally employed.
The  circumstance of  these substances  being called  remedies, does  not
alter the nature of their action  on the  organ.   A small portion  of any
of them applied to the sound eye of a healthy person would produce  a
greater or less degree of inflammation,  and there can be no reasonable
doubt, that in  many instances of  their application to the organ, when
already inflamed, they aggravate or keep up the disease which they are
employed  to lessen or remove.
  Ophthalmic inflammation  may be directly  excited  by the application
of certain  contagious substances, for example, gonorrhceal discharge
from the urethra, and the puriform discharge of purulent ophthalmia.
  The eyes are meant to be  used, and although so delicately organized,
are capable of great  daily exercise  for a long course of years.  But
there are limits to  their power  of endurance.  Excessive exertion on
minute and very bright objects, as  in microscopic and teloscopic  pur-
suits, is  sometimes suddenly injurious.   They suffer again  from habitual
daily employment  for many hours, continued often  by candlelight, in
occupations requiring close attention, as in weavers, tailors, shoemakers,
milliners,  mantua-makers, sempstresses, printers, engravers, painters,
draftsmen, law-stationers, clerks in counting-houses, watch-makers, in-
strument-makers,  working jewellers, and  all  persons engaged in the
various  manual crafts; in students and literary persons, especially when
they read  much small print,  or write  in small characters.   In speaking 
182
CAUSES OF OPHTHALMIC INFLAMMATION.
of use of the eye, we must, however,  distinguish  between active and
passive vision : the impressions of light on the retina are constant during
our waking hours;  but this merely passive sight  is  uninjurious.   The
unnatural excitement of the  organ is  combined, in  many of the  pre-
viously enumerated  instances, with want of exercise, full diet, use of
spirituous and other strong liquors, which cause increased determina-
tion of blood to the head, and at the same time consequently derange
the functions of the  digestive organs.  The injurious influence of over
exertion is shown by the relapses of inflammation  caused by returning
to such occupations  before the organ has completely recovered.
  Air and light, the elements for which the eye is  created, can hardly
ever be injurious to the sound organ of  a  person in  good health;  yet,
under some  circumstances, they  are capable of  exciting disease.  I
shall speak more particularly of various atmospherical influences, in
considering catarrhal  ophthalmia, and  merely observe at present  that
the dense winter fogs of London will cause smarting  and soreness of
sound eyes in healthy individuals.
  The effects of bad air, or noxious effluvia, will be adverted to under
the head  of  purulent ophthalmia; but  it may be  stated here, without
attempting to explain  how it occurs, that  the air of hospitals, work-
houses, close rooms, in  confined situations, is  injurious to  the eyes,
favours the continuance  of  inflammation, and retards recovery from
operations.   Complaints which have been lingering on, in spite of every
effort at cure, in such situations, get well of themselves when the patients
are removed into good air.   The improvement is  often  so rapid,  that
we seem obliged to admit a direct noxious effect of unwholesome air
upon  the organs in addition to the well-known injurious influence upon
the system at large.
  Exposure to light  may be hurtful, either  by the sudden impression of
powerfully luminous objects, as  a flash of lightning, or looking at the.
sun in eclipses, or by the longer use of  the organ under less intense
light, as that of lamps, or gas-lights, or by  its employment upon bright
metals, or other shining objects.  The  injurious effects are aggravated,
if the exposure to light be  accompanied with heat, as  in the case of
cooks, bakers, workers in glass-houses  or  iron foundries, or  with the
excitement of considerable bodily exertion, as  in soldiers making long
marches under a powerful sun.
  Some forms of light irritate the eye more than others; thus,reflected,
is more powerful than an  equal  quantity of direct  light.  The glare
from the sea, or extensive  sandy surfaces,  particularly in warmer cli-
mates than our own, is extremely offensive  to the eye.  Even in  this
country, where we are not much troubled with  the  brightness of  sun-
shine, the white roads in chalky soils  are sometimes found very trying
to the eyes; and the bright white or yellow of houses and walls in some
towns distinguished  by particular cleanliness and neatness, has been
found disagreeable in the same way.
  Exposure to  light is particularly offensive  to  individuals  labouring
under inflammation of the external'tunics of the eye-ball.  This affec-
tion is prevalent among the Esquimaux, and the inhabitants  of other
high  northern latitudes, and is  so obviously caused by the  powerful
reflection of light from the snow, which covers  the earth  for many 
CAUSES OF OPHTHALMIC INFLAMMATION.
183
months in the year, that it is commonly called snow blindness.   Some
of their contrivances for protecting the organ from this source of irrita-
tion are extremely ingenious.
   In  the affection of the  eyes caused by exposure to the glare from
snow, there is intolerance  of light, with profuse lachrymation, and an
uneasy sensation, as if a particle of sand were in the eye, which is ag-
gravated, as the disease advances, to the severe  suffering which might
be supposed to be produced if snuff were thrown into it.   Violent spasm
of  the eye-lids occurs.  The symptoms seldom go  off in less than ten
days, and often last for weeks.   The Tartars protect themselves when
they hunt or travel in the winter, by a contrivance analogous to our crape
spectacles;  that is, by a  net-work  of black horse-hair, made  a little
convex in front,  so that it  may not interfere  with the motion of the lids.
The snoiv-eyes of the Esquimaux, as they are called by travellers, are a
kind of goggles,  made of extremely light wood, resting by a bridge on
the nose like spectacles.   It is excavated on each side, so as to allow
free motion  of the lids.  The excavations are stained black with soot.
A long narrow slit is made in  the wood opposite each eye, correspond-
ing exactly to the fissure between the lids, when they are nearly  closed
in looking at an object under a strong light.   Blumenbach, who has
described and figured these Esquimaux spectacles, says, " I was unfor-
tunate enough lately, having been affected for several months with tonic
spasm of  the eye-lids, to  have repeated occasion to make use of this
excellent and simple contrivance.  Whenever I wanted to examine ana-
tomical preparations, or objects of natural  history in a  clear light, no
other assistance  answered my purpose so well as the snow eyes of these
rude people. It also  serves for a telescope, as all  the  visiters of my
museum  who have tried it can testify;  and we find that ihe Esquimaux
use it for the purpose  of discerning  distant objects more distinctly,
when they are not troubled by the reflected glare from the  snow.'**
   Particular colours, and  combinations of colour, are found to be pain-
ful to the eyes; thus it is well  known that red  is offensive, and green
agreeable to them.  Variegated surfaces, presenting a variety of colours,
are sometimes annoying; thus persons who are obliged to look much  at
patterns of articles in linen and calico, often complain of their painfuli
effect on the eye.
  The causes above enumerated admit of being divided into two classes.
Some of  them, such as external injuries, chemical substances, or mor-
bid animal poisons, will necessarily produce  more or less  inflammation :
one case  may be serious, another slight.  If  we extract a  cataract from
an individual in good health, and whom we  have carefully prepared for
the operation, hardly any  perceptible inflammation occurs; but, if we
operate on a person of  gross  habit, without the  requisite preliminary
cautions, such inflammation may ensue, as entirely to frustrate the ob-
ject of the proceeding.  The other agencies, such as the  application  of
cold and  moisture, and excessive exertion of the organ, do not produce
inflammation invariably.   Many persons may be exposed to cold, windy
rain, or snow, and most  of them will  suffer  no injurious  consequences,
but one may be attacked with  sore throat, another with catarrh, a third

        * Blumenbach, specimen historian naturalis, §c. Goclting. 1816, 4lo. 
184
CAUSES OF OPHTHALMIC INFLAMMATION.
with inflammation of the eye.  Out of a large party sitting down to a
feast and indulging equally, one individual will have an attack of apo-
plexy.  A person in good health receives a slight blow on the foot, or a
twist of the ankle, and experiences a merely temporary inconvenience;
while in  a person of full habit the same causes will bring on an attack
of the gout.   To  produce disease, therefore, it is  necessary, not only
that an exciting cause should be applied to the eye, but that either the
part, or the individual, or both, should be in a state susceptible of the
action of that cause.  The same exposure or employment of the organ,
which would produce no  inflammation in the sound  eye of a healthy
person, will, under certain conditions of constitution, excite inflamma-
tion.   We must, therefore,  inquire  into  those  predisposing circum-
stances, which, though  they do  not  immediately affect the organ, ren-
der the body susceptible of disease.   In investigating these causes, we
find the evidence much less clear than in the other cases.   Those alte-
rations in the constitution,  which bring individuals  from perfect health
into a  state susceptible of disease, are produced  in a length  of years,
and by the continued application of influences, which do not act imme-
diately or visibly at any one time.  We cannot trace their direct influ-
ence,  as we cannot see  the hour-hand of a watch move; but we judge
of it  by the effects  which are sensible  after a  considerable lapse of
time.
  Remote or predisposing  causes.—Among the predisposing causes of
disease, the following are  the principal.   First, natural peculiarities of
organization, either such as are common to many persons, and called
temperaments, or those, which being  confined  to the  individual,  are
called idiosyncrasies.  The law of nature, by which the progeny re-
sembles the parents, extends to these diversities.    Thus temperaments
and idiosyncrasies, and  consequent disposition to certain diseases, run in
families,  like particular  forms of the features.
  Here the question naturally occurs, whether light or dark eyes  are
the most susceptible of  disease.   It  has often been supposed that the
former are the most prone; but this  is  doubtful.   Dr. Smith, an army
surgeon,  found that  of  176 diseased eyes,  116 were light and 60 dark,
which is about two to one.   But in 2,163 sound eyes, there were 1,500
light,  and 663 dark, which is nearly five to two.*
  2dly.  Morbid dispositions, such as scrofula, gout, and rheumatism.
These, in some persons, depend merely on  the original nature of the
constitution derived from the parents; but, in others, they consist in cer-
tain states of the frame, which may be produced  by externa] agents, in
individuals who are supposed to be born healthy.    Morbid dispositions,
therefore, or as they are  sometimes called, diatheses, are either here-
ditary or acquired.
  3rdly.   Age and sex, climate and situation, often have a marked in-
fluence in favouring the occurrence of disease, and impressing on it  a
peculiar form.  The  influence of  the  latter  is exemplified in°the  fre-
quent occurrence and severity of erysipelas and  hepatic inflammation
in hot  countries, and  in the numerous and serious inflammations of the
eye in Egypt and other similar situations.

            *  Edinburgh Medical and Surgical Journal, No. G8, p. 351. 
CAUSES OF OPHTHALMIC INFLAMMATION.
185
   4thly. I have mentioned  excessive exertion  of the eye among  the
circumstances  capable of immediately exciting  disease.   When it is
habitual, it is a powerful  predisposing cause, by  keeping up  an unna-
tural excitement of the organ, and thus it often lays the foundation of
chronic  internal  inflammation, especially where  the digestive organs
and vascular system are constantly stimulated  by imprudent habits of
diet, and the free  use  of fermented liquors.   In  the year 1830, I was
consulted within the same week  by two  naturally healthy young men
from the country, who had followed the occupation of wool-sorting,
which is very trying to theeyes, and in both of whom slow inflammation of
the retina had occurred, with loss of vision in one instance, and serious
injury of sight in  the other.   One of them, thirty  years of age, used to
work twelve hours a-day  in summer, eight in winter.  He ate animal
food three times a-day, drank three pints of ale daily, and spirits occasion-
ally.  In his right eye  there was a  little external  redness and slight
haziness of the  cornea, dilated and motionless pupil.  Vision was nearly
extinct;  he could just  discern my hand  when held towards the light,
but he could not distinguish whether the fingers were open or shut.   By
cupping, purging,  reduced diet, and the use  of mercury, he recovered
in a month, so  as to be able to read the leading article of a newspaper.
   The other, a very stout, man, with large head and full face, was about
forty.   He had always lived well, but, as he stated, not intemperately.
He had lost the sight of his right eye three or four years:  there were
two adhesions of the pupil and no other appearance of  disease.  Two
similar adhesions were  found in  the  left  eye, of which the sight  had
recently become dim and imperfect.
   5thly.  Unhealthy states of constitution, however produced.  Per-
haps the most powerful and general of the remote causes of inflamma-
tion, whether we  consider the accidental form of the  disease, arising
from the immediate application of the agencies already enumerated, or
the spontaneous cases which are said in common  language to  come of
themselves, the causes  escaping our observation, is fulness of habit,  or,
technically, general plethora.  Many persons introduce  into the system
a much  greater quantity of food than the wants of the economy require ;
they sin both in amount and  quality, especially in the  two articles of
animal food and fermented liquors.  This excessive nutrition is attended,
in the first  instance, with a  more vigorous exertion of the various
organs; there is an apparent increase of health and strength, the per-
son looks florid and robust, and seems to be in high health.   Sooner or
later a condition of body results, bordering on disease.  There is a full
and strong pulse,  a disposition to  heat of skin, thirst and headach;  or
these are produced by  slight exertions.   The tongue  is whitish.  The
state, in short, is closely allied to disease, although it is still called health ;
it is a condition in which disease  will easily be induced, and in which,
when it occurs, it assumes  the active inflammatory character.  It is
pure, simple, or common inflammation, which  occurs under such cir-
cumstances; that  is, inflammation arising from the excess of nutrition
in an individual otherwise healthy.
   It has been questioned whether the quantity of blood is increased  in
these cases, that is, whether the expression plethora, or fulness, is lite-
rally applicable to  the state of the vascular system. It is difficult to de-
      24 
186
CAUSES OF OPHTHALMIC INFLAMMATION.
termine the point.  We do not know the regular or normal  quantity
of  blood,  and we  cannot ascertain  the  quantity  which  the ves-
sels of  an individual  contain at a  given  time; thus we want both
terms of comparison.  Under the circumstances  described, we  often
find an unnatural  fulness  and strength  of pulse: and  the blood drawn
from  such persons  frequently presents  the inflammatory  character.
They are in a state very similar to that of females, in whom the cata-
menia have been suspended, where we see flushing of the countenance,
pain of the head,  and determination of blood to some part.   The  same
circumstances are observed in persons, in whom large old ulcers have been
rapidly healed.  I am inclined to believe that there is an unnatural quan-
tity of blood in such cases, and that the expression of plethora is literally
correct.
  Individuals are  not aware of the effects of the habits in which they in-
dulge until at  length symptoms of derangement  and disease manifest
themselves in various parts of the animal economy.   The subject will
be best understood by adverting to cases, in  which such practices have
been carried to a  great degree.   We have  the opportunity in London
of making such observations on an extensive  scale.   A large proportion
of the individuals  who follow certain laborious occupations, obtain high
wages, which they spend chiefly in direct sensual gratification of the
grossest kind.   It is  no uncommon circumstance for men employed in
the coal business, brewers' servants, draymen, porters, and others, who
are, generally speaking, fine robust men from the country, to consume
from  four  to twelve pots of  porter  a day, besides  gin, and a full al-
lowance of animal food.   We certainly see many of these who, if we
regard fulness of  flesh and ruddiness of complexion as signs of health,
may be considered as fine specimens.   But these persons are subject to
inflammatory attacks of the most violent kind, which they bear very ill.
Slight injuries, which in  others would be wholly unimportant, produce
in them severe inflammation, often terminating in gangrene and death.
I have seen the  whole lower extremity  mortified up to the groin, in
thirty-six hours, from a simple scratch of the shin, in a drayman.  They
live, in fact, on the brink  of disease; the slightest  accident may carry
them  off, and if they  escape casualties, the continuance of their intempe-
rate habits leads to inflammation of some of the thoracic or abdominal
viscera, which either proves  fatal in its active stage, or, by causing
dropsy, leads more slowly, but with equal  certainty, to dissolution.  The
majority do not survive the age of fifty;  hundreds of them die in our
hospital from disease of  the viscera, and afford us ample opportunities
of investigating the changes consequent on inflammation, and of demon-
strating, in its fatal termination, the effects of such a mode of life. In
the natives of India we may contemplate the effects resulting from op-
posite habits.  The religious notions of the Hindoos induce them to ab-
stain  from animal food, and they  live almost entirely on rice and other
vegetables.  They are small  in stature, slender  limbed and  very well
formed; the symmetry of their figures  not  being impaired by any su-
perfluous fat; yet, in  active exertion, line, well-fed,Englishmen are quite
unable to compete with these  slender Indians, who greatly surpass  us in
all feats of activity, such as running or walking great distances, &c.
Accidents  or  operations,  which  in  full-fed Europeans would be at-
tended  with dangerous inflammatory excitement, produce  trivial ef- 
CAUSES OF OPHTHALMIC INFLAMMATION.
187
 fects on the natives of Hindostan.   Severe injuries cause  but  little
 febrile disturbance,  and they recover commonly under  circumstances
 which  would  be  considered desperate  in  individuals  of different
 habits.
   Although robust constitution, fulness of habit, and  youth, predispose
 powerfully to acute inflammation, whether of the  eye or other parts,
 they are not essential conditions to the production of such disease, which
 often arises in weakened states of body, and  sometimes where the de-
 bility js great.  Strength, instead of favouring the occurrence of inflam-
 mation, resists its development most effectually.  I mean by strength
 the healthy condition of the frame, in which  all the functions are car-
 ried on perfectly, and  in which  there is the greatest power of regular
 and continued bodily and mental  exertion.   Such are not the attributes
 of plethora, in which the  appearances of strength  are fallacious, and
 accidental inflammations are easily produced.  The numerous class of
 spontaneous inflammations, however, occurs in subjects of unhealthy or
 impaired constitutions; often in those who may be considered naturally
 weak, as the scrofulous, and sometimes where  extreme debility has been
 produced  by disease, as in  typhus fever.  " I have often," says P. F.
 Walther,* " seen acute ophthalmitis, requiring the most powerful anti-
 phlogistic treatment, in weak, badly organized subjects.  Lately I  had
 occasion to treat such an affection in a person recovering from typhus,
 which had left him so weak that he could not stand without support.
 He refused to submit to my recommendation of venesection; and, in the
 course of seven  days, the disease advanced  so  considerably, that  the
 pupil of the right eye was nearly closed, and the left eye had become
 attacked by very active and painful inflammation.   He was bled on the
 eighth day, and again on the ninth, when leeches were also applied.  The
 abstractions of blood gave sudden and permanent relief, both in regard
 to the pain and state of vision; but the latter remained imperfect in the
 right eye in consequence of  a thin adventitious production in the pupil.
  Habitual excess, particularly in  the use of fermented liquors, not only
 produces general  fulness and  excitement, but more especially affects the
 head, causing increased activity of circulation, in which the eyes  par-
 ticipate.  A single hearty meal will cause visible vascular fulness,  red-
 ness,  heat, flushing of the face, beating and throbbing of the head; these
 phenomena being followed by headach, drowsiness, and more or  less
 incapacity for mental exertion. Can we suppose  that the daily repeti-
tion of these causes will fail  to produce ultimately the most serious con-
 sequences?  The mischief is  aggravated when the return of blood from
the head suffers any  impediment.   In  this way tight neckerchiefs  and
the stiff stocks of the military have been prejudicial.
  The suppression  of habitual discharges will obviously favour  the
 occurrence of general plethora;  thus  ophthalmic  disease, as well as
other local affections, often owes   its origin to the  interruption,  or the
 cessation of menstruation, sometimes to its non-occurrence at the usual
 period.
  If the  causes, which have originally produced  plethora continue  to
operate; that is, if into the system, which is already overloaded, exces-
* Abhandlungen, p. 397-S 
188
CAUSES OF OPHTHALMIC INFLAMMATION.
sive and unwholesome supplies are continually introduced, the functions
of the organs begin to be disturbed; they are unable to dispose of what
is thus poured in upon them. Digestion is first deranged ;  the associated
and subsequent processes of chylification, absorption, fecal and urinary
excretion are necessarily perverted.   The secretions of the alimentary
canal, and  of its subsidiary organs, particularly the liver and kidneys,
become vitiated, the contractions are impaired, and  thus the  regular
course of its functions is interrupted.  The digestive organs perform the
important office of preparing the supply of new materials for the growth
and repair  of  the body; they also remove from the system the residue
of the alimentary matter,  after the  nutriment has been extracted from
it.  If healthy supplies of new matter are introduced into the frame, all
the animal actions, whether bodily  or mental,  are  carried  on with
vigour; the body is active, the  mind is alert; and a general feeling of
health pervades the whole frame.  But if the nutritive  system is dis-
turbed, if the  alimentary canal is loaded with undigested matters and
unhealthy secretions, then  materials of disease rather than of health  are
distributed  over the body; under such circumstances, any organ may
become diseased, any mental function deranged.   The unhealthy con-
dition of the  constitution  is now evinced  by changes too  obvious to
escape observation ; the characters of plethora are succeeded by a state
of defective excretion.  There is a foul tongue, deficient, or sometimes
unnaturally voracious appetite; costiveness; the motions, when procured,
being unnatural in colour and consistence.  The  urine is deficient in
quantity, high-coloured  and turbid; the skin is sallow, haish, and dry;
the pulse feeble, compressible, and sometimes irregular.
   Although the most common cause of this condition is excessive nutri-
tion, it may occur  independently of  this, without  intemperance, even
without imprudence in diet.  It may take place in  consequence of cir-
cumstances which act immediately on the  nervous syslem, and which
affect the digestive organs secondarily.  Among the causes referrible to
this  head  may be  mentioned  indolent habits, sedentary occupations,
making people neglect the advantages of air and exercise, which  are
as necessary to health  as food  is to existence, residence  in the im-
pure air of confined and crowded dwellings,  excessive mental exertion,
long continued anxiety and affliction.  Such causes impair the energy
of the nervous  system, rendering  it weak and irritable; this again dis-
turbs the functions of the  digestive organs, producing indigestion, cos-
tiveness, and all their attendant train  of evils.  The effects of impaired
nervous energy and defective assimilation must  be felt over the whole
body, lowering constitutional power, and causing a state of general  de-
bility, in which the frame yields more readily to morbific influences, and
disease, when once excited, is  difficult of control, and lasts for  a long
time.
   Again the origin and protraction of disease often  depend on constitu-
tional weakness, arising from direct debilitating influences, such as  de-
ficiency of food, clothing, or rest, singly or combined, or various other
depressing  agencies.
   When we  consider that, in a  large portion of  the  community,  the
predisposing causes, which have  been now explained,  are united with
the direct exciting influence of excessive exertion of the organ we shall 
CAUSES OF OPHTHALMIC INFLAMMATION.
189
cease to wonder at  the numerous instances of inflammation in all the
textures of the eye, that daily present themselves to our observation.
  From these considerations it is obvious, that in many cases we ought
to direct our attention not so much to the organ which is the immediate
seat of disease, as to the influence of certain circumstances and habits
on the constitution.   At all events, if, under the immediate urgency of
active disease,  the  state of the suffering part  should require our first
care,  the prevention of future disorder cannot be accomplished without
such an investigation as I have just pointed out.
  In  the various cases which I have now considered, we see the effect
of some  direct agency  on the disordered  part, either such as neces-
sarily excites inflammation in some degree, or such as will cause it in
individuals who are predisposed.  There are  other and numerous in-
stances in which we can trace  no direct application to the inflamed part;
but we discover the existence of disturbance in other quarters, and we
find that the removal of those disturbances in many cases either accom-
plishes, or essentially assists the cure of the inflammation.  The former
are called idiopathic, the latter sympathetic  inflammations.  The con-
junctiva may be inflamed by the application of gonorrhoea! matter, or
gonorrhceal ophthalmia  may come on,  without  any such direct  cause,
merely in consequence of the previous disease of the  urethra.   The iris
inflames from injury, or it may suffer from infection of the constitution
by  venereal disease.  Inflammation  of the testicle in gonorrhoea is  a
sympathetic affection.
  The cases to which I have cursorily alluded, under the head of spon-
taneous inflammations, belong to  the sympathetic  class.   It is difficult
to determine whether their occurrence is owing to the unhealthy states
of  constitution  already described, or to the influence of  disturbance in
some particular organ;  whether they take place through the medium
of the vascular or of the nervous system.  That the former has an im-
portant share in the affair in many instances  cannot, I think, be doubted.
Under the constitutional  disturbance  which follow serious local injury,
such  as  compound fracture or other  extensive wound, laceration, or
bruise, inflammation may arise in various important  organs, as in the
peritoneum, pleura, or pericardium, in the lungs, heart, liver, or spleen,
as well as in the joints and the muscular system.  If the active disor-
der excited in the constitution in this way can produce such local effects,
we may easily  suppose  that the less  violent  disturbance which consti-
tutes  plethora, or the constitutional unhealthiness caused by diminished
nervous energy and impaired digestion, may lead directly or  remotely
lo the various local inflammations, the  ulcerations, thickenings, indura-
tions, enlargements, which are said  in common language to originate
spontaneously, or of themselves, and which  have so  much puzzled no-
sologists in the  attempt to account for their causes and mode of produc-
tion. 
(  190   )
CHAPTER V.
               TREATMENT OF OPHTHALMIC INFLAMMATION.

  It is a trite maxim in the treatment of disease to begin by removing
the cause; and the propriety of this course is particularly obvious where
that cause is mechanical, as in the case of extraneous substances getting
into the eye.   This subject has been considered in Chapter III.
            SECTION I.--TREATMENT OF ACUTE INFLAMMATION.

  Protection of the organ from external influences.—Whatever further
measures we may adopt, the eye must be protected from injurious ex-
ternal influences.  Exertion of the  inflamed part increases the distur-
bance and  aggravates the patient's sufferings.  In serious cases, there-
fore, the eye must not be  employed;  nor must the sound eye be used,
when one only is the seat of acute inflammation.   In less severe affec-
tions passive exercise of sight maybe allowed, although active exertion
of the organ would be improper, such as in needle-work, writing, read-
ing, particularly small print and by candle-light, employment before fire,
or on bright or minute objects.
  Exposure to light is generally painful, so  that patients are disposed to
avoid it.  The necessary protection is obtained, in the worst  cases, by
darkening the chamber and closing the bed-curtains.  This is not often
necessary; in general it is sufficient  to exclude strong light by window-
blinds, and to protect the eyes by the common pasteboard  shade covered
with green or black silk, by a  shade of such silk stretched on wire, by
green or black crape or gauze hanging over the face, or by coloured
spectacles.  These means of protection may be required only when there
is much light; not in twilight, or  in dull days.
  It would  be obviously injurious to expose an inflamed eye to the air
in cold or rainy weather; and great vicissitudes  of temperature should
be avoided:  but exclusion of  air is not necessary in favourable states
of the atmosphere.   A  warm, mild air, so far from being  injurious
to the organ, is grateful to  the feelings of the  patient, and benefi-
cial to his general health; there is hardly any state of the eye in which
it could be prejudicial.
  [Our experience has led us to go even further than Mr.  Lawrence, in dis-
pensing with bandages and all kinds of shades to the eyes.  These coverings al-
ways increase  the heat of these organs, as well as render them more irritable,
and favour the persistence  of the inflammation.  In hospital as well as in pri-
vate practice, we have long discarded their use, except as a temporary protec-
tion, in cases of photophobia, when the patient  goes out of doors.   In house,
the degree of light can always be regulated by closing the blinds during the day.
The free access of air to the eyes, not  only when  it is warm, but  even  when 
TREATMENT OF OPHTHALMIC INFLAMMATION.
191
cool, if the temperature be not very low, and the atmosphere damp and raw, is
agreeable to the patient and usually very beneficial.]
  General  indications.—The  measures  already pointed out, of re-
moving the exciting causes, and of protecting the organ against the inju-
rious  influence of exertion, light, and air, are only to be considered as
preliminary, and auxiliary to the main object, that of arresting inflam-
mation  by appropriate means.   Although the  process of  inflammation
is in many cases very violent, and though the sufferings which attend it
are often extremely acute, yet its tendency and  effect, with reference to
the termination of  the disturbance, are  upon the  whole restorative.
Within  certain limits, it does not tend to disorganize and destroy the
part; but is rather calculated to bring it back to a healthy state.   Thus
it may arise, become fully  developed, and decline in an organ, without
any medical treatment, leaving  the part as healthy as it was before.
When violent, however, it  suspends the functions of a part; hence, in
organs, whose  constant exertions are  necessary  to the  continuance of
life, it must be  speedily arrested, or life will be lost.  But the eye does
not belong to this class, and we  are guided by other  views in the treat-
ment  of ophthalmic inflammation.  Its various effects, particularly mor-
tification,  suppuration, and effusion, may render the organ more or less
incapable  of executing its office  after the inflammatory disturbance has
ceased.  Even the  least important of these, interstitial deposition, may
seriously and permanently  impair the function of a delicately organized
part like the eye.   It will enlarge, thicken, and harden a part;  it conso-
lidates and unites structures which were previously loose and separate;
it renders parts, which were naturally transparent, opaque.  These va-
rious changes may result, not only from violent inflammation, but from
such  a  degree  of it, as in most other instances  would be deemed unim-
portant.  Supposing the cornea, iris, or retina to be affected, the case
may  present no serious symptoms; there maybe no sympathetic distur-
bance of other parts.  Yet, in the first instance, the texture may be ren-
dered impermeable to light by interstitial deposition ; in the second, ef-
fusion may obstruct the pupil, preventing or  impeding the passage of
light  into  the interior of the eye; and the third may  be  thickened so as
to  become  insensible to  luminous  impressions.  By  either  of these
changes, according to its degree, vision may be  either impaired or de-
stroyed.  It becomes necessary, therefore, to institute early, and to fol-
low up steadily, effective antiphlogistic treatment, not  with a view of
removing danger to life, nor on  account of the  sufferings of the patient,
which may not be  great, but to prevent injurious changes in an organ,
the perfect state of which is essential to the comfort and  enjoyment of
life.  There is yet another reason why inflammation should be speedily
arrested.  The longer the vessels of a part remain distended, the more
difficultly do they contract to their natural dimensions, the more readily
do  they yield to any new excitement.   Thus the  continuance of inflam-
mation increases the difficulty of recovery, and the  liability to relapse.
The probability of  subsequent inflammation is  in proportion to the de-
gree  of disease that occurred in the first instance, and to the length of
time  it  was  allowed to continue.
   Another consideration must not be overlooked; that is, the relief of 
192
TREATMENT--BLEEDING.
the patient from the local suffering, and the general disturbance caused
by active inflammation of an important organ.
  Loss of blood.—Of the means for reducing inflammation, abstraction
of blood is the most powerful.  Blood is the material by which the in-
creased action of the part is maintained.  In the figurative language,
which the  obviously increased  heat has  suggested, we may say that it
is the fuel  by which the fire is  kept up.  If we could completely com-
mand the supply of blood, the increased action might be effectively con-
trolled or arrested.   In comparison  with  the loss of blood, other means
are of minor importance in lessening the local disorder and quieting the
general disturbance, when acute inflammation exists.
  General bleeding.—We have  to consider, in  the  present instance,
whether  it is necessary to take blood from the  system generally, or
whether local depletion will answer the purpose.   Medical writers and
practitioners have been usually satisfied with the latter; they do not
seem to suspect that an inflamed eye can require more than the applica-
tion of a few leeches.  But we must  act more vigorously if we mean
to prevent all danger of those structural changes which inflammation
may cause in a part.   We  shall  sometimes  find  it necessary to bleed
from the arm), and often to take blood by cupping.
  We might at first suppose that the  best  way of reducing increased
action in any organ would be to draw blood from  the part itself, to take
away from it the material which keeps up the excitement.  This, how-
ever, would be an erroneous  conclusion.  We can take blood out of a
part, but a fresh supply is  still poured in.  General bleeding  is the only
mode by which the supply can be cut off.  The external situation of the
eye enables us to see the decided effect which a  large bleeding has on
the  capillaries of the inflamed  part;  and I know no other example in
which the efficacy of the measure is so clearly demonstrated.  We see
a person with the eye bright red, and very painful; he cannot face the
light, and tears gush out with  great  suffering if  he attempts to do so.
We  bleed to fajnting, and  immediately the  capillaries are emptied, so
that the organ resumes its natural paleness; the pain is gone, the eye is
opened without difficulty, and the full  influx of light can  be borne with-
out an uneasy sensation.   For the time the  part has passed from violent
inflammation to a nearly natural  state; and we  cannot doubt  that the
change thus produced must have a powerful effect in  arresting the dis-
turbance.   With the restoration of the  circulation,  the inflammation will
recur after  this temporary suspension; but its violence is diminished,
and it often gradually subsides.   General bleeding then is necessary in
inflammation of the eye, to prevent the changes of structure that would
subsequently impair the functions of the part.
  I  know  of no criterion  by which  we can determine  in all  cases,
whether general or local bleeding should be employed.  If inflammatory-
fever co-exist with  the local  disorder, we should  abstract blood  from
the system: but we cannot say conversely, that if such fever be absent,
we ought to be content with local depletion ; an inflammation of the eye,
for example, may require  general depletion,  although it should not be
attended with fever.
  The quantity of blood to be drawn from the arm must be such as will
decidedly influence the circulation.  We  cannot determine the amount 
TREATMENT--BLEEDING.
193
beforehand; we cannot decide that ten, twelve, or sixteen ounces will
be sufficient; it may be necessary to take twenty, thirty, or more ounces,
or to produce  syncope, if we cannot otherwise make  the requisite im-
pression on the vascular system.   Professor John Thomson* says, that
from twelve to twenty ounces may be taken, and that the depletion may
be repeated two or  three times in the twenty-four hours, if  the <;ase
should require it.  Langenbeck,-{-  after quoting this  statement, adds,
"this would be too much in our country.   I usually take from eight to
ten ounces, and repeat the depletion according to circumstances."  If
he can arrest  active inflammation by venesections of this amount, his
patients must be very differently constituted from the inhabitants of this
country.   I believe that it  is the  usual practice in France, Italy, and
Germany, to take a small quantity of blood at a time,  and to repeat the
bleeding frequently;  thus, venesection is not  unfrequently  performed
night  and morning for  several successive days.  This  plan, which is
adopted from the fear of injuring the patient by a large bleeding, drains
the circulating system almost to the last drop,-brings" on excessive debi-
lity, and is less efficacious in arresting the local  disorder.  I  have no
hesitation  in stating, that the object last mentioned is effected much more
certainly by a large bleeding in the outset, and that this method accom-
plishes it at less expense to the constitution.  I never saw a person in-
jured  by a single large  bleeding performed for an active inflammation;
while generally the strength is completely restored in twelve or twenty-
four hours, even after bleeding  to syncope.   On  the contrary, weeks
and months often elapse before patients, who have been drained by re-
peated bleedings, recover their strength.
  As the restoration  of the digestive functions and the secretions dimi-
nishes the symptoms,  where inflammatory fever is  present, they who
are afraid of weakening by loss of blood, recommend in preference ape-
rient and  diaphoretic medicines.   If we examine  the history  of  cases
treated in this  way, we find  that two, three, or more days are employed
in these indirect attempts.   Purgatives are given which do not operate;
diaphoretics are tried, which bring on no discharge from the skin; the
local  inflammation increases, the general disturbance  is aggravated,
until the fever  comes to an end, when the secretions and digestive func-
tions  are  consequently restored.   Abstraction of blood  to a proper
amount accomplishes the desired objects at once.  When you have thus
removed the load that oppresses the system, the suspended secretions are
restored, evacuation  of the bowels takes place speedily, and the patient
breaks out into a profuse  perspiration.  Thus the sufferings of the pa-
tient are materially abridged, while the duration of the  local disturbance
is shortened; the latter being a very important point in the case of the
eye.
  A notion has prevailed that persons who live in London,  or in other
large  towns, do not bear depletion well, and consequently that the loss
of blood, which would  be necessary in those who live in the  country,
would be improper  in  the inhabitants of the metropolis or extensive
cities. I consider that this  opinion is supported neither by experience
nor argument.  The inhabitants  of London, from  the  highest  to the

  * hcctures on Inflammation, p. 166.                  1 Nosohgie, vol.  i. p. 266v
       25 
194
OPHTHALMIC INFLAMMATION.
lowest, with few exceptions, indulge their appetites freely; there are no
small towns, nor any parts of the country, in which the consumption of
animal food and stimulating liquors is more general.  These habits, of
which the injurious effects are aggravated in many instances by seden-
tary  occupations  or indolence, produce  their natural consequences,
namely, a plethoric state of the system, and an abundance of inflamma-
tory disease, both  of which circumstances will be immediately recog-
nised, on  attentive observation, whether  among  the higher or lower
classes.  I have not the least doubt that inflammations are as common
and as violent among Londoners as among countrymen; and that they
require the same treatment in both instances.   The dread of depletion
has been transmitted from one writer to another without examination or
inquiry, and has led to an inert practice, under which disease has too
often  been suffered to proceed almost uncontrolled.
  In acute inflammation  affecting the entire globe of the eye, in inflam-
mation of the conjunctiva or of the external proper tunics affecting both
eyes, or where it is very severe in  one, in inflammations of the internal
tunics, general bleeding  should be resorted tor unless contra-indicated
by the patient's age or constitution, or by  an impaired state  of general
power.  A large bleeding will be proper when the circulation is excited:
at all events the blood should flow until an impression is made on the
pulse.  A repetition of the measure will probably not be required.   This
free depletion  will be advantageous in young and robust persons, where
the inflammation is acute, and especially if seated in an important tex-
ture.  In older subjects, and under doubtful circumstances, we  proceed
cautiously, taking a small quantity of blood, and repeating the  abstrac-
tion if the patient bears it well.  Bleeding to syncope is seldom neces-
sary.   In states of constitutional unhealthiness, marked by general de-
bility, venesection would  be obviously improper; it might be  admissible
under peculiar circumstances, as for the purpose of preserving an im-
portant organ  when endangered by the degree  of local excitement.
  Local bleeding.—The next mode of taking blood in point of efficacy,
is by cupping  either from the back of the neck  or the temple, especially
the latter, from which part blood can be obtained quickly and in large
quantity.  Branches of the temporal artery are commonly wounded in
this operation, facilitating the abstraction of the blood,  and  causing
neither danger nor inconvenience.  I have constantly been in the habit
of taking away blood in this way with the best effect.
  Opening the temporal artery is, I think, less advantageous and conve-
nient than cupping.   We sometimes do not get  blood enough, and some-
times there is either a difficulty in stopping the  bleeding, or it  breaks out
again.  To prevent this, compresses are placed on the artery, and se-
cured by a bandage encircling the head, the pressure of which on the
brow and  forehead often renews and aggravates the sufferings of the
patient.  The  subsequent formation of a  small aneurism is not a  very
uncommon consequence of arteriotomy; it requires an operation for its
cure.   Under  many circumstances cupping on the temple cannot be ef-
fectively accomplished: arteriotomy might then be resorted to.  Open-
ing the jugular vein is a  troublesome and  inconvenient operation; and
we are frequently unable to get the required  quantity of blood in  this
way: it is now seldom resorted to,  at least in ophthalmic cases. 
TREATMENT—LOCAL BLEEDING.
195
  Blood may be drawn from the eye by the application of leeches, and
these should be applied near to the part affected.  The best situation is
immediately above or below the upper or lower lid respectively, or near
the external angle, avoiding the lids themselves on account of the ec-
chymosis and subsequent discolouration, which they cause here.   These
effects, however, cause only a temporary inconvenience, as they disap-
pear in a few days.*  It has been proposed to apply them to the mucous
lining of the lower lid, that they may draw blood directly from the con-
junctiva ;  they are easily put  there, but the application of them to  the
external surface of the palpebra will answer the  same purpose.   It is a
common error here, as in  other inflammations, to  apply them  in  too
small a  number;  if  the disease be  active and the patient adult, it will
seldom be proper  to put  on fewer than from eight to twelve, while a
larger number will frequently be necessary, in order to produce decided
benefit.
  The continental practitioners apply leeches, in certain cases, not to
the eye, but to other parts.   They lay great  stress on the influence of
suppressed haemorrhage in  causing ophthalmia, and  consider that the
organ will be most naturally relieved by reproducing the bleeding, or by
drawing blood from the  part which has  usually poured it out.   They
accordingly recommend the application of leeches to the labia pudendi,
to the anus, and to  the ala nasi, when the ophthalmia is supposed to
arise from the suppression of menstruation, haemorrhoidal discharge, or
epistaxis; and they  put them on the feet  in disorders of the head  and
upper parts of the body.   This course of proceeding may often be re-
sorted to with advantage, though it is not applicable in acute inflamma-
tions.  I have sometimes seen great benefit in affections of the eyes, head,
and chest, from putting three or four leeches on each instep, in cases
where larger quantities of blood taken in other ways near to the seat of
disease have failed to relieve.
   Scarification of the  conjunctiva  used to be very common, and it is
still employed more  frequently than it ought  to be.   Can we expect to
diminish inflammation  by making  a number of wounds in the inflamed
part?  Can we  doubt that  such a proceeding would  increase the mis-
chief?  It gives  considerable pain, and causes  but little  discharge of
blood.  In active inflammation, therefore, scarification of the conjunc-
tiva must be absolutely proscribed; there are, however, cases of chronic
ophthalmia in which it is beneficial.  Bleeding from the frontal vein, or
from  the facial  at the  inner corner of the eye, has deservedly passed
into disuse.   But little blood can be procured in  these situations; leech-
ing is therefore more efficacious.
  Local bleeding may  be resorted to with advantage, when the urgent
symptoms have  been subdued by general  depletion; or it may be  em-
ployed alone in cases of  a  less  serious description.   Cupping is a kind

  * [We have so frequently seen the application of leeches to the lids followed, not merely
by the "temporary inconvenience" noticed  by Mr. Lawrence, but by actual ill effects, as
great swelling and stiffness of the lids, productive of great discomfort to the patient; and
erysipelatous inflammation, sometimes involving the whole face—that we no longer direct
their application to those parts. The situations we prefer are, the spaces above the eye-
brows, the temples, and the mastoid processes. We believe that when there applied, leeches
are productive of all the good, without any of the ill effects which follow their application
to the lids.] 
196
OPHTHALMIC INFLAMMATION.
of intermediate measure, although the blood is taken from the capillaries.
An  expert cupper will draw twenty ounces from the back nearly as soon
as we can take it from the arm : we cannot therefore suppose that there
is any material difference in the effect upon  the  system in the two
cases.
  The foregoing observations are applicable to the treatment of inflam-
mation, especially in the eye,  when it is acute, so as to endanger the or-
gan, and when the patient  is  strong.  Of these two circumstances,
however, the condition of the organ is, in the case of the eye, the most
important.  I do not recommend that general bleeding should be adopted
in all inflammations.   In  some  cases  it  is  necessary to abstract blood
both generally and locally; in others, local  bleeding alone will be suffi-
cient; while in some it is not necessary to take blood at all. The state of
the part, more especially as regards the probability that the continuance
of inflammation may produce effects capable of impeding its functions,
that of the constitution and strength, and the age of the patient must be
considered.
  Purgatives  and diet.—It is not sufficient, in the treatment of inflam-
mation  to diminish the quantity of the  circulating fluids by the abstrac-
tion of blood; we must prevent the introduction of  further supplies into
the vascular system by the use of purgatives and the regulation of diet.
We employ purgatives in the first instance, to  clear out  the alimentary
canal, and this in general gives considerable relief.   For this purpose
we may administer a dose of calomel, alone, or  combined with  jalap,
rhubarb, or the compound extract of colocynth; and follow it in  a few
hours  by the  common aperient draught  of infusion of senna, with
Epsom  salt and manna, or a dose of castor oil.  We then give neutral
salts in  small  doses at regular intervals, so as  to keep up a regular
action of the  alimentary canal, or a more active  purge from time to
time.
  In  the worst cases of inflammation,  the diet  should consist chiefly of
fluids, those  of a  diluent, slightly  mucilaginous or  acidulated  kind.
Simple  water, toast-water, barley-water, apple-water,  lemonade, tea,
thin gruel; such is the bill of fare for a patient labouring under a se-
rious local inflammation,  with febrile disturbance of the system.   It is
seldom  necessary to restrict the patient to this kind of fever diet in cases
of  ophthalmic inflammation.   In less  important instances, with tea  or
gruel, a little toasted bread or biscuit may be allowed; also ripe  fruits
or roasted apples.   In  still milder cases,  fermented liquors or  solid ani-
mal food ought not to be allowed ; the use of these would be quite incon-
sistent with active antiphlogistic  treatment; we should  not go beyond
broths,  milk and farinaceous articles, vegetables, light puddings.
   Other internal  remedies.—Loss of blood, purging, and  abstinence,
are the three great means of reducing inflammation ; but there are other
auxiliary measures. Nitre, the liquor  ammonias acetatis, and the alka-
line salts neutralized by lemon juice or the  citric acid, are called refri-
gerants or cooling medicines.  If not very efficacious  they  are  agree-
able to the patient; and the latter are a pleasant  vehicle for aperient
salts, antimony, digitalis,  or colchicum.
   Antimony is one of the most powerful internal remedies of the antiphlo-
gistic kind; especially two of its preparations, the tartrite and James's 
TREATMENT.--INTERNAL REMEDIES.
197
powder.  According to the amount of its dose, emetic tartar excites per-
spiration, nausea, or vomiting.  For the first purpose it is given in a sa-
line draught in the dose of one eighth or a quarter of a grain; a quarter or
half a grain  repeated at short intervals,  will excite and  keep up nau-
sea.   In doses of a grain or grain and a half, it produces sickness.
When this is kept up by repeated doses of the medicine, the action of the
vascular system is speedily and rapidly reduced ; and, perhaps, we have
no other single medicine capable of acting more powerfully in this way.
The employment of the remedy, so  as to  keep  up full vomiting for some
hours, has  been recommended  with the view of cutting  short  acute
ophthalmia.  By diminishing the heart's action, by lessening the force
and frequency of  the  pulse, it will certainly reduce local inflammation.
But, severe as this treatment is,  it will not cut  short inflammation of the
eye.  Moreover, the congestion  in the head caused by the violent strain-
ing in vomiting, acts unfavourably on the inflamed organ.   When a
foul and loaded state  of the tongue, bad  taste in the mouth, and nausea
indicate a disordered  stomach, an ordinary emetic maybe used. If this
condition of the stomach with costiveness, should be the only obvious
cause of the inflammation, as it sometimes is  where the mucous mem-
brane is the seat of disorder, and  the disturbance should not be very
violent, the emetic followed by an active purgative, may be employed
without loss of blood.  Ipecacuanha and the  tartrite of  antimony may
be given in the usual  combination; or a  grain of the latter may be ad-
ministered in solution  every half hour, till the requisite effect is produced.
 The latter remedy generally purges as well as vomits.
   The Italian physicians class emetic tartar among the  most powerful
contra-stimulants, or  means of  combating inflammation; ascribing to it
in this respect an efficacy independent of its  action on the skin or ali-
mentary canal.  With this view they give it in large doses, sometimes
as  much as a dram  in twenty-four hours.  I have used  it frequently
with great benefit in doses of a grain  or a grain and a half every four
or six hours, and  sometimes oftener, in internal inflammations, particu-
larly of the chest; but I have not employed it in this way in ophthalmic
inflammations.
   Mercury is another antiphlogistic remedy of considerable power.  It
 has long been observed that  the free exhibition of calomel, after direct
 depletion, has  a very favourable  effect  in preventing the  changes of
 structure so frequently produced by  inflammation, and in expediting
 recovery.   After the abstraction  of blood, and the evacuation of the
 alimentary  canal, calomel may be given  in doses of  from two to five
 grains, alone, or combined with a small quantity of opium, and repeated
 every six or eight hours.  Affection of the mouth has rather accelerated
 than retarded recovery.   I shall consider at greater length the use and
 action of this remedy, when I come to the interna] inflammations of the
 eye.  Its employment may be begun as soon as the violence of the
 symptoms shall have  been lessened by the general antiphlogistic means.
   I have mentioned the use of colchicum in the subsequent parts of this
 work, which relate to rheumatic ophthalmia,  and rheumatic iritis.
    Counter-irritation.—When inflammation has been checked by the
 means already specified, counter-irritation by blisters  may hasten its
 removal, may prevent it from going into the chronic stage.  An active 
198
OPHTHALMIC INFLAMMATION.
 inflammation in its  full  development, with  all its  sympathetic conse-
 quences, cannot be stopped in this way.  Blistering under such circum-
 stances only adds to the existing irritation  and increases the patient's
 sufferings.  The blisters should be applied at the back of the neck, or
 behind the ears: in active  inflammation they should  never be placed
 nearer to the eye  than these situations.  When they are applied to the
 forehead, temple,  or side  of the cheek, the inflamed organ  may  be
 included within the sphere  of their irritation, with aggravation of the
 local symptoms:  in this way I  have often  seen them decidedly inju-
 rious.
   In treating diseases of the eye, we may avail ourselves of counter-
 irritation  in  other  shapes, such  as ammoniacal ointment or liniment,
 mustard poultice, tartar-emetic ointment, of which the  first two maybe
 applied either on the forehead, or the back of the neck, while the use of
 the third must be  confined  to the latter situation.  We  can vary the
 strength of the mustard poultice according to circumstances, making it
 with flour of mustard, either alone, or mixed with  a portion of linseed
 meal.
   In like manner the ammoniacal application may be made of various
 strengths.  The pommade ammoniacal  de Gondret, much used by the
 French, is made of  mutton suet and olive  oil, each, one part; liquor
 ammonia?, two parts.  This removes the cuticle very quickly.*   A lini-
 ment made with oil  and  lard, in which the liquor ammonise constitutes
 one-fourth of the composition, is strong  enough for ordinary purposes.
 A portion is  to be smeared on the part, and left there till a sufficient
 effect is produced, when  it must be wiped off.
   The emetic tartar ointment of the last  London  Pharmacopoeia  is
 made by mixing one part of the emetic tartar with four of lard.  This
 is a  proper strength for ordinary purposes.   It may be  employed in the
 way of friction, by rubbing a portion for a few minutes on the  back of
 the neck once or twice in twenty-four hours ; or by spreading it thickly
 on lint, and confining it on the part by adhesive plasters.
   The measures now detailed, which, taken  collectively, constitute the
 antiphlogistic plan  of treatment, are necessary when acute inflammation
 of the eye exists in conjunction with excitement of the vascular system, as
 marked by a full and strong, or at least a firm  pulse, or with an unim-
 paired  state of health and general  power.   But inflammation of the
 eye, more or less active,  may occur in weaker  constitutions, where the
 powers of the system are lowered in the way explained in the foregoing
 chapter.   This constitutional debility may have caused, remotely, the
 local inflammation, which is  more difficult of cure under such circum-
stances.  If we were to reduce the patient's  strength further, we should
increase instead of removing the local mischief.  Under such circum-
stances we must take a different, and in  some respects opposite course
 to that now described.  The digestive organs and the secretions must
 be brought into a healthy state; we must attend to  any part  or system
 of which the action  is disturbed  or deficient, as, for instance, the ute-
 rine system in the female. We must raise the general powers by nutri-

  * [Granville's  lotion which has had some celebrity lately as a counter-irritant, and which
 is a mere modification of the pommade of Gondret, answers equally well.] 
TREATMENT—LOCAL REMEDIES.
199
  tious  diet, with  or  without  fermented  liquors,  by strengthening  and
  restorative medicines,  such  as the vegetable tonics and bitters, the
  mineral acids, steel, sarsaparilla; by exercise, and  residence in pure
  air, change  of  air  and scene.  An improved state of constitutional
  power, brought  about by such means, often acts most beneficially on the
  local complaint.  The  progress of that must, however, be  controlled,
  if necessary, by local antiphlogistic means, the  use of which is not at
  all incompatible with the general treatment now recommended.
    Local applications.—The  measures which I have now pointed  out,
  namely, antiphlogistic treatment in most instances, and the somewhat
  opposite or restorative plan in other cases, with protection of the organ
  from  injurious  external influences, are those on which  we  confidently
  rely for subduing ophthalmic inflammation.  They must  be continued
  and repeated, according to the exigencies of the case, until the inflam-
  mation  is removed,  and the natural state of the part is restored.
    Although  it  may be stated  generally that local applications are of
  much less importance  than general means in the  treatment of inflam-
» mation, whether of  the eye or of other parts, they  are often useful  aux-
  iliaries.  At least, they relieve uneasiness, and patients have much  faith
  in them; they wish for something to be done  to the  part, and while
  they persuade themselves  that they derive benefit  from  washes, fomen-
  tations, &c, they induce medical men to place more confidence in them
  than they really deserve.
     The  local application of cold by means of evaporating lotions, has  a
  powerful influence  in reducing increased action.  For  this purpose we
  may use cold water, rose water, iced water, saturnine lotion; the latter
  or  rose water may  be  used with a little spirit to increase the evapora-
  tion ; for example, one ounce of proof spirit, with half an ounce of  vine-
  gar, in  eight ounces of rose water.  Cold applications diminish  the heat
  of  the part, and  lessen the burning sensation which is  felt under acute
  inflammation; but they often cause a chilled and aching feel, after they
  have been used for  some time, in which case the wash may be warmed
  before it is applied, or  it mayr be discontinued.
     In  many instances of ophthalmic inflammation patients find warm
  applications more agreeable than cold;  and we of course comply with
  their  feelings.   We may employ warm  water, the decoction of the
  poppy,  or of chamomile flowers, or the steam of hot water.
     We are hitherto  unable to lay down any precise  rule  to determine
  the choice between warm or cold applications in particular instances.
  The latter are best in diseases which are superficial and in the incipient
  stage: they may cause contraction of the vessels, and  thus restore the
  part to  its healthy state.  Warmth  is found more advantageous when
  the inflammation is  fully developed, or  when it is seated deeply.
     The  preference of cold or warm applications, and the discrimination
  of the cases, to which  they are respectively applicable, have long been
  debated points in therapeutics.  1 recollect when cold washes  were
   used  almost exclusively in inflammation; now, the warm are  more  in
  fashion.
     Some employ a  greater  variety of local applications than  I  have
   mentioned; thus emollient and narcotic fomentations have been recom-
  mended ; but I doubt whether these substances produce the effects which 
200
TREATMENT—LOCAL REMEDIES.
 their  names imply; whether, for instance,  the  skin can  be softened
 by a  decoction  of marshmallow, and whether opium  and  other ana-
 logous remedies, in the form of lotion, act through  the  entire cuticle.
 Opium will exert its particular influence when well rubbed  on the sur-
 face of the body, and it has a decided sedative effect when applied to
 an ulcer, in the  form either of ointment, powder, or lotion;  belladonna
 and hyoscyamus exert their singular property of dilating the pupil, when
 applied to the skin; but  I  have never seen any reason to  believe that
 the aqueous solution of opium, used  as a wash to  the eye, or the addi-
 tion of laudanum to  other washes, has  exerted any sedative influence
 on the part;* nor do I believe that poppy fomentation, or  the other her-
 baceous infusions which have been used in inflammations of the eye, have
 any effect beyond that of simple warm water.  As this want of faith has
 been pointedly rebuked by my friend Mr. James, in  the recent edition
 of his instructive work on inflammation, (p. 190)  I will only observe
 that the substances above alluded to are very different from  ammonia,
 tobacco, and lunar caustic, the local agency of which is too obvious to
 be doubted ; but  that the efficacy of vinegar, applied to the temples and  <
 pit of the stomach, in restoring a person from syncope, is not so unequi-
 vocal  as he seems to imagine.
   Other  local applications, although  recommended  from  sources  of
 high authority, hardly require notice.  The Germans use various  herbs
 and other vegetable substances in a dried form, enclosing them in muslin
 or linen bags, and placing them  over the  eye.f   They  change  these
 herbs  at different stages of the complaint, according to their supposed
 properties and the condition of the organ.   I am  at a loss to conceive
 how persons who know so much of this part of medicine, should per-
 sist in such ridiculous trifling.
   Scarpa  uses bags of mallows boiled in fresh milk, poultice of bread
 and milk with saffron, emollient and  anodyne vapours conveyed to the
 eye with a  funnel, and introduces white of egg and vegetable mucilage
 under  the eye-lids !  I cannot conceive any application more unsuited  to
 an inflamed eye  than  a poultice;  nor can  1 view the practice  above
 mentioned with  any greater respect than the vulgar one of plastering
 the inflamed eye with conserve of roses, which is quite as scientific and
judicious.   The  pulp of roasled apple, which is a popular application
for an inflamed  eye,  is the lightest substance in  a pulpy form; and
retains heat and  moisture  well.  A slice of bread, soaked in cold water,

  * In a valuable " Report of cases treated at the ophthalmic hospital, Chatham," contained
in the 68th number  of the Edinburgh Medical and Surgical Journal, the author, Dr.
Smith says, " In several cases in which the pain was very severe, and not alleviated either
by blood-letting, or the use of anodyne fomentations, considerable and lasting relief was
often procured by exposing the affected parts to the  steam arising from the following mix-
ture, brought to a boiling heat, for ten minutes two or three times a day.  $.  Mist. Camph.
f^ij ; Tinct. Opii. f^ss; Liquor  Amrnon Acetat. f^ij; Aqua Ros. f jiv."  M.
  t Benedict mentions among the ingredients with which these herb-bags are to be filled,
elder-flowers, and dried emollient ? herbs, mixed  with bran, flour! (particularly bean
flower,)  and chamomile powder.   When the state of the eye requires means of a more
exciting character, the bags are to be filled  with chamomile flowers, sage, rosemary,
thyme, and the resolvent species of the dispensatories ; to which, if the organ should be
still more torpid!! camphor is to be added.—Handbuch der prakt. Augenheilkunde, vol. i.
p. 40, 41. 
CHRONIC OPHTHALMIA.
201
is sometimes found an agreeable application ; and a thin soft bread poul-
tice gives ease in some ophthalmic  inflammations, more particularly
where the palpebrae are involved.
  If the antiphlogistic treatment, which I have  already pointed out, be
instituted early, and followed up properly, it will  cut  short ophthalmic
inflammation in forty-nine cases out  of fifty; and, if  it  does not  fully
accomplish this, it will so moderate the inflammatory excitement, as to
prevent any alteration of structure capable of injuring sight.   Long and
uniform experience has shown me the decided advantage of employing
the antiphlogistic  plan  under  the  restrictions and cautions previously
pointed out in  the treatment of ophthalmic inflammation.   Fear maybe
entertained that the loss of blood may debilitate  the patient; and it may
be supposed that these powerful measures are not necessary for inflam-
mations of the eye: but, when the case requires depletion, it is better,
not only on account of the local affection, but  even with reference to
the patient's general health, to cut short the disorder at once  by active
treatment, than to allow it to go lingering on for three  or four weeks,
by resorting to less vigorous means.  Active measures possess the addi-
tional advantage of quickly restoring the functions of  the eye.   The
great error has consisted in treating ophthalmic inflammation too much
as  a local affection, and  relying accordingly on inefficacious  local
means.   In a severe case, after taking blood from the  arm, if the dispo-
sition to  inflammatory congestion  in  the vessels of the  organ should
continue, venesection may be repeated, or we may find it advantageous
to  cup  on the temple, or to  apply a considerable number  of leeches
round the eye.  After bleeding the  patient freely, and evacuating the
bowels in the  morning, and applying leeches or cupping, if necessary,
in the evening, we shall generally find the patient greatly  relieved  on
the following day.  It will seldom be necessary to repeat the bleeding
from the arm, but this does occasionally happen, and  the repetition of
cupping or leeches is often required.  When the inflammation is sub-
dued, a milder course of proceeding may be pursued  until  the powers
of the organ are  completely restored.  For a few days it is necessary
to attend to the state of the bowels, and to regulate the diet.   Most per-
sons have a great delight in eating and drinking;  thus, when these en-
joyments  have been  abridged by illness, they  are anxious  to return
to their practice of stuffing.   We must check this inclination, the indul-
gence of which is the most frequent cause of relapse.
           SECTION II.--TREATMENT OF CHRONIC OPHTHALMIA.

  Inflammation of the eye is not always characterized by the same vio-
lent symptoms, nor does it always require the active treatment which I
have just described.  We often meet with cases in which there is pre-
ternatural redness of the globe and lids, without much pain as long  as
the eye is at rest.  Active exertion  of it, or exposure to strong light,
will  occasion painful sensations, and  produce lachrymal discharge.
Diminished transparency of  the cornea, and more or less  impaired
vision, are sometimes joined to these symptoms.   The organ may con-
      26 
202
TREATMENT OF CHRONIC OPHTHALMIA.
tinue long in this state, and when it has existed for some time, the affec-
tion has been distinguished by the name of chronic ophthalmia.
  If the acute stage of inflammation should  have been inertly treated;
if the patient should have conducted himself imprudently by continuing
to use the organ, or by not submitting to  the  necessary restrictions in
diet; or if, after the inflammation has been in a great measure subdued,
he should have begun to use the eye too soon, or have indulged in drink-
ing or  other imprudences, the chronic stage  of inflammation may be
prolonged indefinitely; the vessels  continue  preternaturally distended,
the  organ is in an irritable state, and easily excited into active and pain-
ful disease.
  In individuals of weak and unhealthy constitution, the acute stage of
inflammation is short, the violent symptoms soon disappear; the chronic
period  then comes on and lasts for a considerable time.  In old persons
of unsound  habit there is sometimes hardlv any well marked acute
stage, but the inflammation exhibits  a languid  chronic character from
the  beginning.
  Scarpa* represents the matter as if there were necessarily an acute
and a  chronic  stage in all  ophthalmias; he considers these as opposite
in their nature and causes, and he  prescribes opposite modes of treat-
ment;  namely the antiphlogistic plan for  the  acute,  and tonics, com-
bined with local astringents and stimulants, for the chronic.   With this
view he regards it as a matter of great importance to mark  the precise
period  at  which  the  acute  inflammation  ends, and the chronic com-
mences.   I consider this view of the subject altogether erroneous, both
in principle and practice.  The shorter the period of violent inflamma-
tory congestion in any part, the sooner will the vessels recover.  Hence
if you treat acute inflammation according to the principles I have laid
down,  the local disturbance is removed, and the part  never  passes into
the  condition of chronic  or protracted inflammation.  But if persons
through fear of debility are averse to  letting out a little blood, and thus
allow the disorder to take its course, the acute symptoms will very com-
monly  be succeeded by chronic inflammation.  If  from  this, or  any
other causes, chronic inflammation has supervened, the question arises,
how are  we to treat it 1  Are  we with Scarpa to adopt the  tonic plan,
accompanied with local applications of  an astringent or stimulating
kind ?  Certainly not.  We must look at the symptoms of the particular
case, and regulate our treatment by them, not  by the length  of time the
complaint may have continued.
  Treatment of chronic ophthalmia; general  means.—Since chronic
inflammation is the same as acute in its essential nature, the difference
being only in degree, it must be treated on the same principles.   The
local symptoms being less violent, and the sympathetic  disturbances
slight or altogether absent, it is not  so often necessary to take blood
generally as in acute inflammation; but the general abstraction of blood
is by no means inapplicable or unnecessary in all the  cases technically
called  chronic.   We  can  sometimes take  blood  from  the arm with
advantage after the lapse of many days, or even weeks, as  in a robust
Treatise, &c. chap. vii. 
TREATMENT OF CHRONIC OPHTHALMIA.
203
and plethoric person with a chronic inflammation affecting important
parts of the eye.   It is sometimes advantageous to take blood in mode-
rate quantity in those states of plethora which I have mentioned as con-
stituting the remote  or predisposing cause of so many local diseases,
and where no inflammation  may yet have been excited in any organ.
The local loss of blood by cupping  on the temple or back  of the neck,
or  by leeches, is  frequently  necessary, and that repeatedly in chronic
cases.  The antiphlogistic  treatment, in short, must  be continued, but
in a less active manner.
   The regulation of  the  digestive  organs is  a matter of  considerable
importance.  In the first  place, the alimentary canal should be cleared,
as in  a case of acute inflammation; then means should be adopted to
ensure the  regular action of the bowels without  purging.  The sub-
stances which stimulate  the large  intestines, such as aloes  and colo-
cynth, are the best  for  this purpose.  We may combine with them
mercurial medicines, when unnatural colour of the fecal evacuations in-
dicates an  unhealthy state of the secretions  into  the alimentary canal.
In this way blue  pill may be given  with aloes,  compound  extract of
colocynth,  or  extract  of rhubarb:  or calomel  may be  employed in
similar combinations.
   If  the tongue should be foul  and loaded, with  nausea, and  want of
appetite, the alvine discharges being at the same time unnatural, dark
and slimy,  it may be necessary to clear the  stomach  by an emetic, or
to administer calomel  with  James's powder and extract of colocynth,
following it after some hours with the ordinary purging  draught of in-
fusion of senna with  Epsom salt.  When the alimentary canal has been
cleared, mercury may be given in  the  alterative form, mild  aperients
being occasionally resorted to.   The compound decoction of aloes with
infusion of rhubarb, or with infusion or tincture  of senna, are suitable
forms.
  Careful attention to diet is still required, although the inflammation is
called chronic.   This  point  indeed is just as important  as the more
strictly professional treatment.   If we content ourselves with directing
the medical or surgical means, and  leave the patient to his own course
in diet, we shall do little  good.   Even in the milder forms  of inflamma-
tion, animal food should  be taken  only in moderate quantity, and  fer-
mented liquors  are, generally, inadmissible.    Tea, milk, gruel, broths,
bread, and  the various farinaceous  articles, vegetables,  and  fruits, will
supply sufficient gradations  between the scanty fare of fever, and the full
diet which  is taken in health.  When the local  excitement is completely
stopped, and the general  disturbance  has  ceased, when the tongue is
moist and  clean,  when, in short, the patient is well, he  may return to
common diet, but not before.
  Chronic inflammation occurs, still more frequently than acute, in con-
junction with debilitv, either existing from the beginning, as  in persons
of the strumous or otherwise delicate constitution, or induced or aggra-
vated by the means employed in combating the acute stage.   Perseve-
rance in antiphlogistic  treatment under a misapprehension  of the local
symptoms,  which are apparently those of increased action, and a mis-
taken view of the case generally, increases the mischief.  All our efforts
must  be directed here to  strengthen  the  constitution, by  nutritious diet 
204
TREATMENT OF CHRONIC OPHTHALMIA.
with fermented liquors according to the powers of the digestive organs,
by stimuli, cordials, and  tonics, combining and  varying these accord-
ing to the circumstances  of individual cases.  The stores of the materia
medica, however, are often  insufficient  when the nervous system has
been considerably weakened by sedentary habits, excessive mental ex-
ertion, care and distress, residence  in  bad air and  other  depressing
influences, and when the circulation and the  restorative  powers of the
system  have  been  consequently enfeebled.    Here  we  must restore
nervous energy, strengthen the system  by residence in pure air, espe-
cially at the sea-side, by exercise in the open  air, by  suspension  of
serious  avocations, and  the substitution of amusing occupations, by
change of scene and every thing that can promote tranquillity of mind.
   When acute ophthalmia has been arrested by active treatment, it may
be well to rest a little,  and not to proceed immediately to new measures
in order to guard against the imaginary evil of weakness.   Allow an
opportunity for the restorative powers of the part, and the constitution,
to exert themselves.   It is not necessary in medicine and surgery to be
always doing  something; to keep up an incessant fire of medicines and
local applications.   Nature will not stand still, even if the surgeon allows
himself a little leisure; she  proceeds, although the treatment be inter-
mitted, in restoring the part to its healthy state.
   If the powers of the system should be really reduced by the long con-
tinuance of disease, and the necessary treatment, it may be expedient
to adopt direct measures for invigorating the system.   Nutritious diet,
fermented liquors in moderate quantity, good air and exercise, are the
best restoratives: these should  be combined with  cautious use of the
organ, which  should  be  freely exposed to the air, and as much to the
light as its irritability will allow.   If the debility  should seem to re-
quire, and more particularly if the patient should think that it calls for,
the aid of the  materia  medica, we must  employ the vegetable tonics and
mineral acids.
   Local measures;  counter-irritation.—This is more applicable to chro-
nic than acutejnflammation;  and we select  in the former those means
which have a  more powerful and permanent action.  Blisters are some-
times used,  and afterwards  the savine ointment.   This produces great
local irritation, which sometimes acts  injuriously on the constitution.
It is even dangerous in children, where it has caused sloughing.  It  is
better  to repeat the  blister, than  to  keep up a'discharge by irritating
applications.  A fresh blister of moderate size, may be applied about once
a week, behind the ear, at the side or back of the neck, sometimes to the
temple or forehead.   The tartar emetic ointment may be used in either
of the  modes already described.   There is a third method in which it
may be employed conveniently.   A few grains of emetic tartar in pow-
der are sprinkled over the surface of a burgundy pitch plaster, which is
applied and left on the back of the neck.
   The permanent counter-irritation of seton or  issue is an efficacious
remedy in obstinate chronic ophthalmia.  No other plan will more de-
cidedly arrest chronic inflammation, and at the same time put a stop to
incipient changes of structure, than this artificial discharge in the neigh-
bourhood of the eye, combined with the general  treatment already de-
scribed. 
TREATMENT—STIMULI AND ASTRINGENTS.
205
  The integuments of the temple may be pinched up into a fold, so as
to allow an elastic gum seton-tape, or a piece of cotton wick, to be in-
troduced in the usual way.   Or an oblique incision may be made in the
fold of skin with  a  double-edged knife, so as to turn up a little flap,
under which two or three peas may be placed.  It  should be made  as
far back as may be  convenient, that the scar may be less conspicuous.
  There are, however, objections  to the  issue  and seton in this situa-
tion ;  first, as they involve the existence of a  discharging sore in a con-
spicuous part;  and  secondly, from the cicatrix which remains  after
they have healed.  We generally,  therefore, endeavour to accomplish
our object in other ways.  This objection does not apply to an issue in
the arm, which may be employed with great advantage in chronic oph-
thalmia, as well as with a view to prevention, where recurrence of dis-
ease might be anticipated.
  The most troublesome examples  of chronic ophthalmia are those in
which acute inflammation has  been totally  neglected, or  very ineffi-
ciently treated.   Among the poor  we see many such cases, in which
the vessels have become permanently enlarged, and changes of struc-
ture have occurred in the surface of the organ from  the long time which
has been suffered to elapse without resorting to effectual means.   This
chronic excitement, probably kept  up and aggravated by  the  patient
pursuing his ordinary  occupation and mode  of living, is  very difficult
to remove, either by local or general treatment.   Steady attention to
diet, the regular use of aperients, repeated applications of leeches, com-
bined with counter-irritation, are the most essential points of treatment.
To  these may be added the local application  of stimuli and astringents
in the manner which I shall proceed to describe.
  Use of stimuli and astringents.—The points which remain to be con-
sidered in the treatment of chronic ophthalmia are, the question as to
the use of local stimulants and astringents: the time and circumstances
under which, if useful, they are to be employed; and the  particular
remedies of  this kind which are preferable.  When the eye is preter-
naturally red, when it is weak and irritable, when exertion of it or ex-
posure to light causes watering and pain, though it  may be easy while
at rest, stimulants and  astringents are resorted to with  the view of
causing the distended vessels to contract, and thus  removing what re-
mains of inflammatory excitement.
  Of stimulants, the vinum opii, or vinous tincture of opium, has  been
much employed, both in this country and on the  continent, in conse-
quence of the recommendation  of it by the late Mr. Ware;* I do not
know whether it was  first introduced into practice by himself or his
partner, Mr. Wathen-I   The mode of employing it is to introduce half
a drop, a drop, or two drops, between  the palpebral, so as  to bring it
into contact with the  surface  of the conjunctiva.  The  fluid may be
taken up with a quill or a director, and, while the patient rests his head
back, it may be dropped into the internal angle of the eye, so that when
the lids are separated it may be diffused over  the globe.  The first effect
is a sharp, smarting sensation, accompanied  with a discharge of tears;
but when this has gone off the patient generally  feels relieved.  The

     * Remarks on Ophthahny, &c.; 1780.          t Ibid.  Preface, and p. 53. 
200
TREATMENT of chronic ophthalmia.
stimulus applied.to the distended vessels is  supposed to promote  their
contraction, and thus facilitate the recovery of their natural dimensions.
It is employed once or twice  a day.  The vinum opii is the tinctura
thebaica of  the old London  pharmacopoeia, often  called  by the conti-
nental  authors, liquid  laudanum of Svndenham;  in which, however,
half an ounce of saffron is added to the ingredients employed in making
a pint.  The ingredients were, an ounce of opium, half  a drachm of
cinnamon and of  cloves, and half a pint of sherry wine.  The opium
and aromatics were macerated for eight days in the wine, and the  tinc-
ture was then strained.  In the modern pharmacopoeias the tinctura
thebaica was omitted, and a spirituous tincture, the present tinctura opii,
substituted for it.   Mr. Ware ascribed a peculiar virtue  to the  combi-
nation of ingredients in the old preparation;  he thought the spirituous
tincture had not the same effect, and he found that opium alone, or wine
alone, would not accomplish the purpose.  I  believe it was in  conse-
quence of Mr. Ware's recommendation, and the general use  of the
remedy in ophthalmia, that the College of Physicians again introduced
vinum opii into their pharmacopoeia: but it is singular  that, as the effi-
cacy of the remedy was so pointedly ascribed to the precise combina-
tion of ingredients in the  old formula, it should have seemed fit to  that
learned body to diminish the quantity of opium one-half.  Mr. Ware in-
forms us in a subsequent edition of his treatise, that this new form is just
as efficacious as the old, in which opinion I quite agree with him.  Ac-
cording to Mr. Ware's  representations, it is a  remedy of sovereign
virtue.  He seems to have  used it indiscriminately in all  cases of  oph-
thalmia, both acute and chronic; in acute, combined with leeches, blis-
tering, purging,  and  the  treatment  ordinarily  called antiphlogistic.
Without  specifying cases, he directs  that the  vinum opii should be
dropped into the eye two or three times a-day; and he employs other
treatment at the same  time.  I should  never think of using it in acute
ophthalmia;  it would  rather  increase  the inflammatory disturbance,
though I must observe, at the same time, that it  is not  a very active
remedy, and that  it cannot do  much mischief.  Its employment  should
be restricted to cases of chronic inflammation, in which patients often
express  that  they derive much  advantage from  its employment.  I
hardly remember, however, any case of a serious or obstinate kind, in
which it  has been  decidedly effectual in arresting the disorder when
employed alone.
  Weak brandy and water is a popular remedy for bad  eyes, and is
used without any discrimination of the nature  or  period of the affection.
However, being applied externally, it is only to be considered as  a cool-
ing wash.
  Various astringent salts are employed in chronic ophthalmia, in the
form of solution.   Alum, in the proportion of two to ten grains to an
ounce of distilled water; sulphate of zinc or copper, from one to six or
eight grains ; nitrate of silver, one to six grains; bichloride of mercury,
from one-eighth of a grain to one or two grains in the ounce of water.
These solutions must be introduced between the palpebrae  so as to come
in  contact with the  diseased  surface.   Their efficacy in common in-
flammation seems to be about equal  to that of the vinum opii.  In cases
of purulent ophthalmia they have a more decided effect, as I shall have 
TREATMENT--STIMULI AND ASTRINGENTS.
207
occasion to mention hereafter.  The liquor plumbi diacetatis, undiluted,
is used as an  astringent.  It might seem at first  that it could not be
safely applied to the eye in this state; but it is by no means an irritating
application, though powerfully astringent.
  A French  oculist, M. St. Ives, proposed a remedy, which has been
much employed on the continent under the name of lapis divinus.   It
consists of a singular mixture: an ounce of alum, nitre, and sulphate of
copper, respectively, are fused together in a crucible : half a drachm of
camphor is added towards the end  of the process.  A solution is made
containing ten grains of the mixture in six ounces of water, the strength
of which is to be increased according to circumstances.   Such a mix-
ture cannot have any effect differing from that of simple solutions of the
salts.
  A German writer, Conradi, has recommended a  collyrium, which is
often mentioned in the writings of his countrymen;  it is composed of
one  grain of oxymuriate of mercury, six  ounces of rose-water, one
dram of mucilage of quince seeds, and half a dram or a dram of  the
liquid laudanum of Sydenham.
  It may be observed generally, with respect to all these proposed  re-
medies, that if active treatment be resorted to in the first instance, and
followed up  steadily, they are  not wanted; and  if insufficient means
have been employed, so that a state of chronic inflammation is pro-
duced, this is a complaint which it  is extremely  difficult to  remove, and
which is  not likely to  yield to the vinum opii, or any  remedies of
that class.
  The use of strong astringents, more particularly the nitrate of silver,
which has been found advantageous in inflammations of the conjunctiva,
has been extended by Mr. Guthrie to other forms of ophthalmic inflam-
mation, both acute and chronic.  He proceeds on the principle " of ex-
citing an action greater, and of a different nature, to that already exist-
ing in the part."   He prefers the form of ointment to that of solution, on
account of its more permanent action:  and he has recommended  the
two following formulae : viz.
  1. R.  Argenti  nitratis gr. ij. ad x;  liq. plumbi  diacet. gtt. xv; ung.
cetacei  3j.
  2. R.  Hydrarg. bichlorid. gr. iij. ad iv; liq.  plumbi diacet. gtt. xv;
ung. cetacei 3j.
  The saline substances must be reduced to an impalpable powder, then
mixed with the ointment on a slab, and the liquor plumbi added.  It may
be done in a glass mortar. These ointments are most stimulating when
first made; they gradually become  less so; but weeks elapse before they
are inert.
  " The manner  of using either ointment is  by introducing between  the
lids a portion, larger or smaller as the case may seem to require it, from
the size of a  large pin's head  to that of  a garden  pea.  The eye-lids
being closed,  are  to be  rubbed  gently with the finger, so  as to diffuse
the dissolving ointment over the whole  surface of the conjunctiva : a
part of it usually,  however,  works out  by  the  motion  of the  lids,
and should be wiped off  (if  the nitrate of silver) to prevent its stain-
ing the  skin.   Both ointments cause pain :  in some persons it is consi-
derable, in others less so, lasting from half an  hour to an hour  and a
half; and, when the ointment is newly made, sometimes for four hours, 
20N
TREATMENT OF CHRONIC OPHTHALMIA.
and even until the next day.  On the subsidence of the pain caused by
the ointment, that which previously existed is  found to be  relieved, if
not entirely removed ;  and on the subsequent day, the patient  usually
acknowledges the benefit he has received with regard to all the symptoms.
When the  application has been severe, and the patient very irritable, a
state resembling white chemosis occasionally takes place, and appears
formidable to a  person  unacquainted with the effect of the remedy: it
soon, however, subsides.  The eye should be  fomented  with warm ano-
dyne fomentations.   I rarely repeat the application until the third day;
but the feelings of the patient are the best guide, the return of some of
the old sensations indicating the necessity for its use, which should be, if
possible, anticipated. In some cases of acute inflammation, two or three
applications will arrest the progress of a serious inflammation, and effect
a cure.  In chronic cases the ointment must be continued for a consi-
derable time, and occasionally alternated with  other remedies.  Where
it creates a state of regularly increased irritation, as it  sometimes will
do, cupping, purgatives, &c. are of service ; when  the remedies may be
again  resorted to."  Mr. Guthrie has generally used purgatives, but
has sometimes found the ointments successful in  serious complaints with-
out any internal  medicine.  Sometimes they have disagreed altogether.
In the London  Medical and Physical  Journal, New  Series, No. 27,
from which the preceding account is derived, as well as in the 31st No.
of the  same work, numerous cases are recited in illustration of the treat-
ment.  They are chiefly instances  of  chronic  inflammation, purulent,
common, and  strumous, with thickening of  the conjunctiva, opacity,
vascularity, and ulcers  of  the cornea.  At  present,  Mr. Guthrie
seems  to employ almost exclusively the ten  grain nitrate  of silver
ointment.*
  Experience  must decide on the merits of the  local treatment just de-
scribed, and determine whether  agents so  powerful can be safely and
advantageously applied to the organ in the  various stages  and forms of
ophthalmic inflammation, for  which they  have been advised.  The ne-
cessity of proceeding cautiously with these strong applications to a part
so highly organized and easily irritated,  if not  obvious of itself, would
appear from what has been stated by Mr. Guthrie ; viz.  that they are
sometimes hurtful, and occasionally cause so much inflammation as to
render the loss of blood by cupping and leeches, and other antiphlogistic
treatment necessary.
  When  the nitrate of silver  is to be employed, the form of  solution is
preferable in my opinion, to that of ointment: since the latter, in which
the caustic is applied in substance, necessarily involves the risk of ex-
cessive partial action.  This is one reason why  I have never used these
ointments ; another is, that I have  seen  many  persons, in whom, from
their employment, inflammation  had become aggravated and rendered
so obstinate as to be removed with great difficulty.  The  value of any
practical proceeding, in cases of common occurrence, is soon deter-
mined  by general experience; and this I believe is to be decidedly unfa-
vourable  to the plan of treatment now under consideration.
  Astringent and stimulating  remedies, such as  the nitrate of silver and

             * hondon Medical and Surgical Journal, vol. i. p. L'ba. 
DIVISIONS OF OPHTHALMIC INFLAMMATION.
209
the oxymuriate of mercury, when employed of proper strength and in
suitable form, are most serviceable in conjunctival inflammation; they
are not only less adapted to inflammations of the external proper tunic's,
but often very injurious in such cases.
   General summary of treatment in ophthalmic inflammation.—If I
were to sum up generally the directions for treating ophthalmic inflam-
mation, I should say, that in  the  young and  strong, in  persons of full
habit, and in those individuals whose circumstances give them a com-
mand,  not only of  the necessaries, but of the comforts and luxuries of
life, we should arrest inflammation  by active antiphlogistic treatment;
and then there will be no chronic stage, but the healthy structure and
functions will be restored by the natural powers of the system.
  In older and feebler subjects, especially in  females, in those whose
constitution is debilitated by excessive labour, by scanty, unwholesome
nutriment, exposure to cold, and  deficiency of clothing—by a want, in
short, of the domestic comforts of life—we should be careful not to de-
press the general  powers of the  system.   In addition to a milder and
particularly  local  antiphlogistic  treatment, we should  invigorate the
system by a better diet,  by the moderate  use  of fermented liquors, by
change of air, if it can be accomplished : to these  means may be added
the use of tonic medicines, and of local astringents in a suitable period
of the complaint.   We must bear  in mind, however, that active local
inflammation may take place in wTeak states of constitution; we may
meet, in old and feeble persons, with  such a degree of ophthalmic inflam-
mation, as will require considerable depletion.  On  the  other hand, lo-
cal disturbance is sometimes rendered more obstinate by depression of
general power;  here depletion aggravates the mischief, and recovery
of the part is promoted by general measures of strengthening and resto-
rative  character.
CHAPTER  VI.
DIVISIONS AND CLASSIFICATION OF OPHTHALMIC INFLAMMATION.  SIMPLE AND
            CATARRHAL INFLAMMATION OF THE CONJUNCTIVA.

  Divisions and classification of ophthalmic inflammation.—Until a re-
cent period inflammation of the eye has been treated of in too general
a point of view, especially by the writers  of  France and England:  it
has been spoken of as  a single affection  under the term ophthalmia.
The subject is  thus considered in the Treatise on the Opihalmy  of the
late Mr. Ware, in  the work of Scarpa, and by his  French  translators,
although it had been much  better  understood long before by the Ger-
mans, as will be clearly seen in the  excellent essay on Iritis of J. A.
Schmidt, and in  the Ophthalmologische Bibliotheh,  which he edited in
      27 
210
DIVISIONS OF OPHTHALMIC INFLAMMATION.
the very beginning of the present century in conjunction with Prefossor
Himly.
  The term ophthalmia, according to its etymological  import, would
embrace all inflammations of the eye.  It is, however, evidently lnvpos-
sible to comprehend in one description the various inflammations affect-
ing the very dissimilar structures, which enter into the composition of this
complicated organ.  Between many of these, the points of resemblance
are few.  What common characters could we expect to find in inflam-
mations of the conjunctiva, sclerotica, cornea,  iris, retina?  Inflamma-
tory affections of the external and internal tunics  differ widely in  their
symptoms.  Hence the attempt to embrace all these affections under one
description must lead to obscurity and confusion.  It produces  an inco-
herent jumble of symptoms belonging to affections  essentially distinct,
where the general description is  overpowered  by the numerous limita-
tions and exceptions, so that no part of the subject is clearly seen.  The
general descriptions of ophthalmia are usually  applicable to external in-
flammation of  the eye only, more particularly that of the conjunctiva,
while the other forms of the affection are in great measure neglected.
The important internal inflammations were entirely overlooked by Eng-
lish writers until within a few years : the subject is not mentioned by
Mr. Ware.
   Another  reason why the inflammations affecting the several compo-
nent parts of the eye-ball should  be described separately, is, that there
are essential differences in their treatment.  To a certain extent general
therapeutic principles are applicable to all inflammations; but the gene-
ral means must be employed in particular inflammations under various
modifications; and there are important differences in the local measures;
so that those which are advantageous in inflammatory affections of the
conjunctiva would be inappropriate or hurtful where  the sclerotica or
the internal structures are the seat of disorder.
   The whole globe may be inflamed at once, but this is a rare occur-
rence.   In  general,  inflammation   affects only  the external or the
internal tunics; and  most frequently it attacks only one  structure at a
time.
   We  might class ophthalmic  inflammations according either to the
structure in which they are seated, or to the nature of the inflammation
itself.  In the latter case it is  divided into idiopathic or common  and
sympathetic or specif c:  syphilitic gonorrbosal, gouty, rheumatic,  scro-
fulous ophthalmia, with some others would come under the last division.
The  arrangement according to the seat  of  disturbance is preferable, as
being the most natural and simple, and certainly the least liable to mis-
take or controversy. Indeed, the true nature of disease is not sufficiently
understood  in  this or in  other organs, to allow of our constructing
a  nosological  arrangement on that basis:  at  least the  opinions of
pathologists  and  practitioners  are not  sufficiently settled  on  this
point.
   Inflammation of the eye is usually limited in its origin, and  becomes
more general in its progress.  Commencing in one structure, it  is at
first confined to that, and does  not extend beyond  its original seat, if
judiciously treated.  But, if suitable  means are not adopted to check its 
CATARRHAL OPHTHALMIA.
211
progress at an early period, it readily extends to the neighbouring and
connected parts, and  perhaps ultimately embraces the whole  organ.
Mr. Wardrop in his Essays on the morbid anatomy of the Eye, takes up
each of the component structures, and gives an account of the changes
which may be observed in it.   This course is necessary in a work illus-
trating the morbid anatomy of the organ ; and I have adopted it as the
best suited to  the present occasion, though it cannot  be  followed up
strictly, since we find it necessary, for practical purposes, instead of in-
sulating the affections  and changes occurring in each  tissue, to  attend
to those aggregates  of phenomena, which most  commonly appear in
practice.
  I now proceed to describe the diseases incidental to each of the parts,
which enter into the composition of the eye-ball, taking them in their
natural order from without  inwards ; and considering in each texture,
the inflammations the  changes produced by the inflammatory process,
and other alterations  or peculiarities  that may  require  professional
notice.
              SIMPLE INFLAMMATION OF THE CONJUNCTIVA.

  The conjunctiva may be the seat of common inflammation, which is
mentioned under the various names of ophthalmia, simple or  common
ophthalmia,  conjunctivitis simplex.  It is produced by common causes;
being directly excited by various  external irritations, such as  injuries,
extraneous substances,  inverted eye-lashes, tumours or other  changes
in the palpebrae; or arising  indirectly from  unhealthy states  of con-
stitution or derangement of particular systems or organs.   It comes on
also in consequence of inflammatory affections in other parts of the eye-
ball.  The phenomena, progress, and effects do not differ, in any essen-
tial circumstances, from those of catarrhal ophthalmia, so that  it is un-
necessary to describe them separately.   The treatment too, whether in
the acute or chronic form, is nearly the  same, and falls under the  gen-
eral rules applicable to the  management of acute  and chronic  oph-
thalmia.
                      CATARRHAL OPHTHALMIA.

  Synonymes. Conjunctivitiscatarrhalis.  Conjunctivitispuromucosaca-
tarrhalis; ophthalmia purulenta mitior—Mackenzie.  The distinct nature
of this affection, and its origin from atmospheric causes or peculiarities,
are denoted in the terms cold or blight, under which it is often popularly
mentioned; while the expression ophthalmia mucosa designates the in-
creased mucous discharge, which is one of its most striking characters.
It is inflammation of  the conjunctiva, either of the globe, or of  the lids,
or of both caused  by  cold ; and it corresponds to catarrhal affections of
other mucous membranes, as those of the nose and its sinuses, of the
fauces, trachea,  and  lungs.  Catarrhal inflammation frequently  goes
through all these parts, and commonly so in influenzas. 
212
CATARRHAL OPHTHALMIA (CAUSES.)
  This kind of ophthalmic  disease has sometimes attacked numerous
individuals, so as to have assumed a somewhat epidemic form.
  Causes.—I do not use the term cold in the sense of diminished tempe-
rature, but to denote what is commonly called catching, or taking cold, i.e.
an injurious influence of cold or moisture applied to the surface, exciting
disease either in the system generally, in the part chilled or wetted, or
in some distant part of the body.  What is the nature of this influence;
and how are the effects produced?   Every body knows the effect, be-
cause every body has experienced it; but the cause, or rather the chain
of causes, connecting  the external agency of  cold or wet  on the skin,
with the production of morbid phenomena in a distant part, seems equally
unknown to  the ignorant and the learned. Why should mucous mem-
branes so frequently suffer from this particular influence?  Some of them
are constantly and freely exposed to the atmosphere, and therefore di-
rectly influenced by its changes and peculiarities: such as the Schnei-
derian membrane, that of  the  fauces, mouth, trachea,  and  lungs; and
these are accordingly most susceptible of such influences.  The mucous
membrane of the eye is open externally, yet the whole  surface is not so
completely and constantly exposed to  atmospherical contact as that of
the membranes just enumerated.   Catarrhal inflammation of the eye,
therefore, is second in  point of frequency.   All mucous membranes are
continuous, directly or indirectly with the skin; and, like the latter, se-
crete freely from their surface; these circumstances probably explain
why they suffer so frequently from causes acting merely on the integu-
ments.  The conjunctiva is a part of the external superficies of our frame,
and its connexion with the common integuments is  more extensive in
proportion to  its entire expanse, than  in the case of any other mucous
membrane.
   Direct exposure of the part to cold  and wet is the most frequent and
powerful cause of catarrhal  inflammation;  exposure  to  cold winds,
especially if combined with fog, rain, snow, or  sleet.  Particular winds
are more capable  than others of producing this effect,  independently of
the actual degree  of cold ; such is the case with east and north winds in
this  country.   In  individuals predisposed  to the affection, being out in
an east wind for a quarter of an hour, or half  an hour, will sometimes
infallibly bring on an attack.  Length of  exposure without exercise fa-
vours the action of the cause; hence  soldiers and sailors on watch, or
in camp, very often suffer.   Great changes in the atmosphere from heat
to cold, within a short period, bring on catarrhal affections.  These vi-
cissitudes are most common in hot climates, where the burning heat of
day is succeeded by a chilly night air, often combined with heavy dews,
to which persons  frequently expose themselves by sleeping  in the open
air.   Officers, being less exposed  than soldiers/suffer less under such
circumstances.  Change of clothing and consequent chill of the surface,
especially  in  variable  climates; partial  exposure to  cold air, or, in
common language,  to drafts  of air; and the  application of  mois-
ture  in  partial or general  wetting, which  most effectually chills the
body, are other  modes of the same unwholesome  influence.   The
application of these causes to the head, or in the immediate neighbour-
hood of the  eye,  will  most probably  bring on  catarrhal  ophthalmia,
when aided by original constitutional peculiarity, or  by the general re- 
CATARRHAL OPHTHALMIA (SYMPTOMS.)
213
mote causes of disease.  Atmospherical influences, of which the nature
is  entirely unknown,  will operate powerfully on the mucous  mem-
branes,  producing epidemic influenzas; but in these the conjunctiva
merely suffers with the other mucous membranes : we have no epidemic
ophthalmias extending over  large  districts, kingdoms,  and even  conti-
nents.
  Catarrhal ophthalmia  is  seated in the  conjunctiva, seldom  going
deeper, and therefore  not dangerous; it maybe  confined  to the lids,
or may  affect the globe also.  The continental writers call the former
blepharoconjunctivitis catarrhalis, and the  latter, ophthalmo-conjuncti-
vitis catarrhalis.
  Symptoms of catarrhal ophthalmia.—Stiffness and  smarting, some un-
easiness on  exposure  to light, watering, and external  redness usher in
the attack.  When fully developed, it is characterized by redness, and
increased mucous not  lachrymal discharge: the pain is inconsiderable,
and there is little or no intolerance of light.
  The redness in catarrhal inflammation is superficial  and of bright
scarlet colour, forming a striking contrast to the rose or pink tint, which
belongs   to  inflammation seated   in  the proper  external  coat  of  the
eye.  The distended vessels are quite superficial, and of scarlet colour;
they may be readily pushed aside by moving the lids.   The trunks  are
seen at the circumference of the globe; they run forwards in a tortuous
course,  sub-dividing  and inosculating as they approach the  cornea.
The redness is generally irregular, in patches, some  fasciculi of vessels
being more filled  than others; hence the membrane has a mottled  ap-
pearance: however in the fullest development of this affection, the whole
surface becomes of a bright red.   The redness begins at  the circumfe-
rence of the globe, and gradually  advances towards the cornea; but in
the commencement it is confined to the palpebral conjunctiva, or to the
angle of reflexion.  Sometimes, besides the redness resulting from vas-
cular  congestion, especially if  the inflammation be severe, we see  red
patches in the conjunctiva; these are spots of ecchymosis, small quanti-
ties of extravasated blood, and  such appearances denote activity of  the
inflammation.   Sometimes there are  little  vesicles, called pustules, on
the conjunctiva, slight elevations of the membrane, containing a serous
fluid, and usually appearing about the margin of  the cornea.
  Unless the affection be severe, with general redness and some  thick-
ening, the sclerotica  may be seen through the inflamed  conjunctiva,
especially round the cornea, of its natural white colour.
  Catarrhal inflammation seldom produces much  swelling of the con-
junctiva, nothing like the  state of chemosis incidental to the more acute
inflammations  of the  membrane.   The  only approach to such an  ap-
pearance is a slight serous effusion, raising the mucous membrane from
the sclerotica into a loose elevation.
  The pain in the commencement  of the affection is not considerable,
except in severe cases, the patient complaining rather of  stiffness, dry-
ness, or sensation  as if sand or gravel had got into the eye.   The in-
tolerance of light  is slight  at first, and after a time the patient  hardly
complains of uneasiness, and opens the eye freely to the light even when
there  is considerable redness.  The feeling as if a foreign body were in
the eye, which is  commonly experienced in conjunctival inflammation, 
214
CATARRHAL OPHTHALMIA (DIAGNOSIS.)
appears to be produced  by the  partial vascular distention, and conse-
quent inequality of surface  and mechanical  irritation on motion.  If
the fulness of the  vessels is lessened by bleeding,  the sensation sub-
sides.
   When the lachrymal discharge observed in  the commencement stops,
its place is supplied by increased secretion of mucus from the inflamed
membrane itself;  this is at first  thin, and  as the inflammation goes
through certain changes, it becomes thicker, assuming a whitish or yel-
lowish appearance, and sometimes putting on a character approximating
to that of pus.   This increased mucous discharge distinguishes the ca-
tarrhal form of inflammation.   Its quantity will depend on the degree
and extent of inflammation.  It may be just sufficient to collect in small
quantity at the corners of the eye; a  whitish streak may be seen on the
inside of the lower lid at the angle of reflection; there may be enough
to form more or less copious incrustations about the cilia, and to agglu-
tinate the edges of the lids at night, or it may constitute a copious muco-
purulent discharge, hardly distinguishable from that of mild purulent
ophthalmia.  The eye-lids participate, more or  less, whenever there is
active catarrhal inflammation of the  eye.
   Other mucous membranes suffer when there is a severe attack of this
inflammation ; hence pain and sense  of weight about the frontal sinuses
and antrum. Under such circumstances there is more or less of  catar-
rhal fever, chills, heat, headach, disordered stomach, and foul tongue,
with impaired appetite or sickness. Such a state of stomach may cause
inflammation of the conjunctiva, bearing all the  marks of catarrhal cha-
racter, without any atmospherical influence.
   The symptoms of catarrhal  ophthalmia both local and genera], remit
by day, and undergo exacerbation at night.   During day the redness is
less, there is no pain, nor intolerance  of light;  the eyes become sore and
uneasy in the evening, smarting and burning, with increased redness
and mucous secretion.
   Termination and prognosis.—The affection is seated in and originally
confined to  the mucous membrane; it passes  through a certain course,
and then subsides; it yields readily to treatment,  and therefore, generally
speaking, is free  from  danger.  If the inflammation be violent, and
either totally neglected or improperly treated, it may extend to the scle-
rotica and cornea, causing ulceration and opacity of the latter, and thus
seriously injuring the organ.  The affection is still manageable, if no mis-
chief has actually occurred to  the cornea.
   Diagnosis.—Its catarrhal origin, the diurnal remission and nocturnal
exacerbation of the symptoms, the absence of pain  and intolerance of
light, even when there is great general redness, the bright red tint of the
membrane and of the distended vessels, and  the superficial position of
the latter, the natural state of the sclerotica and its vessels, and the mu-
cous discharge, distinguish the  catarrhal  from common inflammation
of the external tunics.  It must, however, be remembered, that from the
same exposure to cold, which causes inflammation  of the conjunctiva,
the sclerotica also may  suffer ;  that the affection, which is then called
calarrhal-rheumatic ophthalmia by some writers, is more dangerous un-
der such circumstances;  and  that the symptoms  differ in important
points, being those described in  the account of  inflammation affecting the 
CATARRHAL OPHTHALMIA (TREATMENT.)
215
sclerotica.  From purulent ophthalmia it is distinguished by its much
milder character, as will be understood better when that affection is de-
scribed.   Yet the characters of the two affections approximate, parti-
cularly when we compare the severest catarrhal with the mildest puru-
lent inflammation.  On the  whole, the  difference is rather in degree
than in kind; unless  it should be established, which it is not at  pre-
sent, that the latter always  is, and the  former always is not conta-
gious.
   Treatment.—Catarrhal inflammation of the eye requires antiphlogistic
treatment; but as the affection is not  a  serious  one, and does not pro-
duce injurious consequences to the organ, mild measures will be found
sufficient.  Venesection is not in  general  necessary; but in  a young
subject of full habit, with catarrhal inflammation in both eyes, and  that
severe, a  full blood-letting would  be proper; in ordinary cases, cupping
or leeching will  suffice; and sometimes abstraction of  blood is not ne-
cessary, the general treatment being sufficient.   The bowels should be
freely evacuated by an active  aperient, or if the tongue be foul, an
emetic may advantageously  follow the loss of blood.  Saline sudorific
medicines may then be given, such as the  liquor ammonias acetatis, with
nitre, or tartrite  of antimony, and occasional purgatives.  The patient
should be kept warm, taking plentifully of warm diluent drinks, and no
animal food,  nor fermented liquor.  If blood should have been taken by
venesection or cupping in the morning, and the alimentary canal should
have been subsequently cleared by an emetic and purgative, the warm
bath, or warm  pediluvium  may be used at night, and a full dose of
Dover's powder, (from  ten to twenty grains) given at  bed-time.   The
patient will be nearly recovered the next day, or it may be necessary
to repeat cupping or leeches, to persevere in low diet, diaphoretics, and
purgatives for a few days, and perhaps to  apply a blister to the nape.
In  cases  where  the  inflammatory affection is  not  considerable,  and
seems  entirely  referable  to a disordered sta^  of  the alimentary
canal,  it may not  be necessary to  take blood  from the  part.  An
emetic, and an active aperient containing calomel, or the latter alone,
may be administered, and followed by mild purgatives, the diet being
light.
  The  best local application in these cases is warm water, or poppy
fomentation;  these are better than cold'lotions in catarrhal  inflamma-
tion.  The Germans are anxious to  prevent the application of cold and
moisture  to the eye, when labouring under catarrhal inflammation; they
think that cold, which has originally caused, must aggravate the disor-
der, and hence they are very particular in their directions to use every
thing warm, and  to dry the  surface carefully afterwards.  However,
patients often find cold washes comfortable, and  they are certainly not
injurious.  The sticking of the lids  together during  the night, may be
prevented  by  inserting a little mild ointment between  the tarsal edges in
the evening;  a little fresh butter, a bit of lard, or the spermaceti oint-
ment, will answer the purpose.  After employing these  means until the
inflammation  has somewhat given way, we may resort  to  counter-irri-
tation by blisters ; but the other treatment which  1 have recommended,
will in most cases put a stop to the inflammation. 
216
CATAR.RHAL OPHTHALMIA (TREATMENT.)
   I subjoin the following case to  exemplify the  characters  and  treat-
ment of a case,  simply catarrhal,  but rather severe.
  J. C, fifty-six years of age, of full habit, was seen on the 4th of July, 1826, with
inflammation of the right eye, which had commenced the day before.  The symptoms
were, general bright scarlet redness of the eye-ball, deep  red colour of the palpebral
conjunctiva, with some  thickening of the  ciliary margins and  mucous  secretion on
them, a little mucus lying in the fold between the lower eye-lid ajid the globe, pain in
the eye and head, but no intolerance of light.  The case of a boy, who was seen at the
same time with inflammation of the sclerotica consequent  on  injury of the cornea,
presented a striking contrast to the preceding description.   In the latter, the redness
was pink, with  a violet or dilute claret tint; in  the former, bright scarlet: the sclero-
tica was the seat of redness in one, the  conjunctiva in the other.  The vessels were
large, superficial, and tortuous in the former; small, straight, and covered by the con-
junctiva, in the latter: the redness  covered the whole globe in one; it was confined
to the neighbourhood of the cornea  in the other.  There was no uneasiness on expo-
sure to light where the whole eye-ball was of  a bright scarlet; great sensibility to
light, with copious lachrymation, in the other case where the redness was compara-
tively trifling.  The treatment consisted of venesection to  sixteen  ounces, purging,
abstinence from meat and fermented liquor, and saturine lotion.   On  the 8th the
patient was nearly  well.  He came again  on the 13th with a  relapse.   There was
acute catarrhal  inflammation of both eyes, with  foul tongue.  (Venesection to sixteen
ounces, to be followed by an emetic of ipecacuanha and tartrite of antimony, and  an
aperient the next morning.) Saturnine lotion.  15th, Pain gone; considerable redness
and mucous secretion.   (A blister to  the  nape; one dram of magnes. sulph. in the
infus. ros.  every six hours.  Saturnine  lotion.  Cerat. cetacei to the eye-lids.)  18th.
The patient is free  from complaint, but the redness is not quite gone.  22nd. No trace
of disorder is left.
   Catarrhal ophthalmia,  especially when the inflammation does not ex-
tend beyond the mucous membrane, is  one  of the cases to  which the
use of astringents is more  particularly applicable.   In the  opinion  of
those who have  tried it extensively, this  local treatment may advantage-
ously supersede the general means, particularly loss of blood.  Mr.MELiN
proposed the  employment of a strong astringent in  the very commence-
ment of the affection, as a means of cutting it short, and preventing the
development  of the inflammation.   He adopted this proceeding in ordi-
nary conjunctival inflammation, having considered that acute ophthal-
mia was  in general  treated too actively, and  that a mere  local disorder
could not require such  extensive depletion as was usually practised and
recommended.   He was  further induced to try the  practice, from
having witnessed the good  effects of a solution of lunar caustic, in some
cases of gonorrhoea, both in allaying the pain  and suppressing the dis-
charge.   The strength of the solution employed was four grains to the
ounce of distilled water, which was dropped into the eyes twice a-day; it
excited pain and  a sensation of roughness, with an  increased flow  of tears
for about twenty minutes, after which the eyes felt much relieved, and
in a few days the  cure was effected.    " Since that  period," says Mr.
Melin, " I have  treated nearly three hundred cases  of acute ophthalmia,
some of them of a  severe  nature, in  a  similar manner, without either
local or general  bleeding, and I have had ample opportunities of proving
its efficacy."*   Mr. Bacot informs us that this plan of treating ophthal-
mia originated with Dr. Pudgway, who  uses a  solution of lunar  caustic,
in the proportion of ten  grains to the  ounce, and  has employed it in
gonorrhceal as well as in  common conjunctival inflammation."f
  *  Report of Ocular Diseases at,  the General Hospital, Fort  Pitt; hondon  Medical and
Physical Journal, vol. liii. p. 184.
  |  Treatise on Syphilis, [>. 13(i—140. 
CATARRHAL  OPHTHALMIA.
217
   Mr. Mackenzie trusts to simple treatment, chiefly by local stimuli,
 which he saw employed with great advantage by Beer  in  1817.   He
 uses a solution of nitrate of silver, containing from two to four grains in
 the ounce, and applies to the eye a large drop once a-day.  He foments
 the eye thrice daily with a collyrium of one grain  of corrosive  subli-
 mate in eight ounces of water, lukewarm.   And he applies to the edges
 of the lids at night a small portion of ointment containing one grain and
 a half of red precipitate to  the dram.*  " I have  treated,"  says  Mr.
 Mackenzie, " many hundred cases  of  catarrhal ophthalmia according
 to the plan  above detailed, and with uniform success.   In almost no
 case, (indeed I may say in no case  in which struma did not modify the
 symptoms,) in which  the above simple remedies were had recourse to
 previously  to ulcer  or opacity of the  cornea, did any ulcer or opacity
 ever occur; nor did the symptoms ever fail  speedily to subside."
   Mr. Guthrie uses his ten grain nitrate of silver ointment, see p. 201.
   The utility of astringents, in the treatment of catarrhal ophthalmia is
 now established  by general experience.  When employed at an early
 period, they often cut short  the complaint;  and they abridge its dura-
 tion, at whatever  time  they may be used.  I employ the solution  of
 nitrate of silver,  in the proportion of two to four grains in the ounce of
 water: a drop should be introduced between  the lids once, twice, or
 oftener in the twenty-four hours.   Previously to the use of this remedy,
 or in conjunction with it, I employ such other means as are required to
 fulfil the indications already pointed out, namely abstraction of blood, or at
 all events the means necessary for acting on the  alimentary canal and
 the secretions.
   It is not necessary to cover or shade the eye, unless as a protection
 from strong light, if it should  be offensive; when  the common paste-
 board, covered with green  silk, may be used.  We generally find that
 cool air is pleasant to the feelings  of the patient; that  it will remove
 the sensation of  sand  in  the eye.   It is not necessary to  confine  the
 patient to the house unless the weather be cold, windy, or rainy.  Free
 exposure to a mild atmosphere is advantageous.
   When catarrhal  ophthalmia  has been violent  and long  continued,
 more especially when there have been repeated attacks, the palpebral
 conjunctiva undergoes change of  structure, becoming  thickened, and
exhibiting on its surface the elevations called granulations.   For a more
particular account of this  change, and its  treatment, I  must refer to
chapter vni. on purulent  ophthalmia.  Eble| has observed, that the
lower eye-lid suffers most in catarrhal ophthalmia, and that the granu-
lations take place rather in the conjunctival folds between the lid and  the
globe, than on the lid itself.
   When the eye remains weak after inflammation of the conjunctiva,
whether of the common or catarrhal kind, the vinum opii is often em-
ployed with advantage.
   If the complaint should continue in the  chronic form, and be  found
obstinate, in conjunction with  general debility, the constitution  being
naturally weak, or lowered  by the continuance of disease and the treat-


  * Practical Treatise, p. 334, 335.
  t Ueber den Ban und die Krankhciten der Bindehaut, § 75, 7(>. pi. 3, I'ig. 13.
       28 
218
PURULENT OPHTHALMIA.
ment, or impaired by the various circumstances, which are calculated
to depress nervous energy, strengthening and restorative  measures will
be necessary, such as good diet  with stimuli, tonic medicines, residence
in pure air, change  of  air, and sometimes  even of climate.   In some
cases the changes of  air and scene in travelling,  and the agreeable
occupation of the mind with the various objects of interest  met with on
such occasions, have a beneficial influence  on health not attainable  in
any other way.   If local treatment were necessary under such circum-
stances, it would  consist in mild stimuli and astringents, and mild coun-
ter-irritation.
  Catarrhal inflammation of the eye-lids has been already considered in
CHAPTER II. SECTION II.
CHAPTER VII.
 PURULENT OPHTHALMIA — PURULENT OPHTHALMIA OF  NEWLY-BORN INFANTS.

   Catarrhal ophthalmia forms a connecting link between common or
 simple, and purulent inflammation of the eye, in which the character of
 the  conjunctiva  as a  mucous membrane is  most  strongly marked.
 Purulent ophthalmia is inflammation  of the most acute kind, attended
 with an increased secretion, which in  all its  sensible properties, espe-
 cially colour and consistence, so strongly resembles pus, that the name
 of the affection has been hence derived.   This name is the best, being
 founded on the most obvious and striking  character of the complaint;
 the term blennorrhasa. derived  from the Greek, and generally employed
 by the continental writers,  is equivalent.   Ophthalmia mucosa is a name
 already occasionally given  to the catarrhal inflammation of the eye. Sup-
 purative ophthalmia is an objectionable expression, because the discharge,
 although resembling pus in colour, is not the product of suppuration.
   The affection begins in  the linings of the lids, extends to the mucous
 surface of the globe; when violent and not checked, it soon attacks the
 cornea, which it either entirely disorganizes, or so  considerably changes
 in structure, as frequently  either to destroy, or seriously  injure, sight.
 The whole texture of the  membrane swells, and  becomes thicker;  its
 vascular tissue is developed, the  blood-vessels being distended to  the
 highest degree, and the surface  acquiring  an  intense bright red.  The
 membrane is rendered villous, pulpy, granular; in  short, like that which
 lines some parts of the  alimentary canal;  and  from  the secreting sur-
 face, thus developed, flows the  puriform discharge: but this is a secre-
 tion, or rather an exhalation, and hence the epithet suppurative is inap-
 propriate.  Indeed  this form  of disease does not, like some  others,
 produce suppuration of the  eye.   The changes in the cornea are slough-
 ing,  suppuration, ulceration, interstitial deposition, causing opacity and
enlargement  of vessels or vascularity.   The  sloughing ulceration, 
PURULENT OPHTHALMIA OF INFANTS.
219
and suppuration, often expose the anterior chamber, causing prolapsus
of the iris, and may, by giving rise  to escape of the humours and col-
lapse of the tunics, not only destroy the function, but also the very form
of the eye.
   Purulent ophthalmia is originally seated in and confined to the mucous
membrane, and often goes through its course without extending further:
if it goes  deeper, it is by the  propagation of inflammation through  the
medium of continuous textures, and especially by the  progress of ulce-
ration.
   It attacks at all ages, and under all circumstances, and seems to be
always essentially the same:  yet there  are  modifications.   I  shall  de-
scribe three forms of it, viz.
   1. Purulent ophthalmia of newly-born infants.
   2. Purulent ophthalmia, after infancy.
   3. Acute gonorrheal ophthalmia.
   The first two are unquestionably the same  affection, distinguished
only by circumstances arising out of the age of the patient.   There are
some peculiarities in the latter, referable probably to the specific nature
of the cause.
                  PURULENT OPHTHALMIA OF INFANTS.

  This is the purulent ophthalmia of newly-born infants; ophthalmia
neonatorum; the " purulent eye" of children of Mr. Ware.  I do not know
that any other person has used  the latter term, and I see no good reason
why it should be adopted, as the proper tunics of the eye are not neces-
sarily involved in the affection.*  Beer uses the name  blephar-ophthal-
mitis glandulosa as if the disease had its origin or seat in  the Meibo-
mian glands.  I  am quite at a loss to account  for such an  opinion;
though I do not doubt that the glands may be  involved.
  Symptoms and progress.—This disease is one of considerable  conse-
quence, and the more so from its commencing in  a way not calculated
to excite the attention, or alarm the fears,  of the mother or nurse.  The
child cannot express its  sensations, and the concomitant  swelling  con-
ceals the progress of disease so that serious mischief is often done be-
fore we see the patient.   In the  first  place the inflammation is not im-
mediately  noticed,  and  in  the second, the  measures employed  are
frequently insufficient to check its progress: hence it  causes more blind-
ness than any other inflammatory disorder that happens to the eye; and
the  number of children is very considerable, whose sight is partially or
completely  destroyed by it.  They are frequently brought to us  with
staphyloma, opacities of the cornea, and prolapsus of the iris; or  with
the  tunics  collapsed, and the  very form  of the  eye destroyed.  Mr.
Ryall, of Dublin, mentions that a woman brought  to him in a wine-
glass both  the lenses of her infant's  eyes, with  part  of the  vitreous
humour, which had  escaped before  application was made for  relief.f


  *  hehre, vol. i. § 304 and 323.
  T  Transactions of the Association of Fellows, Sfc. of the College of Physicians  in Ireland;
vol.  iv. p. 343. 
220               PURULENT OPHTHALMIA OF INFANTS.

The parents and attendants are apt to suppose, when this inflammation
first appears, that  it is merely a cold in the eye, which will go off; and
the consequences just mentioned take place, in many cases, before they
are aware of the danger, and before they resort to surgical assistance.
   The inflammation commonly comes on about three days after birth,
but it may take place at a later period.   In the first stage, it is confined
to the mucous lining of the palpebrae.  It is observed that the lids stick
together a little when the child wakes from sleep; their edges are redder
than natural;* and especially at the corners;  the child experiences pain
from the access of light, and  therefore  keeps the eye closed.   If the
lids  are inverted, their linings  are found red  and villous, and  a little
white mucus is  seen  on  the inside of the lower.  The globe is in a
natural state.   This first  stage of the complaint is  the blepharo-blennor-
rhasa of the nosologists ;  that is, purulent inflammation of the palpebral
conjunctiva.
   In the second stage, all the  symptoms are increased ; the inflamma-
tion extends from  the conjunctiva of the lids to that covering the globe;
the  vascular congestion  and  redness are much  augmented; the lids
swell and become red even  externally;  there is a copious secretion of
purulent fluid  from  the  inflamed membrane, which agglutinates the
edges of the palpebrae, and then accumulates between the lids, or pours
over the face, staining the cap and linen.  Exposure  to light becomes
very painful, and the child turns away its head and  contracts its brow,
keeping the eye constantly shut, even if  the  swelling of the lids should
not  close them.  The case now becomes ophthalmo-blennorrhcea.
   The inflammation, the redness, and the tumefaction of the conjunc-
tiva are carried to the highest pitch  in the second stage of  the com-
plaint;  the whole of the  conjunctiva,  both  palpebral  and ocular, is
swollen, and of a uniform bright scarlet colour.   The surface at the
same time assumes a villous character, resembling in the latter respect,
and in  its colour, the appearance of the internal surface of the fetal
Stomach, after a successful injection with size and  vermillion.
   The close adhesion of  the membrane to the tarsi  prevents the palpe-
bral conjunctiva from swelling much; but the loose folds between the
lid and the globe  become greatly enlarged, forming red  tumid rolls,
finely granulated.   These folds, pressed on by  the orbicularis, evert the
tarsi, causing ectropium  of either  or both lids.   This  eversion takes
place when we  attempt to examine the eye by separating the lids, or it
will  be produced even by crying.   It  is generally temporary, subsiding
when the cause ceases to act;  but it  may be more permanent.   If the
case be neglected, no attention being paid to replacement of the everted
lid, the protruded  conjunctiva  swells still more, and  experiences  pres-
sure from the ciliary margin of the tarsus, which causes a kind of stran-
gulation, and  increases  the difficulty of restoring the  parts to  their
natural position.
  There is general, and often very considerable tumefaction of the lids

  * Mons. Billabd, in a note to his translation of my lectures, says, » External redneasof
the eye-lids olten occurs at the outset of the inflammation.  I have seen in infants a trans-
verse red line on the eye-lid before the puriform secretion began.  From this redness Mons.
Baron; has often prognosl.cated  at the Foundling Hospital, the approaching attack of oph-
thalmia."—Traitt Pratique, p. 160, note.                         * 
PURULENT OPHTHALMIA OF INFANTS.
221
from serous effusion into their cellular texture; they become red exter-
nally, and in cases of the severest inflammation, the upper lid presents
a smooth convexity of bright red colour.  When thus swollen, the upper
lid hangs over the  lower.  The redness and swelling are increased  by
crying, when the whole globe is pushed forwards.
  A profuse discharge takes place from the eye, and pours over the face
of the child in crying, or when the lids  are  opened.   The latter  are
agglutinated by the  drying of the discharge, and  then becomes  dis-
tended with the puriform secretion, which issues in a stream on open-
ing the eye.  During the night the eye-lids become so firmly stuck
together, that they must be carefully moistened  and  soaked with warm
water, or  milk and water, to  open  them.   When they  are separated,
the eye is concealed  by the discharge; we wipe it away  with a  soft
rag, and there is still enough to cover the globe  and  hide the cornea,
and ultimately we  find the latter frequently covered by a kind of coagu-
lated layer which must be removed  by syringing. The  discharge may
be whitish, like the pus secreted by  a healthy ulcer, and  it then is gene-
rally small in quantity.  More commonly  it is yellow in various tints,
and more copious; it is straw or lemon-coloured, or it stains linen  yel-
low,  like  the  yellowest  gonorrhoeal  discharge.  This yellow tint is
very deep in unhealthy jaundiced children, sometimes being of a  yel-
lowish  green.  It  may be thinner  and of a reddish  colour;  that is,
ichorous or sanious.   Sometimes there is an admixture of actual blood.
   Effects.—In this second stage, the inflammation has passed from  the
palpebral  lining to the surface of the globe; the conjunctiva scleroticae
is found red, and  it may be elevated by serous effusion.  If the inflam-
mation should  continue, and not  be checked by suitable treatment, it
extends to the  cornea, and thus may reach the interior of the globe.
Some one or more of the following  changes are now produced.
   1.  Sloughing of the cornea, general or partial.   When  this  change
is about to take  place, the cornea is  at  first whitish  and  dusky, then
loses its polish  and firmness of texture, being  converted into  a dirtv
greyish or brownish slough, in which  the loss of vitality is immediately
obvious; a line of separation takes  place at the margin, and the dead
part is soon cast off.  The entire cornea may thus perish and separate,
when  the iris  protrudes through the aperture, presenting an irregular
dirty brownish prominence.  Under such circumstances, the iris may
either be  nakedly exposed, and  the humours  escape, or it  may be
covered by  a thin  pellicle, by what  is  called the membrane  of the aque-
ous humour.  This, however, generally gives way, so as to lead  ulti-
mately to collapse of the globe.   The separation of a partial slough
leaves a whitish flocculent and ragged ulcer, which, unless its charac-
ter be soon changed, speedily makes its way into the anterior chamber,
and causes prolapsus  iridis.
   2.  Ulceration may  take place in  the cornea, more or less considera-
ble in extent or depth; it may affect nearly the whole surface, or it may
penetrate  the cornea,  and lead to prolapsus iridis.  The latter part may
adhere to the ulcerated  aperture, and the ulcerative process stop, or it
may go on, and extend to the interior of the globe.
   3.  Opacity  of the cornea  from interstitial  deposition, either  into
the texture  of the corneal conjunctiva, causing a thin external bluish 
222
PURULENT OPHTHALMIA OF INFANTS.
gray film, or into the corneal substance, producing dense total opacity.
These changes may be confined  to  a small portion, or may affect the
entire cornea.                                    t ,          e   u
  4. Adhesion of the iris to the  inflamed or ulcerated cornea,  bucn
are the principal, more or less serious, visible alterations in the cornea,
anterior chamber, and iris, which take place when severe purulent oph-
thalmia extends from  the mucous membrane, in which it commences,
to the globe; the last of  these, however, although it occurs at this pe-
riod is not discoverable till afterwards,  being concealed  by the almost
invariably concomitant  opaque  state of the cornea.   These several
diseased "processes occur very quickly, and go on rapidly, as we might
expect, a  priori, from the great  activity of the capillary circulation in
infants, and the acute character of the inflammation.
   Examination of the eye is difficult from the swollen state of the lids,
and the smallness of the palpebral aperture ; but it is important, particu-
larly in the first  instance, that we  should  ascertain the  exact state of
the organ, the seat and extent of  the mischief, and thus be enabled to
form our  prognosis.   The painful impression of light  causes the infant
to  resist any attempt at  exposing the cornea, and the ectropium imme-
diately produced by the forcible action of the orbicularis  completely
obstructs  our view.   The best and easiest mode of examining the eye of
an infant  is to open the lids  while  it is asleep;  if the  attempt be made
lio-htly and gently, we generally succeed in  obtaining a clear view of
the cornea without awakening the  patient.  If it be awake, we should
take the opportunity  when it  is  quiet, and separate the lids quickly be-
fore the muscles can resist.   If the child be crying  when the attempt is
made, it is scarcely possible to obtain a view of the cornea, on account
of the violent contraction of the orbicularis; and the force uselessly em-
ployed in attempting to do so cannot but be injurious. In opening the lids,
if the upper be raised by the skin merely, the action of the orbicularis
will produce an eversion of the tarsus, and  hinder us from seeing the
cornea;  but if the tarsus itself be pushed upwards  and backwards, the
accident  will be prevented.   If the lid should be everted, it may be
easily restored by drawing  the tarsus gently downwards.   If we meet
with much difficulty, it  will be  best to discontinue our attempts, and
renew them at a more favourable opportunity.   Forcible and long-con-
tinued efforts will aggravate the inflammation ; and incautious proceed-
ings of this kind, when the cornea is seriously involved,  might cause it
to give way, and even lead to escape of the humours.
   In the  third stage of the complaint, there is a gradual  abatement and
 cessation of all  the symptoms; the redness, swelling,  and discharge are
 diminished; the child bears  the light better, and,  when the  increased
 discharge is removed, it opens  the eyes spontaneously in  the evening,
 or in a dull light.  No ectropium  takes place on  crying, or when the
 eye is examined. We now see clearly the changes that have occurred
 under the active inflammation, and we  have the opportunity of tracing
 the progress of these towards recovery.
    When the entire cornea  has  sloughed, and  the  humours have been
 evacuated, the tunics collapse, and the  globe shrinks to one-third of its
 original size, appearing  as an opaque, somewhat flattened  tubercle.   If 
PURULENT OPHTHALMIA OF INFANTS.
223
the humours have  not  escaped, the projecting  iris  recedes again, and
becomes covered by an opaque pellicle, the front of the eye being  flat-
tened.
  In the case  of large sloughing, or extensive ulceration, the iris  falls
against the cornea, becomes adherent to  it, and partial or general sta-
phyloma ultimately ensues.  If prolapsus  iridis has taken place through
the opening caused  by partial sloughing or ulceration, the  brownish
tumour gradually subsides, and at last disappears; we then see a small
dark point in the  cornea, surrounded with  a white  circle, which  is
the cicatrix of the corneal ulceration.  The iris adheres firmly to the in-
ternal surface  of the cornea at this part, and there is usually change  of
figure,  with more or less  contraction of  the  pupil.   According to the
situation and extent of these changes, vision may be either impaired or
lost.
  The ulcers of the cornea, while spreading,  are of a dusky white, yel-
lowish, or light reddish  colour,  irregular  in their  surface, and often
with a ragged edge; they are surrounded  by a dusky white halo. When
they begin to  heal, they  have  a greyish or  bluish  aspect, become
smoother, have a soft gelatinous appearance from deposition of the  sub-
stance  which is to  repair the breach, and  red  vessels pass to them from
the conjunctiva, through  the  intervening  transparent portion of the
cornea.  They  heal, leaving  a  permanent opaque  cicatrix; and this
opacity will be of  more  or less  importance as it is situated in front  of
the pupil, or at a distance from it.  The red vessels, having fulfilled their
office of depositing the materials necessary to repair the breach, shrink
and disappear.
   Interstitial  deposition into the texture of the cornea leaves permanent
opacity of various extent and density.   When  it  is dense  (leucoma,
albugo,) and when consequently  the cornea has been inflamed through-
out, the inflammation will  readily pass to the iris; that  two inflamed
parts brought  into  contact should adhere  might be expected.   This pre-
ternatural connexion is technically called synechia  anterior.
   No doubt in these cases the surfaces containing the aqueous humour
are generally  inflamed, and it is not uncommon to find a central opaque
spot on the capsule of  the lens, with the leucoma  and synechia ante-
rior: such an opacity may, however, be produced without the  two other
changes.
   Superficial  opacity  caused  by effusion into the corneal conjunctiva,
and the slighter degrees  of impaired transparency from interstitial de-
position into the corneal  laminas, will disappear  spontaneously, sooner
or later.
   In milder cases  none of these consequences are produced; the tume-
faction of the conjunctiva gradually subsides; the discharge is lessened,
but in a whitish form  it  continues for some time, and the conjunctiva
slowly returns to its healthy state.
   When the  complaint is severe, infants suffer constitutionally;  they
become restless and debilitated; the tongue  is white,  and the bowels
are irregular.   They become  pale and  feeble when sloughing has oc-
curred.
   Both eyes are usually affected, but the  complaint does not commence 
224
TURULENT OPHTHALMIA OF INFANTS.
 in  both  at  the  same  time:  there is  generally  an interval  of a few
 days.
   Causes.—In a great proportion of cases  there is  vaginal  discharge
 from the mother, leucorrhoea,  and sometimes gonorrhoea.   The eyes of
 the infant are exposed to the contact of these morbid secretions in pas-
 sing through the vagina ;  hence  has arisen  the natural inference that
 they are affected from the actual contact of this matter, and the tolera-
 bly regular appearance of the  disease on the third day corroborates this
 notion of contagious origin  from direct application of the morbid mat-
 ter.*   I  was acquainted with  a  case, in which  a married gentleman
 contracted gonorrhoea, and  communicated the  disease to his wife then
 pregnant.  The infant which I did not see till four months after  birth,
 had been effected with purulent  ophthalmia; one of its eyes was sta-
 phylomatous, and the cornea of the  other was inconsiderably nebulous.
 The affection had been totally neglected, even the attendant accoucheur
 having stated that it was merely  a cold in the eye, which would do well
 of  itself.  I have seen some cases of rapidly destructive purulent oph-
 thalmia  in infants, when  the mother  has had  gonorrhoea at the time
 of  parturition.   Sloughing  of the  cornea, with extensive ulceration
 spreading to the interior,  and consequent evacuation of the globe, had
 occurred in these instances  before I   have seen them.  An example of
 purulent ophthalmia in an infant, where the communication of gonor-
 rhoea to  the mother, and the infection of the child's eyes by the vaginal
 discharge were unequivocal, is related towards the end of this chapter.
 Although the inflammation was  severe, it did  not produce the serious
 effects just alluded to.
  If the  purulent ophthalmia of  infants arises, as I believe that it does,
 from the direct  contact of infectious matter, we should expect  that the
 discharge from  the eye would  again communicate  the disease.  This
 has occurred in some  instances from the discharge spirting out of the
 eye under syringing;  and  Mr. Mackenzie saw an instance, in which  a
 grandfather was inoculated  from an  infant.   " Both were so severely
 affected,  that the  infant  had  one eye  left  in a  state  of total,  and
 the other of partial staphyloma; while  in  each eye of the  old  man,
 the greater part of  the cornea remained opaque, and  adhered to the
 iris."f
  Again, purulent ophthalmia is  often seen in the children of  healthy
 mothers,  at  least, of such  as   appear  perfectly healthy, and deny,
 when questioned, the   existence  of  vaginal  discharge in any shape.
 As  we  cannot carry the  investigation further,  the  source  of the
 complaint must  remain  at least doubtful  in  such cases,  and con-
 sequently the  contagious  origin of  the  disorder is  still  open  to  dis-
 pute.


  *  « I will not maintain," says Schmidt,  « that blepharo-blennorrhcea of those  new born
 infants, whose mothers have leucorrhoea, is produced by direct contagion like jronorrhcBa;
 but I have ascertained clearly that  in many such cases, discharge from the vagina exists in the
 mother.  And I have further discovered,  not  unfrequently, in the case of female infants,
that the mucous membrane of the female organs was affected as if thev had a clap"—
Ophthalmelogische Bibliothek, v. ii. st. 2, p.  125.
  t  Practical Treatise, 3rd edition, p. 402. 
PURULENT OPHTHALMIA OF INFANTS.
225
  However we may settle the question of contagion considered as the
direct or exciting  cause of purulent ophthalmia in  infants, numerous
facts show that certain circumstances have a great influence in favour-
ing its  occurrence; so that, if the application of matter secreted in the
vagina  immediately excite the disorder in some, there are  others in
whom we can only trace the influence of ordinary causes, and we are
thus led to conclude that the same kind of agencies, which produce
other inflammations, may also excite this particular  form.   All the in-
fluences which depress the system, are favourable to  the appearance of
purulent ophthalmia. It is most frequent and destructive in weakly chil-
dren, in those who  are most exposed to the  various debilitating causes
of bad air, cold, insufficient clothing, and deficient nutriment.  Purulent
ophthalmia is more frequent in premature infants, than in those born at
full time; in  twins than in single children.  It is much more common
among newly-born infants than in children; in children than in adults:
it thus appears that as the powers of the system  become more fully de-
veloped, the susceptibility to this complaint is lessened.  It is  more fre-
quent in damp and cold, than in dry and warm weather, and among the
children of the poor and necessitous, than in those of the higher classes.
It is particularly prevalent, unmanageable, and destructive or injurious
to  the organ,  in foundling hospitals, where infants are collected in great
numbers, and deprived of what  seems  essential to their existence, the
incessant care and watchfulness of the mother.   I do not speak of such
institutions  as the foundling hospital of London, which does not receive
infants; but of the foundling hospitals of Paris, Petersburgh, Moscow,
and Vienna, which receive all the infants that are presented.  The mor-
tality in these establishments is enormous; the infants suffer from various
diseases, and  among them from purulent ophthalmia.   It is of essential
consequence to  the well-being of the child  at  this tender age, that  it
should receive that constant attention  and  affectionate care, which  a
mother only can supply; although the institutions in question  are admi-
rably conducted, they can never make up for this deficiency.  Langen-
beck observes that in the lying-in hospital of Vienna,  where the women
admitted are  of  the lowest class, and  almost universally labouring un-
der gonorrhoea or other vaginal discharge, but where  the infants remain
with their  mothers, purulent ophthalmia is  not  common; while in the
foundling  hospital, where  the  children  have  not   the advantage of
maternal care,  and  where they  are  generally half dead from star-
vation  and cold before  they are received, the affection  is  very fre-
quent.*
  Prognosis.—There is a singular contrast between the violence of this
disorder in newly-born children, and the serious consequences to which
the inflammation so rapidly leads, and the readiness with which it yields
to suitable treatment.   Hence, if  we see a case of purulent ophthalmia
before any injury is done to the cornea, we may assure the parents, and
it gives us great pleasure to be able to  do so, that sight will not suffer.
If the inflammation be confined  to the  palpebra, or even if it has ex-
tended to the  globe, provided the cornea remains clear, it cannot be con-
sidered as attended with risk;  for by the adoption of proper  means, all

                   ' Neue Chir. Bibliothek, vol. iii. p. 208.
       29 
22G
rURULENT OPHTHALMIA OF INFANTS
injurious consequences to the organ will be averted ; even the most vio-
lent form is easily manageable, and will do well  when properly treated.
But if the disease has advanced so far, that the cornea has sloughed, or
extensivelv ulcerated, loss of sight is unavoidable.  Even if the cornea
be of  a dull white, or  has  begun to loose its transparency, injury
or loss of  vision is probable;  it is  most likely that ulceration, pro-
lapsus  of the iris,  or permanent opacity  will follow.   General super-
ficial opacity from thickening of the  corneal  conjunctiva, and even
a general whiteness so dense as  to conceal the iris  and pupil, will
disappear.
  The  appearance  of the discharge  affords some  information;  the
whiter and the smaller in  quantity, the lower is the  degree of inflam-
mation.  The yellower and more copious the discharge, the more ac-
tive is  the disorder.   If it should be thin, ichorous, or sanious,  we con-
clude that sloughing has occurred, and that  spreading  and destructive
ulceration is going on.  The  admixture of blood shows a violent  de-
gree of action in the part, but it is not in itself  dangerous,  although it
alarms the female  attendants.  It often  relieves the overloaded ves-
sels of the conjunctiva, and is thus attended with benefit to the organ.
   Treatment—In  the most acute form of the disease,  when  the con-
junctiva oculi is bright red, and swollen, more especially when the cor-
nea has begun to look hazy; or if the palpebra are much swollen and
bright  red, though  we may* not be able to see the eye  itself, it will  be
necessary to  take  blood from the part by  leeches.  The superior palpe-
bra is  the best situation for the application; and a single leech may be
placed in the middle  of  the red swelling which it forms.  From  the
vascularity of the skin, leech-bites bleed very freely in these young sub-
jects ;  one leech thus applied will almost invariably remove  the redness
and swelling of the lid, and this favourable external change is attended
with corrosponding diminution of the conjunctival inflammation. I have
seldom seen  it necessary to use more than one  leech, and even this
sometimes renders the infant  quite pale;  in  the most robust children I
should not advise more than two, one to  each lid, or one  to the upper
lid of  each eye.
   If the state of the cornea should be doubtful, with congestion still ac-
tive in the conjunctiva, although the palpebrae should not be much swol-
len, it  is better to apply the leech.  On the occasions I have described
saturine lotion made with rose-water may be used. The bowels should
be opened, and kept open by castor oil or magnesia ;  when the inflam-
mation is active, with a white  state  of the  tongue, a grain or two of
calomel may be given previous  to the administration  of the purgative.
The use of blisters has been recommended ;  but I am unwilling to em-
ploy them in infants and  children ; unless,  therefore, such counter-irrita-
tion is absolutely necessary, I consider it better  to be  avoided.   A phy-
sician  of the lying-in hospital of Vienna  recommends the constant ap-
plication of cloths dipped in cold water, and uses no other means, ex-
ternal  or internal.  Knowing the violent nature of the inflammation, and
the serious injury it is capable of producing,  I should  not feel contented
to rely upon  such a plan.
   We must prevent the agglutination of the  lids, and favour the ready
escape of the discharge, by frequently bathing with tepid water or milk, 
PURULENT OPHTHALMIA OF INFANTS.
227
and using a little lard or fresh butter;  we do this, not because the dis-
charge possesses the power which  Mr. Ware  supposed it  to have, of
corroding or ulcerating the cornea; but in order to prevent irritation
from distention of the lids, when glued together, and to obviate excoria-
tion of them or the surrounding parts.
  Having diminished the violence of the inflammation by the antiphlo-
gistic means just described, we  immediately  proceed to employ astrin-
gents; I may observe, however,  that the use of such applications is both
safer and  more advantageous in this form of ophthalmic inflammation
than in any other.   We generally use  a simple solution  of alum, in the
proportion of two grains  sometimes, generally of four grains, which
may be increased to six grains, in  the ounce of  distilled water.   This
solution may be carefully injected between the palpebral, so as to cleanse
out all the purulent  secretion, three or four times in  the  twenty-four
hours.  The use of the syringe, however, is  not free from risk, espe-
cially in the hands of nurses:  the object may be  accomplished by fre-
quently cleansing the lids with  a soft rag dipped  in the  solution, and
afterwards laying it over the eye for a short time.  With the continued
employment of this astringent solution, an occasional dose of some mild
aperient may be combined; and usually nothing more is required.  The
swelling  and redness  of  the  membrane  are  lessened, the discharge
abates, and the  organ recovers its natural appearance, some congestion
and thickening of the palpebral conjunctiva, and some increased mucous
secretion often continuing  for a considerable time.
   In the  great majority of cases, and in all those  where the  conjunctiva
oculi  does not yet participate  in the inflammation, the astringent may
be employed at once.  Such was the  treatment  in forty-nine cases out
of fifty at the London Ophthalmic Infirmary: using no other means than
magnesia internally, and the solution of alum locally ; and out of many
hundred instances, I hardly recollect one where the eye suffered in any
respect, if the cornea was  clear when the infant was first seen.  When
there  is  occasion to change  the  lotion,  from  the eye  being accus-
tomed to the stimulus of the alum, we  may advantageously  resort to
the nitrate of silver, beginning with one grain to the ounce, and doubling
the strength if necessary.   This solution may be dropped between the
lids two or three times a day.
  Mr. Ware, whom I  should have mentioned,  as having given the first
express description  of  this complaint in our own, or  I believe in any
language, particularly recommends  an astringent solution of rather
complicated preparation and  composition, called Bates's camphorated
water.  It may be made  by pouring eight ounces of  boiling  water on
eight grains of  the sulphate of copper, the same quantity of Armenian
bole, and two grains of camphor; let it stand till  cold, and then pour off
the clear  liquor for  a  lotion.   This  composition has  no  superiority
over the solution of sulphate of copper or  alum;  indeed, I consider the
latter, and the lunar caustic, the best astringents, and a solution of them
in distilled water the best form of the remedy.
  The lotion  used   by Schmidt (Lib. cit. p.  141.) was composed of
zinci sulph. gr. ij. liq. plumbi diacet. gtt. iij. spirit, vin. camph. gtt. xij. in
aq. distil, ij. 
228
PURULENT OPHTHALMIA OF INFANTS.
  Mr. Mackenzie* employs the collyrium of corrosive sublimate, (gr. j.
ad  zviij.) three or  four  times in the twenty-four hours.   He  applies
once, or at most, twice a day, to the conjunctiva, previously cleared by
the former collyrium, a solution of lunar caustic, (gr. iv.ad ^j.) or sulphate
of copper, (gr.  vj. ad  ^j.) by  means of a  camel-hair  pencil.  And he
prevents the adhesion  of the  lids during  the night by smearing their
edges  at bed-time  with  the mild  red  precipitate  ointment.  (See
p. 102.)
  Mr. GuTHRiEf uses his nitrate of silver ointment (see p. 201,) apply-
ing it with a brush all over the inside of the lids.
  In cases of ectropium, the lids should be restored to their proper posi-
tion as soon as  possible, and  this should be repeated as  often as the
eversion is renewed.   If replacement should be prevented by strangula-
tion  and swelling, the  conjunctiva may be scarified, and  solutions of
alum  or the nitrate  of silver  should  be afterwards applied.   A light
application of the latter in substance might  be necessary in an obstinate
case.
  When the  cornea has  sloughed, the violence  of the  inflammation
abates, being  succeeded by an unhealthy  and destructive  ulcerative
process, which,  if unchecked, soon penetrates the cornea, and exposes
the interior of the organ.  The separation of the slough leaves a white
flocculent ragged ulcer, in which there  is no disposition to reparation.
The constitutional symptoms undergo a corresponding change, the infant
becoming pale, weak, restless, and irritable.   Under these circumstances
the powers of the system must be supported by tonics,  of which bark is
the best.  The most convenient form for administering the remedy, is that
of the resinous extract, which the infant will take  easily, when  broken
down and blended with milk:  from four to ten grains may be given in
this way every four or six hours.  It speedily renovates the powers of
the system, and  produces an  equally beneficial local  influence.  The
sulphate of quinine  might also be employed, rubbed down with sugar.
The solutions of alum and nitrate of silver may be  used to the eye.
  I relate the following case to illustrate some interesting points in the
disease.  A  gentleman, under my care far gonorrhoea, communicated
the disease to his wife, who had it severely.  Although she used various
means, the discharge continued, and was  still  copious when the infant
was born, on the 12th day of the month.  On the 15th,  the infant's eyes,
which had been remarked  as  clear, strong, and beautiful immediately
after  birth, were observed  to be rather  gummy  and sore, and they
began to run  on  the next day.  I saw it on the 21st,  when there was
inflammation of the  conjunctiva, both palpebral and ocular, with bright
redness, moderate swelling of  the  lids, and copious yellow discharge;
(castor oil and alum lotion g. iij. ad 5J.)   It went on favourably, and I
heard nothing  more of the case till the 28th, when I saw the child under
a great increase of  the inflammation.  The palpebre were bright red,
and so swollen, that it  was difficult to get a view of the eyes.  The left
cornea was now so  opaque, that 1 could  not distinguish  the  colour of
the iris;  the right was also opaque throughout, but in a slighter degree.

  * Practical Treatise p. 363, 364,
  t heclures at the  College of Surgeons,  in the London Med. and Sure  Journal  vol i. 
PURULENT OPHTHALMIA IN CHILDREN.
229
(One leech to each upper lid.)  29th. Much relieved  by the leeches,
which caused free bleeding;  the right cornea  is clear.   (One leech to
the left upper lid.)  1st July. The left cornea is nearly clear.   (Alum
lotion; solution of lunar caustic gr. ij—iij ad ^j. dropped in once daily.)
19th. Both eyes are perfectly recovered.
   Monsieur Billard* has mentioned, in  his translation of my lectures,
(p. 170,171.) an instance of  spontaneous recovery from opacities of the
cornea, which had been considered hopeless.  " At the foundling hospital
at Paris  I saw a  child completely blind  after purulent ophthalmia: the
cornea was opaque throughout in both  eyes.  The  child remained in
the infirmary for  a year, without any attention being paid to the eyes.
The opacities gradually lessened, and sight was restored."
  [We have seen  some striking examples of  the same character, and have
often surprised our friends who have called  us  in  consultation, by prognosti-
cating a restoration of sight in  cases which  seemed to them  utterly hopeless.
The absorbent process in infancy is extremely active, and the  powers of na-
ture alone, or assisted by gentle stimulants will often remove very extensive depo-
sites of lymph in the cornea.   In January  of the present year we were called
to an infant, both of whose corneae were opaque in the greater part of their
extent, and now after  the lapse of only five months the opacity has  so  far
diminished that the cornea of one eye is transparent over three-fourths  of the
pupil, and of the other over about one-third,  The infant's sight is consequently
good; and strabismus and great unsteadiness of the eyes which existed at an early
stage of convalescence, have now entirely disappeared.   A collyrium of one to
two grains of sulphate of cadmium in an ounce of water has been daily used
since the inflammation was cured, and the  clearing of the corneas which has
been progressive will doubtless continue still further.]

   Purulent  ophthalmia  in  children.—The  foregoing  observations,
although directly referring  to  the  purulent ophthalmia of newly-born
children, are applicable to the treatment of  the affection  in those  of one,
two, or  three years old, except that depletion must be  more  active.
When the eye is  bright red and painful,  so as to prevent  rest, two, three,
or four leeches should be applied ; one  application is usually sufficient.
Cold lotions are to be used; and purgatives of calomel, with rhubarb
or jalap, or followed by castor oil.  In older subjects, up to the time of
puberty, leeches  suffice, as  a means of depletion; they may be em-
ployed more freely in proportion as the  patient is older, and should  be
quickly repeated  if the symptoms are not  checked.  Active treatment
by leeches, purgatives, and blisters cuts short the inflammation,and astrin-
gents finish the cure.  In a few instances of acute  local congestion in
a full habit I have deemed cupping or venesection necessary before
puberty.
   Mr. Macgregor has given an  interesting account of the rise, pro-
gress, symptoms, and treatment of the purulent ophthalmia, which pre-
vailed extensively for some years among  the children of the Royal
Military Asylum  at  Chelsea, where  many  hundred  cases came  under
his notice.  " A  considerable  degree of itching was first  felt  in the
evening;  this was  succeeded  by a  sticking together of the eye-lids,
principally complained of by the patient on  waking  in  the morning.
The eye-lids  appeared fuller externally than they naturally are;  and on
examining their internal surface, this was found  inflamed.   In  twenty- 
230
PURULENT OPHTHALMIA IN CHILDREN.
four or thirty hours after the appearance of the above-mentioned symp-
toms, a viscid mucous discharge took place from the internal surface of
each eye-lid, and lodged at the inner  canthus, till the quantity was suf-
ficient to be pressed over the check by the motion of the eye.   The in-
flammation then extended to the  conjunctiva oculi, which became red
and raised, so as to form an elevated  border round  the cornea.   This
was often accompanied by redness of the skin round the eye, sometimes
extending to a considerable distance.
  " The disease evidently began  and terminated in the eye-lids; and
the surface of the eye-ball seemed only to be affected from its proximity;
for they were often in a diseased state for weeks, nay, even for months,
after every symptom of the disease, in the membranes covering the eye-
ball, had completely disappeared.
  Mr. Macgregor employed general bleeding, leeching, saline aperients,
reduced diet, cold lotions, and blisters behind the ears, or  to the nape.
After reducing the inflammation by these means, astringents were used
with great  advantage, particularly the solution of lunar caustic, from
gr.  ss. to g. ij. to the ounce.  The ung. hydrarg. nitratis was found the
most  frequently successful  of  all the  remedies that  were employed.
It was applied to the lids  by means of a camel-hair pencil, at first
mixed with twice its quantity of lard,  but afterwards of the full strength.
The red precipitate ointment was useful when  the citrine ointment had
failed.   The golden ointment was also used with advantage; but it was
injurious if employed while the conjunctiva was inflamed and irritable.
" The vinous tincture of opium, which has been so highly recommended
of late years, was  largely tried, but  did by no means answer the ex-
pectations I had formed of it."
  Mr. Macgregor observed, " that the disease is invariably more severe
and protracted, in persons having red hair and in such as are of a scro-
fulous habit, than in others.   In proof of this I may mention that  two-
thirds of those who lost the  sight of  one eye, or both eyes, either had
red hair, or had the glands  of  the  neck enlarged, or had some other
marks of scrofula existing in their habit."*
  M. Guersent states  that purulent  ophthalmia constantly exists spo-
radically in the Hopital des Enfans at  Paris, and that it is sometimes
epidemic.  It is most destructive in the wards destined to the youngest
children, which are extremely  unwholesome, insomuch that there is a
constant mortality of at least seventy-five  per cent (a peine si en par-
vient a sauver un sur quartre.)   In an epidemic which prevailed during
February and March, 1835, all the children were attacked in the ward
devoted to the youngest subjects, and some of those more advanced in
age.  Complete evacuation of the eye occurred in some cases, particu-
larly in several children affected with other serious diseases.   M. Guer-
sent, who has witnessed several such  epidemics, has found the antiphlo-
gistic method, followed by astringents, the most serviceable.   Cauteri-
zation of the mucous membrane of the  palpebrae with nitrate  of silver
failed completely.*

  * Transactions of a Society fur the Improvement of Medical and Chirurgical knowledge,
vol. iii.
  * i\ole sur une ophthalmie purulcnte epicitimique, qui a reyne ;i I'hdpital  des enfans
pendant les m..is de Fcvrier et Mars. Bulletin ginhak de thirapeuliuue, April, 1835. 
TURULENT OPHTHALMIA IN THE ADULT.
231
  [Purulent ophthalmia has prevailed, at times, in all the large institutions for
children in Phildelphia.  The childrens' asylum under the care of the guardians
of the poor, has  never  been  wholly exempt  from the disease  since its esta-
blishment, and at periods it has been epidemic and destructive  to vision.  In
the St.  John's, St. Joseph's, and Philadelphia  Orphan Asylums  it has also
prevailed epidemically.   In the latter institution  it appeared  in that form in
the winter of  1839-40, and of  97 children in the asylum 95 were affected.
During the first  quarter of 1840, 108 cases, occurring in 77  children came
under our care.
   The treatment consisted in  the  daily application to  the  eyes  of a  solu-
tion of nitrate of silver, of the strength  of from two to eight grains to the
ounce of water;  laxatives, occasionally blisters  to the nucha and behind the
ears; and as the disease abated, in strumous children especially, the adminis-
tration of Lugols strong solution of iodine.   Bleeding was resorted to in but five
cases and in but one of them twice.
   The result of this treatment was  most  gratifying.  In no case was  vision
injured, although many  of  the  children were strumous  and  several of  them
were predisposed to ophthalmia.  In two cases only Avas the  disease followed
by granular lids,  one a girl who was bound out  before the disease had been
entirely cured, and the other one of the elder girls, employed as a servant,
who was attacked only a few days before our  term of service expired.]
CHAPTER  VIII.
                  PURULENT OPHTHALMIA IN THE ADULT.

Synonymes:  Oph. purulent a,  or puriformis;  Egyptian  oph.;  suppurative
  ophthalmia; ophthalmo and  blepharo-blennorrhaza; oph. contagiosa;  epi-
  demic-contagious oph.  Rosas.  Conjunctivitis pnro-mucosa contagiosa
  vel Egyptiaca.   Mackenzie.  Oph. catarrhalis bellica; blepharotis glan-
  dularis contagiosa; adenitis palpebrarum contagiosa.


  Purulent ophthalmia in subjects  beyond the  age of infancy is  the
same affection as that last described, only modified in its course, dura-
tion, and effects, by age;  and requiring corresponding modifications in
treatment.   It is originally and essentially an affection  of the mucous
membrane of the eye-lids: that is, inflammation with puriform discharge.
It  maybe confined throughout to its original seat;  more  generally it
extends to the conjunctiva oculi, when if neglected or improperly treated,
and sometimes in spite  of all  the means that can be employed, it reaches
the globe  itself,  producing  in the cornea and  iris,  injurious  and  de-
structive effects,  similar to those which take place  in  newly-born chil-
dren. 
232
PURULENT OPHTHALMIA IN THE ADULT.
  When we consider its marked character and serious consequences, it
seems strange that it should so long have escaped notice. Yet our know-
ledge of it is subsequent to that more extensive intercourse with Egypt
which took place during the contest for its possession between France and
this country.  I know of no clear description of the complaint previous
to this opocha.  Scarpa does not mention it in his first edition bearing
date 1801, and has only a single paragraph on it, an additional one, in
his last  or 5th edition of 1818. Mr. Ware does not allude to it, until long
after the publications by the English army surgeons, subsequently to the
evacuation of Egypt by our troops. Richter, who seems to have observed
diseases of the eye with the greatest attention, for a long series of years,
and who has  described them with great   fidelity, has not noticed this
affection, which is not mentioned by Beer, nor by others of the Vienna
school.   Beer has entirely passed it over in his first  edition of J 793: in
the second edition of 1812-1816, he only  alludes to it in a paragraph,
in which he mentions that he had been long anxious to procure accurate
information on the subject, and that his wishes had at last been gratified
by a work of Assalini,* which had  convinced him that the complaint
was merely inflammation of the glands of the eye-lids, (blephar-ophthal-
mitis glandulosa, that is, catarrhal inflammation  of  the lids,)  rendered
violent  by the peculiar local circumstances, and passing quickly,  in
consequence of the unsuitable  treatment of the natives, and of the
French  and English army surgeons,  into blepharo-blennorrhcea  and
ophthalmo-blennorrhoea.f
  The following circumstances will sufficiently prove the importance of
the subject.
  Assalini  states, that  two-thirds of the  French army were affected
with the complaint at one time.
  Dr. Vetch  informs us,  in his  interesting Account  of the ophthalmia,
which has appeared in England since the return of the British army from
Egypt, (p. 69.) that" the total strength of the second battalion of the 52nd
was somewhat above seven hundred men; six hundred and thirty-six
cases of ophthalmia, including relapses, were  admitted into the hospital,
from August 1805, when the disease  commenced, till the same month in
1806 ; of these fifty  were dismissed with the loss of both eyes, and forty
with that of one."
  The ophthalmia depot, under the care of this able physician, contained
in the summer of 1808, upwards of nine hundred  cases from more  than
forty different corps.J
  Cases of purulent ophthalmia had  occurred in the  first battalion of
the 52nd, when it went to Sicily, in  1806.   It continued to suffer there.
A part  of the army of Sicily, which had  been detached to Egypt,
brought  back  with it fresh infection.   From this station more than one
hundred and thirty men were sent home totally blind.§
  " It appears from the returns of Chelsea and Kilmainham hospitals,
that 2317 soldiors were, on the 1st of December,  1810, a  burden upon
the public from blindness in consequence of ophthalmia.  Those soldiers,


  * Observations sur la Peste, VOphthalmie d'Egyptc, &c. Paris; an 9.
  t hehre, vol. i. p. 324.
  t Practical Treatise on Diseases of the Eye, 184.            § Ibid. p. 183. 
PURULENT OPHTHALMIA IN THE ADULT.
233
 who have lost the sight of one eye, are  not included in the number
 above stated."*
   In 1804,  within  nine  months, from April to December, inclusive,
 nearly four hundred cases of purulent ophthalmia occurred at the royal
 Military Asylum: and from that time to  the end of  1810, upwards of
 nine hundred additional  cases had  taken place in the same establish-
  ment,  without including  relapses.f
   Some years ago this alarming complaint broke out in a large boys'
 school in Yorkshire.  Blindness of one or both eyes, or serious injury
 to sight from corneal opacities or other causes, took place  in  nearly
 twenty instances.   We cannot suppose that the proportion of unfavour-
 able results would have been so considerable, if  proper  treatment had
 been adopted;  for, in the Military Asylum, where the cases were so
 numerous, only six lost the sight of both eyes, and twelve the sight of
 one eye.J
   Fifteen hundred cases  occurred in the garrison of  Ancona in  1812 :
 in ninety-seven of these one eye was lost, in forty-nine both.§
   Muller treated 1604 cases, including  two hundred relapses, in the
 Prussian garrison of Mentz, in three years and a half;  1344 were re-
 stored to the service  perfectly well; fifteen became blind with both
 eyes, ten by staphyloma, three by entire suppuration  of the cornea, one
 by leucoma, one by dropsy of the globe.   Eighteen remained with im-
 paired vision of both eyes ; six by leucoma, four by cicatrix of the  cor-
 nea with synechia anterior; six by suppuration of the cornea and opa-
 cities ; one by pannus.   Twenty-six remained blind of one eye ;  fifteen
 by staphyloma ; one by cicatrix of the cornea, with synechia anterior;
 nine by opacities; one by pterygium.||
   It has been asserted that 30,000 cases occurred in the Prussian army,
 from 1813 to 1821, and that blindness followed in 1100.1
   [In the Belgian  Army the disease appeared  in 1814, but was restricted to
 four garrisons until 1830, when it spread very generally, affecting indeed,  one-
 eighth of the whole army, and in some regiments half of the soldiers.  In 1840
 there were 5000 cases in  the army which  consisted of  50,000  men,  and
 upwards of 100,000 cases had occurred since the first appearance of the dis-
 ease.**]
  Symptoms and progress.—In the first stage  there  is redness of  the
 palbebral conjunctiva, with watering of the  eye  and  some stiffness of
 the lids; a little whitish mucus is observed on the  membrane.  It is not
 generally seen by the surgeon in this stage, and often  is hardly noticed
 by the patient.   The disease soon extends to the globe, in what may
 be called its second stage; and now we see it marked  by high vascular
 action and bright redness, great tumefaction of the membrane, and pro-
 fuse  discharge.  The redness is uniform and bright; and there are often
 red patches apparently of ecchymosis.  The swelling of the membrane on

  * P. Macgregor, in An account of an Ophthalmia which prevailed in the Royal Military
 Asylum ; Trans, of a society, §c. vol. iii. p. 50.
  1" P. Macgregor, ibid. vol. ni.  pp. 44 and 45.                       Ibid, p. 49.
  (j Omoiiei Cenni sulVOtallmia  Contagiosa d'Egitto.
  II F.rfahrungssate, p. 159, and  following.
  ' Baltz Preisschrift uber die  Entstehung, fyc, der Augenentzundung, welche unlet den
Soldaten einiger Europdischen Armeen geherrscht hat.  Utrecht, 1824, p 57, 58,
  [** Cafpe Journal de Connaiss. Med. July, 1840, p. 290.]
      30 
234
PURULENT OPHTHALMIA IN THE ADULT.
the globe raises it into the elevation called chemosis, which is often so
considerable as to overlap and nearly cover the cornea ; at this period
of the complaint the palpebrae  swell from  serous effusion into their
cellular texture.   In this way they often form two large convex, colour-
less, or slightly red protuberances, which meet and entirely close the eye,
preventing in conjunction with  the chemosis, all satisfactory examina-
tion of the cornea.  The extent to which swelling of the  conjunctiva
proceeds in these cases is  evidenced by the preternatural adhesions
found after inflammation has subsided.  I have seen the conjunctiva of
the upper part of the sclerotica adhering, in the form of a broad trian-
gular band, somewhat like pterygium, to the inferior part of the cornea,
after  sloughing;  and  a  similar broad  adhesion  between  the  orbital
margin of the superior tarsus and the lower edge of the cornea.
   The nature of the swelling in chemosis is explained in the next chap-
ter, on gonorrhoeal ophthalmia.
   The patient at  first complains of stiffness in the eye-lids and globe;
and then experiences a sensation as if sand or gravel were in the organ.
There is at first, lachrymation, then abundant  purulent discharge,  not
only covering the edges of the lids, and the cilia,  but pouring out over
the face, and dropping on the clothes.  The chambers of  the aqueous
humour may be distended by an increased exhalation of that fluid ;  but
there is no formation of pus.  Dr. Vetch* expressly mentions  that he
never saw the latter occurrence, nor effusion of lymph into the cham-
bers, and Mueller! observes that hypopion never took place under  his
observation.
   In the natural state of the disease,  before  blood-letting had been
adopted, Dr. VetchJ states that the quantity of matter discharged in
the day must have amounted to several ounces.
   As the inflammation extends to the globe, the pain is greatly incrased;
it becomes severe and excruciating: it is deep-seated in the eye, often
with  fulness and  throbbing of the temples, and headach.  There  are
remissions and exacerbations of suffering, which are sometimes perio-
dical.   The pain  often  returns, and particularly the sensation of a
foreign body in the eye,  after it has been removed for a time  by treat-
ment.
   In the early stage the constitutional affection is slight; the pulse  not
affected, the tongue not much altered, nor the appetite impaired. When
the  inflammation extends to the globe, the circulation is excited,  and
general feverishness ensues.
   Serious affections of the cornea take place analogous to those which
occur in infants,  but the swelling of the palpebras  and conjunctiva con-
ceals them, unless the eye be carefully  examined.
   In the third stage there is a gradual  remission of the symptoms;  the
swelling, pain, and discharge are lessened ;  the external esdema ceases,
and the swelling  of the  conjunctiva being no longer counterbalanced,
the palpebrae are everted, especially the lower.
   Purulent ophthalmia in its milder form.—The foregoing account de-
picts the features of the disease in its most violent degree, as it prevailed

   • Book before quoted p. 64.                       t Erfahrungstatze, p. 68.
   \ Account of the Ophthalmia,  &c  p. 54, note. 
PURULENT OPHTHALMIA IN THE ADULT.
235
in the British army,  and has been  so well described by Dr. Vetch.
The severity of the inflammation, and the destructive effects on the eye-
ball, would naturally fix attention in these cases, and lead to the descrip-
tion of the affection as being essentially inflammation in its fullest de-
velopment.  In many instances,  however, the disorder does not exhibit
these strongly marked characters. It begins almost imperceptibly, and
continues in a form so chronic, as hardly to excite attention.  Its seat
in these cases is the mucous lining of the eye-lids.  Mr. Macgregor ob-
serves, that " the disease evidently began and terminated in the eye-lids,
and the surface of the eye-ball seemed to  be only affected by its proxi-
mity; for they were often in a diseased state for weeks, nay, even for
months after every symptom of the disease, in the membranes  covering
the eye-ball, had completely disappeared."*  He also observed " that the
sebacious glands of the tarsi were considerably enlarged, and  of a red-
der colour than usual."f   Dr. Vetch repeatedly insists  on  the diseased
condition of the palpebral linings, showing that it remains for an indefi-
nite time after the inflammatory symptoms have been subdued ;  that it
may lead under occasional excitement, to the production of the disorder
in all its  violence; that no case can be considered cured until  this state
of the conjunctiva shall have been removed ; and arguing that so long
as it lasts the power of infection continues.
   The milder form of the complaint  seems to have constituted a far
greater proportion of the cases in Germany, not only in civil life, where
we have had but little opportunity of observing it in England, but also
in the army.  It has been carefully investigated by the German surgeons,
who have thus been led to the discovery, that a certain change of struc-
ture in the palpebral conjunctiva is the primary and characteristic effect
of this contagious ophthalmia ; that the alteration in question, which has
heretofore been regarded as an effect of active inflammation, is,  on the
contrary the first manifestation of disease, and the cause of inflamma-
tion when the disorder spreads to the  globe of the eye; and that, in many
instances, the complaint arising from contagion, and possessing  the
power of infection, is confined to its  original seat, appearing as a slow,
chronic affection, giving the patient but little trouble, and often unnoticed
by him or the surgeon.
  Professor Walther, who observed the disorder in the prison of Brau-
weiler, and the neighbouring country,  represents that " the proper seat,
the birth-place, the nest of the disease, is always, and in all its degrees,
the conjunctiva of the eye-lids.   Here  the disorder strikes its roots, and
hence extends its destructive operation, partly into the substance of the
eye-lid, partly to the eye-ball, the conjunctiva  oculi being  the medium,
by which the disorder is conveyed to the  proper tunics of  the globe."J
He says that the complaint is characterized, in the first and slight de-
gree, by its obstinacy, and by the gradual change of structure of the pal-
pebral conjunctiva, especially in the lower lid, which after several weeks
or months appears merely loosened in texture,  reddish,  velvety, and
granular.   With  the  aid of a  glass, or  even with the naked eye, we
may discover small phlyctena?, and an exanthematous structure which it

  * Lib. cit. p. 41.                                    t Lib. cit. p. 38.
  X Die contagiose Augenentzundung am Niederrhein, fyc.  in Graefe  und WAi/raER'i
Journal, vol. ii. p. 69. 
236
TURULENT OPHTHALMIA IN THE ADULT.
is difficult to describe.   This change  is particularly observable at the
reflexion of the conjunctiva from the eye-lid to the globe, where we see in
the membrane a crowd of yellowish red grains, something like the ova
in the roe of a fish.  Fissures and grooves are seen in the velvety lining
of the lids, entirely destroying its natural smoothness.   Thus the pal-
pebral conjunctiva is  gradually changed into  a fleshy, sarcomatous,
sometimes condylomatous mass, from the uneven surface of which  an
abundant mucopurulent discharge proceeds.*
  Respecting the  nature  of the  complaint, Professor  Walther! ex-
presses the opinion that, although it is an inflammation, the inflammatory
symptoms are inconsiderable in its first degree.  The peculiar change
of structure in  the palpebral   conjunctiva, its  morbid  swelling, is the
principal and constant  phenomenon.   Antiphlogisitc treatment is by  no
means so serviceable as might  be expected, if inflammation constituted
the essential character of the disease.   There is indeed  high inflamma-
tion in the more severe cases,  attended with chemosis: but this inflam-
mation may be prevented  by proper treatment; when present, it may
be checked, and brought back  within the limits of the first degree.  The
complaint still proceeds in its course,  the change of structure goes on,
although the inflammation may have been reduced.  Moreover, where
the inflammatory  symptoms have been  inconsiderable, we often see
abundant granulations  and  vegetations  of  the conjunctiva.  " Since
further observations have confirmed the truth, that an eruption of small
vesicles on the surface of the palpebral conjunctiva is always present in
contagious ophthalmia, I should have no scruple in pronouncing the dis-
order to  be  of exanthematous  character, and in considering it not  so
much an inflammation as  an exanthema, or rather a chronic impetigo
of the conjunctiva."
  Mueller, the  Prussian army surgeon, considers the term ophthalmia
inappropriate, because  the complaint may exist without inflammation of
the eye, which is merely one of its occasional effects.  " Of many hun-
dred patients," says he, " who at  various times came under my daily
observation, it often happened  that the half were free from all affection
of the globe, or  impaired sight; in part, indeed, they could not be said
to suffer  from true inflammation of the eye-lids; nevertheless, the dis-
ease existed in each under the  eye-lids, often for months, and in a state
capable of infecting whole companies."   He considers the characteris-
tic  circumstance to be a morbid state of the palpebral  conjunctiva, in
which part of the  membrane he believes  that an apparatus of mucous
glands exists.J  He had an opportunity of examining  the  parts in a
patient, who had long  laboured under purulent  ophthalmia, with ulcer
of the cornea, and prolapsus iridis, and in whom, under suitable treat-
ment, the purulent discharge had  ceased, and  the affection of the eye
was proceeding  most favourably when death occurred from disease of
the chest.  Although the disorder had  here become reduced to its slight-
est degree, I found that portion of the membrane which I have desig-
nated as  the seat of the mucous glands in both eye-lids, altogether pale,
but uniformly overspread with  innumerable small papillae; they did not

  * Die contagiose Augenentzundung  am Niederrhein, <yc, in Graefe und Walther's
Journal, vol. ii. p. 69.                                f Ibid.  pp. 89—91.
  \ Erfahrungssalze, p. 4. 
                PURULENT OPHTHALMIA IN THE ADULT.              237

exist in the rest of the membrane, which presented a perfectly normal
structure.   Under the membrane thus altered lay the Meibomian glands
quite healthy."  P. 21, 22.
  Mueller describes  three gradations of the complaint.   The first is
inconsiderable.  It  is found where the person, without  any redness of
the eye or lids, has experienced for a few days a sense of pressure, or
an  uneasiness, as if a particle of dust  or sand had got into the eye.
The conjunctiva lining the tarsi has a villous  appearance, and darkish
red colour; these changes extending for about a line beyond the orbital
edges of the cartilages.  The  continuation of the membrane towards
the globe has its  natural smoothness, but its  vessels  are distended.
There maybe congestion in the conjunctiva oculi.  There are increased
flow of tears and mucous secretion; and  irritated appearance of  the
eye-ball; little or no pain.  The disease may prevail extensively in this
mild form; it may become more  serious, or it may end, under proper
treatment, within two or three weeks.  P. 25—28.
  The second  degree is either an aggravation of the first, or exhibits
its more serious character from the commencement.  The conjunctiva
of the eye-lids now looks as if strewed with coarse sand; it has  a  more
granular appearance,  this character being more conspicuous when the
general inflammatory tension  has abated.  The  conjunctiva is  more
swollen, dark red, and covered  by a puriform  discharge.  Particular
vessels are not to be distinguished, but the membrane generally, is pass-
ing into  a deep red aggregation of granulations.  The surrounding
parts suffer more seriously; hence the general swelling of the lids.   The
pain is more considerable, but still resembles that caused by a foreign
body in the eye.  In this form the complaint is disposed to become in-
veterate ; to go on  for weeks or months; and to pass into the third more
serious gradation, especially in particular conditions of the atmosphere.
P. 29—31.
  The third degree, which is the most alarming in its appearance and
consequences, sometimes comes on at once in  all its violence; but more
commonly  it supervenes suddenly on the second, after a longer or shorter
time.  It may be fatal to the organ in twenty-four or  thirty-six hours.
The peculiar disorder here affects the portion of membrane already in-
dicated;  but the disturbance is of the most violent kind, and its conse-
quences are luxuriant morbid  growths of granulations and warty eleva-
tions, the most profuse blennorrhea, enormous swelling of the lids, ec-
tropia, &c. P. 31—33.
  Mueller then proceeds to  give the following general description of
the alteration, which the  conjunctiva  undergoes in this disorder, ob-
serving that it is the constant circumstance of the complaint, showing
itself most decidedly after the cessation or removal of active inflamma-
tion.  " In  the  lowest degree the palpebral  conjunctiva appears  like
velvet, or as if covered with dust: in the higher gradations, like thickly
strewn millet seeds or rough sand, or the  granulations of a  healing
wound, these vegetations sometimes equalling a large  lentil, which is
their utmost size.   They exist in great  number, arising from the  mem-
brane by a broad basis, being rounded on their prominent part at first,
but subsequently becoming flattened by angular  pressure against  the
globe.   The largest  are towards the middle; the smaller, which  are 
238
PURULENT OPHTHALMIA IN THE ADULT.
more closely arranged, are towards the margins of the lids and the an-
gles, especially the  outer.  Sometimes they lie so close together, that
they seem to form  one mass; but close examination will discover the
fissures, sometimes  tolerably deep, which  separate them.  This struc-
ture is more developed under the upper than the lower eye-lid, the wider
surface of the former possessing a greater extent of mucous glands, and
being less exposed  to the  air or the contact of remedies.   The sub-
stance of these  bodies is firm, and  they run together at their bases,
where the membrane  generally is of the same morbid structure.   The
smaller prominences,  examined with a magnifying glass, appear like an
aggregation of hydatids,  or the surface of a ripe mulberry.   Their co-
lour varies according to  the degree of inflammation or vascular tumes-
cence.   Hence we see all gradations, from the darkest blood  red to the
palest brick colour.
  " The  prominence of these characteristic granulations is  generally,
but not constantly, in proportion to the degree or intensity of the inflam-
mation, but  by no means to its extent.  I have often seen them compa-
ratively small  after the  most  acute inflammation, which had spread
with great danger over the eye-ball; and much  more luxuriant under a
slower and  more confined  inflammation.   Whence we may conclude,
that the peculiar inflammatory disturbance in the focus of the complaint,
although less obvious to the observer, had acted  more powerfully on the
affected parts.
  " Where  this change of  structure  has become established, we need
not expect to accomplish  its sudden removal, although there are certain
limits to its progress.  We must not regard it  as a mere effect of in-
flammation, like ordinary thickening, induration, or loosening of struc-
ture ; but rather as the proper organ of the disease, which required an
inflammatory impulse for its development and establishment, but may
then become habitual, lasting for months or years, and constantly pro-
ducing a contagion, capable under certain conditions, of propagating
itself by the infection of others.
  " Although sight is generally impaired by the long continuance of this
morbid change, there  are other cases, or at least periods in these cases,
when after the removal of the symptomatic affections, the  eye-ball is
perfectly free, and yet the disease continues under the eye-lids in its full
luxuriance.  We can  often, indeed, discover externally, from the swell-
ing of the eye-lids, the irritated appearance of the eye, the  narrowing
of the palpebral fissure, together with, in some instances, a slight gaping
of the ciliary margins, that there must be something wrong  under  the
lids; and we find, on everting them, the  above-described changes  in
their linings.  The state  of the weather has a marked influence on the
complaint, even in its, chronic form.  The disease, which seems nearly
removed and quiet to day, may be  much more considerable to-morrow,
and vice-versa.  Yet the  morbid structure shows but little sensibility to
the touch or other external irritants.   No ulceration follows excision or
cauterisation of the granulations.   Abscesses or phlyctenae do not take
place, as in the conjunctiva oculi."  P. 36—41.
   " The  disease begins at the inner edge of the ciliary margin, not in-
cluding the puncta lachrymalia, occupies the lining  of the tarsi, and
ends one line  beyond these  cartilages.  Every thing  beyond these 
PURULENT OPHTHALMIA IN THE ADULT.
239
limits is symptomatic  affection, to which head we must refer the very
frequent participation of the rest of the mucous membrane.   The latter
frequently displays increased redness, chronic swelling, thickened folds,
&c. but never granulations."
   Eble, an army surgeon in the Austrian service, and prosector at the
Josephine Academy, had ample opportunities of  observing the  conta-
gious ophthalmia in the  military hospital  of Vienna, where he had the
charge of the ophthalmic patients.   His account corresponds nearly to
that of Mueller.   He establishes two principal divisions of the disease,
the acute and chronic; describing the latter first, because it exhibits the
peculiar character of the disorder, and because the acute is generally in-
grafted on the previously existing, though not always recognised, chronic
form of the disease.  At the earliest period of the latter, when the indi-
vidual has not complained, and is not aware that any disease  exists, and
when therefore it  very rarely comes  under the  observation of the sur-
geon, he has found small serous cysts or phlyctenules on the surface of
the conjunctiva; these are soon lost in the subsequent  thickening and
granulation of the membrane."*
   Effects  of the Inflammation.—1. Sloughing of the Cornea,  general or
partial?   This, which is not an unfrequent result of acute gonorrhceal
ophthalmia, has not occurred within  my observation, in  the contagious
purulent disease; nor have I found it mentioned in the writings of those
who have seen the disorder extensively prevalent among large bodies of
men.
   2.  Bursting of the cornea.—In this disease, and in acute gonorrhaeal
ophthalmia,  the  eye is  sometimes said to burst.   A paroxysm  of ex-
cruciating pain  is  suddenly terminated  by a  sensation  of  something
giving way; a little hot fluid  runs down the cheek, and great relief is
experienced.   When the subsidence of the palpebral swelling allows the
eye to be examined, we always find, in  such cases, that the anterior
chamber  has been penetrated, that there is  extensive disorganization of
the cornea by suppuration or ulceration, and that vision is lost.   I have
considered this occurrence to  be the result of an  ulcerative process,
consequent  on sloughing, or suppuration of the cornea.   Dr. Vetch,!
however,  represents the matter in a different light.  In one case he saw
the cornea shortly before it burst, and it exhibited no perceptible  altera-
tion.   He examined it  again soon  after, and found  it  presenting so
natural an appearance,  that he doubted the accuracy of the sensation.
He at last discovered a small line, extending across the lower segment
  • Ueber den Bau und die Krankheiten der Bindehaut des Auges, mit besonderem Bezuge
auf die contagiose Augen Entzundung.—Vienna, 1828.
  The serous vesicles of the conjunctiva are represented in Plate III., fi<r. 15.  This, and
the other figures of the same plate, which are coloured and highly-finished, represent faith-
fully and beautifully the various stages and forms of the structural change in the palpebral
conjunctiva.
  Eble  has lately published an express tract on purulent ophthalmia : Die sogenannte
contagiose oder Aegyptische Augen.Entzundung; mit 9 colorirten Abbildungen. Stuttgart,
1839.  The  figures are designed to illustrate the changes, which the conjunctiva under-
goes in purulent ophthalmia, and are well executed.
  Mueller  has devoted two coloured plates to the same subject in his Neuesten Resultate;
the figures arc expressive, though much inferior in execution to those of Eble.
  Other representations may be seen in Graefe, Augen-Blennorrhoe, &,c. Tab. 1, 3, and
4, and in the two works of Vetch.
  t Account of the Ophthalmia, &c. p. 60, and following. 
240
PURULENT OPHTHALMIA IN THE ADULT.
  of the cornea, and remaining unaltered after the eye had been washed
  with tepid water.  The next day a slight opacity appeared along the
  line, and increased daily till the greater part of the cornea was not only
  opaque, but  projected in  an irregular cone.  He  adds, " Other cases
  have occurred, which, by corresponding  with the above, confirm the
  account I  have now given; from  which it appears that the aqueous
  humour escapes by a division of the cornea, nearly as clean  as if cut
  by a knife; and that it is to the  attempts of the part to effect a reunion
  under the presence of disease, that the future deformity is owing," p. 64.
    3. Suppuration of the cornea, and its subsequent destruction by ulce-
  ration.—In the progress of the latter, the  lens  may become exposed, so
  that the patient recovers  for a  short time tolerable sight, which how-
  ever is  soon  lost again, as the progress of disease leads to the escape of
  the humours, and collapse of the globe.
    4.  Ulceration of the cornea.—This may occupy a considerable  por-
  tion of  the surface, or it may be smaller.   Sometimes  it forms a deep
  groove' along the margin of the cornea, occupying one half of its cir-
  cumference or  more.   The ulceration may extend in surface, or it may
  become deep and penetrate the anterior chamber.
    5.  Interstitial deposition, either  into the conjunctival covering, or
  throughout the  corneal laminae, occupying a portion only, or the whole
  cornea, and causing opacity, in  every degree,  from the thinnest film to
  the most dense  leucoma.
    6.  Opacity from cicatrization of  ulcers.
    7.  Prolapsus iridis, total {staphyloma racemosum,) or partial.
    8.  Adhesion of the iris to the cornea {synechia anterior) in various
  extent, consequent on prolapsus, or  occurring  when the cornea is  vio-
  lently inflamed, and therefore  seen in conjunction with the various
  effects of such  inflammation.
    9. Loosening and thickening of the  mucous membrane covering the
  cornea, with  enlargement of its  vessels, and more or less diminution of
  its transparency.   This change  occurs in various degrees from slight
  vascularity to pannus.
    10. Staphyloma, general or partial, dropsical enlargement of the globe,
 or collapse of its tunics, are more remote  effects produced by some of
^the changes just enumerated.
    11. A weak and irritable state of the eye, with want of power to bear
 even slight exertion.   This, which disappears sooner or later, is  a  less
 serious affair  than a degree of impaired vision (amblyopia,) which  has
 sometimes  remained, even  in cases of the milder description, without
 any change in the transparent media  of the eye.   The latter circum-
 stance is explained by appearances observed after death in the exami-
 nation of persons who had been affected with this disease.  The dissec-
 tions in question, which were made by professor Mayer of  Bonn, are
 detailed in the paper of  Walther.*   He found turgidity of the vessels
 in  the orbit, and distended vessels surrounding the optic nerve; the cho-
 roid deprived  of its  pigment almost entirely, or  partially, and red,  or
 violet red, instead of ils natural  brown colour; the retina, in one case
 firmer, and adhering to the choroid; the lens, in one case, and the vitre-

              * Graefe und Walther's Journal, vol. ii. p. 100—108. 
PURULENT OPHTHALMIA IN THE ADULT.
241
 ous humour in another, yellow, like gold;  the vessels of the brain and
 its membranes turgid, with  increased secretion into the ventricles, and
 serous effusion under the arachnoid.   The changes in the choroid were
 seen in three out of five examinations; and in two of these the affection
 of the eye had been  mild.
    12. Although change of structure in the palpebral conjunctiva is the
 commencement of the complaint, and  the  cause of the more general
 inflammation, the latter aggravates  the primary affection;  so that the
 considerable thickening and  induration  of the membrane, with the
 roughening of its surface by large folds and masses of granulation, must
 be regarded as consequences of inflammation.
    13. Temporary and permanent ectropium and entropulm.  Some red-
 ness of the membrane, with slight swelling and a little discharge, often
 continue for a long time.
   There is great tendency to  relapse, especially when the conjunctiva
 has not been restored to a healthy state ;  and inflammation may be re-
 newed  by slight  exciting causes*   I have known the complaint to re-
 turn, in a strongly marked form, many years after its first appearance.
 Hence, when we consider the  difficulty of restoring to its healthy state
 a part which has undergone a change of structure so serious as  that
 which the palpebral conjunctiva experiences in this disorder, we shall
 not be surprised at hearing that patients may suffer from it for ten years
 or  more, and that Walther doubts whether the conjunctiva ever com-
 pletely regains its normal state of nutrition and secretion.*
   Diagnosis.—The characters of the complaint are so strongly7 marked,
 that it is not necessary to enlarge on  this part of the subject.  Catar-
 rhal ophthalmia  is  the  only affection liable to be confounded  with it.
 The peculiar change of structure in the palpebral conjunctiva, the long
 continuance of the complaint,  and the relapses, the great swelling che-
 motic and  palpebral, the violent vascular  congestion and general bright
 red of the membrane, with the profuse purulent discharge, are sufficient
 distinctions.   In  catarrhal  ophthalmia,  the affection  begins in  the
 conjunctiva oculi; or, at  least appears at once over  the whole mem-
 brane: in the purulent inflammation it commences in, and is  often con-
 fined for a  long time to, the palpebral conjunctiva.  The affections of
 the cornea, which are very uncommon in catarrhal ophthalmia, afford
 an  additional ground of discrimination.
  The two diseases, however, if we look merely to an  attack of the
 contagious  disorder,  without embracing the whole history, differ more
 in degree than in  kind: the distinction between a mild catarrhal, and an
 acute purulent case  is obvious enough; but we might  not be  able to
 distinguish  between a mild purulent, and a severe catarrhal ophthalmia.
 There would be no difference in treatment.
  Prognosis.—The  affection is much more  formidable, the  danger to
the eye is greater, than  in infants or children.  The complaint is  Jess
manageable, and  therefore the  issue is more uncertain.  If the cornea
retain its natural transparency, we may expect to arrest the  inflamma-
tion by vigorous treatment; if it be dull, and deep seated pain of the eye
and head announce extension of inflammation to the globe, the event is
31
* hib. cit, pp. 37 and 96. 
242
PURULENT OPHTHALMIA IN THE ADULT.
 doubtful.  After partial suppuration, considerable ulceration, or intersti-
 tial deposition, recovery of sight may take  place, particularly in habits
 not very plethoric.  Much will depend on the position of these changes
 in the cornea;  if they should be towards the circumference, they may
 not interfere with vision.
    Causes of Purulent  Ophthalmia.—Opposite opinions have been en-
 tertained, and  continue to be held, respecting the origin and nature of
 this affection.
   Some consider it a  specific  disease, only communicable by contact
 of the puriform discharge; endemic in Egypt, and brought to Europe by
 the French and English troops: hence the name of Egyptian ophthalmia.
 Others regard  it merely as a  catarrhal inflammation of  the eye, and
 consider that the severity of the disease in Egypt is  attributable to  the
 peculiar circumstances of that country, which are calculated to favour
 the production of catarrhal complaints, and  to render them severe.   Al-
 though it seems to  involve merely a question of fact,  we have not as yet
 the means  of determining which is  the correct view.   If the disease be
 contagious, is it excited by direct application of the morbid  secretion, as
 in gonorrhoea and syphilis ?  Can the morbific influence  be conveyed
 by the atmosphere  as in measles and scarlet fever, or  in both ways, as
 in small pox?   In  order to settle the point,  we ought to institute expe-
 riments, which', for obvious reasons, we cannot do.   We want to ap-
 ply discharge from the diseased to healthy eyes, and  to  observe  the
 effect  of such application;  but this  proceeding cannot  be adopted.
 With respect, therefore, to the question, whether the disease can be pro-
 duced by the direct application  of  matter to the eye, we must content
 ourselves with a few facts presented by casual observation, and with
 indirect arguments.
   Mr. Macgregor in the account whiclr he  has given of this affection,
 as  it occurred in the Royal Military Asylum, mentions three instances,
 in which the origin of the complaint from direct infection was unequi-
 vocal.  The cases are  interesting not only in  this respect,  but as  they
 show  how quickly the  application of the cause is followed by the de-
 velopment of the morbid phenomena.  About four o'clock, p. m., a nurse,
 in syringing the eyes  of a boy, in whom there was much  purulent dis-
 charge found some of the matter spirt into her  right eye.  She felt little
 or no smarting at the  time; but towards nine o'clock  in the  evening the
 eye became red, and  somewhat painful.  When she awoke the next
 morning the eye-lids were swelled,  there was  purulent  discharge, and
 she complained of pain in the eye-ball.   The usual remedies were em-
 ployed, and she got well in three weeks or a month.   The  left eve did
 not suffer.
  Matter was  applied  in  the  same manner  to  the left eye of  ano-
 ther nurse  at nine, a. m.   By direction of  Mr. Macgregor who was
 immediately informed of the occurrence, the  eye was  bathed for several
minutes with lukewarm water.  About seven  in  the  evening, the  eye
began  to itch violently.   When she awoke  next morning, the eye was
considerably inflamed;  the lids were swelled,  and she  had a sensation
as if sand were lodged under  the eye-lid.   In the course of this day,
purulent fluid issued from the eye.   The disorder subsided  in fourteen
days, the right eye having remained sound. 
PURULENT OPHTHALMIA IN THE ADULT.
243
  Another nurse, who had been sponging with warm water the eyes of
a boy suffering  severely  from  purulent  ophthalmia, inadvertently ap-
plied the sponge to her right eye about  eight in the  morning, and took
no means to prevent  infection.   Between three and  four  p. m., great
itchino- 0f the eye took place,  and before  she went to bed it was consi-
derably inflamed.  Next morning  all the symptoms of purulent ophthal-
mia were completely developed; they increased in severity in spite of
all the means employed to check  them, and the eye-ball burst on the
fourth day;  the inflammation  continued for three months:  the left eye
did not suffer.*
  Dr.  Guillie, of Paris, has shown that the disease may be communi-
cated  by the direct application of the puriform secretion  to  a sound
eye.  He introduced under the eye-lids of four blind  children, the dis-
charge from the eyes  of children labouring under purulent ophthalmia;
and the disease  was produced in each instance.f
  [Dr.  de Kirckhoff inoculated different individuals with matter flowing from
the  eyes of patients afflicted with  ophthalmia, and although in so doing, he
states, that he scarcely  touched the edges of  the eye-lids, and in such a man-
ner, that it could  not act  as a  foreign body, ophthalmia  followed in one, two
or three days.J
  M. Hupsch who disbelieved in the contagiousness of the disease, submitted
to be inoculated, and in  24 hours he was attacked with an inflammation so vio-
lent as to endanger his  sight.§
  M. Cunier mixed some pus with 240 parts of water, and applied some of it
to the  eye of a dog, which produced an inflammation  which destroyed the
right eye.||]
  Mr. Mackenzie believes  that the ordinary  catarrhal  ophthalmia is
contagious.  " I regard it," he  says, "as scarcely admitting of doubt,
that the discharge in  catarrhal ophthalmia, especially when  distinctly
puriform, if conveyed from the eyes of the patient to those of others, by
the fingers, or by the use of towels and the like in common, will excite
a conjunctivitis  still more severe, more  distinctly puriform, and  more
dangerous in its effects  on the transparent parts of the eye, than was the
original ophthalmia.  This is the conclusion at which I have arrived, from
the observation  of many instances, in which, as far as  it was possible to
come to  the facts, this disease having arisen in one member of a family
from atmospheric exposure, several others of the family have become
affected without any such exposure that could  be ascertained; and while,
in the  first  affected,  the disease was  comparatively moderate, and
scarcely puriform, in  the latter the symptoms were more violent, and the
discharge thick, abundant, and opaque.^!  He  also considers it extremely
probable that the discharge from the conjunctiva in  catarrho-rheumatic
ophthalmia would excite  disease in the same way if applied to a  sound
eye.**   Dr.  Vetch entertains the same  opinion as Mr. Mackenzie re-
specting the contagiousness of  all the  ophthalmias, which are attended
with puriform discharge.  "  From whatever  cause,"  says he, " inflam-
mation of the conjunctiva may originate, when the action is of that na-
ture or degree of violence, as to produce a  puriform or purulent dis-

  * Page 51—54.                 t Bibliotheque ophthalmologique, vol. i. p. 81.
  [t Memoir upon the ophthalmia which prevailed in the army of the Netherlands.  New
York Med. and Phvs. Journal, vol. iv. 1825, p. 292.]
  [$ Ibid.]                     [|| Observateur Med. Beige Ap. 1834.]
  IT Practical Treatise p. 333.                      ** Ibid, p. 415. 
244
purulent ophthalmia in the adult.
charge (ophthalmo-blennorrhoea,) the discharge  so  produced  operates
as an  animal virus when  applied  to the  conjunctiva  of a  healthy
eye.*"
  Various attempts have been made to illustrate the question of conta-
gion by experiments on animals.  Dr. Vetch! applied the puriform se-
cretion of the conjunctiva to the eye of a  dog, in which it soon produced
considerable irritation ; but the animal was lost, so that the result of the
experiment could  not be  ascertained.  VasaniJ communicated the dis-
ease to  dogs by  applying to the mucous lining of the eye-lids recent
matter  from  the  eyes of patients  labouring  under the  disease, or
matter which had been dried on linen.   One dog contracted the disor-
der by being dipped in a vessel of water,  in which the eyes of two other
dogs labouring under  the  complaint had been frequently washed.  In
these experiments the  inflammation  appeared four days after the appli-
cation of matter.   Graefe§ produced the disease in dogs and cats  re-
peatedly by the application of matter to their eyes.   On  the other hand,
no infection  took  place in  numerous experiments  very carefully per-
formed by Mueller.||   He inoculated five cats,  ten dogs, two rabbits,
two squirrels two  blackbirds, a  starling, a yellow-hammer, and  a cock.
He took matter from  the  eye early in the morning  before  the patients
had washed  their eyes, collected it with  a camel-hair pencil, and intro-
duced  it under the upper and lower lid  in each eye, leaving the pencil
quietly for a few seconds, and then  pressing it so as to squeeze out  the
matter effectually.   He also smeared the matter copiously and repeat-
edly along the edges of the lids.  Not the slightest effect was produced
in any one instance.
  The idea ofcontagion is strongly supported, though not absolutely proved,
by a general view of the origin  and progress of the complaint,  as it  ap-
peared  in Europe.  We know that it had not been noticed prior to  the
occurrence of the contest in Egypt;  that the French  and English  ar-
mies suffered from it severely in that country; that in Sicily,  Malta, and
Gibraltar, places at  which  detachments  of the army  sojourned  on
their return from Egypt, numerous  cases occurred: and that in various
portions of the army, in  this country, the disease has prevailed exten-
sively;  the complaint having broken out first among those  troops who
had formerly been in Egypt, or  in  such  corps as had  had direct com-
munication with regiments returned from Egypt.  The progress of this
complaint has been traced, in all such cases, by the intercourse of fresh
troops with the infected.   The conclusion of its contagious nature sug-
gests itself very forcibly to the mind, on reading the narrative  of  the
gradual development  and progress of the complaint in  particular  in-

  * Practical Treatise p. 175.                   t Account of ophthalmia, &c. p. 13.
  t Sloria dell1 otlalmia contagiosa dello spedale mililare d'Ancona.   Verona, 1816, p.
40, and following. According to Omodei, Ce.nni suW ottalmia contagiosa, p. 101, Rima
hud already performed similar experiments.
  § Die epid. contag. Augenblennorrhoe, p. 35. He mentions that a similar experiment
was performed on a dog and a cat by another surgeon; that  inflammation with  serous dis-
charge followed in both animals on the third  day; on the fourth and fifth there  was swel-
ling of  the palpebral  conjunctiva, with  copious mucous discharge, which  lasted till the
fourteenth.  Ibid. p. 3G.
  II Erfahrungssatze uber die contagiose oder  Aegyptische Augcnentziindung; Mainz, 1821, 
PURULENT OPHTHALMIA IN THE ADULT.
245
stances.  The account given by Mr. Edmonstone* of the disorder  as it
appeared in the Argyleshire Fencibles, published in 1802; the excellent
description of Dr. VETCH,f in a pamphlet published in  1807, and the in-
teresting narrative of Mr. Macgregor, already quoted, may be consulted
on this point.
  The manner in which the disease spreads, leads  us, prima facie, to
the conclusion that it is contagious.  It extends very rapidly, when per-
sons are crowded together in great numbers, as among common soldiers
in barracks where many are  obliged  to use the same utensils  and  the
same linen; whilst the officers, who have  better ventilated,  and more
capacious  apartments, and  live separately, generally escape.   In  the
town of Mentz, which was garrisoned  by Prussians and Austrians, the
complaint  broke out and spread extensively among  the  Prussian  sol-
diers, whilst the Austrians, who inhabited another part of the town, and
were in separate barracks from the Prussians, entirely escaped.J  We see
instances in which the affection has attacked several  individuals of the
same family—the  father, mother, and  several  children—appearing to
have spread  from one to the other.  Again, when the disease  has pre-
vailed  among  bodies of men, it  has  been successfully extirpated by
separating  the affected  from the healthy, and confining each  indi-
vidual  to his own clothes, sponges, and  utensils.  These general views
of the  subject seem  to  have  been strongly  impressed  on  the minds
of  those  who  have  seen the complaint   extensively  prevalent,  and
have led them  to believe that it is contagious: the opinions  of  Mr.
Macgregor, Mr. Edmonstone, Dr.  Vetch,  and other  army surgeons
in  this  country, may  be quoted.  The same opinion has been  held
and defended  on the   continent  by  Rust,§  Walther,||  Mueller,^

  * Account  of an ophthalmia which appeared in the 2nd regiment of Argyleshire Fen-
cibles, &c; also in a Treatise on the varieties and consequences of ophthalmia,  p. 13, and
following.
  t Account of the ophthalmia which has appeared in England since the return of  the British
army from Egypt.  Also Practical treatise on diseases of the eye, part ii. chap. iii.
  t Rust, in the work next quoted, p.  14.   Mueller, Neusten Resultate, &c. p. 21.
  § Die Aegyptische Augenentzundung unter der kanigl, Preuss.  Besatzung in  Mainz
Berlin: 1820.
  Within a few months every third  man in the garrison had been affected ; and Rust
found the disease then spreading rapidly,  p. 21. From June,  1818, to April,  1819,
the whole number of cases, including 2.50 relapses, was 1798, without including  a regi-
mental  surgeon, two hospital-surgeons, and  twelve  nurses, who took  the  disease.—
p. 44.
  || Die  contagiose Augenentzundung der Nicderrhein, besonders in der Arheitsanstalt
Brauweiler, in ihrem Zusammenhange mit der Aegyplischen Ophthalmie Betrachtet; Graefe
und Walther's Journal, vol. ii.
  This  is a very interesting account of the disease as it prevailed for some years in a prison,
where the inmates were kept to hard labour, at Brauweiler, and in the neighbouring country
of the lower Rhine.  Professor Walther describes minutely the phenomena of the com-
plaint, and the points of distinction between it and the other affections of the eye, particu-
larly the  catarrhal and gonorrhoeal ophthalmia?, and the  inflammatory chemosis.   After
the disorder had existed in the prison for some years, appearing like an epidemic, declining
and re-appearing, affecting the keepers and attendants as well as the prisoners, it had be-
come nearly  general in  1819, so that when a  careful examination was made in 1820,
scarcely a single prisoner  was found in whom the eyes were not cither diseased  or in a
suspicious state.—p. 43.
  The disorder as it appeared in this prison and the neighbourhood, had a less  acute cha-
racter than it has shown in the English army.
  IT Erfahrungssatze uber die contagiose oder Aegyptische Augenentzundung; Mainz, 1821.
  Die neusten Resultate uber das / orhommen, die Form  und Behandlung einer ansteck-
enden Augenliederkrankheit unter den Bewohnern des Niederrheins; Leipzig, 1832.
  Of these pamphlets, the first gives an excellent account of the subject, drawn chiefly from 
246
PURULENT OPHTHALMIA IN THE ADULT.
Graefe,* and  Omodei,! who have seen purulent ophthalmia on a large
scale.   Walther is  so  strongly convinced, that he calls it ophthalmia
contagiosa, and compares it, in  this respect, to the  exanthemata.  He
considers the little  granular bodies which  appear on the conjunctiva
to be analogous to  the  eruptions  on the  skin  in the  exanthemata.  I
do not doubt this view, but mention  it merely  to show how strongly
the minds of accurate observers have been impressed with the conta-
gious nature of the complaint.
  Although the evidence afforded by Mr. Macgregor proves satisfac-
torily the contagious nature of the disease, it does not show so clearly
the mode in  which  the  communication is effected.  He says, indeed,
that " the disorder appears  to be communicated by the purulent matter
of a diseased eye being applied to that  of a  sound person ;:'  and he
mentions no  other mode of infection.  Yet we  cannot help concluding
from the facts he  has furnished, that this  is  not the only way in which
the disease may be produced.  If he  had  traced the actual application
of matter in  many out of the hundreds of cases which came under his
observation,  he would hardly have related in detail the three instances
already quoted.   It will be observed, too,  that  in  each of these one
eye only suffered, that to which the morbific matter was applied.   Not
only were the children of the institution affected, but various other per-
sons who had communication with them;  these  must have been aware
of the circumstance, if matter had been applied to their eyes, and would
no doubt have mentioned it, when  the contagious nature of the com-
plaint was so well known.   In May, 1804,  several  bad cases of oph-
thalmia were admitted  into  the  infirmary.   On the morning of the
fourth day after their admission,  two boys in the same  ward labouring
under other complaints were  attacked with inflammation of the  eyes,
and in the course  of  that week the  nurse  took  the disease.   Her son,
who had been in  attendance on the sick,  and in a few  days after her
two younger children were attacked, as were several of the  sick in the
same ward.   In   the course  of  June, in which  ninety fresh  cases oc-
curred,  the nurse  of the girls' hospital caught it, and her husband, an
in-pensioner of Chelsea  Hospital, who came  daily to see her, was also
seized with it, as likewise were two occasional  nurses.   No  other per-
son was at the same time affected with ophthalmia in Chelsea Hospital.
The wife of  a field officer was  at  this time  on  a visit at the Military
Asylum.  She had a son between five and six years of age, who  used
to play with the  other  boys.  He caught the ophthalmia, and on the
fourth or fifth day after it appeared, his sister, two years old, was seized,
and some days after this the lady herself took it.  Great attention was
now paid to the immediate  separation of the diseased from the healthy,
and all other means of checking contagion were adopted :  yet the disease

observation of the disease in the Prussian garrison of Mentz: the latter is principally occu-
pied in showing it s extension, and delineating its forms  and treatment in some districts of
the Prussian provinces on  the Rhine.  The former, and the paper of Walther already
quoted, contain perhaps the best accounts that we possess of the nature and  treatment of
this formidable disease.
  * Die epidemisch-contagiose  Augenblennorrhoe Aegyptens in den Europdischen Befrei-
ungsheeren; ihre Entstehung, Erkenntniss, Vorbeugung und Heilart, wahrend  der Feldzuge
1813, 1814 und 1815, beobachlet.   Folio.  Berlin, 1823.
  f Cenni suit otlulmia contagiosa d'Egitlo; Milano, 1816. 
PURULENT OPHTHALMIA IN THE ADULT.
247
continued to spread, for ninety-five cases occurred in July, and ninety in
August.   A boy and a girl, brought from Scotland, arrived at the Asy-
lum one evening in the end of this month.   They were inadvertently
put  into a ward  occupied  by ophthalmia patients, but immediately re-
moved when the circumstance was observed by Mr. Macgregor next
forenoon; on the third  morning after their arrival both the children had
the complaint.  "All the boys from five to six and a-half years of age
are formed into one company.   It was  observed that in the course of
the last and present month, almost the whole of this company took the
ophthalmia.  Its progress could in their dormitories be traced from one
bed to another, in the order in which they were placed, until nearly the
whole were affected.   The two nurses attached to this company always
slept in their wards, and were the only nurses belonging to the institution
(those connected with  the  Infirmary excepted) that  suffered from the
disease.  About the middle of this month I caught it myself; and though
the inflammatory symptoms subsided in ten days, I did not recover from
its effects for five or six weeks."
  The disease was less prevalent in the Asylum  in 1805  and the three
following years;  but the  number of cases was considerable in the sum-
mers of 1808  and 9  and  the spring of 1810.   As  it was spreading
rapidly in April and May of the latter  year, all  the  affected  children
were removed into a detached building, so as to cut  off the communi-
cation entirely between the healthy  and  the diseased.  From that time
the disorder gradually  declined.
  In proof that the disease did not depend on  a peculiar  state of the
atmosphere, or any other general cause,  Mr.  Macgregor observes  that
the disease had prevailed for nearly a month among the boys before the
girls were attacked; and all the adults, who did not mix with the sick,
escaped it, while those who were connected with them all suffered, the
assistant surgeon excepted.
  Dr. Vetch* is decidedly  of opinion that the disease is not communi-
cable by contagion operating through the medium of the  atmosphere;
he thinks direct application of matter necessary to its  propagation.
  Mueller, on the contrary, who seems to have employed most  dili-
gently his  extensive opportunities of observation, thinks that the conta-
gion is generally conveyed by the atmosphere.  He concludes from this
circumstance that it could also be propagated by contact; but his ex-
perience had furnished him with no direct proofs.f  He never saw an
instance in which the occurrence of the disease  could be traced to the
contact  of matter, by  smearing, injection, or evaporation, unless the
infected person had been  exposed for a considerable  time, and  repeat-
edly, particularly in the night, to an atmosphere rendered impure by an
assemblage of patients.   Relations were allowed to visit the sick, such
visits taking place in a separate apartment, and being limited to half an
hour; disease was never  communicated on such occasions, in  spite of
the  close contact in embracing and caressing, which would necessarily
occur in the meetings of  parents and  children, brothers  and  sisters,

  * Account of the Ophthalmia, &c. p. 10, and following.  Practical Treatise, p. 179.
  T Erfahrungssatze, p. 77. 
248
PURULENT OPHTHALMIA IN THE ADULT.
 husbands and wives.   He knew no instance  of infection by means  of
 clothes, bedding, or the washing or cleansing of linen or other articles.*
   In proof of his  opinion that the contagion does not act through the
 medium of the atmosphere, Dr.  Vetch alleges that the  medical attend-
 ants on the sick were never infected.   WALTHERf on  the contrary, states
 that the nurses and attendants of every description,  and the  physician,
 contracted  the disease at Brauweiler.  MuellerJ also informs us, that  at
 Mentz many nurses and medical attendants suffered, as well as the pre-
 sident of the hospital  commission, and an inspector,  who, in the assidu-
 ous exercise of their  duties, passed much time in  the wards.
   [M. Vansevendonck  exposed himself to what was called the sphere of con-
 tagion; applied his forehead to that of the soldiers  afflicted, but did not con-
 tract the disease, {Specimen Politico Medicum, p. 51.)  He subsequently
 applied the  matter taken from one  of their eyes to his own, and the disease
 was promptly excited in them.
   Mr. Delamarre, one of the most distinguished surgeons of the army of the
 Low Countries, was hospital surgeon at  Ath in 1817-1818, and he had con-
 stantly under treatment  from 20 to  35 cases  of ophthalmia, in a small hospital
 which could scarcely contain 45 men; and during the course of two years, he
 says, " there was a not single individual attacked in the building."  If we
 consider that the establishment was formed  in a private house, it appears in-
 contestable,  he adds, " that if the disease was contagious,  it would have
 spread  among  the individuals, whom the smallness of  the building did not
 permit being separated, and where I often  found it necessary to lodge  those
 afflicted with ophthalmia, the less violent, with those labouring under  other
 diseases."  (Vleminckx & Van Mons. Essai sur l'Ophthalmie de l'armee des
 Pays-Bas. p. 41.)
   Dr. Kirckhoff says, that he has often made those affected with ophthal-
 mia sleep with  the wounded,  and  with  those  suffering  under venereal and
 other diseases, but never saw it communicated. (O. c.  p.  292.)]
   Several arguments  have been adduced against the contagious nature
 of the affection, such  as, in the opinion of some, to leave the point still
 in a state of doubt.  In the first  place, the country in which this conta-
 gion is supposed to have originated, and  where it still remains endemic,
 is one which has attracted the attention  of  philosophic observers in all
 ages.   If it be not the birth-place, it must be deemed the cradle of the
 arts and sciences;  we trace them back  to  Egypt, as the  earliest place
 of their distinctly recognised existence.  We find that at a very remote
period the Egyptians  had made  great  advancement in  sculpture, archi-
 tecture, and painting;  we find that the same prodigious remains which
still astonish  us, existed, nearly in their present state, more than two
thousand years ago.   Egypt  was resorted to  by the philosophers of
Greece; and Herodotus, who travelled in the country for scientific pur-
poses,  and who has  presented  us with an  accurate  description of it,
notices, even in his time, the great prevalence of diseases of the  eye.
Volney§ mentions, that in the streets of  Cairo, where the  disorder pre-
vails throughout the year, but is more prevalent at the vernal equinox, you
may find, out of one hundred persons whom you meet accidentally, twenty

  * Erfahrungssatze, p. 80, 81.
  t Graefk und VValtiikii's Journal; vol. ii. p. 113.    t Erfahrungssatze, p. 82.
  § Voyage en Syrie el en Egypte, vol. i. 
PURULENT OPHTHALMIA IN THE ADULT.
249
blind, ten with only one eye, and twenty more whose  eyes are red,
purulent, or covered with films.  Savary* says, that in the grand mosque
of Cairo  there were eight thousand  blind  persons.  Haller, in his
Bibliotheca Chirurgica, calls Egypt  " Csecorum in  omni tempore fae-
cunda nutrix."  None of the ancient travellers had any idea that the
disease was contagious;  and the  Egyptians themselves,  at  the present
day, have never entertained such a  notion.  None  of the  English or
French army surgeons or physicians, who saw and treated  the disease
in this reputed source of infection, supposed the complaint to be conta-
gious.
   This notion of a specific  contagion, imported from Egypt, originated
in Europe, never  having occurred in  the supposed birth-place of the
virus.   Assalini, who accompanied the French army into Egypt, as sur-
geon to the viceroy of Italy, expressly denies the existence of contagion.
He, and the other  medical  observers who actually witnessed the affec-
tion  in Egypt, refer it to the' ordinary causes  of ophthalmic  disease.
They observe, that the  atmospheric influences capable of producing
catarrhal  affections, are  very powerful here.  The intolerable heat of
the day is followed by night chills and heavy dews;  the land is periodi-
cally inundated and covered with water, which remains to  be evapo-
rated by  the heat  of  the sun.  Such causes  act on the eyes, already
predisposed to disease by a combination of injurious influences : such as
the great  heat of the country ; the powerful light;  the great glare from
the sandy surface; the atmosphere  of dust  caused by the light  sand
composing the soil, being raised into the air by the least breath of wind.
Hence Assalini, and  other direct observers  in Egypt, regard  the  dis-
ease as acute  catarrhal  inflammation, principally affecting those much
exposed to the exciting causes, as soldiers  and the lower orders, while
officers and the wealthier escaped.
  In corroboration of the non-contagious nature of the affection, I may
observe, that in all cases where  collections  of individuals, labouring
under it, have been separated and dispersed, as when troops  are  dis-
banded and go into civil life, the complaint does not extend.   If it were
contagious and capable of producing a like disease in others, we should
suppose that this would be the very way to spread it all over the country;
but we find it the most effectual mode of putting a stop to the disorder.
There is no dissemination of the  complaint in the families, or districts,
to which the soldiers  or other persons so afflicted return.
  Walther! observed, that the complaint seemed to lose its contagious
property when single  patients lived in their families, under the ordinary
domestic relations, even  in  confined dwellings, whatever the stage of
the complaint might be, and however long it  lasted.  He only saw one
exception to this observation.J  Patients labouring under the contagious
ophthalmia were received into the clinical hospital of Bonn,  and at first
carefully separated from the others: but the separation was not con-
tinued, and no infection  ensued, either of the other patients or attend-
ants.   It must be observed, that all  the  arrangements of  this institution
are particularly calculated  to secure the health of the inmates.

  * hettres  sur I' Egypte, vol. iii.                    t Lib. cit p., 119, 120.
  t [MM. Fallot and Varlez, in their " Recherches sur les causes de rOphthalmie," &c,
Bruxellcs, 1829, have collected  many exceptions to this observation.]
       32 
250
PURULENT OPHTHALMIA IN THE ADULT.
  In investigating the contagious or non-contagious nature of this com-
plaint by direct experience, there is a great difficulty, and one not likely
to be soon  removed.  However, we know that  individuals have not
been wanting who, from their desire  of determining certain points of
pathology, have inoculated themselves with matter supposed to be most
infectious and  dangerous.  This  has  been done with  the matter of
buboes in the plague ; and therefore we need not be surprised if some-
body has been found to try the application of the puriform discharge to
his own eyes.   One such experiment is recorded in the 12th volume of
the Edinburgh  Medical and Surgical Journal.  Mr. Mackesy, who had
been with his regiment in  Egypt, where it had suffered much  from puru-
lent ophthalmia, determined, whilst staying on its return  at Messina, in
Sicily, to make a decided  experiment.  He soaked  a  rag in the puru-
lent secretion of the eyes of three patients, and then applied it for more
than an  hour to his own eyes,  and  pressed it  repeatedly against the
lids, to  introduce the  matter between them, which produced a slight
smarting pain.   He then  went  out and walked a mile, a sirocco wind
prevailing and blowing dust in all directions.   He put the rag again on
the eyes at night, and wore it through the night;  he moistened it in the
morning, and applied it again, when  moist, to the conjunctiva;  no in-
flammation ensued.
  Eble* mentions some other  instances, in  which the  puriform  dis-
charge has been applied to healthy eyes without producing any effect.
  Perhaps the apparently contradictory opinions which  have been en-
tertained on the subject may be in some measure reconciled. I cannot
agree with Dr.  Vetch, in  supposing  that the smallest particle  of the
purulent secretion may give the  disease,  and that the contagious pro-
perty remains as long as any purulent fluid is secreted, that  is often for
many months or years.   At least there is, as yet, no sufficient evidence
to establish those points.   If  contagion exists, it must be very different
from that of small-pox, scarlet-fever, or measles;  much less active and
certain.   At the same time, when  I look  to the instances in which the
affection has prevailed extensively; when I see how the disease has
gradually spread through  large bodies  of men, and how effectually its
progress has been arrested in so many cases by insulating the diseased,
and preventing  all intercourse between them and the healthy, I feel fully
satisfied  that the disease is contagious, under certain circumstances and
conditions, although 1 cannot assimilate it to the well-known contagions.
We see  small-pox,  measles, and scarlet-fever, extend themselves in  a
fixed, regular, and determined manner, to which there is  no analogy in
purulent ophthalmia.
  If the accounts of patients themselves can be at all relied on, respect-
ing a fact which they can have no interest in concealing or misrepresent-
ing, there is abundant evidence that the disease arises from other  causes
than from the application  of matter from the eyes of one individual to
those of another.   I frequently  saw, at the London Ophthalmic Infir-
mary, patients labouring under purulent ophthalmia, in whom no com-
munication  could  be traced with others similarly affected. I  should
therefore say that  this disease  may be produced  by common  causes,
* Die sogenannte contagiose Augenentzundung, p. 164. 
PURULENT OPHTHALMIA IN THE ADULT.
251
 without the application of morbific matter to the eye.  But, when once
 excited, it appears capable of propagating itself, under particular circum-
 stances, in a way which we cannot distinguish from a contagious pro-
 pagation.   When individuals are crowded together in great numbers in
 confined habitations, sleeping in the same rooms, using the same linen
 and the  same utensils, and not carefully attending to  personal cleanli-
 ness, deleterious influences on human health are produced from the bad
 air, noxious effluvia, and close personal intercourse inseparable from
 such states.  The injurious operation of such causes is notorious, though
 their nature and mode of action  are obscure.  It is augmented by the
 addition  of unwholesome diet, insufficient clothing, and bad ventilation.
 Hence the only instances of extensive spreading and great virulency of
 purulent ophthalmia have  occurred in  barracks, transports, and other
 ships, in schools, prisons, and work-houses.
   In the doubt which still exists  respecting its contagious nature, there
 is an analogy between this affection and typhus; the contagion in both,
 if we admit its existence, only shows itself under peculiar local circum-
 stances, such  as  an  atmosphere  vitiated by  human effluvia, crowded
 and confined  dwellings, and want of  domestic comforts.  When we
 see that the question  of contagion is not yet settled in  typhus, we need
 not be ashamed  nor  surprised at the uncertainty on the same point in
 purulent ophthalmia.   That  all who are exposed do not become affected
 with purulent ophthalmia, is a circumstance  common to it with other
 contagions,  none of  which  act uniformly and  invariably on all who
 come within their range.  The  presence of the contagion is one only
 out of several conditions necessary to the  production of the morbid
 phenomena : the  state of health  and  of the particular organ  in  the
 exposed individual, and the  surrounding influences, atmospherical  and
 others, are equally important, but as yet  imperfectly understood.  Mr.
 Macgregor observes  that purulent ophthalmia was influenced by the
 state of the atmosphere, being much more severe  in its attacks, and of
 longer duration,  in hot and  sultry, than in  cold, weather.*  Thus, in
 the first year of its appearance at the Military Asylum, it ceased  in the
 winter, although  measures of separation had not  been  adopted.f   In
 the four following years some cases occurred in  the spring, summer,
 and antumn, but none in the winter.  In the winter and spring of 1808,
 the asylum was free from the disease,  which  broke out  again in June,
 when the weather was extremely hot.   In  January,  February, and
 March, 1809,  those previously affected recovered;  but the disorder re-
 appeared in the spring, and became very violent in the summer.J
   Dr. Vetch§ found that the state of the weather and local peculiarities
 were capable of  seriously aggravating the symptoms: a humid  atmo-
 sphere and  marshy soil were particularly unfavourable.  " The disease
 first assumed its violent and characteristic symptoms in barracks, either
 in or  on  the borders of Romney Marsh.  Its next appearance  under
 this form was  at Feversham and  Hilsea, both of them  low situations
and surrounded by ditches, and till very lately proverbial for the pro-
 duction of ague.   Some of the worst cases were also received into the

            *  Lib. cit. p. 37.        t P. 35.        t P. 46, 47.
            §  Practical Treatise, p. 189, and following. 
252
PURULENT OPHTHALMIA IN THE ADULT.
depot from low situations in Essex.  The disease presented itself in the
first regiment of foot, stationed  in  the  Castle of Edinburgh, but  no
instance of particular severity occurred, although a considerable number
were admitted into the hospital.   The high and salubrious situation of
that place is sufficiently known.  The disease, however, still existing in
the regiment, it afterwards broke out at Maldon in Essex, and since its
first appearance, in 1805, it has nowhere produced such cruel ravages,
or sent so many objects of its violence to the  hospitals."  " At the bar-
racks at Aldwick, which formed one of the stations  of the ophthalmic
hospitals, and the situation of which is particularly damp, ten cases of
relapse occurred for one at  Selsea.  In many instances, when the dis-
ease has evinced little disposition to assume its characteristic violence,
and when its nature has been consequently doubted, on the setting in of
wet weather the  suppurative form of inflammation has come on with
the utmost severity."
   That certain conditions of the atmosphere,  and other external causes,
are  necessary to the  propagation or increase of purulent ophthalmia,
may be inferred from what  I have  already mentioned; and that a dis-
order of the eyes may arise and spread, as if  by contagion, without any
reference  to Egyptian origin, or any application of purulent matter, has
been evidenced in various instances.   Dr. Edmonstone* quotes a narra-
tive of the casual development of ophthalmia, in an English ship of war
in the West Indies.   This  ship, the Albemarle, being off the coast of
St. Domingo, met a slave-ship, from which three sailors were taken on
board.  These  had inflamed eyes, and  when interrogated  respecting
the disorder, they said they  were getting well from a  most painful com-
plaint, which had affected  nearly all the  persons  on board the slave-
ship.  On the fourth day after their  reception two sailors of the Albe-
marle were affected  with  inflammation of  the  eyes ; the  next  day,
several  more were seized; and  by the seventh morning twenty-two
had become unfit for  duty from this cause.   The captain  now adopted
the  expedient of  separating the diseased from  the  healthy, and thus
stopped the progress of the  disorder.
   A more remarkable example has happened of late years, on board a
French ship, which left Africa with its  crew and  cargo quite healthy,
and free from all  affections of the  eyes.  During the voyage to the
West Indies, and fifteen days after leaving the coast of Africa, a severe
inflammation of the eyes  broke out  amongst them, accompanied by
puriform discharge.   It made its  appearance first among the slaves,
and then extended to the crew ; and by the time the ship arrived in the
West Indies, there was barely a sufficient number of individuals retain-
ing their sight to work the ship  into the harbour.  Of the crew, who
were in number twenty-two, twelve lost their sight; five lost one eye;
and four  had opacities of  the  cornea.   Of one hundred  and  sixty
negroes, thirty-nine  lost their sight completely, twelve lost  one eye
each, and  fourteen had more or less considerable opacities.f  Here was
a case in which no previous contact with infected  persons could  be
traced; yet an apparently genuine purulent ophthalmia made its appear-
ance, and  spread with the greatest rapidity.  We may fairly conclude

     * Treatise, &c. p. 9.    t Guille, Bibliothiquc Ophthalmologique, vol. i. 
PURULENT OPHTHALMIA IN THE ADULT.
253
that the vitiated atmosphere which these persons  breathed, the depres-
sion of  spirits, the bad food, and  the want of  attention to  cleanliness,
are sufficient to account for it.
  In the limited sense to which I have now adverted, purulent ophthal-
mia may be considered contagious; but I do  not believe that it is an
active, virulent, or certain poison ; and still less that it is a specific con-
tagion of Egyptian, African, or Asiatic origin.  The term Egyptian is
improperly applied to it, inasmuch as the disease has appeared in various
countries without any suspicion of contagion derived from Egypt.  I can-
not help thinking that it has existed in this country long before our inter-
course with Egypt.  Its not having been described does not prove its
non-existence; the distinction between  small-pox and  measles, and be-
tween the latter and scarlet fever, are not of old date.
  In practice, it is the safest course to proceed upon the notion  of the
complaint being contagious;  and, acting  upon that notion, to prohibit
the use of the same sponges, utensils, or linen,  or any other thing capa-
ble of communicating the disease  from one to the other, just as if the
contagious nature were decidedly proved.
   Treatment of purulent ophthalmia.—The violent inflammation which
frequently accompanies the disease, and the consequent serious danger
of the organ, have naturally influenced  the  indications of treatment,
which have been  founded too much on this partial view of the subject.
Antiphlogistic measures, although capable of  removing  the inflamma-
tory symptoms, which are present in  some instances, cannot remedy
the affection of the palpebral  conjunctiva, which is the source of those
symptoms.   The latter object must be accomplished by other means.   I
shall  consider separately the  violent and the  milder forms of the com-
plaint, as different therapeutic principles  are  applicable in the two in-
stances.
   Treatment of acute purulent ophthalmia.—Our object is to arrest the
violent inflammation of the conjunctiva, to prevent its extension from
that membrane to the  cornea.  Blood should be taken from the arm,
and in large quantity, so as either to influence  the circulation decidedly,
or to  produce syncope.  More benefit will be derived from one vene-
section of this kind than from  the repetition o{ smaller ones.  Bleeding
in the ordinary quantity, and that repeatedly,  had been extensively em-
ployed in the British army without any decided benefit, when the in-
creased prevalence of the disorder, together with its violent nature and
destructive consequences, rendered it necessary to  adopt measures  of
greater efficacy.   General  depletion was now employed much  more
freely, and with corresponding advantage.  It was resorted  to  in the
early  stage of the disease, and the quantity was regulated by the effects
produced on the  system.  " The diminished vascularity,"  says Dr.
Vetch,  " is the first effect which ensues, and  before the end of the ope-
ration the eye will often become nearly of its natural appearance.  The
cessation of all uneasiness  should be the sine qua non of stopping the
flow of blood.  This, in a robust man,  will often  not  be obtained until
thirty or forty ounces have been taken away; and  in  a few deliquium
will take place before this is  effected; one or  other of these  effects
should always be procured."  If, which  rarely happened, the disease 
254
PURULENT OPHTHALMIA IN THE ADULT.
 assumed  its violent form in spite of this treatment, the same means
 were repeated.   In this state, fifty or sixty ounces must be taken away
 to relieve the pain or bring on syncope;  " but we can always rely with
 certainty on the benefit which will ensue when either of these effects is
produced.   In every case where such practice is  employed, however
violent the tendency of the disease may  be, its destructive termination
will infallibly be prevented, and with much less expense  to the patient,
than by smaller and more frequent bleedings."*
   Dr. Vetch observes further, that this plan of free depletion had a re-
 markable influence over the symptoms  of the  second  stage.   " The
palpebrae were no longer subject to  the  same  degree  of eversion, the
quantity of pus was diminished, and in no case did  granulation  become
a troublesome symptom.   The swelling of the conjunctiva was less vas-
cular, and appeared like watery vesication; the attacks  of pain were
shortened, and less regular  in  their recurrence."   Besides, therefore,
the actual reduction of the numbers in which the disease advanced to
the second stage, the symptoms were also rendered less violent by the
early adoption of  the  treatment  recommended.  This practice, which
has so fully met the exigency of the case, has not, perhaps, for its decision
and efficacy, a parallel in the practice of medicine; and every person
who has seen it employed, is  sufficiently convinced of its propriety; but
those who have experienced the mortification of  seeing every other
means unequal to combat the disease,  are best able to express a just
sense of its benefits."!
   Rust,  who, like Dr. Vetch, had soldiers  for his  patients, a  circum-
stance that must be borne in  mind when the amount of depletion is con-
sidered, found it necessary to  take two or three  pounds of blood  in order
to produce the  requisite  effect.  He also insists on  the importance of
resorting  to this  active  treatment  as  early as  possible.J  Mueller§
observes to the same effect, that  the quantity of blood to be drawn must
be determined by individual circumstances; that pain, so far as it depends
simply on inflammation, should  be  removed; and  that  vascular tur-
gescence of the eye and lids should be visibly reduced: that these objects
may be accomplished in  one individual by taking a  pint, while in others
it may be necessary to take two or three pints, or even more.  It may
be necessary to repeat the venesection; and, if the symptoms continue
urgent, it should be done without delay.
  Rust||  speaks favourably  of temporal  arteriotomy, which was per-
formed with the most advantageous results more than a hundred times
during the epidemic in Mentz.  I agree with Walther!  in the  opinion
that venesection will do all the good that loss of blood can accomplish;
and I consider it preferable to arteriotomy for  obvious reasons.   In the
practice of Dr. Vetch** " the blood was sometimes taken from the jugular
vein and  temporal arteries,  without any  superior  advantage.   From
the great ease with which the quantity of blood can  always be obtained
from the veins of the arm in a given time, they were generally resorted
to."

  * Account, &c. p. 109, 101.                            t Lib. cit. p.  104, 105.
  t Die Aegyptische Augenentzundung, pp. 212, 216.
  § Erfahrungssatze, p. 122.                            || Lib. cit. p.  213.
  IT Lib. cit. p. 124.                                  ** Lib. cit. p.  102, 
PURULENT OPHTHALMIA IN THE ADULT.
255
  After  venesection,  cupping from the temple and leeching may be
employed.   In a  severe case, after bleeding the patient largely from
the arm, apply twenty or thirty leeches round the eye, and repeat them
quickly.
   Scarifications, whether superficial or deeper, are objectionable, as in
all cases of acute  ophthalmia.  The wounds thus inflicted increase the
local irritation; and  the quantity of blood furnished by them is too
inconsiderable to compensate this disadvantage.
   Walther recommends very strongly the practice of cutting out a
laro-e piece  of the  swollen  conjunctiva, either  from the eye-lid or the
globe, after general bleeding.*  Several drams of blood will  flow from
such an incision with great relief of the  local  symptoms.  He  recom-
mends the removal of as large a piece as can conveniently be cut out,
observing,  that although such a wound is large when  first made, it
appears as a mere line after the inflammatory  tumefaction of the mem-
brane has  subsided.f  He  equally approves of this proceeding in the
subsequent stages of the complaint.
   Active purgatives in the first instance, and afterwards milder aperients,
with reduced diet and rest, must accompany the measures just described.
After general depletion, the tartrite  of antimony may be  administered
with advantage in nauseating doses;  and mercury may be  given for
two or three days, as we  administer  it in other  inflammations after
bleeding, to quiet that disturbance of the capillaries, which might lead
to effusion.  Calomel, alone, or  combined with opium, in small doses,
every four or six hours, will answer the purpose.
   After  depletion blisters may be applied to the nape; and the blistered
surface may be dressed with savine cerate.
   The  active antiphlogistic  treatment, and particularly the large and
repeated bleedings, which have just been  spoken of, have been employed
in army practice, where the patients are generally  in the vigour of life,
robust,  and in high  condition.   Such  means  are not  necessary, nor
would they  be admissible   in the  less  vigorous  or  even  sometimes
enfeebled subjects, in  whom the complaint  may be seen in civil life.  In
the early period of the disease, before chemosis has occurred, the cornea
being clear, moderate antiphlogistic treatment will be sufficient to check
the inflammation, and prevent danger to  the eye.  According to  the
age and strength of the patient,  and the  state  of the circulation, blood
may be taken, either by venesection, or by cupping or leeches: aperients,
antimonials carried to the extent of nauseating, and a short use  of mer-
cury, may be added.   If the conjunctiva has begun to swell, and danger
to the cornea is apprehended, especially in a young and strong  subject,
it  will be necessary  to proceed  more  actively.   If chemosis has been
established, and unfavourable change has already occurred in the cornea,

  * An analogous proceeding is advised  by Scarpa in cases of chemosis generally with
the view of letting out  that supposed effusion of blood under the conjunctiva, which he
regards as the cause ot the chemosis.  The operation "consists in the circular excision of
the projecting portion of the conjunctiva with the  curved scissors, at the part where the
cornea and sclerotica unite; by means of which, not only the whole of the blood which is
extravasated under the conjunctiva is discharged, and with immediate relief to the patient,
but also that which, notwithstanding the abundant general evacuations of blood, might
still greatly distend the vessels of this membrane."—Sir. Briggs's Translation, p. 148.
  t Lib. cit. p. 126—130. 
256
PURULENT OPHTHALMIA IN THE ADULT.
extensive depletion would only weaken the patient, without chance of
corresponding advantage.
  Local applications.—From  the  well-known efficacy of cold  in re-
ducing vascular action, and consequently lessening effusion and swell-
ing, applications of this kind may  be expected to prove most advanta-
geous in purulent ophthalmia; and that  they are so is proved  by the
concurrent testimony of those  who have treated the complaint most ex-
tensively.   I believe, with Rust* and Mueller,! that  nothing answers
the purpose better than cold spring or river water, with which the eyes
may be frequently cleansed : it may be used, too, if it is found comfort-
able, more or less constantly as a  lotion,  by means of light linen rags
dipped in it and frequently renewed; they  should cover the forehead as
well  as the eyes.  Mueller too employed with advantage, in the very
commencement of active inflammation, water rendered still colder by
putting pieces of  ice into it.   A fresh portion of  water should be used
for each cleansing of the eyes.
  WaltherJ also extols highly the beneficial effects of cold water. " In
the severer forms of the disease we apply  cloths  dipped in cold  water,
not only to the eyes and forehead, but also to the entire head.   This
plan  is continued in some cases from fourteen to twenty-one days with
the best result; with great alleviation of the pain, rapid subsidence of
the swelling, and diminution of the puriform discharge."   In several
obstinate cases I  have had  cold water poured over  the head once  or
twice a day with good effect.   " The  cold douche has also been used
in some instances with surprising benefit."  Dr.  Gericke,  who had the
charge of an ophthalmia  hospital, gives the following account.   " The
cold  douche was resorted to in  conjunction with powerful antiphlogistic
means.   It was used in all cases attended with chemosis,  and it never
failed to give immediate relief. When the  affection was obstinate, it
was  often repeated.  The patient  was  seated in  a bathing-tub half full
of warm or cold water;  perhaps the former is preferable.  Cold water
was  then poured over the head from a height of five feet: it produced
a great shock.  The douche was repeated three or four times; the pa-
tient was then put to bed; considerable perspiration ensued, with relief
from pain."  Cold affusion was resorted to with considerable success
by Mr. Peach,§ when the ophthalmia prevailed in  the second battalion
of the fifty-second.   " In some cases where, after the very free  use of
the lancet, the patients felt hot and restless, and  in the very few cases
where these symptoms occurred in the first instance, the usual benefits
resulted from its employment."
   Warm fluids, fomentations,  poultices, and steam,  increase the heat,
and thus augment the vascular disturbance.  When, under the continued
progress of the inflammation,  the  application of cold becomes painful,
the water may be used tepid for cleansing the eye. Unless there should
be spasm of the lids, warm fomentations should not be employed ; though
I have known instances  in which  patients have  found them agreeable.
If the continuation of cold cannot be borne, let local means be laid aside,
* Lib. cit. p. 211.                      + Lib. cit. p. 128—130.
t Lib. cit. p. 130—133.                  $ Dr. Vetch, Account, &c p. 115. 
                  PURULENT OPHTHALMIA IN THE ADULT.             257

 except for ablution; it is not absolutely indispensable to keep the affected
 organ constantly covered with wash or fomentations.
   The free use of mercury is recommended by Rust,* when the inflam-
 mation is advancing in spite  of  active antiphlogistic treatment.  My
 experience corresponds with that of Vetch! ana"  Walther,J who have
 seen salivation produced in  many instances  without the smallest advan-
 tage.  I have  already recommended the use of  calomel, for a limited
 period, in order to prevent effusion of lymph.
   The means before recommended  must be continued and  repeated till
 the bright  redness of the  conjunctiva and its tumefaction are lessened,
 and till the pain is gone.
   The membrane will now  be paler, with a relaxed and flabby appear-
 ance, the discharge still continuing abundant;  we must  alter the plan
 of treatment, and  use  astringents,  allowing better diet, and perhaps
 tonic medicine.  By the judicious employment  of such means, after the
 violent inflammation has  been subdued, we shall remove that diseased
 condition of the conjunctiva which causes so much inconvenience to the
 patient, so  much trouble and perplexity to the practitioner.   Of astrin-
 gents, the solution of alum comes the first in order, being employed  in
 the  same way as  in the infant.   The  oxymuriate of mercury may be
 used (gr. j—ii. ad ^j.) Mueller^ particularly recommends two formulae;
 1st,  one, two, or three drops of sulphuric acid in an ounce of water;
 2ndly, two or three grains of  acetate of copper in the same quantity.
   The preceding milder applications may be followed by solutions of the
 nitrate of silver or sulphate of copper, (gr. ij—yj. ad ^j.) or the undiluted
 liquor plumbi.   Of these fluids, one, two, or three drops should be care-
 fully introduced between  the lids, once or  oftener in the day, the eye
 being still occasionally cleansed and bathed  with the alum lotion.   The
 citrine, or red  precipitate ointment, may be  applied to the  edge of the
 lids  at night.
   Mr. Briggs||  has found the oleum  turbinthinaj to be  the most effectual
 means of checking the profuse discharge in purulent ophthalmia.  He
 introduces " a minute quantity of it, proportioned to the age and sensi-
 bility of the patient, on  the  point of a  camel-hair pencil between the
 eye-lids every morning, the eye being immediately afterwards  immersed
 or bathed freely with cold water and a sponge,  until the uneasiness and
 sense of heat which it  produces in  the eye and surrounding parts  is
 allayed, which  usually continues for some minutes."
  We must carefully observe  the effects  of  astringents  in  the first in-
 stance; they cause more or  less pain, which goes off, leaving the eye
 relieved and stronger.  But  if  the pain  should continue, and the redness
 be increased, we must leave them off  and  return to  the antiphlogistic
 means; for the same reason  we must suspend them at  any period, if re-
 lapse of inflammation should occur.
  Better diet, exposure  of the organ to light, as much as it will bear,
 and exercise in the open air, may be combined with this change of local
measures.  Confinement to the house  does  not seem advantageous at
any period of the complaint, while free exposure of the inflamed eye to
* Lib. cit. p. 219.
* Lib. cit. p. 133.
|| i\\>lc to his translation of'ScARTA, p. 170.
   33
t Lib. cit. p. 88.
§ Erfahrungssatze, p. 143, 
258
PURULENT OPHTHALMIA IN THE ADULT.
cool air, and even  exercise, instead of being hurtful, as  patients and
their  friends suppose, have generally been found  decidedly beneficial.
Dr. Vetch is even disposed to recommend the trial of a journey, in the
commencement of the disease, if the eye be  freely exposed to the air,
and the weather favourable.  He says  that when  the second stage has
commenced, with  chemosis and purulent secretion, he has never seen
any but the best  effects from change of place.   " Soldiers, who have
commenced a march with the disease  completely formed, though  ex-
posed to heat, dust, and fatigue, and not abstaining even from intoxication,
are invariably better at the end of the journey than when they set out.
The instances of this fact, which I could adduce from my own obser-
vation, are innumerable;  and I am informed by Mr. Murray, surgeon
to the forces, that so strongly  did he observe  the  beneficial  effects  of
exposure to the air, when a great number of men affected with the dis-
ease was  sent under  his care to the interior of  Sicily, that he was in-
duced to March them from one place to another, with a view solely to
the good effects which he saw to result from it."*
   If  the patient is weakened, we allow a  good diet, with stimuli, and
we may have recourse to bark, cascarilla, and  the mineral acids.   In
the irritable state, which remains after  considerable depletion, with the
eye suffused and intolerant of light, with considerable pain not referra-
ble to inflammation, and often periodical, Mueller! employed the remedy
first mentioned in  substance, repeating  it at short intervals : he used it
generally in the treatment of the contagious ophthalmia, after depletion,
if there was no decided  contra-indication.  Improved diet should  be
combined with the bark.
   The internal use of opium has been resorted to as a remedy for pain;
and it may sometimes be  used with  advantage  after depletion, either
alone or in the combination of Dover's powder.  Some have considered
its local use  advantageous before  proceeding to  astringents, or when
they cannot be borne.   The forms employed have been the aqueous solu-
tion as a collyrium; vinum opii  dropped into the eye; and  the  sub-
stance alone, or  combined with mercurial ointment, rubbed over the
brow.
   Spreading ulceration of the  cornea, attended  with  debility, will
require a  decided tonic and  stimulating treatment;  that is, good diet
with  porter, or wine, bark,  or the sulphate of quinine,  and local as-
tringents.
   In that  peculiar kind of ulceration, where there is a deep groove in
the margin of the cornea, after stopping the inflammation, raise the gen-
eral powers by good  diet  and tonics,  and  leave the ulcer to nature.
The very diligent use of astringents and  stimuli, particularly the stronger
ones, often  does mischief. The  most rapid  recoveries I have seen in
extensive  ulcers of this kind, have been  where no local means but simple
tepid ablutions have been employed.
   In that ectropium of the lower lid, which remains after the inflamma-
tion is gone, and presents a large red fleshy mass, without much sensi-
bility, the nitrate of silver in substance may be freely used.   A few ap-
* Practical Treatise, p. 208.
f Lib. cit. p. 137—141. 
                 purulent ophthalmia in the adult.              259

plications of it soon remove the swelling and restore the lid to its natu-
ral position.
   There are, in  short, two points for us to bear in mind in treating acute
purulent ophthalmia;  first,  to check inflammation  by  antiphlogistic
means, and then to employ astringents.  If we proceed on this plan, we
shall prevent that chronic thickening  and granulation which are so ob-
stinate and troublesome.
   The free use of powerful astringents, such as  the sulphate of copper,
the diacetate of  lead, and a strong solution of  nitrate of silver, or an
ointment containing the same  substance, has been recommended in the
commencement of purulent inflammation, to cut short  the complaint.
The remedies thus employed  come  into  contact with the very seat of
disease, and act  directly on  the vessels, which are in a state of distur-
bance; hence we derive a rational explanation of their beneficial opera-
tion when the disorder is confined to the mucous lining of the palpebrae,
or in its first degree of extension to the conjunctiva of the globe.
   I have already quoted (p. 216) the experience of Mr.  Melin on this
subject.
   Very strong testimony in favour of the astringent plan of  treatment
in ordinary purulent ophthalmia is given by Dr.  O'HalloraN,! who had
enjoyed  ample  opportunities  of  observing the disease, as an army
surgeon, for many years, and in  various climates.  He had  become
dissatisfied with the  antiphlogistic treatment, from  having found it fre-
quently either insufficient or injurious, and was  hence led to use astrin-
gents,  not only in the early  stage of the disease, but when the purulent
discharge and chemosis were fully established.   He employed the sul-
phate of copper in substance, rubbing with  it the inner surface of  the
eye-lids after everting them, or he dropped  into the eye the ten grain
solution of nitrate of silver; and  generally used one or the other once
a-day.  He gave purgatives  and  applied fomentations.   If the symp-
toms indicated that  the internal parts of the organ were  affected, he
directed the application  of leeches.   After mentioning a case treated
successfully with the sulphate of  copper and the  caustic  solution, he
adds, "The  foregoing case,  with some hundreds  on  record, of  the
different varieties, show  with  what efficacy and safety blue-stone may
be applied to The eyes when under disease:  its  effects in  removing  the
affection of the parts and allaying  the irritation are remarkable.  1 can
safely say, that  abstraction  of blood  will  be rarely necessary in  this
disease, if the plan recommended  be strictly attended to ; and  1 more-
over am of opinion, that if any inquiry be instituted amongst the army
surgeons, it will  be found that those,  who  used  the  greatest  depletion,
were the least successful practitioners, and that sloughing, ulcers, &C.
more frequently  succeeded the evacuating plan, than when  the patient
was partly left to nature."
  [Our views with regard  to the detraction of blood in  purulent ophthalmia
coincide entirely with those of  Mr. Lawrence; but our experience leads us to
ascribe greater  remedial powers to the nitrate of silver than  is done by him,
and also to employ it earlier and of greater strength.   AVe resort to it at once,
if there be no great heat and pain in the eyes, with inflammatory excitement in

  t  Practical Remarks on Acute and  Chronic Ophthalmia, and on Remittent Fever; Lon-
don, 8vo. lt-24.  Part 1, ch. 1. 
260
PURULENT OPHTHALMIA IN THE ADULT.
the system, and if these symptoms be present we only delay the application
until they are abated by free  venesection; and we afterwards continue its em-
ployment, conjointly with  topical depletion,  purgatives,  diaphoretics counter
irritants, &c.  We graduate the strength of the solution to the profuseness of the
purulent discharge ; when the latter is great,  using a solution  of from thirty to
forty drachms of the salt to one ounce of distilled water.  Generally, however,
a solution of from  ten to fifteen grains to the ounce will be sufficient, and  its
strength must be  diminished as the discharge abates; for patients who have
used the strongest solution when the  disease is at its height will experience
severe pain from a far weaker one, even of four  grains to the ounce, at an
advanced stage of convalescence.  We apply this solution but  once a-day, and
then only two or three drops at a time, which  is to be dropped on the eye from a
quill or glass tube.   Either of these may be introduced into the solution so as
to allow the requisite quantity to pass into the tube, the upper end of which is
then to be closed with  the fore-finger, and  the  lids being separated, and the
tube held over the eye, the  finger is to be raised when the fluid will flow out.
By this means the application may be best made  to the eye, and  the quantity
may be most accurately graduated.  To cleanse  the eye we ordinarily employ
pure water, or a collyrium consisting of one grain of corrosive sublimate in six
ounces of water; its temperature to be regulated  by the feelings of the patient.
   We attach  much importance also to the use of mustard pedeluvia at night
with a full dose  of Dover's Powder.   These means tend greatly to the comfort
of the patient, by abating the  pain, giving a good night's rest,  whilst, by deter-
mining to the extremities and surface, they act as revulsives.]
   The  treatment proposed by Mr. Tyrrell of incisions  through ihe
chemosed conjunctiva, and first employed by him in acute gonorrhoea!
ophthalmia, is  equally applicable to the  common purulent form of the
complaint.   It is fully described  in the next chapter, at  the end of the
first section.
   Treatment of purulent ophthalmia in its milder form.—If inflamma-
tion, although not considerable, should have occurred in the conjunctiva
oculi, or if we think its occurrence probable, it will be proper to employ
moderate antiphlogistic treatment, such as abstraction  of blood by cup-
ping  or leeches, cold  washes, regulated  diet, and  aperients.  When
active disturbance is subdued by these means, the local use of astrin-
gents to the  diseased palpebral linings is necessary, and must be con-
tinued  until  the   morbid  change  already described  shall have been
completely removed.   The solutions of  alum, sulphate of  copper, and
nitrate  of silver,  at first in a weak form, and gradually increased in
strength if necessary, dropped into the  eye once or twice a-day, and
the red precipitate or  citrine ointments to the ciliary margins, are the
best remedies for this purpose.  The liquor plumbi  diacetatis, undiluted,
may be used, if the complaint should  be  tedious, and a stronger astrin-
gent be consequently required.   Confinement within doors is not neces-
sary;  on the contrary, exercise in the open air, and  exposure of the
eyes to  it for some hours  in the day, particularly in warm or  mild
weather, is decidedly advantageous.   The protection  of a shade must
be used, if the light should be too powerful.   The army-surgeons have
found that this inflammation, even  in  its more active form, instead of
being aggravated, has been decidedly checked by free exposure  to the
air; and thus that patients have been much  better after  marches, even
in bad weather.
   Mueller strongly  recommends, from long  experience,  mercurial 
PURULENT OPHTHALMIA IN THE ADULT.
261
applications in the form of ointment, which I have not seen employed.
These are the hydrargyrum oxydulatum nigrum,* which seems to be a
mild dark grey or blackish oxyd of mercury, in the proportion of four
or six grains to one dram of lard; the white precipitatef in the pro-
portion  of seven or eight grains to the dram; or the  red precipitate.
These ointments are to be smeared over the diseased surface once or
twice daily.  If the eye does not bear their application in that manner,
we are advised to rub  the  former,  sometimes  with the  addition of
opium, into the  eye-brow, forehead, or cheek; or  to apply over the lids
a piece  of linen thickly spread with it.J
  As the complaint is now strictly local, the above-described topical
measures  are the  best  calculated to  remedy  it.    That Mueller§
should have found blisters, issues, and  setons unavailing, need not sur-
prise  us.
  Treatment of the diseased palpebral conjunctiva in  the  chronic
state.—When purulent ophthalmia has been neglected or inefficiently
treated,  and when the eye has  consequently been repeatedly inflamed,
the  palpebral linings  become thoroughly altered  in  structure, and we
cannot be surprised that  it should be difficult, and indeed hardly possi-
ble, to restore their healthy state.  For  this purpose the use of  local
means still more active  than  those already  specified, has been recom-
mended.  This condition of the  parts  has been called by  English
writers,  the granulated state of the eye-lids.  It is hardly necessary To
observe  that  this  phrase, and  the  term granulations, which is so fre-
quently  employed in the account of purulent ophthalmia, merel)' denote
the  external  resemblance of the  morbid structure  to the surface of a
healing  ulcer, without indicating any affinity in origin and nature.
  A very important effect produced by this state of the  lids  is vascu-
larity and opacity of the cornea.   The mechanical friction of the granu-
lations on the surface of the  cornea causes  its vessels to be enlarged,
so that the texture of  its  conjunctival layer is loosened and thickened;
hence haziness, a nebulous state, or more considerable opacity is pro-
duced.  This change  must be distinguished from the effects of active
inflammation.  In the present instance, the following is the order of
events:—1st. Disease of the palpebral lining; 2ndly.  Acute inflamma-
tion of the conjunctiva; 3rdly.  Full development of the granular surface,
with thickening and  hardening  of the membrane; 4th!y. Vascularity
and opacity of the cornea.
  The morbid change is frequently confined to  the  upper half of the
cornea;  that is, to the portion over which the rough surface of the upper
eye-lid moves ; while the lower half remains transparent.  Granulations
are  hardly developed  on  the narrower surface of the lower lid, which
has a  much less range of motion  than the upper.   Hence the  lower
part of  the cornea escapes the irritation, which  affects  the  upper so
injuriously.   The vascularity may proceed  to the extent of covering
the  cornea with  a net-work  of  red vessels; and its  mucous covering
may be  so loosened and  thickened  as  to  exhibit  the state, technically
called pannus,  in which the boundary of  the cornea can hardly be
seen.

    * Neueste Resultate, p. 50.   t Ibid, p, 42.   t Ibid. p. 52.   § Ibid. p. 63. 
262
PURULENT OPHTHALMIA IN THE ADULT.
   With these changes  may be combined the results of severe inflam-
mation;  viz. leucoma, synechia anterior, prolapsus  iridis, staphyloma,
amblyopia.   Sometimes there is active inflammation of the membrane,
with blennorrhoea; for the eye is weak  and irritable, and subject to
relapse of inflammation from slight causes.
   In the first place, we must remove inflammation by suitable means.
The eye should be protected from  external excitement without con-
stantly covering it, and certainly  without confining the patient  to the
house, which would be decidedly prejudicial.
   Excision  of the granulations, either  by knife or scissors, was prac-
tised at one time; and a dispute arose which method deserved the pre-
ference.   This was terminated by the entire abandonment of the pro-
ceeding, which had been found injurious.
   Walther,* however, still advocates the plan of excision as the most
effectual means for removing the  preternatural growth of the conjunc-
tiva, to which purpose he  has  found  caustics inefficient.  He observes,
that the granulations will be reproduced, and  that it will be necessary
to repeat the  operation, which causes no local  excitement, so that it
may be speedily followed  by the use of astringents or escharotics.
   Supposing the eye  to be free from irritation,  and the  disease thus
reduced within its original boundaries, we may try, even in these chronic
cases,  the astringents  already specified, such as the solutions of alum,
nitrate of silver, or bichloride of mercury.   The liquor plumbi diacetatis
undiluted, and the citrine  or red precipitate ointments  to the  ciliary
margins, are among the most serviceable local remedies.
   If these means should not  be sufficient, the use  of  escharotics has
been recommended.   In resorting to them we should always bear in
mind the powerful action of such substances, and the delicate organi-
zation  of the part to  which they are to be applied.  We  should begin
with the weaker, and proceed to the stronger applications.  To pre-
vent their injurious action on the healthy conjunctiva, we should take
care that they touch only the diseased part.  We  should therefore evert
the lids, and keep them everted until  the effect of the application is pro-
duced.  The surface,  when thus exposed, may be freed from moisture
before  the escharotic is applied ; when its action is over, the membrane
should be carefully washed to remove any remaining portion  of the
application, before the lid is restored to its natural position.   The smear-
ing with oil, which has been adopted for the same purpose, is not more
efficacious than  ablution with a soft sponge and simple water.  The
substances may be applied in solution, in powder, or in substance; the
first and last  forms are the best. Change of application is often ad-
vantageous.
   The acetate of copper in concentrated solution, or in powder, is one
of the weaker means.  The sulphate of copper has been used in powder
and in substance; in the latter form it is one of the best remedies of this
kind.   The whole of  the  granulated surface  should be gently rubbed
until it assumes a dirty bluish tinge;  after waiting a minute or two, the
lid should be carefully washed and restored.
   The nitrate of silver has been employed  in  solutions of various
* Lib. cit. p. 128, 129. 
PURULENT OPHTHALMIA IN THE ADULT.
263
strength, sometimes even saturated, or in substance.   The prominent
points of the morbid surface should be lightly touched in the latter case;
in the former the palpebrae  must be everted, and the liquid applied with
a  camel-hair pencil to the granular  surface.   In Belgium, where the
affection has prevailed extensively in the army for a long time, the nitrate
of silver has been relied on principally as a  remedy for the granulated
state of the lids, and  has been principally used in substance.  They
have rubbed the diseased surface freely, then passed over a brush dipped
in oil, and  restored the lid  to its place.   Mr.  Gouzee, at the head of
the  military hospital  at Antwerp, says, " that  this proceeding  may be
safely employed in the lower lid; but that he has often found it, when
used to the upper, produce  very serious  symptoms, such as ulcerations
and  greenish-yellow spots."  The  pain  is so great, that patients often
refuse to submit to a  repetition of the application.  Hence, he has left
off this method, and employs instead a solution of the caustic in an equal
quantity of water.  He applies this  by means  of a camel-hair pencil,
not taking up much of the liquid, then touches the surface with  another
pencil  dipped  in oil.   Two  or three cauterizations  are sufficient to
remove the inequalities of surface, but the thickening of the membrane
cannot be got  rid of  without a greater  number.   One upper  lid  only
should be touched with the pencil at a time;  both lower palpebrae  may
be cauterized at once with the stick of nitrate of silver.   Mr. Gouzee
adds, " that the nitrate of silver is the most efficacious remedy in these
cases ; that the sulphate of copper is not  sufficiently powerful; and that,
when the granulations are  large, especially in the upper lid, it is advan-
tageous  to excise, in the  first instance, the most prominent  portions
with curved scissors."*
   The nitric and muriatic  acids, diluted with three parts of water, have
been recommended.   These  may be applied, like the  solution  of lunar
caustic, with a camel-hair  brush.
   These strong applications, as  might be   expected  produce,  and
aggravate  local  excitement,  causing pain often very severe,  redness,
swelling, and  increased  discharge.  They   must  not  be repeated,
until these effects have  gone  off, that  is,  until  the  third  or fourth,
or from that  to  the  sixth  or eighth day.  Longer  delay, and  anti-
phlogistic treatment  are sometimes necessary.  In the  interval of the
escharotics, some of the  astringent  solutions  already mentioned may
be employed.
   I  could not  adduce much personal experience in favour of this escha-
rotic treatment; having found more benefit from antiphlogistic means in
the first instance, and the subsequent  use of mild astringents,  such as the
solutions of alum, sulphate of  copper, or lunar caustic, and the liquor
plumbi, with  regulation  of diet, and the digestive organs, residence in
pure air, exercise, repose, or moderate  use of the organ.   With such
means 1 have sometimes advantageously combined issue in  the temple.
Great  and  rapid  improvement has occasionally been observed when the
general plan above mentioned, with merely  soothing local applications,
has  been substituted for strong astringents and escharotics.  The  latter

  * Des Granulations des  Paupieres, et dc leur Traitement.  Journal des Connaissances
Medico chirurgicales, July, 1839. 
264
PURULENT OPHTHALMIA IN THE ADULT.
should not I think be employed, until the gentler measures have  been
tried, and then very cautiously.  The great tendency to relapse  must
be borne in mind; should active mischief return, the escharotics must be
laid aside, and the milder plan resumed.
  Walther,*  whose experience in  this complaint has been much more
extensive  than mine, has come to the same conclusion respecting the
use of escharotics. " The benefit derived from them," he says," is on the
whole inconsiderable; even when methodically and cautiously employed,
they either do not effect a complete cure, or bring it about very slowly.
I used in the ophthalmic hospital of Bedburg the means recommended by
Rust, which  are  chiefly of a  powerful  escharotic  kind, in  numerous
cases, according to the rules he has laid down, but without the expected
benefit.   Most of them are so strong that the eye, even in its relaxed
state will  not  bear them without experiencing inflammatory reaction.
We therefore  again  reduced  our  ophthalmic formulary into  a small
compass after having enlarged  it  without advantage.   I  am indeed
astonished when I see one of the  most delicate  organs attacked with a
series of applications so powerful and destructive, from corrosive subli-
mate  to arsenic.   The number of these local remedies is  calculated to
excite distrust.  When a  disease can  be  easily and safely cured, the
remedies are few, simple, and recommended by reason and experience.
They become  multiplied in proportion to the obstinacy and tediousness
of the complaint."
  Mr. Tyrrlel has also objected strongly  to the escharotic plan in the
chronic stage  of purulent  ophthalmia, accompanied with the granular
state  of the  conjunctiva, having generally found it unsuccessful.   He
takes  a little  blood, by a leech or two on  the lid, when the membrane
is bright red and turgid; at  other  times he uses mild astringents, of
which  he has found the  undiluted  liquor plumbi  diacetatis,  applied
to the  morbid surface with   a  camel-hair pencil, the  most  useful;
sometimes he  draws  blood  from the membrane   by two or more
transverse incisions; and he occasionally employs counter-irritation by
blistering.!
  The presence of various  changes produced by previous active inflam-
mation, such as ulcer, opacity, nebula, vascularity of the cornea,  pan-
nus, prolapsus iridis, partial staphyloma, affords no contra-indication to
the  use of escharotics  or  astringents.   On the contrary, when  these
affections  have  long  resisted  other means,  they often  are either
greatly  improved, or  rapidly  disappear under the treatment above
described.
  After the use of escharotics, the conjunctiva  does not regain its  nor-
mal state ; it exhibits traces of the former affection, which, however, do
not interfere with its function.  It is thicker, and has a leathery appear-
ance,  with a darker red colour than in the natural state, and sometimes
we  observe whitish cicatrices.
  [The morbid condition of the palpebral conjunctiva termed granular lids, is
a most troublesome affection—extremely  obstinate—subject to sudden and vio-
lent exacerbation from the slightest causes, and  therefore  demanding the inces-
sant attention  of the practitioner—and  when  allowed  to continue, tending
* Lib. cit. p. 148, 149.
t Vol. i, p. 132—138. 
PURULENT OPHTHALMIA IN THE ADULT.
265
 surely to the impairment and  most generally, indeed, the total  destruction of
 vision.  A very large proportion of the applicants  for  admission into Wills
 Hospital,  labour under  this  disease, and the treatment  which they represent
 themselves to have undergone, as well as the statements of private patients,
 leads us to infer that physicians generally are not as well acquainted with  the
 complaint as it is desirable they should be.  Some brief additional remarks,
 and a few cases illustrating the character of the affection and  the means of cure,
 may be therefore useful, to American practitioners.
   The abnormal condition of  the palpebral  conjunctiva, termed granulations,
 presents several different appearances; the chief we have observed are the  fol-
 lowing:—1st. The conjunctiva instead of its natural smooth polished surface,
 becomes villous, 2nd, it resembles an ulcerated surface, the granulations exhibit-
 ing most of the phases presented by such a  sore;  sometimes being small and
 pale, at other* large and flabby, and bleeding on the  slightest touch.  3rd.
 The granulations have a warty appearance,   are firm, pale,  cut  like cartilage
 and yield little blood.  4th, the conjunctiva is thickened and fissured some-
 thing like the surface of a mulberry, and this appearance we have observed most
 frequently  on the fold of the conjunctiva where it passes from the  lower lid to
 the eye-ball.
   The situations in which these granulations are most generally found are  the
 conjunctiva lining  the upper  palpebra, and   that of the lower where it passes
 from the lid to the globe and especially towards the external angle of the eye.
 To see these granulations, it is of course, necessary to evert  the lids.
   In the selection, and mode of application of  local remedies to these  granu-
 lations, great judgment and care is required.
   When the granulations are very vascular and spongy, scarifications will be
 beneficial.
   Of the  local applications, the sulphate of copper is the one which  is most
 generally found advantageous.  In some cases this is not sufficiently active, and
 then the nitrate of silver  or the dilute nitric acid may be employed.
   In making these applications, the  lids must be everted, and a basin of tepid
 water and a very soft sponge, should  be within the surgeons reach.
   AAAhen the sulphate of copper is to be used, a  clear crystal should be selected,
 which  should be fixed in a quill and  then cut into a wedge shape.   This is to
 be passed a few times over the  granulated surface,' which is then to be freely
 washed, before the lid is restored to  its natural  position.
   The nitrate of silver ought  also to be  fixed in a quill and cut into a conical
 form.  This is  to be passed lightly over the  granulated surface which is to be
 immediately washed as just directed.
   The nitric acid is to be applied by means of  a camel-hair  brush, and  in the
 same manner as the last  mentioned remedy.
   The first effect of the last two applications, is to produce  a puffiness of the
 lids, with increased  lachrymation,  and some  burning,  which  subside in a
 few hours and a purulent discharge takes place.   In some cases, the symptoms
just  indicated  become  excessive,  and  persist for  several  days;  arising
 either from the  remedy having been too freely applied, or to the  wrong one
 being selected,  and  a change must  consequently be made,  either in  the  re-
 medy or the freedom of applying  it.  A common  error is  the too frequent
 repetition of local applications.  The sulphate of copper should not be used
 oftener than once  in  two, three, or  four  days, the  nitrate of silver and
 nitric acid,  only once in four, five, or six days.
   Where the eye is very irritable, with injection of the ocular conjunction and
lachrymation, the most prompt  and  marked  relief  is afforded by a cold salt
 water bath to the eyes.
   Sea-air often produces  the most beneficial effects in this disease.  We have
       34 
266
TURULENT OFHTHALMIA IN THE ADULT.
seen some very remarkable instances  illustrative of the benefits  derived from

B WeVaddgthe following cases, to show the plan of treatment we  have found
most successful in this affection.                                   f„mW on.i,
  Case I -Terence  Hagan, slat. 30, admitted into Wills Hospital, September 30th,
l£W_This man stated that  he had been attacked in November, 1835, with inflam-
mation of both eyes, accompanied with discharge of matter; that  after having been
some time treated by a physician in New Jersey, finding his disease not abating, he
went, the following March; to the city of New York, where he was treated by scari-
fications of the lower lids, repeated cupping from the head, and took pills which made his
mouth sore.   Being dissatisfied with the result of this treatment, he came on to Fhila-

  CWhen he applied at the hospital, the propriety of granting him a certificate that he
was not incurable, which is necessary for  admission, seemed to me doubtful.   At  this
time, his cornea was so completely opaque, that  he could barely distinguish day from
niahf  his ocular conjunctiva was a mass of red vessels, through  which  the natural
coTour of the sclerotica could not be seen; the palpebral conjunctiva of the upper lids
were covered with large, firm, wart-like looking granulat.ons; and that ot  the lower
lids showed numerous cicatrices, resulting from deep scarifications   There was some
intolerance to light, with cephalalgia, and sense of weight in the head ; pulse mode-

^The^ayTe was admitted, ten or twelve ounces of blood were taken, by cups applied
 to  his  head, and an active purgative was prescribed.   These remedies relieved his
 headach, and abated the intolerance of  light.   He was  then subjected to the follow-
 in* treatment, which was persevered in  with little variation during the three months
 he°continued under  our care.  Cups were applied to  his  head  every tew days, the
 period  determined by the recurrence of  the headach, which was frequent, and by the
 increase in the injection of the conjunctival vessels; purgatives were given as revul-
 sive*  and to correct the torpid slate of  the bowels;  a  mild, light diet, principally
 vegetable, was directed; and the solid sulphate of copper applied every two or three
 day's to conjunctiva  of upper lids, and occasionally to that of the lower.   This  local
 application  was made with difficulty in  this case, inasmuch as the upper eye-lida
 were  so dense and  rigid  that it was impossible to evert them.   The only way  in
 which  the sulphate of copper could be applied, was by drawing the lid from the ball, in-
 serting a thin piece of the salt, fixed  in a quill, between the lid and ball, and then rubbing
 it  against the former.  Under this treatment, the  granulations diminished, as also the in-
 jection of the ocular conjunctiva, and absorption of the lymph in the cornea commenced.
    The treatment was continued by my colleagues, modified occasionally to suit vary-
  mo- circumstances or  in conformity to  peculiar views.  The only change, however,
  we need notice is  the administration of iodine, which was given partly to promote
  absorption and partly to relieve scrofulous swellings of the  glands of his neck, which
  occurred and proved troublesome;  suppurating and causing much discomfort to the
  patient.
    On  the 1st of October, 1838, Hagan again came under our care.  His eyes during
  the interval  had much improved.   Distinct  vessels could  now be seen on the ocular
  conjunctiva, between which the natural colour of the sclerotica was visible.  The
  granulations had nearly disappeared, and a large portion of the  lymph on the cornea
  had been removed.
    The upper lids could now be everted and the sulphate of  copper was occasionally
  applied to them.  Hagan still suffered  at times from  headache, from which he was
  always relieved by cups to the head, and this remedy also  served  to  diminish the
  injection of the conjunctival vessels. The shower bath was also directed as long as the
  weather permitted, and as his bowels were still inactive, the pil. cathart. comp. two
  or three at bed-time.  The glands of his neck, particularly of right side, were swollen,
  indurated  and occasionally discharged  pus.   To correct  this condition,  which  we
  suspected might have some dependence on a syphilitic taint, we  ordered on the 10th
  of October, the sirup of sarsaparilla §j. three  times a-day with one-tenth of a grain
  of corrosive sublimate.  The  latter was given as follows: R. corros. sub. g. j.; spt.
  vin. 3j. solv. et add. aq. purse %v. M. liq.  A table-spoonful with the syr. sars. three
  times a-day.
    This was continued for  a month, at  the  end of which the swelling of the glands 
PURULENT OPHTHALMIA IN THE ADULT.
267
 had diminished and also the injection of the eyes.  A seton was then inserted in his
 neck, and  a few drops of vin. opii  placed daily on his eye, and mustard  pedeluvia
 were ordered twice a week at bed-time.  Cups were  still occasionally required, and
 also the sulphate of copper.
   Early in December (5th) Hagan complained  much  of nausea, loss of appetite and
 general feelings  of malaise.   His diet  was then  changed.  Soups  which had pre-
 viously constituted the  principal  part of his food  were forbidden, and a little meat
 allowed daily with soft boiled eggs, rice, and  milk.   The following pills were also
 prescribed.  R.  pulv. rhei gj. bicarb, soda? Qij. extr. gent.  gss.   M.  Ft. pilul. xl.,
 three to be taken morning and evening.   These pills were continued for several days
 when he was given the sulphate of quinine in small doses.  Under this treatment his
 stomach recovered its tone.  The vinum opii was continued.
   By the 1st January 1839, when my term of service expired, Hagan was able to dis-
 tinguish the different persons in  the house.   The granulations had  entirely disap-
 peared, there were but  few red vessels in the conjunctiva, and the colour of the iris
 could be distinguished around the circumference of the cornea.
   During the month  of May,  1839, we had charge of the house in consequence of the
 indisposition of our colleague Dr. Fox,  when  we  found Hagan  still  there, and with
 improved vision.   My immediate successor, Dr. Isaac Parish had removed portions of the
 conjunctiva around the cornea which seemed to have promoted absorption of the lymph
 on the cornea.
  Hagan could now see sufficiently well to make himself useful  by working in the
garden.   The seton was still  in his neck and discharging freely.  A drop or two of
 the undiluted liquor plumb, subacet. L. P. was directed to be placed on his eyes every
two days, and iodine  to be given internally.  In a couple of weeks his mouth  became
sore, which was, he says, the case when he took the last previously, and it was discon-
tinued, and an astringent wash was directed for his mouth under  which the ulceration
began to heal.
  The most rapid improvement took place during this month, principally attributable,
I think,  to the use of the liq. plumb, subacet. and  on the first of  June, when Dr. Fox
resumed the service  of  the hospital, Hagan was able to read large  letters—as the
heading of a newspaper.
  He was soon afterwards discharged.
  Case II.  Conjunctivitis with  Granular Lids and  Opacity of the Cornea.—Ber-
nard M'Crossin, setat. 25, a native  of Ireland, labourer, admitted July 14th, 1839.  The
principal facts which we have  been able to gather of the early history of this case, are,
that the patient was  first admitted into Wills Hospital  on the 9th of March, with acute
catarrhal conjunctivitis, accompanied with considerable swelling of the lids,  and great
photophobia.   By the latter end  of the  month  he was convalescent, but had a very
severe relapse about the 1st of April.  Convalescence  was again established, but was
followed by another relapse on the 1st of May, and this was repeated twice during the
following month (1st and 14th June.)  On the 13th of July the  patient was discharged
well.  Four days afterwards he was readmitted with a relapse;  and  during this and
the two succeeding months, the same disposition to aggravation of the disease, as soon
as its  violence  was  conquered, manifested  itself.  Three or four relapses occurred
within this period; the  last, on the 9th  of September, was a severe one, and proved
very intractable.
  On  the 1st of  October,  the patient came under my care, at which  period his eyes
were  in the  following  condition.   Right eye—ocular conjunctiva  injected, vessels
distinct;  palpebral conjunctiva thickened, that of the upper lid granulated; granu-
lations rather pale,  firm; cornea nebulous,  a few  red vessels  running over the
margin.
  Left Eye.   Ocular conjunctiva  similar to that of the right; palpebral conjunctiva
thickened, that of the upper lid granulated; granulations firm, very  red, larger than
those of the other eye.   Cornea, whole surface nebulous, of a dark colour.
  Excessive photophobia, vision being imperfect, most so in the  left  eye, pain in the
head,  pulse hard.
  October  11th. Scarified left upper lid, conjunctiva cut like  cartilage.   Applied
solid sulphate of copper to the right upper lid.   Ordered ten  ounces of blood  to be
drawn from back of the  neck and  temples by cups.
  7th. Eyes  much improved, injection  and photophobia diminished; vision  better.
Applied solid sulphate of copper to both superior palpebra?. 
268
PURULENT OPHTHALMIA IN THE ADULT.
  9th. Yesterday was better.  To-day there is increased photophobia, heat of the head
and cephalalgia; ordered cups to back of the neck and temples.
  llth.  Better.  Cupping relieved the head.  Applied  solid  sulphate of copper to
both upper lids, and introduced a seton into the back of the neck.
  lith. Photophobia and injection diminishing; vision improving.  Dropped in the eyes
solution of nitrate of silver, one grain  to the ounce.
  16lh. Yesterday there was increase of photophobia and injection, with cephalalgia.
Cups were applied to the head, and  though little blood was obtained, it afforded relief to
the latter symptom;  the others remain the same.   Ordered vin. rad.  colchic. gtt. xx,
morning, noon and bed-time;  to take with the last dose 25 drops of solution of sulphate
of morphium.
  18th. Photophobia and injection diminished.   Vision  with the left  eye better than
for a long time; can distinguish large letters;  slept well.  Applied sulpha-te of cop-
per to upper palpebrse.
  21st. Photophobia and injection continues to  diminish;  conjunctiva of upper palpe-
brae paler and smoother; no headach; seton discharging freely.
  23d.  Palpebral conjunctiva paler  and smoother;  some return of headach with
active pulse,  venesection, §xij, liquor plumb, subacet. to eyes.
  25th. Granulations of lids diminishing, few remaining at present, except near the
edges of the tarsi; two ulcers on superior  palpebral conjunctiva, which  bleed  freely
on being touched ; eyes free from pain ; sight continues to improve.  Applied sulphate
of copper to the granulations.
  23th. The eyes continued to improve until  to-day.  This  morning his right eye
became somewhat painful, and the  lids  are thicker, more granulated, and injected  ;
pulse active ; venesection 5xij.   Solid nitrate of silver to both  upper lids.
  30//t. Eyes have continued painful  ever  since the application of nitrate of silver;
lids tumefied; great photophobia; griping pain in  the bowels; head feels light. R.
Sulph. zinci, gr. i.; Aq. purse, §i. M.  Ft. collyr.  A few drops to the eye twice a-day.
  November  1st. Eyes easier; tumefaction and redness of the lids diminished; ulcer
on left palpebral conjunctiva  not so deep, does  not  bleed  when touched;  right upper
palpebise thick,  and firm; did not sleep well last night.   Bowels  loose;  pulse rather
feeble.   Applied solid sulphate of copper to both upper lids.  Ordered  the following
to be given three times a day: R.  Sulph. quinin. gr. i.;  Hydrarg. c. creta, gr. ii. M.
And the face to be dipped daily in  a  basin containing a  saturated lotion  of common
salt in water, with the eyelids open.
  Ath. Continued improvement; lids  less thickened, granulations diminishing, ulcers
healing; sleeps pretty  well.  Continue powders,  and salt bath  to eyes.  Applied
sulphate of copper to lids.
  6th. Eyes feel and look better; photophobia  diminished;  sight  improving daily;
thinks he derives great benefit from  the salt  water; right upper palpebral smooth,
though still thickened.   Applied liquor plumb, subacet. to eyes.   Continue powders.
  *lh. Yesterday there was increased intolerance, and some pain  in left eye;  did not
sleep well; bowels rather loose, for which last he  was given an ounce of the  spiced
sirup of rhubarb.  To-day there is  less intolerance; his bowels are less deranged  ;
slept well; sight improves.   Applied solid sulphate of copper  to  both upper lids, and
ordered a solution of the same, one grain to the ounce of water, as a collyrium.
  llth.  During the past two days the photophobia diminished; to-day  there is an
increase of it, and greater injection  of  the eyes;  mouth quite  sore from mercurial
action.  Discontinue powders.  Applied solid  sulphate of copper to both upper lids
and ordered  tonic infusion.
  loth. Not so well; granulations increased.  Applied  solid nitrate of silver very
lightly to both upper lids.
   17th.  Lids have been swollen, with some purulent discharge, since last application;
intolerance continues.   Ordered infusion of chamomile flowers with a  small  portion
of  opium  dissolved  in it, to  be applied  warm  to the eyes.  Vin. rad. colchic. thirty
drops three times a-day.
   l?th.  Eyes better, lids less swollen.  Applied  nitric acid, diluted with four  parts of
water, to conjunctiva of upper lids.
   22d". Eyes much  improved;  less  photophobia;   palpebral  conjunctiva smoother.
Applied dilute nitric acid.
   25th. Eyes were much better yesterday; seems to have taken cold  last evening, 
PURULENT OPHTHALMIA IN  THE  ADULT.
269
and to-day they are worse. Left eye quite sore, palpebrse swollen ; purulent discharge;
photophobia; cephalalgia.  Ordered six grains of tartarized antimony, to betaken in
divided doses, to-morrow morning.
   21th.  Head is  much relieved since operation of emetic, feels more comfortable than
it has done for three months past.   There is great  photophobia, cornea more opaque;
slight catarrh.  Liquor plumb, subacet. to eyes.
   29th.  Eyes free from pain, but intolerant of light.  Right eye much improved ;  left
cornea very opaque and vascular.   Feels very weak, no appetite, quite feeble; skin
cool.  Ordered one grain of sulphate of quinine, four times a-day, with tonic infusion.
   December 1st.  Considerable diminution of intolerance, cornea clearing.  Salt  water
to eyes.
   Ath. Better; eyes improving; bowels costive.   Liquor plumb, subacet.  Continue
salt water.  &. Hydrarg.  c. cret. gr. ii.; Pulv. rhei, gr. iv. three times  a day.  Dis-
 continue quinine.
   6th. Much better, free from  headach or pain in eyes; bowels open; less injection
and photophobia.   Says his eyes always feel better and  has less photophobia after  use
of salt water.  Applied solut. nit. argent, gr. viij  to §i,  to the eyes.
   9th. Sight improved, can now open his  lids wide; conjunctiva of upper palpebrse
not yet quite free from granulations. Applied dilute nitric acid to granulations.   Con-
tinue salt water.
   13th. Dilute nitric acid was applied  to  upper lids, on  the llth.  Eyes have con-
tinued to improve; at present very little photophobia; sight improved.  Left upper lid
pale, with a few granulations; right injected.  Applied  diluted nitric acid to left  upper
lid, and scarified right.
   16th.  Granulations  on left upper  lid  have been diminished  by application of  nitric
acid.  Right upper lid quite  pale and tumefaction has disappeared since scarification.
Liquor plumb, subacet.  Continue salt water.
   From this period the patient steadily convalesced.   Liquor  plumb,  subacet. was
applied  every alternate day to  his  eyes, and after  that period, every night, and  the
salt water once or twice a day.
   '30th. The redness  and thickening and granulations of the conjunctiva has entirely
gone; not the least photophobia; right cornea clear with the exception of a small speck
below the centre; left cornea not perfectly clear  and polished, but having something
of the appearance of  greenish glass.  I advised the patient to remain in the house a
month or six weeks to confirm  his convalescence; but he considered himself as quite
cured, and begged me to discharge  him at the conclusion of my term of service.   He
was accordingly discharged.
   Case HI. Chronic  Conjunctivitis—Granular Lids—Opacity of Cornea.   James
Murphy, setat. 43, native of Ireland, admitted  September 7th.  This  man's eyes had
been inflamed for  nearly  a year before his admission.  The treatment to which he
was subjected after his  entrance, consisted principally in the  application of solid sul-
phate of copper to his palpebral conjunctiva, blistering behind the ears, and purgatives,
under which he improved.  When  he came under my care on the 1st of October, his
condition was as follows: Skin pale—relaxed; hair light; irides pale blue; pulse rather
feeble; stature short,  thin ; constitution apparently not robust; eyes feel very sore and
uneasy; lachrymation; some photophobia; lids tumefied and puffy.  Right eye—ocular
conjunctiva slightly injected; palpebral conjunctiva very red, thickened, spongy, that
of the upper lid  granulated;  granulations  large, very vascular and  flabby; cornea
slightly nebulous  at the centre, remaining portion clear.  Left eye—similar to  right,
except that the granulations are not so  large, and cornea was nebulous  to a greater
extent.  I scarified the conjunctiva of both upper lids; the right bled very freely, the left
less so.   A sufficient  quantity of blood was obtained to colour deeply a large basin of
water.
   October 5th.  Eyes feel much better; granulations diminished.   Ordered the follow-
ing collyrium to be used warm.  R. Corros. sub.  gr. i.   Aq. purse, 3jvj.
  1th. Eyes more  injected;  collyrium  causes much irritation: bowels costive.  Dis-
continue collyrium; scarified  both upper lids; senna and salts.
  9th. Left eye much improved, less injected; right eye also better.  Applied solid
nitrate of silver to both upper lids.
  21st.  Since last report, the lids have been once scarified ; the solid  nitrate of silver
has been twice  applied, and a few drops of a solution  of this salt (one  grain to the
ounce) have been occasionally applied to the eye.  To-day the eyes feel much easier; 
270
PURULENT OPHTHALMIA IN THE ADULT.
the thickening of the conjunctiva is diminishing;  conjunctiva of the left  upper lid is
now pale and  smooth, that of the right less red than it was, but still injected; bowels
open, sleeps well.   Applied solid sulphate of copper to both upper lids.
  23d. Eyes free from uneasiness;  intolerance diminished; lids less flabby.   Left eye
■—conjunctiva of the  upper lid almost free from granulations except near  the  outer
margin of the tarsus.   Right eye—less improved than left; still  granulations on the
conjunctiva of upper lid ;  conjunctiva of both palpebrse injected and flabby.  Applied
sol.d sulphate  of copper over the conjunctiva of both lids of the right eye, and to the
margin of the  upper Hd of the left eye.
  November 16th. The treatment since the preceding date, has consisted in the applica-
tion to the left eye, every two or three days, of the solid sulphate of copper, and occasion-
ally the nitrate of silver,  when the former failed to keep down the granulations; and
of the latter  salt  to the right  eye.  As a collyrium, he  finds tepid water  the most
agreeable.  Three days since he had a blister to the  back of  his neck.  To-day his
eyes are greatly improved, particularly  the right one, the lids of which are  now less
puffy and vascular; cornea clearer; sight improved.
  December 1st. Has had the solid nitrate of silver applied  twice, and once the diluted
nitric acid since last report.  Has also used the solution of nitrate  of silver (four grains
tolhe ounce) as a collyrium; and has taken for a few days, sulphate of quinine and
hydrarg. c. creta, one grain of the  former to  one and a-half of the latter, four times
daily; and latterly the quinine with carbonate of iron.  He  has also been occasionally
purged.  His  eyes now  appear  better,  conjunctiva less flaccid  and more  polished:
opacity  diminishing;  two red vessels still on  the left cornea.   Guthrie's ointment
applied  to the eye; continue quinine and carbonate of iron.
  10th.  Guthrie's ointment has  been applied but once, as it did not produce  as much
improvement as I anticipated, and the solution of nitrate of silver  (eight grains to the
ounce) was substituted.  A fomentation of chamomile tea, with opium,  has  also been
used, and yesterday diluted nitric acid was applied to the lids.   To-day the eyes are
less injected ;  photophobia diminished;  conjunctiva  less  watery and flabby; portions
of the conjunctiva  palpebralis perfectly natural in appearance.
  20th. Diluted nitric acid was applied on the llth and 13th inst., since which period
the applications  have  been salt  water and a few  drops of  liquor  plumb, on the 16th
and 18th, with ung. hyd. rub. to the tarsi at bed-time.  These applications seemed to
be productive  of much benefit, especially the former; but  three days since, without
any well ascertainable cause, his eyes became more injected and watery, though the
lids remained  smooth.  His pulse  was  also rather fuller.   The  tonics were discon-
tinued two days since; and to-day some blood was drawn from his head by cups, which
was followed  by considerable diminution of injection and  lachrymation.  The liquor
plumb, subacet. was employed every two or three days; a blister was kept open on his
arm;  and he was occasionally purged.  Under this treatment he  improved so rapidly,
that I hoped to be able to discharge him cured by the end of the month.   Three days,
however, before  this period, both eyes became irritated and injected, and he complained
of the sensation of foreign a body in his  eye.  I found that this  was caused by some
inverted eye lashes.   These  were immediately extracted.
  31st.  The removal  yesterday  of  the hairs afforded prompt relief.  The injection of
the eyes has much  decreased, and  also  the lachrymation; both  upper palpebrse are
entirely free from  granulations, conjunctiva smooth and pale.  As there seemed to be
a disposition in the cilise  to grow irregularly, and  the  patient's  eyes had been long
affected, I feared a relapse might be induced from  this cause, and he was transferred
to the care of my successor.  1  learn that his right eye continued well, but that he sub-
sequently  had a  slight relapse  of inflammation in "his left.  Various remedies were
employed, but none seemed to afford him so much relief as  the salt water bath .to the
eyes, and the liquor plumb, subacet.] 
(  271  )
CHAPTER IX.
GONORRHEAL OPHTHALMIA.
  Three distinct forms of ophthalmic inflammation occur in conjunction
with, or dependence  on,  gonorrhoea;  namely, 1st, Acute inflammation
of the conjunctiva; 2nd, Mild inflammation of that membrane; and 3rd,
inflammation of the sclerotic coat, sometimes extending to the iris.
                            SECTION I.

I. Acute gonorrheal inflammation of the conjunctiva; gonorrheal ophthal-
  mia; blepharophthalmia, and ophthalmia gonorrhoica vera of Beer.

  The name of this affection sufficiently indicates its nature.   It is a
violent inflammation of the mucous membrane of the eye-ball and lids,
attended with a profuse discharge  of fluid, closely resembling in all its
sensible characters  that which issues  from  the inflamed urethra in
gonorihoea, and  occurring in some kind of connexion with that com-
plaint.  It  is  the  most violent and  rapidly destructive inflammation to
which the eye is subject; and, fortunately, it is comparatively rare.  It
sometimes  destroys the eye within  a very short time; and the organ is
often irreparably injured before the  patient seeks for surgical relief, espe-
cially when the affection occurs in the lower classes.
  Symptoms and  progress of acute  gonorrheal ophthalmia.—This affec-
tion presents all the characters  of  purulent ophthalmia  in their fullest
development.   There is the greatest degree of vascular congestion, the
most intense and general external redness; excessive tumefaction of the
conjunctiva;  great chemosis, with  corresponding swelling of the pal-
pebrse ;  and profuse yellow discharge.  In the first stage of the disease,
which is short, the inflammation is confined to the conjunctiva, and is
attended with soreness and stiffness, with the  sensation of sand or dirt
in the eye,  and with more or less uneasiness on exposure to light or using
the organ.  The affection soon  extends  to the cornea with severe  and
agonizing  pain in the globe, orbit, or  head, augmented  to intolerable
suffering on exposure to light, and  with febrile disturbance of  the sys-
tem of inflammatory character.  The danger to  the organ is now most
serious and imminent; indeed, when the disease has thus advanced, from
the mucous membrane to the globe itself, we can hardly expect by any
kind of treatment, to  avert entirely its destructive consequences.  The
violent inflammation, which causes the yellow puriforin discharge from
the mucous surface of the conjunctiva, produces  effusion into the cellu-
lar texture  connecting it  to the  surrounding parts.  Hence the  general 
272
GONORRHEAL OPHTHALMIA.
 swelling of the membrane, and that more considerable tumefaction  on
 the front of the sclerotica, round the cornea, which is  called chemosis.
 The latter is often so considerable, that the swelled conjunctiva overlaps
 the cornea all round, so as nearly to hide it.  Similar effusion takes
 place into the cellular texture of the eye-lids, enlarging them considera-
 bly, more particularly the upper, which hangs over and sometimes com-
 pletely covers the lower.  This palpebral swelling is sometimes cedema-
 tous, with the integuments but little redder than natural;  in other in-
 stances it  is firmer, with the skin, particularly of the upper eye-lid,
 bright red.  The latter state denotes more active inflammation, and
 greater danger to the organ.  The chemosis, and  the  swelling of the
 lids, make it often difficult, and sometimes impossible to get a clear view
 of the cornea.  Although it is desirable to do this, in reference to prog-
 nosis, when we first see the  case, we should not persist in our efforts at
 the risk of augmenting the inflammation, or the  patient's sufferings.
 The oedema of the eye-lids declines in the progress of the affection, and
 then one or both  of them  may become everted, the convex edge of the
 tarsal cartilage being pushed forwards by the swollen conjunctiva.
   The chemosis  and the  tumefaction of the eye-lids  are analogous  in
 their nature and  mode of production to that swelling which takes place
 in the neighbourhood of any active inflammation: they  owe their origin
 to that interstitial deposition, which is a  genera] attendant on such vio-
 lent vascular disturbance.  The effusion may be either fibrinous or serous,
 the tumefaction being firmer in the  former, looser in the latter instance.
 Fibrine is effused under the highest inflammatory action, in  a  strong
 subject;  serum, when the inflammation is less violent, and the constitu-
 tion weaker.
   That the chemosis should have been referred heretofore* to the depo-
 sition of venereal matter in the cells of the part, and that incisions should
 have been recommended for its evacuation, will not surprise us; but we
 could hardly have expected  to find such  a mode of accounting for the
 phenomenon adopted by Beer and Richter.  The swelling of the che-
 mosis, according  to  the former,  arises from the effusion of gonorrheal
 matter under the  conjunctiva; he mentions the practice of making inci-
 sions for the discharge of this matter, and represents that from such in-
 cisions there flows out a purulent fluid, ora yellowish acrimonious ichor.
 He says that gonorrhoeal  matter is  sometimes seen at the  very begin-
ning in the chambers.f  " Sometimes," says Richter,J  " the conjunc-
tiva swells up round the cornea,  as in chemosis; this swelling depends
entirely on an effusion of true gonorrhoea] matter into the cellular tex-
ture and the conjunctiva,  and the matter  flows out on making incisions
through that membrane.   Sometimes gonorrhoea] matter is found in the
anterior chamber."
  The inflamed  membrane exhales at first  a  thin whitish mucus  in
small quantity; as the inflammation proceeds to its full development,
the discharge becomes thicker, yellow, and abundant;  the yellow tint
and  the quantity  of  the exhalation  being in proportion to the violence
of the inflammation.  When the latter is  at its height, the discharge

  *  Astruc ; lib. iii. c. 3. Camerer, Dissert, de Ophthalmia Venerea.
  t hehre der Augen-krankheilen, 1st edition, vol. i. p. 294, 295.
  t Anfangs grundc, vol. iii. p. 63. 
GONORRHEAL OPHTHALMIA.
273
 closely  resembles in its  appearance, and in the stain communicated
 to linen, that  which proceeds  from the  urethra in venereal  gonor-
 rhoea.
   Although the  pain  is generally most severe, both in the eye and in
 the head, as in other instances where the dense and  unyielding texture
 of the cornea is  the seat  of inflammation, and although patients often
 complain of burning pain, of tension as  if the eye would burst, of deep-
 seated and intense agony, with extension  of these  distressing  and
 almost intolerable sensations  to the brow, forehead, and  head gene-
 rally, there are  some instances in  which  little or  no pain is expe-
 rienced.
   The symptoms of acute gonorrhoeal  ophthalmia are not equally vio-
 lent through the whole course of the affection: it begins with swelling
 and increased redness of  the conjunctiva, and some pain in the  organ;
 then the puriform discharge takes place, with increased uneasiness; and
 lastly, the inflammation extends to the cornea, with great  aggravation
 of suffering.  Thus the course of the affection may be divided into three
 stages, of which the limits cannot be marked very accurately.  In the
 first, there  is vascular distention and swelling of the membrane, with
 swelling of the lids;  the commencement of the second is marked by the
 occurrence  of the puriform discharge, and that of the third  by extension
 of the  inflammation to the cornea. The duration of each of these varies
 in different  instances according to the  constitution and state of health
 of the  individual, and, perhaps still more according to the nature of the
 treatment adopted.  This variety, however, is observed less in the first
 and second  than  in the third stage; the two  former, and more particu-
 larly the first, usually passing  off very rapidly.  In one case, the  second
 stage may be said to have  begun  in twenty-four hours from the first
 perception of uneasiness:  the  lids were red and  swollen at that time,
 and  there was thin puriform discharge.  In thirty-six hours  the swelling
 was so great,  that the eye could not be seen, and there  wras profuse
 yellow  discharge, while  severe pain  of the eye and  head denoted
 clearly extension  of  the  disease to  the cornea.   In another instance,
 the first stage occupied  about  thirty-six hours, and the second between
 three and four days.  In  a third, pain and weakness were first  felt in
 the eye on the 1st of November, and on the 6th I found the cornea had
 sloughed.
   Effects of the inflammation.—The immediate effects of the inflam-
 mation on the cornea are sloughing, suppuration, ulceration,  and inter-
 stitial deposition; while the consequences, to which these changes lead
 more remotely, are,  escape of the  humours and  collapse of  the globe,
 obliteration  of  the anterior chamber and  flattening of the  front  of  the
eye,  staphyloma, prolapsus  iridis,  obliteration of the pupil, cornea]
opacity, and anterior adhesion of the iris.
  I have spoken of the cases in which the cornea  is said to  burst under
purulent ophthalmia, see p. 239.
  The cornea becomes dull and hazy before it sloughs, or indeed  before
undergoing any of the changes just enumerated.   Its transparency and
polish are completely destroyed, when it has sloughed; and it is con-
verted  into a dirty yellowish, or brownish opaque substance, which is
immediately recognised as deprived of life.  At first it looks like  a por- 
274
GONORRHEAL OPHTHALMIA.
 tion of wetted leather; it is soon separated from the living parts, when
 it has  a loose, soft, and ragged appearance.  As the lens and capsule,
 which are exposed by this separation, are transparent, the patient some-
 times  recovers, for a short  period, tolerably good  vision.  After  the
 slough is detached, the chambers of the  aqueous humour, may  be  ex-
 posed  by ulceration;  the humours will then  escape, the  emptied coats
 will collapse, and the  globe remain  permanently shrunk  in the socket.
 More commonly, although the whole cornea seems to slough, the entire
 thickness  does not separate, and the anterior chamber is not exposed.
 The interior layer of  the cornea, or the  membrane of the  aqueous  hu-
 mour is left, and is soon pushed forwards by the iris, which  forms  an
 irregular  brownish, and dirty looking protuberance on the front of  the
 eye.   As  the  inflammation declines, this protuberance recedes, until it
 disappears  altogether, the front of the  eye remaining  flattened,  and
 being formed  by the  iris, covered by a thin, smooth, and more  or less
 opaque pellicle, through which the fibres of the iris may  be partially
 seen, giving it  a  somewhat  streaked  appearance.  Sometimes   the
 iris is  permanently protruded, and forms a dark, more or  less smooth,
 protuberance, partially subdivided on the surface,  {staphyloma race-
 mosum.)
   The separation of the slough when it has been partial, leaves an ulce-
 rated surface, which is soon raised  into a vesicular protuberance con-
 sisting of the membrane of the aquous humour, with the iris, which has
 become adherent during the previous inflammation of the cornea {pro-
 lapsus iridis.)   This  shrinks as the inflammation declines, and the  re-
 gular figure of the cornea is restored ; but the iridis remains adherent,
 and is covered only by a thin pellicle, which  is partially  opaque, while
 the boundary of the adhesion presents a deeper opacity in the cicatrix
 of the corneal lamina?.  If a considerable portion, such as one-half or
 one-third of the cornea, should have perished, a permanent tumour is
 sometimes formed, consisting externally of an opaque covering, and  in-
 ternally of the adherent iris; its cavity,  which is  an extension  of the
 anterior chamber, being filled  with aqueous humour: this is termed
partial staphyloma, and differs  from prolapsus iridis, or  complete sta-
 phyloma, only in size.   I have seen it occur in both eyes of  the same indi-
vidual, with little injury to the sight, as the protrusion of the iris hardly
 interfered  with the pupil.
   Suppuration  of the cornea may be general or partial:  it  is usually
 the former.  The cornea first becomes  white, and then assumes a
 yellow colour.   The effused substance is not a fluid, nor  is it collected
 into a cavity; it is a thick  viscid  matter deposited in the  texture  of the
 cornea.  Ulceration takes place, and exposes an opaque vellow sub-
 stance, which looks like  ordinary matter, but it cannot be wiped off.
 The ulcerative  process  extends  until this is removed,  if the  whole
cornea should  be destroyed, the  humours may escape, and the globe
will shrink.  Or, the humours may remain, and  the tumid  conjunctiva
scleroticae contract from the circumference towards the  centre  of the
space  left  vacant  by the cornea, until  it completely fills  that  space,
when the eye appears like a red fleshy mass, in which even  the original
situation of the cornea cannot be distinguished.  The ulceration  of the
suppurated cornea  may penetrate the anterior  chamber  at  different 
GONORRHEAL OPHTHALMIA.
275
 parts, at each of which  the  iris  may protrude, the front of  the organ
 remaining ultimately flattened.
   When ulceration takes place without previous suppuration, it gene-
 rally attacks the margin of  the  cornea, and extends rapidly through
 thelaminas, so  as to  form a deep trench,  seldom occupying less  than
 one-third, often one half, or two-tbirds of the circumference, and some-
 times extending round the whole  circle.  In the latter case, the portion
 insulated by the ulcerative process sloughs.  On the sides  of this ulce-
 rated trench, the laminae of  the  cornea may  be  often  seen very dis-
 tinctly.  Beer says that they turn up like the leaves of  a  book, which
 has been much read.   If the ulceration should  not occupy more  than
 two-thirds of the margin, the vascular supply of the cornea w7ill still be
 carried on, and the mischief may be repaired.  As the  margin of the
 cornea is covered by the swollen conjunctiva, these ulcers are at first
 concealed from view, and we do  not  know of their existence until the
 chemosis  begins to subside.  When  the ulcer  has gone  through the
 corneal laminae, the membrane of the aqueous  humour  may rise  as a
 transparent vesicle in the cavity (ceralocele, hernia cornea?,) or it may be
 pushed forwards  by a protruding portion of the iris.   The ulcerative
 process may penetrate the anterior chamber, when the  iris will either
 fall against the opening, or be pushed into it  and block it up.  If the ulcer,
 whether it should have arisen from  the separation of a slough, or have
 occurred in the manner  just described, should be spreading, .the in-
 flammation remaining unchecked, its surface is whitish, and ragged,
 or flocculent;  or  of a  dirty yellowish cast, with surrounding haziness.
 When the  inflammation subsides, it becomes transparent.  The com-
 mencement of the restorative process is marked by the  surface of the
 excavation assuming a light  greyish  tint, with  a jelly-like  appearance.
 A soft semi-opaque substance slowly fills up the breach, when the sur-
 face becomes smooth,  and the regular figure of the cornea is restored.
 No secretion of pus is observed,  either  during  the  stage of ulceration
 or that of  reparation; the latter process  is slow, several days often
 elapsing without any sensible change in the size or appearance of the
 ulcer.  The same process of contraction takes place here, as after the
 cicatrization of other ulcers,  so that the size of the opaque cicatrix is
 less than that of the previous corneal ulcer; and as  these ulcerations
 take place on the circumference of  the  part, one that  has been of  con-
 siderable size leaves a  mark that  is  only observable on close inspection,
 while, where the ulceration  has  extended  over the edge of  the pupil,
 the cicatrix may leave that aperture quite unobstructed.
  The existence of the ulcer  makes no difference in the kind  or degree
 of pain during the active period of the disease:  no pain is felt when the
 inflammation is stopped,  although a large ulcer may still exist.
  When interstitial deposition takes place, the  corneal laminae are the
 seat of the  mischief;  and the  opacity thus produced is of the dense
kind called leucoma, or albugo.  It is usually accompanied with anterior
adhesion of the iris {synechia anterior.)
  Contraction or obliteration  of the pupil may occur in consequence of
protrusion of the iris in partial  staphyloma, or at the smaller apertures
produced by ulceration;  or of its adhesion  to a leucomatous portion of
the cornea. 
276
GONORRHEAL OPHTHALMIA.
  When the cornea has been weakened  by extensive sloughing, or
ulceration, the iris having previously become adherent to it during the
active period of the inflammation, the conditions necessary to the forma-
tion of  total staphyloma exist; and this accordingly is one of the ulti-
mate  consequences of gonorrhoeal ophthalmia.
  Diagnosis.—-Between the  highest degree of purulent inflammation,
and acute  gonorrhoeal  ophthalmia, there is a near resemblance in the
local  symptoms.   The  discharge may be more abundant and thicker
in the latter, in which the conjunctiva oculi is more swelled, while the
swelling of the eye-lids is more considerable in the former.  The pecu-
liar change of structure in the palpebral conjunctiva, that is, the forma-
tion of  phlyctaenae and  of granular irregularities in the early stage, and
the tedious and obstinate  state of granulation  in  the chronic form, are
an especial character of the contagious ophthalmia; at least, I have not
seen  them in the gonorrhoeal.  The  latter  occurs in single  instances,
and is uncommon; the  other  affects great  numbers of individuals who
are living  together.   The one takes place in persons who have had, or
still have gonorrhoea, the other in  those free from such  complaint, but
who  have been exposed to the contagion of purulent ophthalmia.  That
the discharge of gonorrhoeal ophthalmia will  affect the eye of a sound
person  if applied to it,  is well known; but it certainly possesses no indi-
rectly contagious property.   In  purulent ophthalmia the lining of the
palpebrse is first affected, and the  disease extends to the mucous mem-
brane of the globe.   In a ease of gonorrhoeal ophthalmia, which I saw
at the very outset, the  complaint began at once in the conjunctiva oculi.
The  latter comes on suddenly with the utmost violence, and proceeds
with the greatest rapidity, coming to  an end in a few days, either by
 recovery, or more commonly by destruction of the organ.  In the con-
 tagious disease there is a milder period at  the beginning; the disease is
 in general less rapid and destructive; it goes off and returns again, and
 thus  may  last for months or years.  In general, gonorrhoeal ophthalmia
 attacks only one eye, while  the purulent disease affects both.-  The
 latter may however be confined to  one  eye, as  is proved by the cases
 quoted at p. 242-3, while the gonorrhoeal form of the disease often attacks
 the second eye,  after a short interval.  One eye only was affected in
 nine out of the fourteen  cases, which I  have recorded in my Treatise
 on the  venereal  diseases of the  eye.   In this disease the cornea is fre-
 quently destroyed by sloughing, which does not take place in the con-
 tagious ophthalmia.  The  latter is characterized by the peculiar change
 of structure  in  the conjunctiva,  and by  frightful ectropia consequent
 on it.
   'Prognosis.—The violence of  the  inflammation, its  rapid course, and
 the disorganization or changes of structure, which it quickly produces
 in the  cornea, are  attended, under all circumstances, with the greatest
 danger to sight, which, in a large proportion of these  cases, is  either

   * Dr. Vetch says, "there is not one case in a thousand in which one eye only becomes
 affected."—Practical Treatise, p. 195.
   Waltheh observes that contagious ophthalmia almost always appears in both eyes toge-
 ther, but not in the same degree.—Lib.  cit. p. 83.
   Eble states that  the  contagious  ophthalmia  has not confined itself to one eye in any
 insxancc.^- Ueber den Bau,  &c. p. 215. 
GONORRHEAL OPHTHALMIA.
277
lost, or  seriously injured.  Thus of the fourteen  cases which  I  have
related in my treatise, loss of vision took place in nine from sloughing,
suppuration, or opacity of the  cornea.   In two  of these one eye was
lost, and  the other recovered.   Sight  was restored in the other five,
with partial opacity of the cornea, and anterior adhesion of the iris in
three  of the number.  So short a  period intervenes between the  com-
mencement and  the full  development of the  complaint, that in many
instances irreparable mischief is done to the eye before our assistance
is required.  If we see the complaint in the first or second stage, we
may expect to arrest its progress by active treatment; but success does
not invariably attend our efforts even under  such favourable circum-
stances.   Our prognosis will principally turn on the state of the cornea;
if that should possess its natural clearness, the eye may be saved.  If it
should be hazy and dull, and more particularly if it should have assumed
a white  nebulous appearance, consequences  more or less  serious will
inevitably ensue.  Great swelling  of the conjunctiva, more particularly
great  chemosis, profuse discharge of a yellow colour, and bright  redness
of the  swollen upper eye-lid, are unfavourable circumstances, as indicating
a high degree  of inflammation.  The changes, to which the cornea is
liable, do not always destroy sight: their effect depends on  their extent
and situation.   Sight  may be  restored  after  partial sloughing of the
cornea; and extensive ulceration may occur in its circumference  with-
out injury to vision.
  The inflammation is not equally violent in all cases;  and, of  course,
the prognosis will be less serious in proportion to its comparative  mild-
ness.
  When both eyes are attacked in succession, the disease is less severe
in the second, which, therefore, is  usually saved.   Sometimes, however,
the inflammation is equally violent and destructive  in  both, and total
blindness ensues.
   Causes.—In investigating this part of the subject, we have to inquire
what is  the nature  of  the connexion between this inflammation of the
eye and gonorrhoea ? whether the former can be  produced by the appli-
cation of gonorrhoeal matter to the organ ?  If so, whether an individual
can infect himself? whether  the  application of matter from  another
source be necessary'? or whether the infection may occur in both ways?
Whether, on the other hand, gonorrhoeal ophthalmia may be an example
of that peculiar transference of diseased action, which is called metas-
tasis 1    To some it may appear necessary to examine a previous  ques-
tion;  viz. whether there is any connexion at all between the inflamma-
tion of the urethra  and that of the eye?   For  Mr. Pearson*  directly
denies the existence of such a connexion, on the ground that, in many
thousand cases  of gonorrhoea, he had  not seen one instance of inflam-
mation of the eye that could be ascribed to the gonorrhoea.
  From this statement we can merely  infer  that Mr. Pearson had not
seen gonorrhoeal ophthalmia, which is very strange, when we consider,
as he  informs  us that many thousand cases  of gonorrhoea had  fallen
under his notice.  I may oppose to his negative  testimony the  positive

  * In a  letter to Mr. Bkiggs, printed in his translation of Scarpa's Treatise, p.  164—16G,
note. 
278
GONORHEAL OPHTHALMIA.
experience of many competent observers, and the evidence of numerous
facts which have come under my own observation.
   Whether this dangerous ophthalmia can be produced by  the applica-
tion of gonorrhoeal matter to the organ, is a more doubtful point, which
the nature of the subject prevents us from settling in the only satisfactory
way, that is, by direct experiment.
   It is stated incidentally by Beer,* and in the same kind of way by
Scarpa^ that, if  gonorrhoeal matter be  applied to  the eye, it excites
only a slight degree of inflammation.  These  statements are not accom-
panied by any narratives of cases, or other detailed illustrations, so that
we do  not  know on what  kind of proof the assertions rest, nor how the
application of the morbid  secretion to the eye was ascertained.
   Since infectious matter does not produce disease  in the same indivi-
dual, although it is capable of affecting others, analogy would lead us to
infer that gonorrhoeal discharge  applied to the  eye of the same person
would  not cause gonorrhoeal ophthalmia.   This conclusion is supported
by the  result of  experiments made by Dr. Vetch.J  He took matter
from the eyes of persons labouring under acute purulent ophthalmia,
and applied it in each  case to the  urethra of the same individual: no
disease was  excited.   But,  when  he  applied the same  matter  to the
urethra of  a different individual, it produced a very virulent gonorrhoea.
He infers from these  experiments, that  gonorrhoeal  matter  taken from
the urethra and  applied to the eye of the same individual would excite
no inflammation of the eye. The inference is  probable, but not neces-
sary.  Because the purulent secretion of  the eye does not  affect the
urethra, we cannot conclude that the gonorrhoeal secretion of the urethra
will not affect the eye. These morbific influences are not in all instances
reciprocal; inflammation  of the urethra often  causes inflammation of the
testicle, but the latter seldom or never produces the  first.   Dr. Vetch
further mentions, that an  hospital assistant,  named  Smith, applied
gonorrhoeal matter to his own  eyes, with impunity.  When we con-
sider how this matter is diffused over  the linen of patients, both male
and female, how  often the fingers must be smeared with  it, and how
inattentive to cleanliness  the lower classes  are, we cannot help con-
cluding that gonorrhoeal  discharge must be often applied  to the eyes
of the  same individual;  yet gonorrhoeal ophthalmia is comparatively
rare.
   Although these various considerations  would lead us to  expect  that
gonorrhoeal discharge  would not affect the eyes of the same individual,
we meet in practice with cases, from which there  is every reason to
draw the contrary conclusion.   It is a well known  popular remedy for
sore eyes to wash them with one's own  urine; and persons labouring
under gonorrhoea are sometimes so thoughtless as to resort to this prac-
tice.  Experience teaches  us that this  direct application of infectious
matter is capable of producing,  not such a slight inflammation as Beer
and  Scarpa speak of,  but acute  gonorrhoeal  ophthalmia in its most de-
structive form. This is fully proved by Case IV. of my treatise,^ where
both eyes were  lost, and  Case XIV.|| 'in which the  vision of one was
destroyed.   In Case  VIII.,1" in which partial  sloughing  of one  cor-

   * Lehre, vol. i. § 540.                      t Treatise, &c. 2d edit. p. 164.
   t Practical Treatise p. 242.
   § Page 6:».          || Page 101.           r, Page 85. 
GONORRHEAL OPHTHALMIA.
279
nea occurred, the patient had used to his eyes a towel soiled with gonor-
rhoeal discharge from his  own urethra.   Mr. Wardrop communicated
to me two cases, which occurred under his own  observation.  In one
of them, that of a young gentleman labouring under gonorrhoea, who had
inadvertently touched his eyes when his fingers were contaminated with
the discharge, violent puriform ophthalmia  occurred and ended in the
suppuration, and collapse of both eye-balls.   A soldier, who had gonor-
rhoea, was advised to bathe his eyes  in his  own urine, as a remedy for
a slight affection of the lids: purulent ophthalmia seized  one eye, which
suppurated and burst.   Astruc* saw a case in  which both eyes became
inflamed from this cause;  but the affection  does not seem to have been
very severe.   Another instance is detailed by Mr. Foot ;f the  ophthal-
mia, which was of the most acute kind, ended  in opacity of the cornea
and loss of vision.
   [We have met with several cases in which  this disease was produced by
the patient washing his eyes  in his urine whilst labouring under gonorrhma.]
   Experience clearly proves,  that  we should  have expected  d priori,
that gonorrhoeal ophthalmia may be produced by the application of go-
norrhoeal matter from another individual.  This cannot be a very fre-
quent occurrence, for obvious reasons ; and I  have seen no instance of
the kind.  Mr. Wardrop has furnished me with two examples.  An old
lady went into the dressing-room of her son, who had gonorrhoea, and
washed her face with a towel which he  had been recently making use
of.   Purulent ophthalmia quickly supervened, and destroyed  the eye in
a few days.   A washerwoman, who  had been employed in cleansing
foul  linen, was seized in a  few hours with puriform  ophthalmia, which
terminated in the suppuration and collapse of  both eye-balls.   Del-
pechJ mentions the instance of a young and healthy woman, who washed
her eyes with goulard-water and a sponge, which had  been used by a
young man  affected with  gonorrhoea.   Violent  ophthalmia came on,
and quickly terminated in loss of the eye.   Mr. Bacot§ distinctly traced
the origin of the disease to infection, by means of matter from another
individual, in three instances, two of which were washerwomen.
   In a great proportion, however, of these gonorrhoeal ophthalmia?, we
cannot trace the disease of the eye  to the  application of  infectious mat-
ter, either from the same or another individual.  The eyes are said to
suffer by metastasis ; it is  stated that the  gonorrhoeal discharge is sup-
pressed, and that the inflammation  of the  eyes  occurs inconsequence of
that suppression.  Such is the representation of Richter,|| Scarpia,"[[ and
Beer,** who accordingly consider the restoration of the  discharge from
the urethra a principal indication in the treatment of the disease.  In
none of the cases,  which have come under my own observation, has the
urethral discharge been stopped; although it has generally been lessened,
it has continued in  some with little diminution.ff If, therefore, the notion

  * Vol. i. p. 295.                    t Treatise on hues Venerea, 1820, p. 98.
  t Chirurgie Clinique, t. i. p. 318.              § Treatise on Syphilis, p. 132.
  || Aufangs-grunde, vol.  iii. § 57.              V Treatise, &c. p. 162, 63.
  ** hehre, vol. i. § 533. " In all the instances," says Beer, " which I have seen, this oph-
thalmia has occurred in young, plethoric, robust, and truly athletic men ; and it has always
taken place in a very short time, generally in a few hours,  after the suppression of gonor.
rhceal discharge from the  urethra."
  tt Delpech gives nearly a similar statement.  " II est bien reconnu que 1'ecoulement nc 
280
GONORRHEAL OPHTHALMIA.
of metastasis includes the cessation of disease in its original  seat, go-
norrhoeal ophthalmia cannot, according  to my experience, be deemed
metastatic in any cases.  On the  other hand, the sudden stoppage of
gonorrhoea, when effected by surgical treatment, is not followed by in-
flammation of the eyes.  Since, then, gonorrhoeal ophthalmia may occur,
while the discharge from the urethra continues, and since it  does not
take place when  that discharge is stopped, we cannot admit that the
affection of the eye owes  its origin to the cessation of disease in the
urethra.
   I am inclined to refer its occurrence to the state of the constitution,
without being able to point out in what that  state consists; and to re-
gard  it as a pathological phenomenon analogous  to  those successive
attacks of different parts which are observed in gout and rheumatism.
The two other forms of ophthalmic inflammation, which take place in
conjunction with gonorrhoea, show themselves only in rheumatic sub-
jects, and generally in connexion with other arthritic sufferings; and the
difference between one of these and the affection now under considera-
tion is only in degree.  This view of the  subject may throw some light
on the  circumstance that, though  direct infection operates equally on
the eyes of both sexes, the gonorrhoeal ophthalmia, said to originate in
metastasis, seems to be confined to the male.   I have  never seen it in
the female; and Beer, in the passage last quoted, says, that he has ob-
served it only in young, robust, and plethoric men.   The state of con-
stitution, whether  hereditary or acquired, which leads to gout and simi-
lar affections, is much  less common in women than in men ;  and will
hardly  be  found  at all among those  young and  previously healthy
females, who are the principal subjects of gonorrhoea.  Again, the mor-
bid influences, which are experienced and exerted by the male urethra,
are different from  those of the vagina.
   Treatment.—The antiphlogistic plan, and particularly the general and
local  abstraction  of blood, have been  carried  to their utmost extent;
sometimes with complete, in other instances  with only partial  success.
In many cases, the result must be unfavourable  whatever treatment is
adopted, because,  from the rapidity and violence of the disorder, irre-
parable mischief has been done before our assistance  is required.  Of
six cases seen at an early period, and treated  by extensive depletion,
loss of the eye occurred in one only ;* these persons were not seriously
weakened by the measures adopted for them.
  It has been represented that the complaint may be stopped in its out-
set by applying  strong astringents  or escharotics  to the eye;  such as
a ten-grain solution or  the ointment of lunar caustic ;  (see pages 207
and 259.)  Destructive or injurious consequences have  so frequently re-
sulted under  the usual management of the disease, that the local mea-
sures just mentioned ought to be adopted in any favourable case;  that
is, where the affection has not extended beyond the conjunctiva. Blood-
letting might precede or accompany the topical application.  The pro-

cesse pas toujours en pareil cas; que quelquefois, et meme assez souvent, il subsiste dans
toute sa force."—Chirurgie CUnique, vol. i. p. 319.
  [Our experience is to the same effect.  We have seen the discharge from the urethra
continue  most profuse during the greatest violence of the ophthalmia.]
  * Treatise on the  Venereal Disease of the Eye, p. 46. 
GONORRHEAL OPHTHALMIA.
281
priety of this treatment is more questionable, if the cornea has begun to
suffer; but the usual results of such cases are so unfavourable, that they
could hardly be aggravated by the plan  now  proposed, which, there-
fore, deserves trial in a doubtful case.
   For reasons already stated I  should  use the solution in preference to
the ointment of lunar caustic;  and I  should not  employ it  at  first of
greater strength than four grains to the ounce. Even in this milder form  I
have seen it cause so much excitement, with increased redness, discharge,
and pain, that the patients and  myself have agreed  in regarding  it as
injurious.
   [The solution of the nitrate of silver, of the strength recommended by Mr.
Lawrence, our experience leads us to believe  to be  entirely too feeble.  The
necessity for the most prompt, decisive, and active treatment, in severe cases
of this disease, is imperious, and the  only application we have found equal
to the emergency,  is the solid nitrate of silver.  The lids  being  everted,
a small cylinder of this salt should be freely passed over  the whole surface of
the swollen conjunctiva, and  then  the parts freely washed with tepid water,
before the lids are returned.   After the tumefaction and other primary effects
of this application subside  a solution  of 9j to 9ij of  the same salt to an
ounce  of water  should  be  daily dropped on the  eye,  the strength of  the
solution to be diminished as the puriform discharge decreases.
  In all cases, where the general condition of the patient will admit of it, a
copious bleeding should be practised previous to the local application, and gene-
ral or local depletion,  with a general  antiphlogistic course should be afterwards
employed concomitantly with the local remedies.  Opium, especially in  the
form of Dover's powder given at night, will conduce much to alleviate the suf-
ferings of the patient and also to ameliorate the  disease.
  In the advanced stages, and perhaps in some cases from the commencement,
tonics are required.   The infusion of Carscarilla, and Quinine are those  we
have usually employed.]
  I have seen mercury employed in these  cases without any advantage.
  I can place no reliance on the means advised by Richter, Beer, and
Scarpa, for reproducing  the urethral discharge,  which  has not been
suppressed in the cases under my observation.
  If the antiphlogistic treatment be preferred, it  must be pursued ac-
cording to the principles laid down under the head of purulent ophthal-
mia.  Blood must be taken from the arm  largely,  and perhaps a repiti-
tion of the venesection may be  necessary.   For the  slighter  symptoms
which may remain  after  the  inflammatory action  has  been subdued,
local  bleeding  will  suffice.  The more vigorous  depletion  is  recom-
mended where the inflammation is fully developed, without the cornea
being yet affected, or where the condition of the cornea may be doubt-
ful; that is, where we may entertain the expectation of saving the organ
from injurious change ; and where the patient is young and strong, with
a good constitution  and unbroken health.  Under  the opposite circum-
stances of a weak constitution  and bad health, where the powers of the
system are impaired by the various depressing influences, general ab-
straction of blood would be  out of the question ; and it may be necessary
to proceed cautiously even  with local bleeding.
  If sloughing or suppuration should have already occurred, it  will be
of no use to pursue this active  treatment, although more moderate de-
pletion may still be necessary.   General sloughing, or general suppura-
tion  of the cornea,  is usually attended by diminution of the inflamma-
       36 
282
GONORRHEAL OPHTHALMIA.
tion, and cessation of pain, or at least  comparative ease; the loss of
blood therefore is no longer required for the relief of suffering; and it
would be without an object, as vision is irreparably destroyed.  On the
contrary, a tonic and restorative plan, both in medicine and diet,  may
be advisable.                                 .      .        .    ,
  But inflammation may continue with  undiminished violence alter tne
occurrence of partial sloughing; and active depletion may still be neces-
sary, both to limit the extent of the  mischief, and  to favour the process
of separation and  restoration.   In two  cases,* free  depletion,  both
general and local, was employed after the cornea had suffered partially
in this way ;  and the treatment was completely successlul  in preserving
sight.   In a  third, where  one cornea had  sloughed entirely, and the
other eye was  actively inflamed,  the venesection  and local bleeding
employed on account of the  latter  had no prejudicial effect on the
former.                           .      •. •       in:     4  LT
   Experience does not warrant us in ascribing  much efficacy to blis-
ters: they are only to be regarded as an auxiliary measure, and  may
be resorted  to after antiphlogistic means.
   The ordinary local applications  are only to be considered as means
of lessening suffering, and thus  contributing to the patient's comfort;
not  as having the power of checking this violent disorder.   They pos-
sess in fact so little decided efficacy, that some patients find the warm
most beneficial, others  cold.  The  latter seem to me  the best, at  least
in the early  period of  the  affection ; and I should be unwilling to em-
ploy the former  for the reasons mentioned at  page  256.   Of warm
applications, none is better than the  poppy fomentation, which may be
 rendered astringent by the addition  of alum, in  the proportion of two
 or three  scruples to the pint.   The eye-lids and  cheek must be fre-
 quently cleaned, particular care being  taken to  prevent  accumulation
 of the'discharge and incrustation on  the edges of the former; for which
 purpose, it may be necessary sometimes to  smear them with some mild
 unctuous substance.
   Although we may  succeed  in  checking the inflammation by the
 means just  specified, its  effects are not immediately removed;  some
 time is required for the restoration  of the membrane to its natural  state.
 The swelling of the conjunctiva,  and  of the eye-lids,  is lessened, the
 membrane  becomes paler with  a somewhat flabby  appearance, and the
 purulent discharge is still  abundant.  The  patient is probably pale and
 weak.  Under these circumstances it is advisable  to change the  treat-
 ment; to administer tonics internally, and to employ astringents locally.
 When the inflammatory symptoms have been quickly and  completely
 subdued in  a healthy and strong subject, the effects of the disturbance
 will pass off in a little  time, as in  other inflammations, without the aid
 of  astringents and tonics. It will be  sufficient  to  remove the restric-
 tions in diet, and to regulate the bowels.
    There is  a  marked  change,  both  in the  local and general symptoms
 when  sloughing, suppuration,  or extensive ulceration  has occurred.
  The swelling is lessened, the conjunctiva is paler, the discharge thinner,
  the upper eye-lid less  tumid, and  perhaps of a  dull red or  somewhat
* Treatise on the Venereal Diseases of the Eye, p. 86 and 90. 
GONORRHEAL  OPHTHALMIA.
283
livid colour.   The pulse is quick  and feeble, the surface pale, the  ex-
tremities cold: there is great general debility with sense of weakness.
Such svmptoms may occur  in conjunction with an unfavourable slate
of the corneal  ulceration, in  which, although the  swelling and redness
of the conjunctiva are  diminished, the ulcer spreads with a ragged sur-
face, and irregular edge.  This condition,  both of the part and system,
will take place more particularly in those  of delicate constitution, and
after the activemeans employed to combat  the disease in its acute stage.
Here the combined effect of good  diet,  tonic  medicines,  and other
restorative influences,  with  local  astringents, such  as the solutions of
alum and  nitrate of silver, is  obviously required.
   Astringent lotions may be safely employed whenever the inflamma-
tion has been checked: although they may not  accelerate, they will
not under such circumstances materially retard recovery.  Sometimes,
however, they act as stimuli,  and cause renewal of inflammation.  This
relapse is what we  have principally to guard against: the  best mode
of averting it will be to avoid local excitement, and to regulate consti-
tutional  power either  by mild antiphlogistic means, or  by tonic  and
restorative measures, according to circumstances.
  The best forms of astringent applications  are the solution of alum,
from two to ten grains to the ounce of water, the solution of the nitrate
of silver, and the  undiluted liquor plumbi diacetatis.
  Local means of this  kind, especially the nitrate of silver, have been
thought  advisable in  ulcers  of the cornea, particularly those  accom-
panied with protrusion of the iris; and, in the  latter case, the remedy
has been used in substance.   I have found  recovery to take place most
speedily where none of these means have been employed.
  TREATMENT OF GONORRHEAL OPHTHALMIA BY INCISION OF THE SCLEROTIC
                            CONJUNCTIVA.

  Mr. Tyrrell* has lately proposed to employ this proceeding in puru-
lent  ophthalmia, whether gonorrhoeal,  or of  the  ordinary kind,  when
chemosis is fully established, and imminent danger consequently  exists
of destructive changes in the cornea.
  In acute ophthalmia, attended with chemosis, Scarpa  recommended
"circular excision of the  projecting portion of the  conjunctiva with
curved scissors, at the part where  the cornea  and sclerotica unite;  by
means of which, not only the whole of the blood which is extravasated
under the conjunctiva is discharged, and with immediate relief  to the
patient, but  also  that  which, notwithstanding the abundant general
evacuations of blood, might still greatly distend the vessels of this  mem-
brane."!
  This mode of proceeding has been employed for some years by Mr.
SansonJ at the Hotel Dieu, in cases of  gonorrhoeal ophthalmia.   The

  * On a successful Plan of arresting the Destruction  of the transparent Cornea from
acute purulent Inflammation of the Conjunctiva,; Medico-Chirurgical Transactions;  vol.
xxi.   A practical Work on Diseases of the Eye; vol. i. p. 72—95.
  t Treatise; translated by Briggs, 2nd edition, p. 148.
  X De I'Emploi de I'Excision, Sfc. dans VOphthalmie Blennorrhagique, par  E, F. Jul..
liard. Paris, 1835 ; quoted in the hondon Medical Gazette, vol. xxiii. p. 595. 
284
GONORRHEAL OPHTHALMIA.
eye-lids being  separated  and everted, the tumid conjunctiva is seized
with  a pair of dissecting forceps, and removed wTith curved scissors.
The  whole of  the  swelled  membrane should be  excised, if possible:
when the blood has ceased to flow, the everted surfaces of both lids are
to be rubbed freely with lunar caustic.
   In  entertaining the notion that the swelling of the conjunctiva arises
from  the effusion of blood, Scarpa confounds chemosis with ecchymosis;
an error which  I have  adverted  to in  another place.  (See chap.
xxii.  § 1.)
   It would  be  always difficult, in many cases impossible, to  procure a
sufficient exposure of the organ for the purpose of  this  circular exci-
sion; and I do not understand how complete eversion of the lids is to
he accomplished, either alone, or in conjunction with exposure of the
globe.
   Mr. Tyrrell mentions that he  had tried  the  method of depletion
fully  and fairly in many cases where the  disease  had advanced to the
state  of  complete chemosis,  and generally with  unfavourable result.
"I have  tried also," he  says, " locally, strong  solution of  nitrate of
silver, and  the undiluted  solution of the diacetate of lead; but I have
never seen  the slightest advantage gained  by such remedies, in  the
state  of the disease, in which complete  chemosis  existed:  in the early
stage, I grant that powerful astringents are sometimes of much service,
as they are in the catarrhal affection; but I consider their employment
to  be more frequently prejudicial than beneficial, adding, as it were,
fuel to the fire, and do not therefore recommend their use, because the
first stage of this disease is always curable by simple means.*
   The treatment by  incisions was adopted by Mr. Tyrrell,  from con-
sidering  the mode in  which the cornea is destroyed in purulent ophthal-
mia.   He says " the  principal supply of blood to this  texture, is through
the vessels  of  its  conjunctival covering, as may  be distinctly seen in
some  morbid  conditions of these  structures: for  the larger  vessels
ramify in the conjunctiva layer,  and send  minute  branches to the tex-
ture of the  cornea.   The occurrence of chemosis, or elevation of the
conjunctiva covering the sclerotic, around  the margin of the cornea,
by rapid deposition in the sub-conjunctival cellular membrane first  im-
pedes, and then altogether interrupts the circulation in the corneal por-
tion of the membrane; and this arises from the pressure, at ihe margin
of the cornea, by the  deposition, and from the tension and displacement
of the membrane; for the attachment of the  conjunctiva, over the junc-
tion of the cornea  and sclerotic, is so firm, that it undergoes little or no
change, whilst  rapid  and  extensive  alteration  takes  place in  the mem-
brane around, but its organization is so delicate, that the circulation is
easily interrupted by  the combined efforts of pressure  and  tension.  The
cornea does not mortify from an extension of inflammatory action to it,
but solely from interruption to its supply of nutritious fluid."f
   "The remedy that suggested itself to'me, under  these circumstances,

  * Practical Work, vol. i. p. 72. Mr. Middlemore gives an equally unfavourable opinion
of this  practice in the eariy stage of the disease, which he had tried in many instances,
with every disposition to adopt  the practice generally, if it had  been  found successful.
Treatise, vol. \\ p. 215.
  t Ibid, p, 51. 
GONORRHEAL OPHTHALMIA.
285
  was free division of the chemosed part, so as to  relieve the tension of
  the conjunctiva, and to allow of the escape of fluid from the subjacent
  cellular tissue, and thus get rid of a great deal of that which I conceived
  to operate mechanically, in obstructing the circulation of the cornea.
  Mv opinion of the probable efficacy of this proceeding, was heightened
  by" a knowledge of the excellent effect of a similar plan of treatment in
  cases which I  consider somewhat  analogous; viz. in cases of severe
  phlegmonous inflammation of cellular tissue, in other parts of the body;
  havinof often  witnessed  the  arrest of gangrene  and  mortification, by
  making free incisions in such cases, through the skin and cellular mem-
  brane; which no doubl acts  beneficially by relieving the tension of  the
  former, and by partially including the latter, and  thus  taking off a pres-
  sure, which impedes or arrests the circulation."*
    The attempts at relief by circular excision, were considered by Mr.
  Tyrrell  more likely to be injurious than useful,  by dividing totally or
  partially, the vessels passing  to the corneal portion of  the  conjunctiva.
  The plan that he proposed was to make incisions through the sclerotic
  portion of the conjunctiva, and  its subjacent  cellular  tissue, beginning
\ at the margin of the cornea, and  extending towards  the edge of  the
  orbit, but avoiding the transverse and  perpendicular  diameters of  the
  globe, that the larger vessels passing to the cornea might not  be injured.
  '• The patient was seated in a low chair, and  I stood behind him,  so as
  to receive his head when inclined backwards, against  the lower part of
  my chest; I then carefully, and with as little force as possible, elevated
  the superior palpebra with the point of the forefinger, (as in the operation
  of extracting a cataract,) having the finger covered with a piece of fine
  linen to prevent its  slipping;  one of my pupils depressed the  lower lid :
  next with a fine cataract knife I divided  the  conjunctiva  and the sub-
  jacent cellular membrane from the margin of the cornea, in a direction
  between the attachment of the recti muscles;  making two incisions in
  each of these positions, or  eight in all: in passing the knife, its  point
  was  made  to  penetrate the  membrane, just  over the junction of  the
  cornea and sclerotic, and the back or blunt part of the instrument was
  opposed first to  the cornea, and  afterwards,  as  the  incision was  ex-
  tended, to the sclerotic"!
    Mr. Tyrrell states that his plan, in numerous trials, has proved  more
  successful than he could have  expected; that it  prevents the necessity
  of severe general depletion, and saves the patient from the injurious and
  long continued effects of such  treatment.  He adds  that it has  been
  found  equally successful by his colleagues and  many others;  and  he
  says, " from my present experience in the plan of treatment, I feel  satis-
  fied  that  its  adoption  will certainly save the cornea, which has  not
  already become  affected, whatever may be the extent and violence of
  the surrounding conjunctival disease; that when the cornea has become
  hazy, but still retains its brilliancy, or  property of reflecting light, the
  operation will prevent further mischief, and that the cornea will proba-
  bly be entirely restored to its original integrity; at all events, in such a
  case submitted to this treatment, the cornea will suffer but triflingly  ; that
  when part of the cornea has lost vitality, which is indicated  by its per-
* Ibid, p. 73.         t Ibid, p. 75. 
280
GONORRHEAL OPHTHALMIA.
fectly opaque state and dulness, or loss of reflective property, the division
of the chemosis will prevent the extension of the mortification, and save
that part of the cornea which may still retain life;  that the effect of the
operation is not promoted  by any means which tend much to  depress
the general power, nor is it frustrated  by a tolerably full action of the
heart and arteries; that  its influence  is purely local, and its beneficial
operation not likely to be interfered with, unless by two extremes, viz.
great excess of arterial  action  with fever; or  extreme  feebleness  of
vascular power.   It is only, therefore, in cases in which such extremes
exist, that I now  deem it requisite to adopt other than simple and ordi-
nary treatment generally, such as regulating the secretions, and allow-
ing a diet adapted to the power and age of the  patient, excepting when
the chemosis is unusually  firm or fibrinous, when I give mercurials  to
check such deposite."*
   The swelling of the  ocular conjunctiva  and of the  palpebrae may
make it  difficult to obtain an exposure of the globe sufficient for making
these incisions.  It may be necessary to elevate the upper lid with the
elevator of Pellier.  Perhaps we shall not be able to  make so  many
incisions, nor to  carry them far from the  edge of the cornea.   Under
such circumstances, the plan may be  pursued  as far as the case will
admit.
   Warm fomentation should be employed immediately after the inci-
sions, and  may be  continued for twenty-four hours or  longer: the use
of astringents may then be begun.
   After the incisions, the  case must be treated in other respects  accord-
ing to the general indications; by abstraction of blood generally, locally,
or both  in succession; by good diet, tonic and restorative means; or by
simple regulation of the diet and  alimentary canal.  The exhibition of
mercury may be useful here, as  in other cases, after  the disease has
been checked  by antiphlogistic means: it will not be necessary to con-
tinue it longer than two, three, or four days.
   This proposal  of Mr.  Tyrrell presents two points for our considera-
tion; the practical proceeding, and the pathological views by which it
was suggested and is explained.   In the former respect nothing can be
more satisfactory than  the testimony adduced by Mr. Tyrrell, from
his own experience and that  of others, to the advantages resulting from
these incisions.  If these favourable results should  be confirmed, as they
no doubt will be  by general  experience, the treatment will constitute a
valuable addition to our  means  of  contending with a violent, rapidly
destructive, and most alarming disorder.
   Difference of opinion  may be expected  on the theoretical part  of the
subject, on which indeed a  slight controversy has already occurred.!
We have at present no direct proof that the death  of the cornea in
purulent ophthalmia is caused by strangulation  of the conjunctiva, and
consequent interruption of vascular supply; nor do we see how direct
proof is to be attained.

  * Ibid. p. 92.
  t Remarks on Mr. Tyrrell's Paper on the Treatment of acute purulent Ophthalmia, by
Mr. T. W. Jones,  hondon Medical Gazette, vol. xxiii. p. 591.   Reply by Mr.  Tvrrell,
ibid, p. 702.  Further Remarks on Mr. Tyrrell's Rationale of his Operation in the puru-
lent Ophthalmy, by Mr. Jones,  ibid. p. 815. 
                     GONORRHEAL OPHTHALMIA.                   287

  If the cornea perishes, as the strangulated intestine does in hernia, a
complete interruption of the circulation should be shown in the former,
as in the latter case.   In this respect the two instances seem widely
different.  We do not easily comprehend how the deposition of fibrine
and the tension of the membrane, can act so equally and efficiently on
the whole circumference of the cornea, as to produce an  effect analo-
gous to that of the stricture on a strangulated bowel.
   That the cornea derives its principal supply of blood from the vessels
of the conjunctiva, is rightly stated by Mr. Tyrrell.  Yet the corneal
vessels from this  source  may be distinguished into two orders, a super-
ficial, and a more deeply seated one.   Strangulation, if it  exist at all,
may be supposed to act on the former.   The latter are derived from the
trunks, situated between the conjunctiva and the sclerotica, and adhere
closely to the latter membrane.   They are not affected  when the con-
junctiva is pushed from side to side, or when a fold of the membrane is
drawn up.   They do not seem, properly speaking, to belong to the con-
junctiva.  What proof is there  that these vessels, thus adhering to the
sclerotica, are involved in the chemosis, so as to partake in the strangu-
lation which may  affect the superficial  order?  Again, vessels enter
the cornea on  its posterior  surface;  and it may be presumed, on the
analogy  of  all similar  instances, that  they communicate with those
derived from the conjunctiva.   No change in the state of that membrane
could affect this source of supply.
  If the circulation of the  cornea be  interrupted, the whole structure
should perish, as the entire  fold  of constricted intestine  does.   The
sloughing of the cornea is frequently partial; and the part not included
in the mischief recovers its normal state.
  Chemosis  happens  frequently in  acute  purulent ophthalmia;  slough-
ing of the cornea is a comparatively rare occurrence.   I  have seen it
in the adult, only in cases of gonorrhoeal ophthalmia; nor  do I find it
mentioned as an effect of the common disease by those who have seen
and treated it most extensively.   The swelling and tension of the con-
junctiva are apparently  as considerable where sloughing of the cornea
does not take place, as where it does.
  Although the interception of vascular supply might account for slough-
ing of the cornea, it  will not explain the other morbid changes which
occur in conjunction with the complete chemosis. Under a tumefaction
of the conjunctiva,  apparently as considerable  and complete  as  that
which accompanies sloughing, we may have suppuration of the cornea,
or interstitial deposition, clear proofs of increased vascular activity.
Ulceration, which may occur under the like circumstances, is  also an
effect of inflammation generally;  and it is thus seen on other occasions,
in the cornea.
  Mr. Middlemore*  believes that sloughing of the cornea may proceed
"either from an excessively inflamed state of that portion of the  con-
junctiva which covers and supports it, or from the strangulation of those
vessels, which pass to that part and thence to the cornea."   He adduces
no proof on the latter point, which he speaks of in  this as well as  in
other passages of his  book, as if it were an ascertained matter; nor does
*  Treatise on the Diseases of the Eye, vol. i. p. 61. 
288
GONORRHEAL OPHTHALMIA.
he mention any circumstances by which the two kinds of cases maybe
distinguished. "Mr. M. also strongly recommends free scarification of the
chemosed conjunctiva, making very numerous incisions,  and carrying
them deeply, so as to let out  the fluid effused into the subjacent tissue.
" You would also freely scarify the conjunctiva ;  having selected for this
purpose the instrument previously  described, (a narrow lancet termina-
ting in a rounded cutting edge,) draw it firmly and  steadily along first
the sclerotic, and afterwards the palpebral portions of the conjunctiva, at
distances of half a line from each other, taking care to divide the  tex-
ture of the conjunctiva at each sweep of the knife, so as to penetrate as
far as the fluid effused into  the sub-conjunctival cellular  membrane."*
The direction of the incisions is not mentioned.
   SECTION II.--MILD GONORRHEAL INFLAMMATION OF THE CONJUNCTIVA.

  External redness of a bright scarlet tint, from distention of the super-
ficial  vessels of the  globe,  and' increased mucous  secretion,  are  the
principal symptoms  of this  complaint.   In slighter attacks the redness
is not deep or  general; the  membrane is not swollen; there is little if
any pain; and the increased secretion consists merely in a few streaks
of whitish mucus lying  between the eye-lids  and globe, or adhering to
the margins of the  former.  The characters of the affection,  when
more  severe, approach to those  of acute purulent  ophthalmia.   The
conjunctiva swells,  becomes  bright  red throughout, and secretes a
yellow mucus, which is discharged copiously from the eye.  The com-
plaint yields readily to antiphlogistic treatment, and is  not  attended
with danger to the organ, if properly managed.  In its  more violent
form, it requires active  measures; and, if not checked by their timely
adoption, it may cause ulceration or opacity of the cornea, with serious
injury of sight.
  This  mild gonorrhoeal inflammation of the conjunctiva may be  safely
and advantageously  treated  on the astringent plan, particularly by the
solution of lunar caustic, the  use of  which may be preceded  by anti-
phlogistic means in  patients of full habit, or where we fear that  the
organ is in danger from probable extension of inflammation to  the
cornea.
SECTION III.— GONORRHEAL INFLAMMATION OF THE EXTERNAL TUNICS AND IRIS.

  The vascular trunks lying between the  conjunctiva and  sclerotica
are distended, and the anterior portion of the latter membrane becomes
pink or  purplish  red.  As the  conjunctiva participates  but  slightly in
the affection, these changes  are distinctly seen through  it.   There is
increased lachrymal secretion, severe  pain in the eye with sense of ten-
sion, intolerance of light with discharge of tears  on the slightest expo-
sure.  The pain and  intolerance are sometimes  excessive, so that the
smallest access of light cannot be borne.
* Treatise on the Diseases of the Eye, vol. i. p. 207. 
GONORRHEAL OPHTHALMIA.
28'J
   The inflammation soon extends to the iris, which loses its brilliancy,
 assuming a  dull and deeper  hue.  The pupil  contracts, and lymph is
 effused from its margin.  The external redness is increased, the vessels
 of the conjunctiva being more distended.  The  cornea at the same time
 becomes hazy, and vision is more or  less impaired.   Nebulous opacity
 and speck of the cornea are  sometimes produced.  As the  inflamma-
 tion  subsides, the iris  recovers  its natural  colour, and  vision is re-
 stored.
   If the  inflammation be considerable, it may cause adhesions of the
 pupil, with contraction of the  aperture; and the adhesions thus formed
 are sometimes white as in arthritic iritis.   Even permanent  dimness of
 sight may be produced.  Sometimes repeated attacks of the disease
 occur, each of which causes fresh  adhesion, so that  at  last the pupils
 are fixed  in their whole circumference and considerably contracted.
   This  affection must be treated by the abstraction of blood, general or
 local, and by other corresponding measures.  If  the  inflammation be
 considerable, if  it should occupy both  eyes,  and the patient should be
 young, robust, and  plethoric,  general bleeding  will be required.  Cup-
 ping and leeches will  suffice in  the  milder instances.  Warm local
 applications are generally the most agreeable to the patient's feelings:
 the poppy fomentation  answers the purpose very well.  Exclusion of
 light  is  absolutely necessary so  long  as the intolerance  continues.
 When the inflammation is checked by these  measures, blisters may be
 advantageously  applied, and the  cure  may be  completed by the admi-
 nistration of Plummer's pill once or  twice a-day, with mild aperients
 and a regulated diet.   If the  iris  should  be  involved  in  the affection,
 mercury should be administered after depletion.
   Colchicum is  often used with advantage on account of the rheumatic
 symptoms which accompany this affection;  and the eye maybe  ex-
 pected  to participate  in the  benefit, although the remedy cannot be
 depended on as  a means of counteracting dangerous inflammation of
 the organ.  The same observation is applicable to residence at the sea-
 side  and warm bathing, which are more advantageous to  the linger-
 ing arthritic  ailments, under which patients frequently suffer so long in
 these cases, than to the ophthalmic affection.
   It is not uncommon for the same individual to experience at different
 times, in consequence of or in  connexion with gonorrhoea, both this  in-
 flammation of the external tunics  and  iris, and mild inflammation of the
 conjunctiva.   Some  cases recorded  in my Treatise on the Venereal
 Diseases  of the Eye*  exemplify this circumstance, which  was  also
 observed in two  of the cases related by  Sir Benjamin Brodie.!
   Rheumatic inflammation of the joints accompanies both these forms of
 ophthalmic disease, when they take place in consequence either of go-
 norrhoea or of other discharge from the  urethra. All the cases of these
 affections  related in my treatise, except one, exemplify this combination.
 Sir B. Brodie has  mentioned five cases of this description, in all of
which the disease of the eyes was that which  I have called mild go-
norrhoeal  inflammation  of the conjunctiva;  while  in two  of them,

 * Cases xvi., xix., and xxi.
 t Pathological and Surgical Observations on Diseases of the Joints, p. 55 and 60.
      37 
200
GONORRHEAL  OPHTHALMIA.
although the conjunctiva had been affected on one occasion, the sclero-
tica and iris suffered on another.*  Inflammation of the joints occurred
in all.
   Dr. Vetch| relates the case of an officer, who had  contracted go-
norrhoea, of which the symptoms were well marked and  violent, having
been attended in the first instance with hernia humoralis.  Rheumatic
inflammation of the joints and inflammation of the external proper tunics
of the eye followed on each  occasion.  After the second attack, Dr.
Vetch found an "irregular and contracted pupil, with some opacity of
the capsule of the lens, and adhesion between  it and the iris;  and on
causing him to shut the sound eye, the vision of the left eye was found
very much impaired."
   Inflammation sometimes  exists at the same time  in the  urethra, the
eyes, and the joints; in other instances these parts are affected succes-
sively.
   The affection of the eye last  described is exactly the same as rheu-
matic inflammation of the sclerotica and iris occurring independently of
gonorrhoea.  Both this and the mild  purulent inflammation  of the con-
junctiva are to be regarded as rheumatic affections of the organ excited
by gonorrhoea; that is,  they take place in individuals, in whom  this
constitutional disposition is shown by inflammation  affecting either the
synovial membranes or the fibrous structures of several joints. Although
the organs  seem at first view very dissimilar, there is an analogy of
structure between the parts which suffer in  the two instances;  that is,
between the synovial membranes and the conjunctiva, and between the
ligaments and fibrous sheaths and  the sclerotica.   Hence we need not
be surprised at finding that the eyes  suffer  under the  influence  of that
unsound state  of  constitution, which leads to these  affections of the
joints.  The structure originally affected, the lining  of  the  urethra, is
also a  mucous  membrane, which sometimes becomes  inflamed,  and
pours out  a  puriform discharge, in gouty and rheumatic subjects, from
internal causes.
   That the essential source of this combination of morbid phenomena
is peculiarity of constitution, may be inferred  from  the repetition of
attacks, and the length of time for which some individuals are harassed
by successive appearances of disease in various parts.   In one patient
rather severe  purulent ophthalmia occurred in  August, 1822, and a
similar affection followed soon after; from that time to the  present, six
attacks  of rheumatic iritis have taken place.  In  another, discharge
from the urethra without infection occurred  four times;  then inflamma-
tion  of  the foot; three years after, severe inflammation of the cham-
bers of the aqueous humour;  then gonorrhoea and mild purulent inflam-
mation  of the conjunctiva, followed by  rheumatic  inflammation  of
various  joints;  and afterwards severe rheumatic inflammation of the
sclerotica  and  iris.  In  a  third, violent  gonorrhoea was followed by
acute inflammation of the external tunics; a  second gonorrhoea excited,
first purulent ophthalmia, then acute inflammation of the external tunics,
and  subsequently rheumatic  inflammation   of  various  joints.   Two

             * Pathological and Surgical Observations, p. 55—63.
             T Practical Treatise, &c. p.  161. 
GONORRHEAL OPHTHALMIA.
291
 years after, severe rheumatism was  brought on by cold.   I lately saw
 a gentleman with gonorrhoea, mild  purulent inflammation  of the eye,
 and rheumatic affection of the foot and back: it was the fourth attack
 he had experienced of the same combination of symptoms.   One patient
 seen by Sir B. Brodie had undergone four attacks, all of  which began
 with  gonorrhoea; it  was followed,  first  by purulent ophthalmia, and
 then by inflammation of the synovial membranes of several joints.*   In
 another there had been eight  attacks  at various intervals during  a
 period of seventeen years.f
   In the London Medical Gazeite'l I  have related a case of acute gonor-
 rhEal ophthalmia with rheumatic  affection  of various  joints;  also,
 another instance of a gentleman, thirty-six years old, who has suffered
 repeatedly, during the last twenty  years, from gonorrhoea, inflamma-
 tion of the joints, and ophthalmia, excited and maintained by all kinds
 of irregularity.  I saw him under the eighth  or  ninth attack of inflam-
 mation of the external tunics and iris.   This had appeared  on the ces-
 sation of discharge from the urethra following the use of copaiba.  Both
 knee-joints w7ere swollen, the right  enormously, from effusion into the
 cavity; and had been so for a long  time.§
   As the train of diseases just described must be referred  principally to
 peculiarity of constitution, gonorrhoeal infection  is  not essential to their
 production; it is only  to be regarded as  one of the exciting causes, and
 perhaps the most frequent.   There  could be no doubt that  gonorrhoea
 bad been contracted in several cases of which I investigated the history.
 In another instance the patient was convinced that he had not received
 infection; and, according to his description,the usual characteristics of
 gonorrhoea virulenta had been wanting.   Sir B. Brodie seems to have
 considered that the discharge from the urethra, in some of the instances
 which he  had seen was not caused  by infection.   In the case of the
 gentleman who had had eight attacks, inflammation of the urethra with
 discharge was the first symptom, and occurred before the age of twrenty;
 he believed, however, that he had not been exposed to the risk of infec-
tion.  In three of the attacks, purulent ophthalmia was  the  first symp-
tom, being followed by discharge from the urethra  and inflammation  of
the synovial membranes.  In the other four attacks, inflammation  of
those  membranes occurred without any  previous disease of  the eye or
urethra.||  In another case  discharge from the  urethra  brought on  by
use of a bougie was  the first symptom,  (p. 63.)

  * Pathological and Surgical Observations, &c. p. 63,          f  P. 60.
  t Vol. xxiii. p. 509.              ^ hondon Medical Gazette, vol. xxiii. p, 511,
  I! Pathological and Surgical Observations, &c. p. 60, 
(  202  )
CHAPTER  X.
ERYSIPELATOUS OPHTHALMIA ,* PUSTULAR OPHTHALMIA ; STRUMOUS OR

                  SCROFULOUS OPHTHALMIA.
               SECTION I.--ERYSIPELATOUS OPHTHALMIA.

  The external inflammations of the eye exemplify the great variety in
local and general symptoms, which diversities of organization, habits,
age, sex, and all other  contingent  circumstances are capable of pro-
ducing in the phenomena of disease; and they illustrate not less strongly
the essential similarity of these  apparently different processes, and of
the means necessary for their treatment.  Under  the denomination of
erysipelatous ophthalmia, the Germans have described a  modification of
conjunctival inflammation, which is  occasionally seen, but which is
neither sufficiently peculiar nor important to require any long conside-
ration.  The vascular congestion in the conjunctiva is not considerable,
nor does the patient usually experience much inconvenience.   There is
watery effusion into the subjacent cellular tissue, making the membrane
appear cedematous; this fluid gravitates towards the lower part of the
globe, so that the conjunctiva projects a little at the edge of the lid, with
a watery, or jelly-like  appearance.  The eye has altogether a watery
look, which might justify the term ophthalmia serosa or humida. Some-
times  the sclerotica participates, and there is greater redness, with more
or less pain, and sensibility to light.  In these severer ca^e?, the palpe-
brae and surrounding parts exhibit some erysipelatous redness and swel-
ling; there is pain in the head, with furred tongue, nausea, and general
feverishness.   The affection is seen in persons of, or after, middle age,
and generally of an unhealthy constitution.—An  active aperient, which
may be preceded  in some cases by an emetic, will remove the complaint
in its slighter forms.   When the excitement is more  considerable, local
bleeding and  blistering may be required.  Warm fomentations are the
most agreeable application to the eve.
                 SECTION II.--PUSTULAR OPHTHALMIA.

  Aphthous inflammation of the conjunctiva; Morgan.—This is an inflam-
mation of the mucous membrane, constituting an intermediate link be-
tween catarrhal and  strumous  inflammation.  The small  elevations
called pustules  are occasionally seen in catarrhal  inflammation of the
membrane, and they occur frequently in  strumous ophthalmia, but we
designate by the epithet pustular an inflammation seated in the con-
junctiva  and confined to it, occurring in  young subjects, and attended 
SCROFULOUS OPHTHALMIA.
293
for a short distance on the cor-                Il?-l ■
nea, the pustule then being formed on the latter part.   The pustules con-
tain at first a kind of watery fluid, and therefore they have been called
phlyctcBnce, or phlyctenules.  Sometimes we  find only one, sometimes
more, in different parts of the conjunctiva, and sometimes there is a great
number of them, extending completely round the margin of the cornea.
They vary in size, being sometimes small, at other  times large ; when
only  one pustule forms, it may be as  large as the half of a pea, but in
proportion to the number  are they smaller.  In this affection there  is
scarcely any pain  and  no intolerance of light, and were it  not for the
appearance  of the pustule  and  the redness, the  patient would hardly
think  there  was any thing the matter with  the eye.  Under a proper
treatment  it does not extend to the sclerotic coat; but if neglected, and
especially if there be any scrofulous disposition,  it may be more serious.
If the complaint continues, and the inflammation proceeds, the pustules,
whether situated over the sclerotica or on the cornea, ulcerate; the ulcer
being rather disposed to spread.   Under proper treatment they disperse
without ulcerating.   Mild aperients and saturnine lotion are generally
sufficient.   More acute cases may require leeches and  blisters.  If the
complaint  should be protracted, in a weak constitution, vegetable tonics
or bitters may be required.
          SECTION III.--SCROFULOUS OR STRUMOUS OPHTHALMIA.

  Conjunctivitis scrofulosa;  Phlyctenular ophthalmia;  Mackenzie.—
This is an external inflammation of the eye, exhibiting modifications in
its symptoms, progress, and consequences, derivable from peculiarities
of constitution in the individuals whom  it affects, and requiring corre-
sponding modifications of treatment.  We may therefore say that scro-
fulous ophthalmia is  inflammation of the eye occurring in scrofulous
subjects.
  Scrofulous constitution.—All mankind  are not formed after one pat-
tern ; if it had been so, the business of the physician and surgeon would
have been much more simple than it is.   There are diversities of natu-
ral  organization, and analogous varieties in the forms of disease.  Each
individual has something peculiar in constitution, as well as in  form and 
291
SCROFULOUS OPHTHALMIA.
 features.   But the peculiarities, with which it is more important that
 we should become acquainted -medically, are those which  distinguish
 classes more or less numerous;  and of  these none is more  common
 than the scrofulous.
   The word scrofula is used in two senses; either  to designate that as-
 semblage of characters, which mark a particular disease; or to denote
 the peculiarity of constitution, generally original or connate, from which
 such distinctive characters are derived.   In the former sense, scrofula
 is equivalent to scrofulous disease; in the latter, to scrofulous constitu-
 tion.  We can point out  certain external marks of scrofula; but we
 have not yet discovered  the differences in the elementary composition
 of the frame, on which the characteristic peculiarities of scrofulous dis-
 ease depend.  The morbid disposition, however, is strongly  marked :
 certain forms of disease are so easily excited, and return so readily, that
 it is almost impossible  to  keep them off.  The  absorbent glands, and
 some other organs of glandular structure, the mucous membranes and
 skin, the lungs, bones,  and joints, are the parts most liable to scrofula.
 Of the membranes, such as are exposed to the external air suffer most;
 for  instance, those of the  eyes, nose, and  lungs.
   Two kinds  of constitution, differing considerably in some respects,
 are observed in  persons called scrofulous.  In one there  is a  pale and
 bloated countenance,  a  swelling of the  upper lip  and septum of the
 nose, and a tumid abdomen.  The mucous membrane of the stomach
 and bowels is easily disordered by errors  of diet, or by trifling causes,
 which would have little or no effect on other persons.   When  these im-
 portant organs are disturbed, the nutrition of the entire body is more or
 less impaired.   There is a languid state of circulation,  so that the  skin
 is pale and rough, and the extremities are cold ; the muscular flesh is
 loose and flabby; and  there is a kind of  torpor  in all  the functions,
 bodily and mental.  In the other  set of  subjects  the integuments are
 thin, and the ramifications of the cutaneous  veins are distinctly seen;
 there is an almost unnatural colour  in the cheeks.  The circulation is
 rapid, the nervous system irritable, and both  are easily excited.   The
 various functions of body  and mind are performed  quickly.  A prema-
 ture development of intellect is often observed in such children, and they
 are affected  powerfully by all external influences.   We cannot suppose
 that the phenomena and treatment of disease will  be the same in the
 two kinds of constitution just described, though the term  scrofulous is
 used  in both  instances.
   Exciting causes of scrofula.—Of these, cold is  the  most powerful,
 especially when combined'with moisture.   Hence scrofulous disease is
 most prevalent in countries with a moist and damp atmosphere, such as
 Great Britain, the north of Germany, and of France; but it  is found
 elsewhere, and that in extensive prevalence.  Beer states, that nine-
 tenths of the ophthalmic inflammations in  children  at Vienna are stru-
 mous.*  Benedict considers that in Breslau the proportion is greater; he
 says 95 in lOO.t   The late Dr.  Gregory, of  Edinburgh, used to  say

  * hehre, vol. i. p. 588, note. lie adds, that there are few families in Vienna, in which
 some of the children do not exhibit the scrofulous diathesis.
  f " Of one hundred ca.ses nf ophthalmia in children, ninety.five or more are scrofulous."—
Handbuch, vol. ii. p. 165.  He assigns as reasons for this great prevalence of scrofula,' the 
                      SCROFULOUS OPHTHALMIA.                   295

that there was not a single family in Scotland free from  scrofula.   Dr.
John Thomson even represents that " it is rare to meet with an individual
who has not at some period of life, experienced disease  in some shape
or other belonging to one of the several forms of scrofula."*
  The next in order of the direct causes is insufficient or unwholesome
food, excess, or irregularity of diet.  The effect of this cause is aggra-
vated by sedentary habits, neglect of exercise, and residence in an im-
pure atmosphere.  Parents are often over anxious that children should
begin their studies, that they should employ themselves in acquiring learn-
ing and accomplishments.   Thus young persons are compelled to devote
to sedentarv pursuits many hours which they would otherwise  occupy,
and probably with greater advantage to mind as well as body, in active
exercises.
  The combined action of several direct causes, such as insufficient and
unwholesome food, deficient clothing,  the want of domestic comforts
generally, sedentary occupations, the impure atmosphere of crowded
dwellings in the  confined parts of  large cities, is  capable of  producing
in those originally healthy a state of constitution  hardly distinguishable
from the scrofulous, as we  frequently  see in the poor  inhabitants of
towns.  This acquired morbid disposition is marked  by disordered
digestive organs, perhaps by a  tumid belly,  by  pallid  and  unhealthy
skin, cold  extremities, and flaccidity of  muscle; that is, by the same
characters which belong to congenital  scrofula.
  The liability to  scrofula does not extend equally  through  the whole
of life.  Disease of this character generally, and  strumous ophthalmia
in particular, are not seen in infants at the breast, which, being kept
warm, and having  a supply of  wholesome  food prepared  by nature,
escape the two  great exciting causes.  They prevail, however, exten-
sively from the end of suckling to the age of  puberty, in which period
the processes of nutrition and growth are going on actively, and easily
disturbed by the circumstances already alluded to.   Strumous  ophthal-
mia is seldom seen after puberty;  but other forms of  ophthalmic in-
flammation are  often found more obstinate in persons  of  scrofulous
constitution.
  Strumous individuals  are liable  to inflammations  of the  lids, which
take on the form of induration  and thickening, or of hordeolum.  The
lachrymal  sac  and  nasal duct  also frequently suffer in  such habits.
These subjects I shall not advert to at present, meaning  to describe an
external inflammation of the eye,  originally seated in the conjunctiva,
often affecting the sclerotic coat and cornea, seldom going deeper, but
occasionally extending even to the iris.
  Symptoms and Course.—The external redness, which  is often incon-
siderable, and sometimes more apparent in the lining of the lids than in
the eye, is partial in the latter situation.   Particular vessels, or  fasciculi
of vessels, are distended on the surface of the membrane, run  towards
the cornea, and extend  over its margin, or stop short  at the boundary
between it and  the sclerotica.   Where  these fasciculi  terminate, we
observe the small  elevations, called pustules or phlvctaense.   These,

marshiness of the ground on which Breslau stands, the narrowness and filthiness  of the
streets, and the use by the poorer families of unwholesome food, such as dumplings, pota-
toes, black bread, and bad beer.
  * hectures on Inflammation, p. 163. 
 29G                   SCROFULOUS OPHTHALMIA.

 which may have a whitish appearance, or contain a little clear or yel-
 lowish fluid, may be single, or in greater number, situated on the cornea
 or sclerotica, or (which is most frequent) on the boundary between them.
 The occurrence of these elevations, which is characteristic, though not
 belonging exclusively to  the  present affection, has  led  Mr. Mackenzie
 to regard strumous ophthalmia  as " an eruptive disease, affecting the
 conjunctiva, not as a mucous  membrane, but as a continuation of the skin
 over the eye;" (p. 382,)  and  to call it phlyctenular ophthalmia.  These
 phlyctaenoe, however,  although  generally present, are  not a constant
 symptom.
   The access of light to  the eye is painful, and the uneasiness produced
 by this cause is carried to  an extreme degree, so as to constitute  a dis-
 tinguishing symptom of the complaint.   The head is always held  down
 in strumous ophthalmia to avoid the light.   The lids are spasmodically
 closed, and a powerful contraction of the orbicularis palpebrarum  offers
 an  effectual  obstacle  to any attempt at opening  them.   If  they are
 forced open, the cornea is turned up under the edge of  the orbit,  away
 from the light.   The  spasmodic  action of the  orbicularis, excited by
 exposure to light, causes actual pressure  on the eye,  and makes the
 child scream with pain.  This action of the muscle makes the lids look
 as if they were swollen, but  they are  not so.  The child makes every
 effort to protect the organ from the painful impression of light, contracts
 the brows, throws the integuments between them into wrinkles, draws
 down the skin of the forehead, elevates the lips and ala? of the nose, and
 in short puts into action all the muscles of the face to protect the suffer-
 ing organ.  Hence arises  a  peculiar  and characteristic physiognomy
 of the disease,  so  that we can easily determine  its  nature on the first
 sight of the patient.   The  painful impression of light upon the organ,
 in severe cases, is such, that  the child seeks the very darkest corner of
 the room, to escape from the light, and if in bed, it will turn  the face
 against the pillow, or hide it under the clothes, to accomplish the  same
 purpose.  For the same reason, if brought into the  light it presses the
 hand against the eyes and holds the  head down; great irritation, red-
 ness, and eruption being often produced upon the forehead and nose by
 this cause.   This position of  the head produces determination of blood
 to the affected parts, aggravating the disease in the eye.   If the patient
 comes  to the  light, to have the eye  examined, the head is held down
 involuntarily;  if he raises  it, the eyes are  immediately closed;  or, if
 opened  for a moment, they  are instantly shut again  more firmly.  The
 attempt  to  open them causes a working  of the alae  nasi, the  brows,
 cheeks, and upper lip.
   The great sensibility of the retina {photophobia scrofulosa) is  not the
 result of inflammation, nor is  it in  a direct proportion to the increased
 redness, being often excessive  where the eye appears almost natural;
 indeed redness  is not  essential to the disease.   It is a sympathetic or
 functional affection.  In such  cases as I am now describing there is no
 immediate disorder of the retina; the child will be able to open its eyes,
 and to see as well as if there was nothing the matter with them, to-
 wards dusk.  It is a disordered  sensibility  of  the retina, dependent on
 the state of the  alimentary  canal.  This  symptom need not excite
any fear of injury to vision.  If the inflammatory symptoms are active, 
SCROFULOUS OPHTHALMIA.
297
 with much external redness, there may be considerable pain; but under
 other circumstances the patients do not suffer much so long as light is
 excluded.
   There is a copious flow of tears when  the affection begins; the  ex-
 ternal surface of the organ suffers great irritation, the lachrymal gland
 sympathizes with that irritation, so  that when we  attempt to examine
 the eye, a quantity of  clear fluid, which seems hot to the patient, runs
 out from between the lids.   When the eye is exposed to light, a copious
 discharge of these scalding tears takes place; the passage of them into
 the nose excites sneezing, often for several times  in succession.  These
 irritating tears  produce redness of the lids, and excoriate the palpe-
 brae and face.  They cause itching and soreness in the parts over which
 they flow, and aggravate the  original complaint;  the child  rubs and
 scratches the lids and face, which become red, sore, and pimply.  Small
 yellow pustules  form on this inflamed skin, and produce a discharge
 which incrusts.  The affection  extends on  the  forehead, temples, and
 face, the pustules and  incrustations increasing;  in its worst form it is
 called crusta,  or  porrigo larvalis, from its  coating the face like a
 mask.  The term porrigo is inappropriate;  the  disease not resembling
 that pustular inflammation of the hairy scalp, but  presenting all the cha-
 racters of impetigo.   An eruption of this kind, commencing in the lids
 and spreading over the face and head, will  sometimes extend over the
 body.
   The affection of the eyes is accompanied  by disorder of the stomach
 and bowels.  There  is costiveness, with white or furred tongue ; often
 fetid  breath,  distended abdomen,  morbid  appetite,  grinding of the
 teeth  during  sleep.   The head is hot in the  beginning; sometimes
 there is also heat of skin, especially at night, with restlessness;  but,
 in the progress of the  complaint, the surface becomes pallid, and feels
 dry and harsh.
   The edges of the  lids are often red, swollen, and painful.   The mu-
 cous membrane of the nose  is frequently affected ; there is an acrid se-
 cretion with excoriation of the nostrils, with  swelling and redness of the
 alae nasi, and often of the upper lip.  The ears are red and sore,  and
 excoriated behind; and the absorbent glands of the  neck are frequently
 swelled.
   The symptoms are wrorse during the day; there is a remission when
 the sun has descended  below the horizon.  Children, who have hid them -
 selves in the dark all day, recover their activity at night and open their
 eyes without pain.*
   Generally both eyes  are  affected, though not in an  equal degree.
 The disease may begin in one, and pass to the other; or they  may suf-
 fer alternately.
   The inflammation  of the eye may suddenly get  better, and will return
 as suddenly.   There  are often   repeated attacks at  longer or shorter
 intervals, and slight exciting causes will renew disorder where the dis-
position is strong.  In this way  the affection lasts for months or years,
and it is difficult  to say when  the  patient  is permanently recovered.

  * [We have not found this to occur in all cases.  Children, sometimes, will not  raise
their heads from their pillow, even at night.]
       38 
298
SCROFULOUS OPHTHALMIA.
The affection of the eye often alternates with other symptoms; the ears
become worse, and the eyes get better, or vice versa.
  Effects.—Scrofulous inflammation of the eye  often produces serious
changes, particularly in the cornea; and this  may happen, although ex-
terna! redness does not exist in a great degree.   We are accustomed to
measure the violence of inflammation and to judge of its probable conse-
quences, in other forms of external ophthalmia, by the extent of rendess,
but in strumous inflammation, the progress of the complaint is insidious,
and we may  have changes of structure produced in the cornea, when
the visible symptoms are not alarming. The elevations of the conjunc-
tiva previously mentioned  under the names  of pustule  and phlyctaena
may subside,leaving a thin opacity, which gradually disappears.  Some-
times there is a considerable thickening and elevation of the corneal con-
junctiva of a white colour, with a fasciculus  of red vessels passing to it:
this leaves an opacity, which becomes diminished,  but does not disap-
pear.  The pustules' and phlyctaenae  more  commonly ulcerate.   The
ulcers, which are irregular in figure, and have  a rather ragged edge,
may either extend superficially, or make their way into the corneal sub-
stance;  in the latter case, they may penetrate into the anterior cham-
ber, and thus lead to prolapsus iridis.
   The  vessels,  which  pass from  the conjunctiva over  the  cornea,
instead of forming pustules, may extend laterally, and unite  by their
ramifications, the texture of the  corneal  conjunctiva becoming at the
same time thickened, and more or  less opaque.  These changes may
go to the extent of making the whole corneal  covering thick and vas-
cular {pannus.)
   There is often general dulness of the cornea from interstitial deposi-
tion ; this may be accompanied by enlargement of  the proper corneal
vessels, giving to the part a  red  colour.  This discolouration is some-
times of a dull brownish red tint, and apparently caused  by interstitial
effusion of blood.*
   In such a great and serious  affection of the  cornea, the iris  will
occasionally become adherent to it;  and as the texture of the cornea
is weakened, it  may yield to the pressure from within, and be enlarged
into the external protuberance called staphyloma.
   These are the changes effected  in  the external parts of the eye by
strumous inflammation; and the  alterations  of structure  are generally
limited to the exterior of the organ.   Occasionally  the effects  of stru-
mous inflammation extend to  the sclerotic  coat  and iris, and even to
the parts seated  behind them.   We  have  seldom  an opportunity of
observing the first stage of  this iritis, on account of the changes going
on in  the cornea.  When scrofulous ophthalmia has existed a  long
time, or when the patient  has  had repeated and  severe  attacks, the
sclerotica and the more deeply seated parts  may  be so much changed
in structure, that the form of the eye may be altered ; the external  coat
may yield to the pressure of the  contained parts.   A greater secretion
of the  humours taking place,  the eye-ball gradually enlarges,  and
hydrophthalmia is produced.  The  sclerotica may  give way partially
to the pressure from within, when staphyloma  scleroticae takes place.
* See the work of Dr. R. Froriep next quoted, fig. 1 and 2. 
SCROFULOUS OPHTHALMIA.
299
 Sometimes there is a general bulging of the sclerotica round the cornea,
 apparently from morbid enlargement of the corpus ciliare.*
   Diagnosis.—Strumous ophthalmia is distinguished by the characters
 I  have mentioned; by the intolerance of  light combined with trifling
 external redness and  copious lachrymal secretion, and by the  pustular
 elevations of the conjunctiva.   These  symptoms frequently co-existing
 with strumous inflammation in  the lips, the nostrils,  behind the  ears,
 and in glandular structures in other parts of the body, form altogether
 so well  marked  an affection, that it  can  hardly be confounded  with
 others.
   Prognosis.—The prognosis is favourable so long as  the cornea re-
 mains clear.   It is still favourable if the cornea should be opaque, pro-
 vided  the  opacity be only superficial,  or if it  appear  to be owing to
 deposition  between the laminae of the cornea; for we generally succeed
 in removing it  by suitable  treatment.   Ulceration  leaves behind  a
 permanent opacity, which  seriously injures vision  when  it is opposite
 the pupil.  Should it be attended with prolapsus iridis, the consequences
 are worse, but much depends on the position and extent of the protru-
 sion.   Vascularity of the  cornea, even when considerable, will dis-
 appear when the  inflammation is removed ;  but restoration of the
 natural smoothness and transparency can hardly be expected, if the
 change of structure should have attained  the  extent  of pannus.  If
 ulcers  should have extended  deeply, if the cornea  should have become
 generally opaque, and if there  should  be also affection of the iris, or
 change of structure in the sclerotica, the prospect is most unfavourable.
   In describing diseases, we find it necessary to select the instances in
 which  the  characters are  best  marked.  We do not find them exactly
 as they are described in books and lectures;  and they, who are only
 acquainted with them from such  sources,  discover when  they have to
 examine  the sick, that  several  morbid  affections are not so clearly
 characterized as they expected.  We  give names to such forms of dis-
 ease as are clearly marked; but we see many cases which do not  come
 under our descriptions.  There is an insensible  gradation from one form
 to another, so  that we  cannot draw  an accurate boundary  between
 them.  This is the case with strumous  and  common ophthalmia.   If we
 find the nosologies  imperfect, we  must recollect that  they are not the
 productions of nature, but the work of man.
  A troublesome inflammation  occurs  in the eyes of children, which  is
 referable to the state of the skin, stomach,  and bowels, but does not
 present all the characters  of  the  strumous affection just  described.
 There  is  more external redness; not so much intolerance of light; nor
 so many marks of strumous disposition in the system.
  In some instances of delicate  strumous children, we  have intolerance
 of light without any other symptom,  and we  find that  this has some-
times received  a distinct name, having been called photophobia scrofu-
losa, or scrofulous intolerance of light.   Between this simple intolerance

  * This is called by Dr. R. Froriep, staphyloma corporis ciliaris. Diss. Med. de Cor-
 neitide scrofulosa, Jena. 1830, 4to. fig. 8.  In the same work, the  author has described
and delineated the various changes which  scrofulous  inflammation  may cause  in the
cornea and in the more deeply seated textures of the eye.  The figures are also published
in the Chirurgische Kupfertafeln, part 53. 
300
SCROFULOUS OPHTHALMIA.
on one hand, and acute  external inflammation with general and vivid
redness on  the  other, there is every possible intermediate degree.   In
infants who are the subjects of crusta lactea, the eye suffers sometimes
from the extension of the cutaneous affection.   These various disorders
may be considered,  in  point  of pathology and treatment, as  coming
under the head  of strumous ophthalmia.
   Causes.—Exposure to cold and wet favours the occurrence of stru-
mous affections generally, and not less so that of scrofulous ophthalmia.
Hence children suffer much, especially when insufficiently clothed, from
cold winds, and from sudden changes in the weather.   The complaint
may depend on disorder of the digestive organs, on an  inactive state of
the  skin, or a sluggish condition of the uterine system.   The disposition
to  strumous  inflammation  will  be called into  action  by any  circum-
stances which weaken the  constitution;  it occurs frequently  after mea-
sles, small-pox,* hooping cough, scarlet  fever,t  in short, after the opera-
tion of any causes which may have reduced constitutional  power.
   Treatment.—We must  endeavour, in  the first  instance,  to remove
that unhealthy condition of the  digestive organs and skin, which is so
prominent  a feature in the complaint, and consequently to invigorate the
constitution.  Unless these objects can be accomplished, means applied
to  the eye  will  be  of  little  service.  Hence  the general treatment is
more important than the local.   The state of the alimentary canal must
be  attended to.   The  use of  purgatives is generally necessary;  and
those of an active kind are often required, even in young children.  We
should begin by  giving a dose of calomel with jalap or rhubarb, or calo-
mel followed by the senna  draught, or by castor oil;  and  it may be
necessary  to repeat these  purgatives  two or  three times, so  that the
canal may be completely cleared  from  the  accumulated  load  of ill-
digested food and unhealthy  secretions.    The  administration of two or
three such doses often produces  the greatest  relief to the  sufferings of
the child.   When this has been accomplished, a mild course of altera-
tive and aperient medicines will be useful; such as calomel and  rhu-
barb in  small doses, every second or third day, calomel with antimony,
or the hydrarg. c. creta  with some gentle aperient.  When  the tongue
is clear, and the motions of  natural consistence and  colour, mercurial
medicines  are  no longer  necessary.   Rhubarb, magnesia, sulphate of

  *  Juengken represents vaccination as one of the most frequent causes of scrofulous oph-
thalmia.  He considers that a  certain degree of  energy is required, in order to remove
from the system the poison introduced by the inoculation:—"If the child is too weak or
too young, some of the morbific matter remains behind, and calls into action the scrofulous
diathesis.   Hence the practice of vaccinating children as early as  possible cannot be ap-
proved; for  the greater number of  those  who are vaccinated  in the  first year, become
affected afterwards with scrofulous ophthalmia."—hehre  von den  Auaen-KrankheUen;
p. 218.
  t  The disease described by Mr. Wardrop, in his " Account of the Exanthematous Oph-
thalmia, with Observations on its Treatment," contained in the  Transactions of the Medico-
 Chirurgical Society of Edinburgh, vol. ii., and that to which Mr. Christian has given the
name of porriginous ophthalmia, in his " Observations on a particular species of Ophthalmia,
occurring in connexion with Porrigo,and usually termed Scrofulous Ophthalmia" contained
in the Glasgow Medical Journal, vol. i., do not seem to me to differ in any essential respect
from strumous ophthalmia, nor to require separate notice.  I will only observe, that Mr.
Christian ascribes the occurrence of the ophthalmic affection  in the  cases to which he
alludes, to infection of the eye by the discharge of the porriginous pustules conveyed by
the fingers of the patient. 
SCROFULOUS OPHTHALMIA.
301
 potash, senna, castor oil, and the compound decoction of aloes, are the
 best medicines for regulating the bowels;  and these, or some other ape-
 rients must be employed whenever they do not act naturally.
   TFor regulating the bowels, we have found no medicine so useful, as a com-
 bination of equal parts of rhubarb and prepared chalk.  This  should be given
 morning and evening or only at night, in sufficient doses to produce two alvine
 evacuations daily.  Milk  of Sulphur and Cream of Tartar form also an excel-
 lent combination which may be used in  the same way as the preceding one.]
   In the state of debility to which the  young sufferers  are frequently
 reduced by this painful  and  obstinate complaint, tonic medicines  may
 be employed advantageously after the  alimentary canal  is cleared; of
 these bark is the best, and the sulphate of quinine the most efficacious
 form.   Mr. Mackenzie has commended this remedy strongly, and I
 agree with him to  the full extent  of  his statement.   " After a trial of
 numerous and various internal remedies in this  disease, I have found
 none so useful as  the  sulphate of quina.  It exercises  a remarkable
 power over the constitutional disorder which attends this ophthalmia, and
 thereby over the local  complaint.  The dose which  I employ is gene-
 rally a grain thrice a-day, rubbed up with a little sugar ;  in very young
 children half a grain ; and in adolescents  or  adults two grains."   He
 adds, that its powers in all other forms  " are  insignificant in compari-
 son to those of the sulphate of quina.   In most  instances, its effects
 are  very remarkable;  and, indeed, (although I have met with a few
 cases,  which have  appeared to resist its beneficial influence,) in most of
 the little patients, to whom I have administered  it, it has acted like  a
 charm ; abating, commonly in a few days, the excessive intolerance of
 light and profuse  epiphora, promoting  the absorption of pustules, and
 hastening the  cicatrisation of ulcers of the  cornea.   The use of this
 medicine may be  begun as  soon as the stomach has been cleared by
 an emetic, and the  bowels  put to  rights by repeated  doses of  calomel
 with rhubarb, or some other such  purgative, unless  the  pulse is very
 quick, when small doses of tartar  emetic  will be  preferable, or when
 an impetiginous  eruption is observed on  the surface of the body, in
 which case a course of purgatives ought to be adopted." O. C. p. 393, 394.
  Steel may be given with advantage to  pallid  and  languid patients.
 The carbonate of iron, the ferrum tartarisatum, the tinct. ferri ammon.,
 and the vinum ferri are eligible forms.
  [The best of the preparations of Iron in these cases is the sirup of Ioduret
 of Iron prepared according to the following formula.  Take of pure iodine one
 hundred grains; iron filings  fifty grains; distilled water one  ounce.  Digest
 these for some time,  filter and wash the ferruginous mass with a little distilled
 water;  unite the fluids and add half an ounce of sugar; then evaporate  down
to one ounce.   Four parts of this sirup contains one part of Ioduret of Iron.
 Two to six drops of this may be given three times a-day according to the age
 of the child.
  It is often very advantageous to give it in combination with the compound
sirup of sarsaparilla.]
  The dilute sulphuric acid is a good tonic for scrofulous subjects, and
may be combined with  the vinum ferri.
  It  is of great importance in these cases to regulate the diet, both  in
respect to the quantity and quality of food, and  the  number of meals.
Errors are often committed on  these points, not only by patients, but
even by their medical attendants.   The notion has been entertained that 
302
SCROFULOUS OPHTHALMIA.
scrofula consists in debility; and hence the inference  has been drawn,
that it is to be remedied by the free use of animal food  and fermented
liquors, of tonic and stimulating medicines.   These views seem to me
altogether erroneous, and the practice is decidedly pernicious.  Scro-
fulous subjects are weak in one sense; they are imperfectly organized,
and they cannot do and bear many things which others can.  External
agents affect them more powerfully;  their organs are more easily ex-
cited, and this is particularly the case with the alimentary canal.  Can
we, then, expect that they should bear a quantity of meat, of stimulating
liquors, and of tonics, that would surely disorder the stomach of a healthy
and strong individual 1  The diet of the scrofulous, and indeed of young
persons generally, should be nutritious, but not stimulating.  The at-
tempt to strengthen them by making the  diet chiefly animal will never
succeed.  The mixture of animal and vegetable food has been found by
the experience of all ages and countries, to be the best suited to the human
organization.  I see no reason whatever for  prohibiting scrofulous sub-
jects from taking vegetables; a moderate portion of animal food  may
be allowed once a-day; and the rest  of the diet  may consist of well-
dressed vegetables, of milk, bread, and other farinaceous articles, of ripe
fruit.   Some of the more excitable  scrofulous subjects cannot bear ani-
mal food daily; in such instances it may be  allowed every second day.
Fermented  liquors, as wine  or beer, may  sometimes be  allowed to
children in small quantity, and for a short time; but they are not always
admissible, even in the apparently weak subjects of  struma, as  they
easily excite the circulation.  The  proper beverage for children, gene-
rally, is pure water.   Many scrofulous  subjects will  not bear excite-
ment  either by food or medicine; tonics are injurious to them in all
shapes.   The quantity of food must be carefully attended to, especially
where, in conjunction with disordered stomach and bowels, there is an
unnatural appetite.  Three or four meals may be taken daily, and no-
thing should be allowed in the intervals ; particular care should be taken
to keep off the unwholesome trash so frequently given to children by
kind but injudicious friends.
   When the skin is pallid, dry, and harsh, and its capillary  circulation
and secretions  are imperfectly performed, we cannot  expect an indivi-
dual to be well—we cannot doubt that the restoration of this extensive
surface  to its proper  state will materially conduce to the recovery of
health and  strength.   Under such circumstances, small doses of the
hydrarg. c.  creta maybe given in conjunction with  James's powder.
Warm bathing is advantageous;  where this cannot be accomplished,
washing the body once daily with warm water, and rubbing it dry, may
be substituted.  Some salt may be added to the water;  and  its temper-
ature may be gradually diminished  till the cold or shower-bath can be
borne.  The skin should be well rubbed  daily, more particularly after
the bath.
   Scrofulous subjects should be warmly clothed, especially in the colder
part of the year.   The attempt at  hardening these weak beings by ex-
posing them to cold and atmospherical vicissitudes, especially if they
are lightly clad, is very dangerous.  The animal powers, being natu-
rally defective, cannot withstand  these agencies.   It is found by expe-
riments on animals, that the power of generating heat is less in young 
SCROFULOUS OPHTHALMIA.
303
 subjects than in adults, and it is less in proportion to the early age of the
 individual.
   It is always desirable that scrofulous subjects  should take exercise;
 and I would by no means confine them to the house, even in cold wea-
 ther, but allow them to go out, protected by sufficient clothing.  If chil-
 dren are left to themselves, they naturally engage in a variety of active
 sports, which sufficiently exercise their muscular system.
   When scrofulous disease exists, the principal object  should be to re-
 establish and secure health;  education  should  be considered as a mat-
 ter of  secondary  importance, especially in  those  points which afford
 sedentary occupation.
   Residence in pure air is of great importance to the scrofulous, and
 they often recover from serious disease, merely by being removed from
 large towns to the country or the sea-side.   The air of the coast during
 the milder  months of the  year is advantageous to such constitutions.
 But  the glare of light from the water and the sand is offensive to  the
 eyes, so long as the intolerance continues; and a morbid sensibility, or,
 as it is called, weakness of the organ, often lasts after the other symp-
 toms have  been removed.   A healthy  inland situation is preferable to
 tha coast under such circumstances.   When, however, this particular
 source of inconvenience no longer exists, the air of the sea-side will be
 beneficial.
  [We have seen  surprisingly rapid recoveries from scrofulous  ophthalmia,
 effected solely by a removal to the country or to the sea-side.]
  Local treatment, and other measures  required by the state of the or-
gan.—In the early period of the complaint, especially in cases which ap-
proach to  common inflammation,  and are attended with  considerable
redness and pain, a white tongue, and hot skin;  or at any time when
 such symptoms may supervene, abstraction of blood by leeches, and their
repeated  application, may be necessary.   In a severe attack, about or
 soon after puberty, cupping on the temple might be advisable.   It may
be expedient to administer an active aperient  before leeching.  After-
wards tartar emetic may be employed, either alone, or in combination
 with calomel or sulphate  of magnesia.  This remedy, given so as to
produce vomiting  or nausea, may sometimes supersede the abstraction
of blood.   The intolerance of light is not an indication for the use or *s
 repetition of leeches.  This symptom has sometimes been regarded as a
 sign of inflammation, and hence depletion has been carried to unneces-
 sary and injurious  lengths.   It  increases the irritability of the organ,
and aggravates the  local symptoms, which  are lessened by tonics and
good diet.  Abstraction of blood should  be avoided, as much as possi-
ble, in strumous ophthalmia ; and it should not be carried beyond the
amount just necessary to accomplish the temporary purpose.
  Scarification has  been recommended;  but I have not practised it in
these cases.
  In the commencement of the affection, when the neighbourhood of the
organ and  the head generally are hot, cold may be applied  to the eye
with advantage.   But in most cases warm water or poppy fomentation
is more comfortable to the patient's feelings.  When the intolerance of
light and_spasm of the lids are considerable, they may be  relieved by 
304
SCROFULOUS OPHTHALMIA.
applying a bit of soft flannel wrung out of a strong decoction of poppies
and chamomile-flowers, as warm as it can be borne.
  The local employment of opium is resorted to when the last-mentioned
symptoms are severe.  The liquor opii sedativus of Mr. Battley is an
eligible form.  A drachm  of it may be added to an ounce of water, to
be used tepid; a few drops may be  allowed to  pass between the lids.
The steam of a mixture of tinct. opii 3f5. with mist, camphorae 5vii. 15
may be applied to the organ.
  Dr. Seeds has recommended  rubbing  round the  eye in various oph-
thalmiae, a composition of spirit, ether,  sulph. comp. and spirit, ammon.
aromat. aa. 3J.  spirit vin.  camph. 5j.*   The vinum opii  has not been
found of much service.
  Benefit may be derived from  local stimuli after the  inflammatory
symptoms have been  removed,  and the alimentary  canal  has been
brought into a healthy state.  The solution of lunar caustic, from one to
four grains to the ounce, dropped between the lids is the best, and has
great influence in diminishing the irritability of the  eye, and promoting
the cicatrization of ulcers.   Opinions are divided respecting the  utility
of these applications; some practitioners reject them  altogether, as being
more  likely to be  injurious than serviceable.  I have  seen strumous oph-
thalmia recover as favourably and speedily without  as  with them.
  The red precipitate ointment  may be usefully applied to the lids when
their edges are red and swollen.
  Counter-irritation is very useful in strumous ophthalmia in conjunction
with, or rather after depletion, where that has been required,  and toge-
ther with the means necessary to  remove disorder  of  the digestive
organs, and  improve the  general powers of the system.   It is, indeed,
an imitation of what we observe in  the natural course  of the affection,
where the inflammation of the eye will cease on the appearance of dis-
ease in some other quarter, or vice versa.  We  may apply blisters be-
hind the ears or to the nape; but we must proceed  cautiously, as they
may cause excessive irritation in weak unhealthy subjects.  They should
not be left on longer than four, six, or eight hours ; nor is it safe to keep
up a discharge by irritating applications to the blistered surface. I have
seen great mischief, and even fatal mortification, ensue from the neglect
of these precautions.   A safer mode of employing  blister is  to take a
portion of cotton wick, or  a few worsted threads, cover them with the
lytta ointment, and place them,  during the night, in the fold between the
ear and the head.   A decided but mild irritation is excited in this way;
not requiring dressings.
  I prefer tartar emetic ointment, rubbed on the back and  shoulders, to
blistering, as a more  manageable and effectual means of accomplishing
the object.  The ammoniacal liniment answers the  purpose very well.
An issue in the arm has an excellent effect, both in arresting the dis-
ease, and in  preventing the relapses, which are so frequent and trouble-
some.
  As  a general plan of  treatment, I find none more  successful, after
putting the alimentary canal in proper order, than the use of the emetic
* hondon Medical and Surgical Journal, vol. i. pp. 550 and 700. 
SCROFULOUS OPHTHALMIA.                   305
 tartar ointment, with the sulphate of quinine internally, tepid fomenta-
 tion, and regulation of the bowels by means of rhubarb.
   If disorganizing  inflammation is  going on  in the cornea, or in the
 more deep-seated  structures of the eye, we must resort to mercury, pro-
 ceeding cautiously, so as not to  depress  the already feeble powers  of
 these subjects.  The hydrarg. c.  creta maybe employed in small doses,
 in combination with James's powder, or  the pulv. ipecacuanhas comp.
 Strengthening medicines, such as bark and steel may be given at the
 same time, with good diet.  When  the general powers  are thus  sup-
 ported, the mercurial remedy may, if necessary, be carried so far as to
 affect the mouth; this, however,  may be  accomplished  by small and
 what may to some appear minute doses of the  medicine.   If it should
 exert an injurious action on the system, it must be given up,  as the local
 mischief will be aggravated under such circumstances.   Under the ge-
 neral treatment which  I  have recommended, the intolerance of  light,
 and spasmodic closure of the lids, which  cause so much suffering and
 annoyance in strumous ophthalmia, are soon  alleviated.  The use  of
 belladonna has been strongly recommended as a remedy for these symp-
 toms.  The Baron Dupuytren says that he has employed the powder
 and extract with great advantage.  Mr. Arnott, London Medical Ga-
 zette, vol.  xxiv. p. 23, introduced between the lids a  solution of the ex-
 tract, twice a day, in a case of great obstinacy; in  two  days the eyes
 could be opened  freely.   The editor of  the Lancetle Fran$aise, June
 1839, quotes Mr. Arnott's case,  and observes that belladonna, occupy-
 ing the first rank among remedies capable of lowering the action of the
 brain (remedes  hyposthenisans cephaliques) is  well  suited to states  of
 over-excitement  in  the retina  (sur-excitation de la retine;) but that the
remedy  is more active, when administered by the mouth.   He gives half
 a grain of the freshly prepared powder of the leaves  twice or oftener in
the day, and says that the dose may be increased until dilatation of the
 pupil is produced, when the photophobia invariably disappears.
  [We have employed with the same view the extract of cicuta, and have found
 it in some cases productive of the best effects.]
  The treatment of the crusta lactea requires, in the inflammatory stage,
aperients, and mild  local applications; such as tepid ablution, sperma-
ceti cerate, elder-flower ointment;  afterwards, the  oxyd of zinc, one ✓
drachm  to one ounce of rose-water,  will soon dry up the  pustules.  The
incrustations present at first a formidable appearance;  but the  com-
plaint is quite superficial, and leaves no marks  behind.  Apprehensions
of ill consequences  have sometimes  been entertained from the  sudden
removal of such an  eruption; and these apprehensions are not  ground-
less.  It would be imprudent to  stop the crusta lactea suddenly in the
inflammatory stage, even if we could accomplish it; but  when the ex-
citement of this period has been removed  by suitable internal and exter-
nal remedies, there is no danger in the use of mild astringents.
39 
(  306  )
CHAPTER XI.
         VARIOLOUS, MORBILLOUS, AND SCARLATINOUS OPHTHALMIA.

  Analogies between the skin or common integuments of the body and
the conjunctiva are observable in  the natural structure of the parts, as
well as in their common office of  constituting the superficial covering
of the frame.   The  conjunctiva of the negro has a dull, muddy hue ;
and it often  displays a dark brown or black colour  round the cornea,
which is gradually shaded off.  The separation of the surface of the eye
with the epidermis generally, when that covering is  annually renewed
in the serpent tribe and other reptiles, and the actual growth of hair
from this membrane in the zemni, or mus typhlus, are further striking
points of analogy.  Hence we shall not be surprised at finding the con-
junctiva  participate in diseases of the skin, and at observing some of its
morbid phenomena, which are only explicable when it is  regarded as a
part of the common integument.
  The infantile eruption called crusta lactea extends  from the face to
the surface of the eye.  The eye-lids often suffer in venereal disease, as
is more particularly explained in Chapter II. § 3.  I have seen tubercles
form on  the  conjunctiva oculi, and extend partially over the edge of the
cornea  in the tubercular  elephantiasis.  The analogy to the common
integuments even shows itself as deep as the iris, the  colours of which
follow the same laws as those of the skin and hair:  thus  we have iritis
accompanying some  cutaneous affections.  In no instance is the parti-
cipation of the eye in diseases of the skin more strongly marked than in
the contagious exanthemata, in all of which the eye  suffers, sometimes
very severely.

                       VARIOLOUS  OPHTHALMIA.

   Small-pox is very injurious to the organ of vision,- affecting different
parts of the  apparatus, and in various ways.  It causes inflammation of
the lids, of the eye, and of the lachrymal sac during the active period of
the eruption; it produces an inflammation of the eye after the eruption
has dried up ; and it gives origin to chronic inflammation of the lids and
of the nasal duct, and to strumous  ophthalmia.  Thus, from this  single
source of mischief arise active inflammations, which often  destroy or
impair sight, and chronic affections, which  not only disfigure the indi-
vidual, but continue more or less troublesome for many years.
   Variolous pustules form  on  the external  surface of the lids and on
their ciliary margins.  When they are  numerous, as in bad cases, espe-
cially of confluent small-pox, they  cause great swelling, and completely
close the eyes.   The oozing of matter and its incrustation, the aggluti-
nation of the palpebrae, and the confinement of the conjunctival and pus-
tular secretions, irritate the eye, produce increased lachrymal discharge, 
VARIOLOUS OPHTHALMIA.
307
 and add to the sufferings of the patient.   As the complaint declines the
 swelling subsides, the lids are opened, and the eye  is found uninjured:
 thus we hear of persons being blind in small-pox for so many days, and
 then recovering their sight perfectly.  They have been blind only as a
 person is  who has a bandage tied over the eyes.
   Although the globe may not have suffered, the lids are often greatly
 injured.  The pustules on the ciliary margins partially destroy the cilia,
 alter the form of the part, making it uneven, and leave behind red marks,
 which  are permanent through life.  Eye-lids thus affected are liable to
 inflammation and excoriation from slight causes.
   In addition to  the general treatment, which the state of the patient
 may require, we should use such local means as may lessen irritation.
 We may evacuate the  matter by pricking the pustules;  we  may care-
 fully remove incrustations, after softening them with some mild unctuous
 applications; enjoin  frequent ablution with tepid milk and water, and
 lessen  inflammation by  the application of soft rags moistened with cool
 or tepid washes.
   It might be advantageous to adopt the proceeding recommended by
 M. Velpeau, for the purpose of checking the development of the variolous
 pustule; this consists in touching the eruption in its  early stage with a
 strong solution of nitrate of silver, or with the caustic in substance.  If
 effusion should have already begun, the cuticle may be  punctured or
 snipped off before the caustic is applied.
  The  greatest danger is to  be  apprehended when the inflammation
 affects  the conjunctiva  and cornea, constituting variolous ophthalmia,
 properly so called, {ophthalmia externa variolosa,) that is, acute exter-
 nal inflammation of the eye.  The essential nature of the disease is the
 same in the cornea as in the skin; it is inflammation, so violent as quickly
 to produce suppuration, or even sloughing.   This  disorder, however
 acute and  extensive,  is  of little  consequence in the  skin, so far as the
 organ  itself is concerned, but its effects on the cornea are most  destruc-
 tive and serious.  Suppuration and sloughing of this part are attended
 with severe external inflammation of the eye, probably affecting the
 sclerotica as well as  the conjunctiva, and the ultimate condition of the
 organ presents those changes which  sufficiently prove the previous ex-
 istence  of such violent  disturbance.   Evacuation of the  humours and
 collapse of the globe, staphyloma, prolapsus iridis,  synechia anterior,
 contracted or closed pupil, opacities  in various degree, blindness  or
 injured sight, are the  frequent consequences  of this  variolous ophthal-
 mia.
  The opinion has generally prevailed  that the injurious and destruc-
 tive changes, which affect the eye in small-pox, are owing to the for-
 mation of variolous pustules on the cornea; and I represented the matter
 in this  light, in the former edition of my treatise, following the received
 notions  on a point, in  which I had no  experience, except of the perma-
 nent mischiefs to the eye; these being such  as accord very well with
 the prevalent doctrine respecting the nature of the complaint in its early
 stage.   It  now appears that  the generally received notion  on this sub-
ject is incorrect.
  Dr. George Gregory  says  that the eye in  small-pox  suffers  from
 common inflammation only, " the pustule on  the cornea not appearing 
308
VARIOLOUS OPHTHALMIA.
till the eruption is on the decline, and therefore  not being a primary or
essential feature of the disease."*
  M. Guersent,  physician to the hospital  for  children at Paris, says
that  " variolous ophthalmia is an inflammation without pustules, which
appears  during the variolous eruption,  and often after  the  complete
desiccation of the pustules on the skin;" and he denies that small-pox
pustules ever form on the cornea.f
  Dr. J. F. Marson, the  able  surgeon  of  the  small-pox  hospital  has
given an interesting account of the subject in the London  Medical
Gazette, vol.  xxiv.   He says, " I have never seen a  small-pox pustule
formed on the eye.   The eye itself appears to me to possess complete
immunity from the eruption of small-pox.  It  remains uninjured all
through  the  eruptive stage  of this  disease."  He says, however, that
common  inflammation  sometimes attacks the conjunctiva during the
first  five or six days; that the occurrence is unfrequent, and not dange-
rous.
  He then proceeds, " the common abscess of small-pox, familiar to
all practical men, forms on the eye between the  conjunctival membrane
and  sclerotic coat, and also between the layers of the cornea, of which
I may have seen five or six cases in the treatment of 1500."   ''These
abscesses were  small, took place contemporaneously with abscesses in
other parts of the body, and the eyes recovered  unimpaired."
  He further mentions a deep-seated inflammation, occupying the inter-
nal structures, and  occurring in  those who  have small-pox in a very
severe form,  and who die on the seventh or eighth day.
  The more  common  and so  frequently destructive disease occurs in
 be proportion of one in thirty-nine.
  Dr. Marson found that  there were twenty-six cases of variolous oph-
thalmia in a thousand;  and of  these eleven  lost an eye.  It begins on
the eleventh or  twelfth day, or later, from  the first  appearance of the
eruption.  " It  comes  on after the  secondary fever  has commenced,
with redness  and slight pain in the part  affected,  and very soon an
ulcer is formed, having its seat almost invariably at  the margin of the
cornea:  this  continues to spread with more or less rapidity, according
to the degree of  secondary fever present; in the more  violent cases an
ulcer being formed  on each side of the cornea at the same time, show-
ing the disease to be advancing with  great severity, and presenting a
tolerably  certain indication, that  the  eye  will  be entirely lost.  The
ulceration passes through the  different  layers of the cornea, until the
aqueous humour escapes,  extending itself too  laterally,  and if  the part
of the cornea  destroyed  be  large, the  iris will  protrude  through  the
opening.  In the worst cases there is  usually suppuration, and when
the  matter is discharged, the  crystalline  lens  and  vitreous  humour
escape; or the humours may escape from deep and extensive sloughing
in the first instance, without  the  formation  of matter;  this being suc-
ceeded  of course by the  total annihilation  of the form of the eye, as
well as the sight."
  Dr. Marson has seen more than once  the entire cornea swept away

  * hondon Medical Gazette, vol. v. p. 222.
  t Mr. Middlemore's Treatise, vol. i. pp. 311 and 313. A regular small-pox pustule on
the cornea is delineated by Beer, heitfaden; vol. i.  tab. 1, fig. 2. 
VARIOLOUS OFHTHALMIA.
309
within forty-eight hours; and this may happen without pain: and he
lately saw ulceration extend completely round the margin  of  the cor-
nea,  so as to loosen three or four  layers, which came away almost in
an entire state.   He considers this sloughing and ulceration to be ana-
logous to the abscess and mortification of the cellular membrane  and
skin, which occur in small-pox  about the same  period, and to similar
occurrences taking place  after  measles,  scarlatina,  erysipelas,  and
typhus.   The treatment will consist in antiphlogistic  means, such as
venesection, cupping, or leeches, where the state of the constitution and
strength will allow, with mild aperients, and warm ablution of the organ.
In debilitated  subjects, good diet, with cordials and tonics, must  be re-
sorted to.  If the effect on  the  cornea produced by the disease should
consist simply of interstitial deposition, we may expect great improve-
ment, when the inflammation has come to an end by the natural powers
of restoration.   A patient  seven years old, who had recently gone
through small-pox, the eyes having been inflamed, was brought to me
at St. Bartholomew's. " The  whole cornea was  opaque,  so  that  the
iris and pupil could not be seen; there was slight external redness, and
no pain.   The child was emaciated  and very feeble.  She was treated
by tonics with nutritious diet, and simple tepid ablution locally.   The
cornea rapidly regained its transparency, so that in three months hardly
a trace of opacity  remained, and vision was perfect.
  As the eyes are closed by tumefaction of the  lids, and consequently
cannot be immediately inspected, it is difficult to determine whether the
globe is  inflamed or not, and to give an opinion on the important ques-
tion of danger to sight.  If the patient feels pain in the ball  itself, with
dryness, stiffness, and  the sensation of sand or gravel in the eye, if the
uneasiness be increased  on attempting to move the eye-ball, and espe-
cially if it be aggravated on exposure  to light, which will affect the
organ powerfully even through the  swelled palpebrae; and if, in addi-
tiori to the purulent secretion of the pustules on the ciliary margins of
the lids,  there be increased lachrymal discharge, we may conclude that
acute variolous  inflammation exists,  and that the  organ is in the great-
est danger.  The absence of the symptoms just recited shows the affec-
tion to be confined to the lids.
   The only ophthalmic inflammation connected with small-pox, that I
 have seen in its active state, is what I should call secondary-variolous
ophthalmia, that is inflammation of the cornea, and other coverings of
 the eye, coming on after the desiccation of the pustules, when the scabs
 have fallen off, and the patient is convalescent, that is, two,  three, or
 four weeks after the apparent termination of the  complaint.   I do not
 know whether Dr. Marson considers  these cases as included in his
 account of the affection, nor whether he would regard the appearances
 in  the cornea as variolous pustules.   It seems to me that, allowing for
 difference of structure, the affection is essentially the same in the cor-
 nea as  in the skin: we could  not expect that the appearances should
 correspond exactly in two textures  so very different  from each other.
 This secondary variolous  ophthalmia is  a  milder and less dangerous
 complaint than  the primary disease.  We have the advantage of seeing
 its orio-in and progress, and of being unfettered in its treatment by difn-
 culties&connected  with the serious, if not dangerous general condition of 
310
MORBILLOUS AND SCARLATINOUS OPHTHALMIA.
the patient.   A whitish opaque spot, with a more or less considerable
dusky halo, forms on the cornea, and is attended with external inflam-
mation of the eye, embracing both the cornea and the sclerotica.   The
white appearance becomes more extensive, and the part turns yellow.
If two or more such white spots should appear, the whole cornea will
be rendered  nebulous,  or the same effect may be produced from a sin-
gle large one.  Redness of the sclerotica and  conjunctiva, pain, in-
creased sensibility to light, and lachrymation are present.
   If the complaint has been allowed to take its natural course, the occur-
rence of suppuration will be quite unequivocal.   The part where  the
matter has been deposited subsequently ulcerates, as in common inflam-
mation  of the  cornea; or, by  arresting inflammation, this ulceration
may be prevented, and the matter  may  be  absorbed.   A  permanent
white cicatrix remains after ulceration, and some degree of opacity will
continue after absorption of the matter has occurred.
   I have not seen sloughing, in this form of the disease, as an effect of
acute inflammation: but I have known the ulcerated surface to lose its
vitality from  the great  general weakness of the subject.   I have related
a case of this kind, and mentioned some other examples of the secondary
affection,  in the London Medical  Gazette, vol. xxiii. p. 507.
   In the active inflammatory complaint now described, our object will
be to check the local excitement, so as to prevent  suppuration of the
cornea; or if this  should have occurred already, to prevent ulcera-
tion.
   In two  cases which came under my care at St. Bartholomew's, the
disease of the eye  began just as the skin had become cleared of the
scabs.   A white spot showed itself on the  cornea, in each, surrounded
by nebulous opacity.   There was redness of the sclerotica, severe pain,
increased lachrymation, and feverishness. By active antiphlogistic treat-
ment, the inflammatory disturbance  was lessened; suppuration did not
occur, and the opacity disappeared almost entirely during the employ-
ment of counter-irritation by friction of the tartar emetic ointment on
the nape.   As the corneal affection was  seated in both  these instances
nearer to  the circumference  than to the centre of the  membrane, the
slight remaining opacity, which was only discoverable on close inspec-
tion, did not  interfere with sight.
   If the disease  should occur in a debilitated subject, and the corneal
affection should be  seen in the state of ulceration spreading from weak-
ness, or even proceeding  to sloughing, the eye will be in the greatest
danger, and the only chance of benefit, either locally or generally, will
be afforded by generous diet, stimuli, and tonics.
              MORBILLOUS AND SCARLATINOUS OPHTHALMIA.

  In measles and scarlet fever an external inflammation of the eye is
common, but it is less severe  in its nature, and less injurious in its con-
sequences, than the variolous.  There  is the same  relation in point of
degree between the ophthalmia marbillosa  and scarlatinosa, and the
variolous ophthalmia, as there is between  the  cutaneous inflammation
in these several exanthemata.  In measles and  scarlet fever, the change 
VARIOUS AFFECTIONS OF THE CONJUNCTIVA.
311
which the skin undergoes amounts to little more than vascular conges-
tion ;  and so in the inflammation of the  eye, we have merely exterior
redness of the organ, and vascular congestion of the conjunctiva and
sclerotica, with pain, increased lachrymal discharge, and uneasiness on
exposure to light.  Sometimes pustules and ulcers form  on the cornea;
the vessels of the latter may enlarge and produce interstitial deposition
into its texture.
   Together with the other symptoms  there  is, particularly in measles,
catarrhal affection of the lining membrane of the nose and air passages,
with  sneezing and cough.   The  ophthalmic affection  arises and  pro-
ceeds with the cutaneous disorder.  It  is  generally a companion of
measles, although we may have the disorder of the skin without  any
affection of the eyes; there  are  instances of rubeola sine catarrho, as
they have been termed.   Inflammation of the eye is not so common in
scarlet fever as in measles.
   The conjunctiva is affected alone, or together with the sclerotica. A
severe inflammation of the external tunics, with ulceration of the cornea,
sometimes follows these exanthemata.
   The affection of the eye in these cases  does not usually require active
treatment.  Protection from light, if it should be offensive, a cool or
tepid wash, and aperient medicine, will generally suffice.  If, however,
the inflammation  should be more severe,  a few leeches may be applied,
and afterwards a  blister behind the ear, or at the back of  the neck.
We are  not to suppose, that  because the ophthalmic affection occurs in
measles, it requires no local means: we  must observe the state of the
or^an and of  the  constitution, and regulate our proceedings accord-
ingly.  Ulceration and  opacity  of the  cornea,  with injury  or loss of
sight, may ensue  from negligence.  I  have seen extensive ulceration
and staphyloma,  with  blindness,  in  the ophthalmia following • scar-
latina.
CHAPTER XII.
               VARIOUS AFFECTIONS OF THE CONJUNCTIVA.

  The thickened  and  granulated  state of the conjunctiva has been
noticed in the description of purulent ophthalmia.  (See page 237.)

  Ulcers.—The elevations called pustules frequently ulcerate, forming
small sores, which soon  heel.   Syphilitic ulceration of the conjunctiva
has been described in Chapter II., § 2.
  I have seen a few  instances of conjunctival ulceration not referable
to any specific cause.  A gentleman, about thirty years of age, of good
constitution, consulted me for inflammation of one  eye.  It was a smart
attack of external ophthalmia.   I found an ulcer, with wrhitish surface,
about three-quarters  of an inch long, and one-quarter  wide, on the con-
junctiva scleroticae, below the cornea.   The circumstances of the case 
312
PTERYGIUM.
 afforded no  explanation of the  appearance.  It was  necessary to take
 blood by cupping and  leeches: the  inflammation was soon  removed,
 and the ulcer healed quickly.   In the case of another young man, more
 severe and  obstinate external ophthalmia existed in  conjunction with
 ulcer of the conjunctiva.  Within a few weeks  I have seen a patient
 under thirty, with a small ulcer on the conjunctiva oculi of one eye,
 and on the semi-lunar membrane of the other.  There was considerable
 surrounding inflammation, with  pustules of the ciliary margins.  The
 complaint soon disappeared under mild antiphlogistic treatment.

   Pterygium.*—In the affection thus designated, (see figs. 14,15,  p. 314.)
 a  portion of the conjunctiva, of triangular figure, belonging partly to the
 sclerotic, partly to the corneal division of the membrane, becomes thick-
 ened or otherwise altered, with  enlargement of its vessels and increased
 redness.  The basis and the larger part of the pterygium lie upon the scle-
 rotica, the basis being towards the circumference of the globe; the nar-
 rower portion is situated upon the cornea, on which the apex gradually
 advances. Mr. Tyrrell, (O. C. vol. i. p. 187,) however, mentions that he
 has seen some few cases, in which the usual position of pterygium has been
 reversed, the basis having been at  the margin of the cornea, and the
 apex directed towards the circumference of the globe.f  We  do not
 usually see it in the early stage, as it causes neither pain  nor inconve-
 nience, and the patient  is  not aware of  its existence  until the  altered
 appearance of the membrane is noticed by himself or others.  Some-
 times, however, we have the opportunity of observing the  development
 of pterygium in one eye when it exists in a more advanced stage in the
 other.  It begins with the appearance, in the conjunctiva scleroticae, of a
 few vessels rather larger than natural, and running from behind  forwards
 nearly parallel to each other.  After some time, the membrane is found,
 on accurate  inspection,  to be a little raised; but the surface is  smooth
 and entire.   It gradually assumes the triangular shape, the basis  extend-
 ing towards  the circumference of the eye, while the  apex passes over
 the junction of  the sclerotica and cornea, and advances  on the latter.
 In proportion as it increases, it  becomes thicker and redder: hence it
 is  raised above  the natural level of  the membrane, both on the sclero-
 tica and cornea;  and red vessels  are seen in the latter situation, on a
 more or  less opaque ground and bounded  by slightly raised  opaque
 margin.  The  thickening  and  vascularity  are greatest  at the  base,
 where  the conjunctiva  and the subjacent cellular texture are loose:
near  the  anterior  boundary of  the  sclerotica, and  on the  cornea, the
increased density and closer  adhesion  of the membrane  to the  parts
below afford a  greater  resistance to the change of structure.   Hence

  * Greek irrtpvym, diminutive of wrtfvj;, a wing: the name having probably been given
from the shape of the affected portion.  Synonymes.  Lat. unguis, or ungula ; Eng. web. Fr,
taie, or onglet ; German, Nagelfell; Fliigelfell.
  An elaborate account of Pterygium, including the nature and treatment of the disease,
 and the opinions of various authors, will be found in Mr. Middlemore's Treatise, vol. i.
 chap. 2, § 4.
  t In the fourth plate, fig. 21 and 22 of his Klinische Darstellungen, pt. 1, Ammon, has
represented two examples of what he <m\te peculiar excrescences of the sclerotica. In appear-
 ance, he says, they resemble inverted  pterygium, but are quite different  in their  nature
 from that disease.  They have a broad basis corresponding to the edge of the cornea, on
 the outer side in one, on the  inner in the other;  and they proceed outwards, gradually
tapering off.  They are yellow, like Pingueculae, and considerably elevated. 
PTERYGIUM.
313
we explain the triangular  or wing-like  figure which the disease al-
ways assumes, and  constantly preserves,  as  the  apex slowly  makes
its  way  towards  the  centre  of the cornea.   It must,  however, be
observed that  the  end of the  narrower corneal portion  is rather ob-
tuse than pointed.   The texture of the membrane is  not simply thick-
ened; it assumes a fibrous aspect, which is often  strongly marked, so
as to produce  a tendinous appearance, and sometimes, in conjunction
with the increased redness, to  give on first view an  almost muscular
character to the diseased  part.  It is loosely connected to the conjunc-
tiva and cornea, so that we can easily raise it from the subjacent parts:
this circumstance, in conjunction with its rising a little above the gene-
ral surface of the membrane, gives it, in  some degree, the appearance
of an adventitious  growth.
   From observation of the disease, in the living eye, and of the appear-
ances presented on  operation, I should conclude that pterygium  con-
sists in a morbid change of the conjunctiva, in which  the  affected por-
tion of the membrane is thickened, rendered firmer and more vascular,
and assumes a fibrous character.  Mr. Middlemore, (p. 369,) considers
that there is a deposition  beneath the  membrane,, which raises it in the
manner already mentioned.
  Pterygium is  most frequently seated at the inner canthus, and seems
to proceed from the semilunar fold of the conjunctiva; at least its thick
basis is connected to this  part, when the growth is fully formed, though
at an earlier period there is no  such connexion.   It  is less Commonly
seen at  the external canthus:  its appearance on the upper part  of the
globe is still more rare, and it is most uncommon on the lower aspect.*
It may be formed on the internal side of  one eye or both;  or  on the
inner and outer side of the same eye.   Mr. Middlemore, (p. 366,)  says
that instances are not wanting of four pterygia formed on one eye, so
that the points have met  upon the cornea and completely  obscured the
pupil.  I have not seen this, nor  the occurrence of the disease at the
upper and  under part of the eye at the same time.
  Pterygium comes on quite insensibly, and grows very slowly.   The
patient experiences no uneasiness, and is not aware that the disease
exists till it has made some progress. Its  slow increase is a distinguish-
ing character of  the  affection: it  will exist  for many years without
making much advance.   Yet it gradually proceeds towards the centre
of the cornea, and the advance of the opaque body in  this  direction na-
turally excites apprehension that it may ultimately interfere with  vision,
especially if there should be one on each side of the eye.   I  have seen
instances, in which it  has been  apparently stationary for  a  very long
time, so that at the end of from ten to twenty years it has not enlarged
so as to affect sight.
  It occurs about the middle  period of life;  I  have never  seen true

  *  A membranous pterygium on the upper part of the globe {p. tenue superius) is deli-
neated by Ammon, Klinische Darsteliungen, pt. 1, tab. 1, fig, 12. In  Mr. Wardrop's
Essays, vol, i. pi. 3, there is a representation of an inferior  pterygium.  In this figure,
which, like all the rest in the same work, is admirably executed, the characters of true
pterygium are wanting. The case appears clearly from the engraving, as well as from its
explanations (p. 153) to have been a thickening and increased vascularity of the conjunctiva
scleroticffl and corneae caused by repeated inflammations.
       40 
314
pterygium.
Fig. 14.
Fig. 15.
pterygium in young persons.  It has been most frequent, within my ex-
perience, in  those who had passed much time  in hot climates, particu-
larly the East or West Indies.
  The formation of pterygium has been referred to inflammation of the
conjunctiva; on what grounds,  I do  not know.  The diseased change
begins and  proceeds without the presence of  the circumstances gene-
rally  admitted to constitute proof of inflammation; while the whole
                                  course of the  affection, and espe-
                                  cially its long  duration, are totally
                                  different from  what we see in in-
                                  flammatory affections.  Individuals
                                  labouring under pterygium are not
                                  even found to have been previously
                                  subject to inflammation of the eyes.
                                     Pterygium presents itself  under
                                  various forms,  which  have  been
                                  designated by particular  epithets.
                                   Thin  or membranous  pterygium,
                                   (p. tenue) fig. 14, appears on the
                                   cornea  as a  thin and often very
                                  delicate fibrous and vascular layer,
                                  through  which  we  can  see  the
                                  transparent  cornea.  The growth
may be  more thick and compact like a dense membrane, but still with
                                more or less of  fibrous character it
                                forms a thick and opaque layer on the
                                cornea, becoming thinner at the mar-
                                gin.  Fig. 15. This is thick pterygium
                                {p. crassum,) of which the fleshy kind
                                {p. sarcomatosum or carnosum) is only
                                a more strongly marked  form.
                                  A peculiar kind  of thick  or  fleshy
                                pterygium is sometimes seen on the
                                upper surface of the globe, where it
                                forms a preternatural connexion be-
                                tween the upper lid  and  the cornea.
                                The basis occupies the upper or or-
                                bital edge of the tarsus in its whole
                                breadth, and the narrower part, which
however is  not pointed, adheres to the lower portion of the cornea. The
production itself is an elongated portion of conjunctiva, not connected to
the globe except at its lower end: it can therefore be raised by passing
 a probe or director  under it.   I have  mentioned  it-as  an  effect of
purulent ophthalmia, (see p. 234) and have only seen it  as  a  conse-
 quence of that disorder.   The  union between the conjunctiva of the
 upper eye-lid  and the  cornea takes place  during the great  swell-
 ing of the  former, in  consequence  of which  it hangs over the lower
 lid.  If the surface of the  swollen membrane should be  ulcerated, we
 can understand how accretion of it to the ulcerated cornea may take
 place.   When the swelling of the eye-lid has  gone, and the tarsus has
 resumed its natural position, the conjunctiva  will  be drawn into a tri-
 
PTERYGIUM.
315
angular fold, as we see in these cases.  Two pterygia of this kind are
figured by Mr. Travers.*  I have seen the same kind of pterygium un-
der another  modification ;  the  conjunctiva  of the upper  part  of the
globe having become adherent to an ulcer at the lower part of the cor-
nea.  The cases now described are totally different in nature from true
pterygium, resembling it merely in their triangular form, in their position
on the globe, and attachment  to the cornea.   I suspect that the ptery-
gia said  to  have been seen on the upper part of the globe, were ex-
amples of the change now described; as I have never seen true ptery-
gium in that situation.
  A malignant or cancerous pterygium has also been mentioned.   I have
never seen such an affection: and I suspect that  the appearances  which
have given rise to the description, may have arisen  from the injudicious
use of the stimulant and escharotic  applications which have been re-
commended for pterygia of the common kind.   Mr.  Wardrop! has re-
presented, under the name of  fleshy pterygium,  a diseased state  of the
conjunctiva, in which it formed a thick  mass, covering the inner part of
the  cornea, involving the caruncula and  semilunar membrane, and se-
parating  the two lids, without, however, the triangular shape and regu-
lar surface of pterygium.   He  says that it occurred in " the eye of a
young gentleman, who had the  common  triangular shaped pterygium
from early life.  Its growth having become rapid, a surgeon employed
repeated   scarifications; but  these instead  of causing it  to diminish,
made it grow more rapidly."
  Diagnosis.—The insensible origin, the  very slow growth, the trian-
gular figure, the peculiar vascular and fibrous change of the membrane,
its loose  connexion to the surface of the globe, and the absence of pre-
vious or concomitant inflammation or uneasiness sufficiently distinguish
true pterygium from thickening, swelling, and increased vascularity of
the  conjunctiva, and from opacity and vascularity of the cornea depen-
dent on inflammation.   If  the term pterygium be confined to a change
of texture thus characterized, it will not I  think, be  seen before the mid-
dle period of life.
  Treatment.—So long  as the disease remains in  the quiet stationary
condition I have described, neither interfering nor seeming likely to in-
terfere with vision, it should be left alone.J   The  astringents, and sti-
muli, the escharotics, the scarifications  and incisions which have been
recommended for its treatment, seem to be more likely to accelerate than
retard  the progress  of the mischief.
  Extirpation of the morbid growth has been recommended, if it should
have advanced on the cornea  so as to impede vision, which I have never
seen, or if it should  threaten such  an impediment. It may be easily cut
away either with a  knife or scissors.  The eye  being a little turned in
the direction of the disease, the pterygium  should be seized with forceps

  * Synopsis, pi. 6, fig. 3 and 4. See  also Ammon's Klinische Darsteliungen, pt. 1. tab. 1.

  f Essays on the Morbid Anatomy of the Eye, vol. l. p. 155, pi. 3, fig. 3.
  t " The fleshy pterygium is sometimes a chronic and even stationary condition of dis-
ease, producing no inconvenience, nor threatcning-to interfere with vision. Whenever this
is the case, I am decidedly of opinion  it should be let alone."—Mr. Travers's Synopsis of
Diseases of the Eye, p. 274. 
316
PTERYGIUM.
and raised a little.   A pointed narrow-bladed knife  is passed under it
with the flat surface towards the globe, and carried forwards  so as to
shave off the thickened membrane as far as the edge of the cornea. The
basis may afterwards  be detached, being  raised by the forceps and cut
away by the knife or scissors.  The surface heals readily;  nothing is
required except cold or tepid water to the eye ; stimulating applications
would be  injurious; the portion of the growth  left  on the cornea will
shrink and disappear.   This  mode of proceeding is applicable both to
the thin and the thick pterygium.
  [We must caution the practitioner against the extirpation of the entire basis
of the pterygium, especially when it proceeds from  the internal angle of  the
eye.  We have seen  very great inconveniences to the patient follow a neglect
of this caution.   Two years since, we removed a pterygium Avhich  had  ex-
tended so far over the cornea as almost to cover the pupil, in the hopes of pre-
venting its further growth, and a consequent entire loss of vision.  After  the
wound healed, some  red vessels occupied the site of the pterygium;  but,  be-
lieving that in time these might contract, and at all events that it was not pru-
dent to again resort to the knife, we recommended a mild astringent wash, and
that no further operation should be attempted.  The patient then sought other
advice, and was persuaded to have the enlarged vessels excised, and the whole
base of the pterygium completely extirpated.   Red vessels being speedily re-
produced, caustics were applied.   Some months afterwards, he again applied
to me when I found that bands of adhesion had formed between the  ball and
the eye-lids at the inner angle of the eye, which much impeded the motions of
the ball, and proved very distressing to the patient, a result which we had pre-
dicted.  His sight was also worse, and he bitterly lamented not having followed
pur advice.]
   The immediate effect of the operation seems favourable in getting rid
of the complaint.    We  have not any satisfactory evidence  respecting
the more important point of its ultimate result.   I was consulted two or
three years ago by  a gentleman from the north of England, who said
that he wished  me to remove a pterygium from his eye.   I found that
the complaint had existed for many years without causing any incon-
venience, that it had been removed some time previously by his medical
attendant in the country, and that various applications had since been
made  to the part.  I found that  the pterygium was reproduced: the
patient said it was  larger than before the operation, and troublesome,
which it had not been before.   I advised  that all local means should be
discontinued, and  that no operation should be performed unless circum-
stances should arise actually calling for  it.   .Having heard nothing of
this patient since,  I  conclude that the complaint  has become stationary.
   If  a case were seen,  exhibiting the characters supposed  to indicate
malignity, all sources of irritation  should  be removed ;  so that the eye
may be  brought into a quiet state before  we decide on the real nature
of the disease.
   In that  condition of the eye, in which  the  conjunctiva of the upper
eye-lid has become adherent to the cornea, it would be easy to separate
the adhesion ; but the success of the operation in respect to  sight would
probably be frustrated by the state of the  cornea, which must have suf-
fered greatly before such adhesion could  have  been established. Mr.
Middlemore operated without any advantage on a case, which was  ap-
parently of this description.  (Treatise, vol. i. p.  379.) 
DRY CONJUNCTIVA.
317
  Pterygium pingue, or pinguecula,  is badly named, being altogether
different  from pterygium, which  it resembles only in situation.   It  is
not a morbid change, but a natural alteration in the part, coming on at
or after the middle period of life.  It  consists of a few little yellow gra-
nules, supposed from their colour to be adipous, as the name expresses,
appearing under the conjunctiva, which  retains its  normal structure,
just behind the margin  of the cornea, and sometimes almost encroach-
ing on that membrane,  at the  lateral aspect of the globe,  on one, but
more frequently on both sides.  This deposite is sometimes large enough
to be rather conspicuous; and hence we are consulted on the subject.
It attains a certain  magnitude, never such as to  cause inconvenience,
and then is stationary.   I never advised  nor performed  the removal,
which  is  quite unnecessary.  If, however, a person disliking  the appear-
ance, should wish to get rid  of it, nothing could be easier than to raise
the part with forceps, and then snip it off with the convex scissors.
  Dry, or cuticular conjunctiva; xerosis,  or xeroma conjunctiva (from
typo?, dry.)—We meet occasionally with a singular change  in the state
of the membrane, for which  we possess no remedy, the pathology being
at the same time quite obscure.  The conjunctiva loses its character of
a mucous membrane, and no longer secretes; the surface of the eye has
a rough cuticular appearance, and the cornea is dry and dusky.*  The
lids become gradually adherent to the globe, producing symblepharon.
I  have seen it a  few times in young subjects, in whom I could neither
obtain  any clear account of  its history, nor render service by medica]
or surgical treatment.  In these instances, the affection had been of long
standing, and the changes in the organ  so considerable, as to render
curative  efforts hopeless.
  Professor Von Ammon has given a  good account of this singular and
rare affection, under the name of xerosis conjunctivce, in the  first volume
of his Zeitschrift fur die  Ophthalmologie, accompanied with a detailed
history and description of some cases which had come under his obser-
vation.f   His attention was first directed to it by Professor Jaeger of
Erlangen, who called the disease Ueberhdutung der conjunctiva, that is,
skinning over of the conjunctiva..J  The resemblance which the surface
of the membrane presents to that of  the cuticle is  denoted in the name
employed by Mr. Travers, of cuticular conjunctiva.^
  In a patient, who has had the complaint some years, there is partial
symblepharon, especially at the internal canthus, where the lids adhere to
the caruncula, and  to each other.  In one eye both puncta lachrymalia
are  closed ; the  lower punctum is obliterated in  the other eye.  The
lids cannot  be shut  on  account of the symblepharon.  Contraction  of

  *  The first figure in the seventh  plate of Mr. Wardrop's Essays, vol. i. represents very
well the dry dead appearance of the  eye.
  Von Ammon has also delineated the appearances of the disease in its various stages, in
his Klinische Darsteliungen,  pt. i. pi. I, %. 16 and 19—21.
  t Beobachtungen, Ansichten und  Zweifel uber die Enlstehung der Xerosis conjunctiva:,
art. vi. p. 65.
  X Bcricht uber die chirurgisch augendrztliche Klinick vom Jahre 1828—1829 : in the
Medicinischchirurgische Zeilung, 1830, vol. i. p. 31.  The inaugural dissertation of Dr.
Klingsohr, die Ueberhdutung der Bindehaut,  with a coloured plale, Erlangen, 8vo. 1830,
was written at the suggestion of Professor Jaeger ;  see Ammon's Zeitschrift.
  § Synopsis of the Diseases of the Eye, p. 120. 
318
DISCOLOURATION OF THE CONJUNCTIVA.
the tarsus, with partial trichiasis, exists in both upper lids. The palpebrae
cannot be drawn away from the globe, on account of the symblepharon.
When an attempt is made to raise the upper, the conjunctiva is drawn
into folds below the  cornea.  The  conjunctiva oculi is quite dry, and
of a dirty white dead appearance, which is particularly remarkable over
the cornea.  The form of the latter is regular, and the blue iris can be
distinguished through  it, though the outline  of the  pupil is not seen
clearly.   The eyes  are  so insensible,  that they can be rubbed  pretty
strongly with the finger without exciting pain.   Warm water is used to
the eves, and agrees with them better than cold.  In  former time  this
patient had suffered much from inflammation of the eyes, connected with
entropium of the upper lids.  Another patient, forty-seven years of age,
had experienced in childhood repeated attacks  of strumous ophthalmia,
and had suffered much from inflammation of the eyes, with entropium,
in the last twenty years.   In the left eye, the lids adhere to each other
and to the caruncula at the internal canthus.  The puncta are closed ;
their-situation being visible.  Partial  trichiasis exists in both lids; the
upper is so shortened, that the eye cannot be shut, producing the state
of lagophthalmos.   When the globe or lids  are moved, the conjunctiva
oculi is thrown into folds.   The latter  membrane is  dry, dirty, and as
if covered with  dust: it is  white, and  firm, but moist at the angle of
reflection from the globe to  the lids.   No vessels are perceptible in the
membrane.  ]No moisture is perceived on rubbing the cornea.  The iris
can just be distinguished ; but the margin of the pupil is not perceptible.
The patient can see objects with this  eye;  but they appear eveloped in
a thick cloud.  She sees better in moonlight than in sunshine.  If she
weeps, no tears flow on this side; but the eye becomes prominent, blood
red, and painful, and copious lachrymation occurs on the other side. The
eye does not bear cold, nor  cold with  moisture; but washing with warm
water is agreeable.  The patient often feels a dryness, as if  sand were
between the lids.  In the right eye the tarsi are contracted, and the cilia
inverted; the conjunctiva  round the cornea is partially elevated, and
forms folds;  the cornea obscure.  The lachrymal secretion is natural.
   Professor Von Ammon has some further observations on the subject in
the second volume  of  his  Zeitschrift, p. 381.   He  relates a  case, of
which the principal circumstances correspond to those of the preceding
instances.  The patient, a female, twenty-seven years old, had suffered
in her early years  from strumous ophthalmia,  for which no other re-
medy but the ointment  of red precipitate had  been employed.  When
grown up, she laboured under chronic ophthalmia with trichiasis.  The
puncta  are closed, the palpebrae and  caruncula  grown together; the
conjunctiva dry, and almost scaly over  the cornea, which is so obscure
that the colour of the iris and the state of the pupil could not be distin-
guished.  Painful pressure  is  experienced in  the eyes, with  redness in
weeping,  but no tears flow.  The patient is most comfortable in cold
weather, and most uneasy in the heat of summer.  Bathing with clear
water and milk agrees best with the eyes.*
   Discolouration of the conjunctiva by nitrate of silver.—The conjunc-

  * A case of the affection, in a less advanced state, is related by Mr. Mackenzie in the
hondon Medical Gazette, vol. xii. p. 44, under the name of Xeroma conjunctiva. 
EXCRESCENCES OF THE CONJUNCTIVA.
319
tiva sometimes  acquires a livid  or olive tint in persons who have long
employed the nitrate of silver locally; and, as far as I know, the change
of colour is permanent.   The long-continued internal use of the same
remedy produces  a similar effect on the integuments generally, giving
them a dirty appearance, with a livid or bronzed tint; and this change
seems permanent.
   Dr. Jacob, of Dublin, who has observed and described this change of
colour in the conjunctiva, has remarked, as I have found, that it is owing,
not to the strength, but to the long continued employment of the caustic
solution.   He considers  it analogous to the effect of  colouring matters
on the skin, in tattooing, and, consequently, as  an additional  proof of
the identity of the two structures.*
   [We were consulted last summer by a young lady, who had used for a long
time, as she informed us, a solution of nitrate of silver dropped on the eye, for
the cure of an obstruction  of the lachrymal passage of one side.   The whole
conjunctiva of the corresponding eye  was of a brownish colour, which will
doubtless  be permanent.]
   Polypi, warts,  and other excrescences of the conjunctiva.—I  have
seen small polypi, analogous to  the innocent or mucous polypus of  the
nose, growing from the  palpebral conjunctiva, and  the fold between  the
lids and globe.  Excision is the obvious and easy remedy.
   I met with a tumour, growing from the  tarsal surface of the upper
eye-lid, equal in size to  a large pea, and connected by a slender stalk.
It had  a smooth mucous surface, and I considered it to be polypus.  In
snipping  it off, I found the  peduncle hard, so as to require some force
in dividing it.  It was found to be fibro-cartilaginous and thoroughly
hard internally, conjunctival externally; it  had probably grown  from
the tarsus, to the orbital  edge  of which it had been  attached.  The
complaint had  existed  fifteen years, and had caused trichiasis of one
quarter of the upper eye-lid.
   Vascular  excrescences,  in the  shape of  warts  or fungus, may be
thrown out  by the  membrane  in  other situations,  in consequence of
irritation.  They may occur in the fold of  the  membrane, or on  the
anterior part of the  globe.  They are red, soft, fissured, or granulated
on the surface, which  is otherwise smooth, sometimes  pedunculated,
and  sometimes growing by a  broad basis.  They  may acquire such
size as to irritate  the globe and lids, or  to cover the cornea inconveni-
ently.  They should be seized with forceps or  hook, and cut off with
the convex scissors.
   A singular example of peculiar morbid growth, resembling a con-
geries of dark purple roundish  masses like black  currants, proceeding
from and covering the  cornea, has been described  and delineated  by
Mr. Travers.  He says, " I excised the anterior hemisphere of the eye-
ball in an elderly  lady, in whom the cornea was  concealed by a tumour,
of a dark purple colour, protruding to such an extent between the eye-
lids, as to occasion  great inconvenience and  deformity.  It had  the
appearance  of  being disposed in lobes, somewhat  resembling a bunch
of currants of  unequal  size.  On  dissection, the cornea and sclerotica
proved to be entire, and the morbid  growth, lying upon and adhering

          * Dublin Hospital Reports, vol. v. p. 366, plate 1, fig. 1. 
320
EXCRESCENCES OF THE CONJUNCTIVA.
 to the corneal and a small portion of the sclerotic surface, had acquired
 the  lobulated appearance, as if by degeneration of the covering con-
 junctiva; for delicate white bands, the only vestiges of this meinbrane,
 were seen intersecting the lobules at irregular distances, in the form of
 septa.  The substance, in section, was firm, of a dark colour, here and
 there mottled with white, and measured a quarter of an inch in thickness
 from the  external surface of the cornea."  " It was not characterized
 by any symptom of malignity;  neither pain in the ball nor in the head
 worthy of notice, nor any affection of the constitution.   The deformity
 and  the fear of its increase were the  inducements  to  the operation,
 which was done about a twelvemonth ago.   This was  attended by no
 untoward symptom, and up to  this  time the subject of  the disease has
 continued well."  (Lib. Cit. pp.  102  and 427.)
   In the description of the figures, Mr. Travers says, that the sub-
 stance of the growth was in some  parts pulpy, in  others firm; that
 there was at one part, near the  surface, a whitish spot of cartilaginous
 hardness: that the fungus was covered by a thin membrane easily torn,
 supposed  to be the  conjunctiva: he concludes that  the disease  origi-
 nated from the latter membrane, and supposes,  from its lobular arrange-
 ment, that the morbid growth occupied the cells of the  substance con-
 necting the conjunctiva to the cornea.
  Mr. Wardrop has delineated  two growths,  covering, each of  them,
 about half of the cornea, and being apparently change  of structure in
 the  corneal conjunctiva.  One  was of flesh  colour,  and, in its firm
 granulated texture, very much  resembled  some  of the warty  excre-
 scences which are formed on  other mucous  surfaces:  it had grown
 very slowly  on the eye of  a patient sixty years of age.  The other
 was  thick, of peculiar  brown colour, and was first observed after an
 attack of inflammation.  The surface was  irregular, the mass  being
 composed of several smaller swellings,  and  it was plentifully supplied
 with red vessels. (Essays vol. i. pi. 4, fig. 2 and  1.)
   Cartilaginous formations in the conjunctiva.—I  once saw, in a
 young lady, several cartilaginous bodies, about the size  of pins' heads,
 in the substance of  the conjunctiva sclerotica.   They were imbedded
 in the membrane, which was otherwise normal, projecting on the sur-
 face  sufficiently to be seen  and felt.  As uneasiness was  experienced
 in the eye, which the  lady referred to this peculiar condition of the
 mucous membrane, I removed a few of the bodies, using a small hook
 and scissors.   The patient left  London after this slight  operation, and
 I have not seen or heard any thing more of the case.
   Tumours of the conjunctiva.—I have seen examples of conjunctival
 swellings  existing at the  time  of birth. They  have been soft  white
masses, the size of a pea or  horse-bean, smooth on the surface like the
rest of the conjunctiva, and connected rather  loosely to the subjacent
parts.   They have been seated on the boundary between the sclerotica
and  cornea, but covering the former principally.  No  inconvenience
has been caused by the disease, which has not increased so as to require
surgical treatment.
  Mr. Wardrop saw a congenital case  of this kind.   On the left eye
of a girl there was a  conical  mass growing from two-thirds of the cor- 
TUMOURS.
321
 nea and a small portion of the adjoining sclerotic coat.  It was firm
 and immoveable, and had a granulated surface.  It was small when first
 observed, and increased in size in  proportion with  other parts of the
 body.*
   Tumours  with hairs growing from them.—Congenital swellings of
 whitish colour, and softish consistence,  with  smooth mucous  surface,
 from some part of which hairs proceed, have been met with on the scle-
 rotica, or between it and the lower eye-lid.   Such growths have been
 described by Wardrop. Mackenzie, Himly,  Graefe, and  Ammon.!
   The patient, whose disease is described and delineated by Mr.  War-
 drop, was more than fifty years of age.   The tumour which had existed
 from birth, was about the  bulk of  a horse-bean, situated on the sclero-
 tica, and  covering a small  portion of the  cornea, next the external can-
 thus.  Its surface was smooth, presenting the  colour and  appearance of
 the conjunctiva.  Upwards of twelve long and  strong hairs grew from
 its middle, passed between the eye-lids and hung over the cheek.J
   In a boy of fifteen there was a flat white  tumour,  with circular base,
 situated partly on the cornea, partly on the  sclerotica,  towards the ex-
 ternal angle  of the eye.  Two hairs, similar to those of the tarsus, grew
 from its centre.§
   [Dr. W. T. Taliaferro formerly of Maysville, Ky., now of Cincinnati, Ohio,
 relates an interesting case, in which there  was  a  congenital tumour on each
 eye of a  young lady 15 years of age,
 arising from  the  subconjunctival coat.
 The tumours  were of a delicate pink  at
 their base, becoming brownish at their
 apices.  They were  discovered imme-
 diately after birth, and had had a steady
 gradual growth.  When she  applied to
 Dr. T. the tumour of the left eye (see
 fig. 16.) covered  an oval  base, about
 five lines  in its long, and  three and a
 half in its short diameter, and rose in a
 flattened conoidal shape  to  about six
 lines in height.   Its long diameter ran
 nearly parallel with a line drawn from
 the inner to the  outer  canthus  of the
 eye.  It covered nearly the lower two-
 thirds of  the pupil in a  pleasantly
 shaded light.   From the apex grew some  ten or  twelve hairs, about sixteen
 lines in length, a shade darker than the cilia.  As  the  tumour grew from the
 outer and lower part of the cornea perpendicular to the globe, it bore the lower
 lid far downward and outward.   The  upper  lid was drawn  down and  could
be elevated but very slightly; the cilia of the upper lid came  in contact with
the globe and  the tumour.   Exposure to the wind or  light,  produced a free and
slightly purulent discharge, rendering her situation exceedingly distressing.
The tumour occupying the two lower thirds, and  the  superior lid the  upper
Fig. 16.
  * Ibid. p.  32.  Mr.  Tyrrell has delineated two small congenital tumours, seated
over the junction of the sclerotica and cornea; one on each side of the eye. Vol. i. pi. 8,
fig. 4.
  f Klinische Darsteliungen, pt. 2, tab. 1, fig. 8 and 9. In these, as in all the other quoted
instances, the swelling was seated on the external aspect of the globe.
  t Essays, p. 32, pi. 4, fig. 3.                        § Ibid, p. 33.
     41 
322
TUMOURS.
 third of the pupil, she could distinguish no object clearly with this eye.  The
                                     tumour of the right eye, (see  fig.  17.)
                                     in shape and  situation, relative to the
                                     globe, was  like to  the left;  its  size
                                     about  half  that  of  the left, covering
                                     about  the lower  sixth of the pupil.
                                     The vision of this  eye was good on
                                     a  horizontal line and  upward.   The
                                     pupils of both eyes were larger  than
                                     natural;  the left about  a  third larger
                                     than  the right.   Her   education   had
                                     been impossible, and her situation alto-
                                     gether  was   most  deplorable.   ' Al-
                                     ways advised  never to disturb the tu-
                                     mour,  or the eyes would be inevitably
                                     destroyed.'
   After having reduced the activity of the circulation by medicine  and diet, Dr.
 T. removed the tumour of the left eye on the 1st of June, with  Charier e^ deli-
 cate cornea knife, curved scissors and hooked  forceps.  " The operation  was
 rendered tedious from the exceeding vascularity of that portion of the conjunc-
 tiva reflected over the tumour, which was supplied with numerous large tortu-
 ous vessels converging from either canthus.   In its texture the tumour seemed
 as if composed of lamina, far separated by spongy cellular substance.   It  was
 very tough.  From the pressure, probably, the  external lamina of the cornea
 were almost entirely absorbed at the lower part, and greatly thinned and  soft-
 ened throughout the extent  occupied  by the tumour.   In fact it was quite  im-
 possible to distinguish whpre the tumour ended and the cornea began; of course,
 therefore, the corneal texture was much encroached on.  The treatment was a
 dressing of light pledgets, kept constantly wet with  cold water,  to the eye;  ape-
 rients, and a gruel diet,  &c. &c.   In eight or ten days, an evident discharge was
 begun from the wound, as if for a reproduction of the  tumour.   This was again
 dissected off; cold applications made as  before growth began again: argent.
 nitrat. two grs., aq. distillat. 3j, M. was used.   Growth not checked; the solu-
 tion of nitrate of silver was increased in strength to twenty grains  to the ounce
 with little improvement; the solid  argent, nit.  was resorted to, and sulphate
 of copper alternated; healthful  healing began  and continued steadily till  the
 wound was well."
   In the latter part of June, Dr. T. removed the tumour of the right eye. Treated
 for a few days with pledgets wetted with cold water, and followed  by the appli-
 cation of the solid  nitrate of silver.   " Not a  single bad symptom  supervened.
 An opacity is left on each eye equal in extent  to the bases of the tumours.  The
 patient was  kept in a pleasantly shaded chamber for about eight weeks, and
 restricted to a vegetable diet.  One or two drops of a solution  of  ten grains of
 nitrate of silver in  one ounce of water was daily applied to  each eye.  At  the
 termination of the period just named, the sight of both eyes was perfect.  The
 opacity in the right eye is scarcely  perceptible, and in the left is only visible
 when the eye is turned  upwards.  The lids have resumed  their normal posi-
 tion."
   A similar  case  is recorded by Mr. W. W.  Cooper in the London Medical
 Gazelle, for November,  1841, p. 278, with a figure.]
   Swellings of this kind may be safely extirpated if they should cause
irritation or inconvenience of  any kind  by their bulk, position, or  the
hairs  growing  from  them.   Mr.  Mackenzie  removed  one of these
tumours,  seated towards the  external angle of the eye.   " It was firm
andwhite, and had  a number of  fine hairs growing from it.  It  had
 
DISEASES OF THE SCLEROTICA.
323
long kept up an inflamed  state of the  conjunctiva, which entirely sub-
sided after the tumour was removed.  It was so incorporated with the
sclerotica, that its root was left, but died away under the use of  nitrate
of silver solution."*
   HiMLyf excised one of  these tumours with four black  hairs growing
out of it, from the external side of the eye, in a girl of twenty.   It was
easily removed.   It contained fat, so that  the hairs grew in the same
soil as in other parts.
   GraefeJ removed a small one, which  had two hairs growing out of
its centre, from the boundary between the cornea and sclerotica, on the
temporal side of the eye.   The interior consisted of fat, the surface being
conjunctival.  Graefe conjectures that these growths will be found gene-
rally to  be adipous; considering, in conformity with the  observation of
Himly, that the presence of fat is  necessary to the  development of the
hairs.  Ammon calls these growths adipous (lipomatose.)
   Encysted  tumours.—Cysts may be  developed  in  the subconjunctival
cellular tissue, but they  are  uncommon.  Ammon  has delineated one,
which grew  on the internal surface of the  lower lid near the external
canthus.  It was equal in  size to a large horse-bean,  and  though project-
ing by two-thirds of its  surface, completely covered by the lid.  On
excision it was found to adhere closely to the tarsus.  It was a thick
white sac, containing a honey-like substance.
CHAPTER XIIL
                 DISEASES OF THE  SCLEROTICA.

            SECTION I.--INFLAMMATION OF THE SCLEROTICA.

Synonymes:  Sclerotitis; ophthalmia sclerotica, or sclerotic inflammation.
  Vetch.  Rheumatic ophthalmia.   Inflammation of the  external proper
  tunics of the globe.   The ophthalmitis externa idiopathica of Beer is in-
  flammation affecting the conjunctiva, sclerotica, and cornea.

  External inflammation of the eye may be seated in the conjunctiva
only, or in the sclerotica; the cornea  being  usually more or less impli-
cated in the latter case.  Both diseases  are included under the vague
general term ophthalmia.   Although both may,  without impropriety, be
called external inflammations of the eye, they are very different in their
symptoms, progress, termination, and treatment.  In the latter instance,
or that of inflammation originating in  the  sclerotica, the  conjunctiva
will be soon involved, if the affection  be acute.
  Simple  inflammation of the conjunctiva is, generally speaking, an un-

  * Practical Treatise, p. 237.           t Ophthalmolog. Bibliotliek, vol. ii. p. 200.
  t Journal, vol. iv. p. 134. A front and side view of the  swelling are given in tab. 2.
He proposes to call the disease irichosis bulbi. 
324
INFLAMMATION OF THE SCLEROTICA.
important affection.   In consequence of its loose texture, the vessels of
the membrane yield readily; there is  little pain or inconvenience, and
no danger to ihe organ.  The firmer textures of the sclerotica and cor-
nea  do not  give way unless the excitement be  more  powerful;  they
yield to distention slowly and with pain; their vessels do not easily re-
cover, so that inflammation is  with  more difficulty subdued ; and  the
implication of the cornea, with the ready transition of inflammation to
the iris, exposes the organ to serious danger.
   I have mentioned the intimate connexion between the sclerotica, cor-
nea, and iris   We cannot in the natural state trace the actual passage
of vessels carrying red blood from the sclerotica to the iris and cornea;
but there must  be  a close vascular intercourse between them, for the iris
find  cornea  are  never inflamed without the sclerotica becoming red.
On the other hand, when inflammation affects the external proper tunics
of the  globe, it  readily passes to the iris, and thus may extend to the in-
ternal  structures of the eye.
   Symptoms and progress.—The symptoms  of inflammation affecting
the sclerotica, are, external  redness, pain, intolerance of light, increased
lachrymal discharge,  with more or less febrile  disturbance of the  con-
stitution.
   The external  redness begins on the anterior part of the globe, imme-
diately round the cornea, where it forms a red zone.  If we examine
the circumference of the globe, we shall find  distended blood-vessels
advancing from the posterior part upon the sclerotica, following a rather
straight course,  and branching  out into numerous ramifications, which
are at leng'h lost in the red  zone that surrounds the cornea.   In inflam-
mation of the conjunctiva the redness commences in the circumference,
the anterior part being at  first  comparatively  free, and the sclerotica
retaining its natural white appearance.   The character of  the red tint
differs remarkably in  ihe two cases.   The vessels'distended in sclerotic
inflammation are  those seated immediately  upon the  sclerotic  coat;
they  are therefore covered externally by the  conjunctiva, and, being
seen through that  meinbrane, appear of a pink, or rose red, and some-
times  almost of a violet  hue,  which forms  a striking contrast to the
bright scarlet  of  the  vessels distended  in  conjunctival inflammation.
The redness of the inflamed sclerotica is a rose or pink tint, being seen
through the conjunctiva, and such is the colour of the red  zone which
surrounds the cornea  in the early period of the affection.   The redness
is uniformly diffused through the sclerotic, as if it had  been tinged by
some colouring  substance;  thus we find that this membrane is copiously
supplied  with vessels, although  they do not, in  the natural  state, circu-
late red blood.   This diffused  rose or pink redness is confined in ihe
beginning, and in  milder cases, to the anterior portion of the membrane,
being  at "the same time of  a light tint; in severer attacks, and in the
progress of ihe  affection, the colour is deeper and more general.  Small
vessels containing red blood  are sometimes  seen  advancing on the
cornea.
   When the inflammation is considerable, a dense arrangement of ves-
sels may be seen lying under the conjunctiva, and occupying the whole
surface of the sclerotic coat; in short, the inflammatory affection seems
to produce a kind of new vascular creation, enlarging, and thus render- 
INFLAMNATION OF THE SCLEROTICA.
325
 ing visible, a vascular plexus, of which  we  see  nothing in the natural
 state of the part.   In  inflammation of the conjunctiva, the vessels are
 not only of a bright scarlet colour, but lie nakedly on the surface  of the
 membrane.  When inflammation, without being  very violent, is seated
 in the conjunctiva and sclerotica at the same time, we may observe the
 marked difference in situation and tint between the two orders of ves-
 sels.   They also differ in their course, those of the  sclerotica  running
 in straight lines from behind forwards, while  the vessels of the conjunct
 tiva are irregular and  tortuous.
   The conjunctiva soon participates in the affection, if it is acute;  its
 vessels become distended  and  partake  the  inflammatory disturbance.
 The cornea assumes a dull appearance; it is not actually nebulous  or
 opaque, but its transparency and polish are impaired.
   The patient complains of stiffness and  dryness  in the eye;  frequently
 he feels a sort of stinging, burning, or aching pain;  sometimes there is
 a sense of fulness, tension, or pressure;  and occasionally a  throbbing
 sensation.    The uneasiness  is  increased by  warmth, and  the  parts
 around the eye are even warmer  to the  touch.  As the  inflammation
 proceeds, the pain increases, and extends to  the  back of the orbit, to
 the neighbouring parts, and more or less to the  corresponding side  of
 the head.   Not unfrequently  the  eye  is  comparatively  easy, and the
 patient complains of  pain in  the brow,  temples,  cheek, or side of the
 nose.   Often the suffering increases towards night,  becomes so  much
 aggravated, as to prevent sleep,  and abates considerably in the morn-
 ing.  It is worse in a  cold, windy, and  wet  state of  the  atmosphere,
 and relieved by mild and warm weather.
   Intolerance of light is a marked symptom from the commencement;
 the pupil contracts to exclude  the light, and the patient avoids exposure
 to it.   Here is  another striking contrast between this affection and con-
 junctival inflammation; for in the latter the patient generally opens the
 eye freely, and experiences no pain from the access of light.   We na-
 turally inquire what cause can  be assigned for this striking  difference
 in the phenomena attending inflammation of the two textures so conti-
 guous  to  each other.   Considerable inflammation  may  exist in the
 mucous membrane of the eye, without  any affection of the globe;  thus
 the disturbance does not  approach the retina.   But inflammation of the
 sclerotica and cornea requires for its production a more serious exciting
 cause;  and this disturbance, being seated in the globe itself, must affect,
 more or less, the internal tunics  generally, and  the retina in particular.
 Hence the intolerance of light accompanying inflammation of the scle-
 rotica and cornea, which is often observed where the transparency of the
 latter is impaired; a circumstance which, if the internal  tunics  were
 unaffected, might, a priori, be  supposed calculated to lessen the impres-
 sion of light on  the organ.  This intolerance,  even when excessive, is a
 strictly  functional affection ; it does not depend  on disease of the retina,
 or lead  to any suspicion of internal inflammation.
  The pain and the intolerance of light depend on the degree of inflam-
 matory disturbance, and on the stage of  the disease.   In  slight cases,
or when the disorder has lasted for  some  time,  they may be trivial, or
altogether wanting.   At the commencement of this  affection the eye
feels dry and stiff, {xerophthalmia o. sicca) there  is  an interruption of the 
326
INFLAMMATION OF THE SCLEROTICA.
ordinary exhalation;  but this is  soon re-established, and an increased
lachrymal secretion takes place, from the sympathetic influence of the
inflammatory excitement on the lachrymal gland; so that whenever the
patient opens the eye, especially in a strong  light, there is a copious
flow of tears.
  A general disturbance exists, varying in  character  and  degree, ac-
cording to the patient's constitution, age, and health, and to the amount
of the local disorder.   There may be a frequent and full pulse, with
white tongue and general headach ; or a disturbance of the  digestive
organs, marked by foul tongue, deficient appetite, and costiveness, with
sallow countenance, dry and inactive skin.
  Diagnosis.— Inflammation of the sclerotica is distinguished from that
of the conjunctiva by the redness being originally seated in and confined
to the former membrane; by its being of a pink, and  sometimes  even
light  violet  tint; by the distended vascular trunks being of the same
tint, deep-seated, straight,  and  not tortuous, and connected  with the
sclerotica, so that they  do  not move with the  conjunctiva;  by the in-
creased lachrymal secretion, and the absence of mucous discharge; by
the pain, which  is so  frequently circutnorbital, and by the intolerance of
light.  The eye-lids  participate in conjunctivitis, not  so in  sclerotitis.
The latter is distinguished from internal ophthalmia by the natural state
of the iris  and  pupil, and  the  unimpaired  vision.  However, sight is
affected if the cornea should be involved in the mischief; and still more
if the disorder should extend to the iris.
   The sclerotica participates in inflammatory affections of the cornea,
iris, and  other  internal tunics,  whether  accidental  or  spontaneous.
Sclerotitis  may be directly induced by atmospherical causes, or other
external agencies ; or it may arise indirectly from unhealthy states of
constitution, or  from disturbance in some organ  or system.
   Inflammation of the sclerotica, considered  in itself, is not a dangerous
affection.   It is frequently obstinate, but it yields sooner or later to pro-
per treatment.   Of the  other affections, with which it may be associ-
ated, several are of serious  character, and may lead to  injury or loss
of sight.
   The observations on  treatment, in the following section, comprise all
that is necessary to be said on this subject in addition to the general re-
marks in  Chapter V.
       SECTION II.--RHEUMATIC OPHTHALMIA ;  CATARRHO-RHEUMATIC
                            OPHTHALMIA.

  Rheumatic oPHTHALMiA.-^-Although many points in the pathology of
gout and rheumatism are obscure, we know that these diseases particu-
larly affect the fibrous structures, such as enter into the composition of
joints, and are found in their neighbourhood, and the synovial membranes.
When any morbid affection is the  result of a particular constitutional
disposition, there is a tendency in all the structures of the same kind to be
affected under certain circumstances; accordingly those textures of the
eye, which resemble the fibrous, as the sclerotic and cornea with the closely
connected iris, and the mucous membrane of the eye, which is analogous 
RHEUMATIC OPHTHALMIA.
327
to the synovial membrane of the joints, frequently suffer under the same
state of constitution, which give rise to rheumatic inflammation of simi-
lar structures in other parts of the body. The urethra often participates
in the  affection, and a discharge, like  that of gonorrhoea, takes place
from the canal.  These remarks are exemplified in the affections  last
described, of which the two latter might with as much propriety be called
rheumatic as gonorrhoeal  inflammations: for they are  seen to occur in
instances, where the patients are not aware of having contracted infec-
tion; and when they result from gonorrhoea, that is only to be regarded
as their occasional or exciting cause.
   The name of rheumatic ophthalmia {Sclerotitis Rheumatica vel Jlt-
mospherica.—Mackenzie,) is, however, applied more particularly to an
inflammation of the  sclerotica, caused by exposure to cold, and pre-
senting the general characters already described.  The local symp-
toms are not of a  violent  kind, as the disorder is chiefly confined to the
sclerotica.  It is usually accompanied with haziness and dulness of the
cornea, and corresponding indistinctness of vision;  but it does not-often
lead to  any serious change in  that part.   I  have not seen  interstitial
deposition  with opacity,  nor  suppuration  of the cornea  in  the cases
which  I have regarded as rheumatic.  The disease may slowly creep
on to the iris.  The conjunctiva  is not affected, or only slightly; and
the same  remark may be applied to the eye-lids.   There  is a dull
aching  pain, with  sense  of  tightness; and  often more serious  pain
around  the eye, as in the brow, temple,  cheek, nose, and side of the
head, than in the eye itself.  This pain becomes worse at night.  Ex-
posure to light is  not found  very troublesome: this, however, as well
as the watering of the eye, depends on the degree of the inflammation.
There is more or  less constitutional disturbance of a febrile character.
   The treatment must be regulated according to the degree of inflam-
mation, the great object  being to  lessen  that, and guard  against  its
effects.   Venesection  is necessary if the patient be plethoric, the pulse
full and  hard, and the tongue  white.  Cupping from  the temple, and
leeches  may  follow,  or be  sufficient  alone.  The bowels  should  be
opened by calomel and James's powder combined with extract of colo-
cynth, and followed by an aperient draught.  Care must be taken after-
wards to insure their regular action.   Diaphoretics and warm pediluvia
may be serviceable.  The diet should be light, without solid  animal
food or fermented liquors.
   Calomel and opium in a nightly dose, or in a smaller quantity two or
three times in the day, after  the  more active antiphlogistic  treatment,
relieve the pain, and  soon remove the other symptoms.  Mercury is
more especially required, when extension of disease to  the iris is appre-
hended.  Affection  of the mouth is not necessary, but when it occurs,
seems rather advantageous than otherwise.   If the pain at night should
be considerable, and the  use  of mercury is  not  indicated, opium may
be given alone, or in the form of Dover's powder.
  The  welbknown  efficacy of colchicum, in  the treatment of certain
rheumatic affections, has  led to its employment in this  form of ophthal-
mic disease; and  it has  sometimes proved very efficacious.  Twenty
or thirty minims, or even a larger dose, of the wine of the seeds may
be given in combination with  carbonate of soda or potash, and some 
328
RHEUMATIC OPHTHALMIA.
rhubarb, if an aperient is advisable, three times a-day; or, two or three
grains of the acetous extract of colchicum may  be administered, once,
twice, or three times in the twenty-four hours.   If colchicum affords
relief at all, it does so  quickly.   Blister to the nape, or mustard poul-
tice may be employed with advantage after  depletion.
   Local applications are  not  of much  avail in this affection.   The
warm  are preferable, such as poppy fomentation,  and  steaming with
hot water,  alone, or with the addition of tinctura opii.  If the nocturnal
pain should be troublesome, a grain or two of opium mixed with a few
grains  of mercurial  ointment,  may be  rubbed  on the forehead, pre-
viously to  the  time at which the pain usually begins.   Simple opiate
frictions may be  tried, either with powdered  opium  combined with lard,
or  in  the fluid form  as liniment.  The  extract of belladonna, either
alone  or in conjunction with opium, has  also been  recommended for
rubbing over the brow.  It would be beneficial if  affection of the iris
had commenced.   When the eye remains  weak  and irritable, after the
treatment now pointed  out, the  vinum  opii  may be dropped in with
advantage  once or twice in twenty-four hours.
   In chronic  rheumatic  ophthalmia, at least in certain  instances, the
affection is confined to the sclerotica; the conjunctiva, cornea, and iris,
not  being  at  all  involved,  and the  complaint is  very obstinate.   The
following was a well-marked example.
  I was sent for to a gentleman, who  laboured under severe rheumatic affection of
one foot and knee, and one hand, with pains in  the back, and great constitutional
excitement;  the parts were swollen, slightly red, and very painful : it was one of the
cases commonly called rheumatic gout.  Active antiphlogistic treatment, followed by
colchicum and other means, removed the  rheumatic affection, and the patient con-
sidered himself well.  After  a short  interval, I called to inquire  about his health,
when he said that something was the matter with his  eyes, and wished me to examine
them.  I  looked at them hastily;  the room was dark,  and the  day dull; and I s;uv no
appearance of disease.  When I called again, after a  few days, as  the complaint  was
repeated, I examined more attentively. On bringing him towards the  window, he
obviously felt the light troublesome; he drew down the  eye-brows, and half closed
the lids to avoid it.  The conjunctiva was natural, but the  whole of the sclerotica had
a livid  red and  mottled  appearance, which might have  been called  dull, or almost
dirty, in comparison  with the red colour of common active inflammation.  The scle-
rotic vessels  were partially distended ;  the redness terminated short of  the cornea, 60
that there was a distinct white rim round  the latter, as if it  had been drawn with a
compass.  Vision was  perfect: there was no pain, so long as the  eye remained at
rest, but exertion of the organ, particularly under strong light, brought on uneasiness.
The nature of this gentleman's occupations, and of his tastes, which were literary,
prevented him from giving his eye the  necessary rest; and the above described con-
dition of the  sclerotica lasted for three or four months, making me apprehensive that
some serious  mischief to the organ would  ensup.   The affection, however, was con-
fined to its original seat, merely exhibiting ihe obstinate nature which belongs to dis-
orders of  such structures;  and it at last disappeared completely, leaving the eyes
with their organization and  powers unimpaired.  Cupping,  leeches, and blistering
were employed, with regulated diet, and occasional aperients.  Plummer's pill  was
taken daily, or twice a-day, for  about  three  months.  Bark  was tried without  any
advantage.
   I  saw a  case, which lasted nearly a year, the disease having been
confined  to the sclerotica, with  greater redness  than in the preceding
instance, but without any change in the cornea, or diminution of vision.
Sometimes the symptoms nearly  disappeared, and then came on again
unexpectedly.   Quinine, colchicum, and  sarsaparilla, were fairly tried
with doubtful benefit.   More advantage resulted  from cupping on  the 
RHEUMATIC OPHTHALMIA.
329
temple, the tartar emetic ointment on the nape, Plummer's pill with ape-
rients, and the exchange of country air, with free exposure  to it in ex-
ercise, for a more sedentary life in the atmosphere of London.
  Foreign writers, particularly the Germans, lay great stress on that
peculiar state of constitution, which gives rise to these affections, and
prefer the employment of such measures as they consider  calculated to
remove that state, to the use  of  means strictly antiphlogistic.   They
enumerate a variety of remedies, which they suppose to be antiarthritic,
such as decoctions of bark,  and other tonics, guaiacum, antimony, Do-
ver's  powder,  &c.  In the first place, it is doubtful whether these reme-
dies are specifically antiarthritic; and we know from  experience that
it is difficult to remove such a condition of the system.   In the second
place, the exclusive  reliance on such measures  appears to me to com-
promise the safety of the organ, when  it is labouring  under active in-
flammation.   Perhaps the mild antiphlogistic treatment which the eye
may require, may be the most effectual means of removing that state of
the system called arthritic,  or rheumatic ;  since in many such  cases
there  is either  general  plethora, or local  inflammation.  Colchicum,
however, possesses  decided antiarthritic influence; hence, as well  as
from  its well-knowrn general antiphlogistic power, it may become  a use-
ful  auxiliary in  rheumatic affections of the  eye, whether of the more
acute or chronic form.   I have seen its rather free employment of de-
cided advantage in the former.
  [We have employed in some cases with great benefit, the iodide of potass,
in doses of five grains, three times  a-day; and also, corrosive sublimate with
compound sirup of sarsaparilla, one-tenth  of a  grain of the former with  an
ounce of the latter three times a-day.]
  Bark is sometimes  serviceable in articular rheumatism, and it has
been  used with advantage  in  rheumatic ophthalmia.  Mr. Wardrop*
has strongly recommended  it, particularly in small doses.   He  gives
five grains of  powdered bark  with  the  same quantity of  carbonate  of
soda  every three or four hours.   Mr.  Tvrrell  has often  found this
plan successful after the  useless  trial of other  means;  and that  these
small doses  will be of service, when no  good has been derived from
larger quantities. (Vol. i. p. 297.)
  In persons of  weak  constitution  or impaired  health, lowering  treat-
ment  must be  used cautiously; while benefit will be derived from  bark,
from  other tonics, from good diet, and the general restorative influences.
I have often employed the small doses of bark and soda, recommended
by Mr. Wardrop, with the best effect.   If the local symptoms and the
general disturbance should be of active  inflammatory character, general
depletion and  the use of mercury will be necessary: the bark and soda
will come in  with advantage subsequently.   They  are, however, often
used with decided benefit where the  state  of the eye, especially in re-
spect  to redness, might lead us to suppose that antiphlogistic  treatment
would be more advisable.

  * Medico chirurgical Transactions, vol. x. p. 14.  Mr. Wardrop says that bark seems to
possess as specific an effect in rheumatic ophthalmia as in ague; and he mentions the
dose of five to eight grains in a little warm water, every two hours, or as often  as the
stomach can bear  it.  He also recommends the mineral aciJs, which, he says, may be freely
used while the patient is taking cinchona.  He has, however, subsequently been  in the
habit of using the bark with the alkaline carbonate, as mentioned in the text.
       42 
330
STAPHYLOMA SCLEROTICA.
   Much cannot be expected from local means in  such cases  as  those
now described.  The vinum opii is the most likely  to be of service.
   Catarrho-rheumatic ophthalmia.—The conjunctiva and the sclerotica
may be inflamed at one and the same time, when we shall have a  com-
bination of the appearances and symptoms already  described as belong-
ing to conjunctivitis and  sclerotitis respectively.   In the early stage of
the affection, we distinguish easily the characteristic tints of the inflamed
conjunctiva and sclerotica, as well as  the  position and  colour of the
superficial and deep-seated order of distended vessels.  There may be
the sensation of sand or  gravel in the  eye, with pain in the globe, and
in the parts around the orbit.   There is constitutional disturbance, often
to a considerable extent.
   If we follow some writers in employing the term catarrho-rheumatic,
we must not take it  in its literal  sense, as implying  that the patient
labours  under both catarrhal  and rheumatic affection, but only as de-
noting the co-existence of affection in the mucous and fibrous membranes
of the eye.  This inflammation, which is indeed of serious character, is
the consequence, or at least concomitant, of active and serious disease
in the cornea, without any apparent dependence, in many instances, on
the influences which produce, or are supposed  to produce, catarrhal or
rheumatic affections of the eye.
   The inflammation may predominate  in the  mucous  or fibrous struc-
ture; most frequently in the latter.  It  proceeds to  chemosis in the for-
mer, when the corneal affection is violent.
   The treatment falls  entirely under the general rules detailed in Chap-
ter V.
                6ECTION III.--STAPHYLOMA SCLEROTICA.

  The sclerotica is sometimes thinned, and raised into prominences of
various magnitude.  This altered state of  the  membrane, having  been
considered analogous to the thin and expanded state of  the cornea in
staphyloma, has received  the name of staphyloma sclerotica?.  The
change may affect the anterior, lateral, or posterior portion of the mem-
brane.   It is not a  primary affection, nor a consequence of any primary
disease of the sclerotica; but it is a secondary effect of inflammation
seated  in the interior of the globe, more particularly in the choroid coat.
Vascular  congestion in  these  parts, when violent  and long continued,
powerfully distends the sclerotica from  within, while  the resistance of
the  membrane is probably lessened by its participation in  the inflamma-
tion.   The elevations of the sclerotica continue, and are indeed  perma-
nent, after the inflammation has  ceased.  The violent  internal  inflam-
mation, of which  this change is a consequence, destroys sight;  I have
never seen it preserved in  a case of staphyloma scleroticae.
  The morbid prominence of the membrane is  readily recognised in the
anterior staphyloma sclerotica?, unless it should be very small.   It may
consist of one or more elevations, varying in size from that of a small
pea to  a large bean or filbert, the rest of the membrane being healthy;
or the  whole anterior portion of the membrane  may be raised into a cir- 
STAPHYLOMA SCLEROTICA.
331
cular elevation round the cornea.  The surface of the altered portion is
uneven, raised into irregular prominences.   Hence anterior staphyloma
sclerotica? [fig. 18,] is distinguished               Fig. 18.
lar or tuberculated  enlargement, partially opaque and white, in other
situations thinner and semi-transparent or blue;  in which the boundary
of the sclerotica and cornea is sometimes hardly to be traced.*
  Mr. BriggsI has mentioned  an interesting  case  of partial anterior
staphyloma sclerotica? in a patient thirty-two years of age.   There was
a dark purple  tumour on the  upper and outer part  of  each eye-ball
behind the edge of the cornea, producing a slight elevation in the cor-
responding portion of the upper lid.   The  disease has been increasing
during ten years, with slight pain only at intervals;  and on one side no
pain had been  experienced.  Sight  was very imperfect,  and the  pupil
was irregular in one eye.  The part was punctured on one side with a
fine  needle;  a  considerable  quantity of limpid  fluid escaped, and the
part became flaccid and paler.  Mr. B. did not  see  the case again.
  The existence of lateral and posterior staphyloma sclerotica? is onlv
detected on dissection.  An  example  of the former  is  delineated  by
Ammon, (Tab.  7, fig. 7 and  12.  Another  delineation will be found in
Froriep, fig. 7.)   He had the  opportunity of examining the eye, and
found the sclerotic enlargement filled with fluid, which had pressed the
choroid inwards.
  Scarpa has described and  figured two cases of posterior staphyloma
sclerotica?, which he dissected.   The enlargement occupied  in both, as
in all the other recorded instances, the temporal side of the optic nerve.
The swelling was formed by the sclerotica and  choroid, rendered ex-
tremely thin ; the retina did not enter the enlarged part.   The vitreous
humour was of watery  consistence.  In one of the cases it was known

  * Representations of anterior staphyloma scleroticae may be seen  in Ammon's Klinische
Darsteliungen, pt. 1.  Pig. 20, tab. 4, is a view of the  affection when the sclerotica is uni-
formly enlarged in front, the cornea and iris being normal.  From various views of the
same eye dissected, in tab. 7,  fio-. 8, 9, 10 and  11, the disease appears to have been gene-
ral dropsical enlargement of the globe, the choroid, retina, and iris not being much altered.
Tab. 4, fig. 21, and tab. 5, fig. 17, are other views of the disease;  in the first of which the
whole anterior portion of the sclerotica forms a large tubercular prominence.  In tab. 7,
fig, 6, we have a view of the  entire globe, where the  anterior half of the sclerotica was
involved: while in fig. 5, a circular staphyloma is represented, occupying the middle por-
tion of the membrane, the anterior and posterior parts not having suffered.  An anterior
staphyloma seleroticae is represented by FRORiEr de corneilide scrofulosa;  fig. 8, and by
Mr. Tvrrell, vol.  i. pi. 2, fig. 6.
  t Translation of Scarpa, p. 339, note. 
332
CYSTS AND TUMOURS OF THE SCLEROTICA.
that sight had been lost some years before from an obstinate ophthalmia
attended  with most acute habitual pain in the head.*
   Two examples of posterior staphyloma are represented by Ammon; a
small one in an early stage, where the swelling was lined by the choroid
and retina; (Tab. 7, fig. 14 and 15.) a larger, in which the distended tunic
had yielded, the retina was in a partially collapsed state from fluid effused
between it and the choroid, and the crystalline had  passed backwards
into the middle of the globe.  (Tab. 7, fig. 7.)

           SECTION IV.--CYSTS AND TUMOURS OF THE SCLEROTICA.

  Case I.—Small watery cyst in the  sclerotica  of  a child; successfully  treated by
cutting away the prominent portion of the cyst.—A child, ten years old, had a semi-
transparent firm oval  swelling, as large as a small pea, on the sclerotica, close to the
margin of  the cornea, where its existence had been  noticed  for some years.  There
was no change in the conjunctiva.   It had been punctured ; watery fluid escaped, and
the accumulation was soon renewed.   Two or three gentlemen, who had seen the
case, advised that no further proceeding should be resorted to.   As the swelling already
constituted a slight blemish, and was increasing in  size, my recommendation of an
operation was readily adopted.  I punctured the cyst, and  then  cut away its promi-
nent portion with curved scissors.  It  was thin but tough, the sides being firm enough
to retain the figure of the swelling after it had been opened.   The interior wassmooth,
and a small round aperture was seen in the middle of  the  basis, apparently passing
through the sclerotica.   The surface exposed by the operation slowly healed over
without any unpleasant symptom, and the blemish was completely removed.   At the
distance of two years  from the operation, the eye continued  perfectly well.
  Case II.—Larger cyst of the sclerotica;  excision of its prominent portion.—A
gentleman, about thirty years of age, of robust frame and full habit had lost one  eye
by violent inflammation, which had caused extensive opacity of the cornea, with adhe-
sion of the iris.  A cyst formed in the sclerotica, and  slowly acquired the size of an
almond, not only increasing the deformity, but also causing irritation in the motions of
the globe and lids.  I  removed the  exterior  portion  of this  bag, as in the  last case;
but I did not see the patient again.
   Scrofulous tumours on  the sclerotica.—" I have seen," says Mr. Mac-
kenzie, "several cases of albuminous or scrofulous tumours, originating
from the  sclerotica, sometimes  single,  sometimes in  clusters, soft in
some cases, firm in others, but with little or no vascularity.  The sub-
jects of such  affections were always  cachectic  children, and the  af-
fected eyes  had generally suffered from  internal scrofulous ophthalmia
before the appearance of the tumours.   Several of the patients died of
chronic  disease of the lungs."  Op. cit. p. 601.
   A short notice of three cases is subjoined.
   Von Ammon has delineated a dark coloured excrescence slightly lobu-
lated, with smooth surface, growing from the sclerotica near the margin
of  the cornea, which it overlapped.   It  was equal in size to a large
filbert, and the eye-lids scarcely covered  it; occasionally it bled a little.
In  appearance it might have been considered melanotic; but the normal
condition of the iris, and other internal structures, rendered this supposition
inadmissible.  It had been treated  with  escharotics.   It was removed
by the knife, leaving  behind  merely a slight mark, showing  where it
had grown from the  sclerotica.f
   I have  referred  to two figures, representing a morbid condition of the
sclerotica in a note to p. 312.

             * Translation by Briggs, p. 400. PI. 2, fig. 9 and 10.
             t Klinische Darsteliungen, pt. 1, tab. 21, fig. 12—15. 
(  333  )
CHAPTER XIV.
                   DISEASES OF THE CORNEA.

               SECTION I.--INFLAMMATION OF THE CORNEA.

   Although the vessels of the cornea are not visible in the normal and
perfectly transparent state  of the texture, they  become enlarged under
inflammatory  excitement,  whether acute  or chronic, and  admit red
blood; and  they are sufficiently numerous to allow of the part becoming
generally red under active or long-continued congestion.  The various
results of disturbed vascular action, such as union by adhesion, inter-
stitial deposition, softening, thickening, induration, ulceration, cicatriza-
tion, suppuration, mortification, occur in the cornea as rapidly and per-
fectly as in  structures of which the  vessels are larger, and apparently
more numerous.
   Inflammation of the cornea may  be either acute or chronic; but its
course and character are most frequently of the  latter description; at
least it produces interstitial deposition and opacity, or ulceration, much
more frequently than the more serious results of suppuration and morti-
fication.   In general the appearances commence gradually and proceed
slowly.   The  vessels of so dense a texture do not easily become en-
larged;  considerable  excitement is  necessary  to produce  this  effect:
hence the uneasiness is greater than the mere degree  of visible change
would lead us to expect.   For the same  reason recovery is tedious.
   The affection of the cornea  may be primary or idiopathic;  the inflam-
mation, excited by causes acting directly on the part, beginning in the
cornea, and extending more or less  seriously, according to its degree,
to the neighbouring and connected parts;  viz. the sclerotica, conjunctiva,
and surface of  the anterior chamber;  or, the disorder may  commence
in the conjunctiva and sclerotica, more particular  in the former, and
spread to the cornea, the latter suffering as a part  of the external cover-
ings of the globe.
   I have already shown how the cornea  is involved in external inflam-
mations of the eye, particularly in the purulent, scrofulous, and various
ophthalmia?, and have described  in the chapters devoted to those  sub-
jects, (chapters vii. viii. ix. and x.,) the phenomena and  results of its
mortification, suppuration, and ulceration, as well as  those of effusion
into its texture and consequent opacity.
   Sloughing of the cornea  may occur  in consequence of acute inflam-
mation of the conjunctiva.   In this shape I have seen it only in the pu-
rulent ophthalmia of newly-born infants (see p. 221,) and in gonorrhoeal
ophthalmia (see p. 273,) or it may be seen  in  conjunction with great
general weakness, and reduced local action, as  in some cases of vario-
lous ophthalmia (see p. 308.)  Mr. Middlemore says  that old  persons 
334
INFLAMMATION OF THE CORNEA.
are sometimes affected with gangrene of the cornea from a very slight
degree of inflammation, and occasionally without any previous inflam-
mation whatever.   The loss of vitality in the cornea, under such cir-
cumstances, has been considered analogous to the mortification of the
toes in old persons.
   In cases of this description, the strength must be supported by good
diet with a proper allowance of beer, wine, or both.   Mild astringents,
such as solution of alum, sulphate of zinc, nitrate  of silver, may be used
locally.
   Suppuration of the cornea has been already spoken of at pages 158,
240, 274, and 3J0; and some further  remarks on the subject will be
found in  a future part of this chapter.
   The vessels of the cornea may become enlarged, so as to admit red
blood, under the influence of direct excitement in external inflammation.
This is most frequently seen in young subjects.  The vessels are so mi-
nute, that close  observation, or the use of a  glass, is  sometimes neces-
sary to show that the  red  appearance is vascular.   They are closely
arranged, and form, on the margin of the cornea,  a band, which gradu-
ally becomes broader.   These vessels are obviously derived from those
of the conjunctiva.  Whether they are derived from vessels belonging
to the surface of the membrane, or from those situated between the con-
junctiva and the sclerotica, are questions which we cannot  as yet satis-
factorily answer.  In a  child, eight years of age, labouring under an
attack of  external ophthalmia, this state of  the  cornea was  strongly
marked.  By two applications of leeches, and other antiphlogistic mea-
sures, the eye  became  well in a week.  The distended  vessels con-
tracted, and the portion of cornea, which had been reddened, was again
quite transparent.
   When the  inflammation begins  in the cornea, the  case is properly
termed inflammation of that membrane corneitis,  {ceratitis, or kera-
titis.)
   Acute corneitis with suppuration.—I suspect that the variolous ophthal-
mia, in its secondary form, commences with affection of the cornea, that
is, with the development of an inflammation analogous to the variolous
pustule of the skin : the inflammation, which is of acute character, soon
extends to the sclerotica, so that when  our  attention is drawn to the
case, it appears as an inflammation of  the  external  tunics generally.
See p. 309.
   In the  Third Chapter, on icovnds of the eye, at  page 158, I have
spoken of inflammation of the cornea as the consequence of mechanical
injury, and have  described  both the  milder  form of the affection,
and the more serious degree, which proceeds to suppuration  and hy-
popyon.
   When active inflammation of the cornea causes suppuration, the scle-
rotica and conjunctiva participate in the local excitement, the latter often
passing into the state of chemosis.  The cornea becomes dull, then grey-
ish; it turns white, cloudy, and then yellow, as if  pus were deposited in
its texture.  In fact, we may say that the cornea  has  suppurated ; the
only objection to such an expression being that the matter thus deposited,
though yellow like pus, is not fluid, but of a  thick  consistence, viscid, 
INFLAMMATION OF THE CORNEA.
335
 and apparently infiltrated in the corneal texture.*   If we puncture the
 part, matter does not escape; it does not make  its way to the surface,
 point, and discharge, like the contents of an abscess; but the cornea ul-
 cerates; the newly-deposited yellow substance is exposed, and gradually
 removed by ulceration.   A similar  process seems to occur internally,
 at least an effusion takes place into the anterior chamber, and a yellow-
 ish substance falls down to the  bottom  of it, producing the phenomenon
 of hypopyon.   We can sometimes distinguish the ragged opening, by
 which the yellow substance has escaped, and we even see small yellow
 shreds hanging from it.   Corneal suppuration is discharged  into the an-
 terior chamber more frequently than externally.
   The cornea sometimes  bulges where suppuration has taken place;
 but more frequently its figure is unaltered.  The  matter formed in the
 cornea may be more fluid and constitute a  small abscess.
   When the cornea suppurates generally, ulceration may  extend into
 the  anterior chamber at more  than one place, the  aqueous  humour
 escapes, the iris comes in contact with the inflamed and ulcerated cor-
 nea, and is often  protruded at one or  more points.  When  the inflam-
 mation subsides, the  cornea is  opaque, the iris  adherent to it, and the
 anterior chamber abolished; in  short, the eye, so far as  the  purposes of
 vision are concerned, is  lost.   Sometimes matter  is  only deposited in
 one point of the cornea; there  is a yellowish  appearance at this spot,
 and a general nebulous whiteness pervades  the rest of the structure.   In
 this case, if  the ulcerative process has taken place, its further progress
 maybe  checked, and the  ulcer may heal; or, by active treatment,
 ulceration may be altogether prevented: the  matter will be absorbed,
 the cornea nearly regain its natural appearance, and vision  be restored
 entirely, or with little defect.
   It has been commonly represented that when  the cornea  suppurates,
 the effused matter insinuates itself between  the lamina?, finds its way to
 the bottom,  and,  accumulating  at the lower  edge, produces  there an
 appearance which has been called onyx or unguis, from  its resemblance
 to the mark at the root of  the nails.   I believe  that the cornea  is  too,
 dense to admit of this mechanical sinking of the  matter,  and  cannot  say
 that I ever saw onyx in this sense.  I believe that the  matter remains
 in any part of the cornea, in which it may  have been deposited.
   The appearance similar to the white mark at the root of the nail takes
 place where matter  is effused  into the anterior  chamber, that is, in
 hypopyon, rather than in suppuration of the cornea or onyx.f
   As the suppuration of the cornea frequently makes its way into  the
 anterior  chamber, onyx and hypopyon  will be  seen together in many
 instances.   In other cases they  occur separately; the corneal suppura-
 tion may break externally, or the effused matter may be absorbed under


  * Mr. Middlemore states that the effused matter is either lymph, or a somewhat con-
sistent and tenacious substance, which he calls puro-lymphatic; vol. i. p. 459.
  t As these terms are often employed incorrectly, I subjoin the explanation of them from
Lexicon Medicum of Blancaud, edited by Kuhn.
  Onyx; abscessus inter lamellas cornece.
  Hypopyon; puris sub tunica cornea in  cameris oculi collectio.
  Blancard defines hypopion, a word employed  by Galen, "Sugillatio, sive sanguinis
effusio sub palpcbris et adnata oculi, aut sub palpebra inferiore." 
336
INFLAMMATION OF THE CORNEA.
proper treatment, so that hypopyon does not take place.  Again, hypo-
pyon occurs in  inflammatory affections of the  eye, not involving the
corneal substance.   See the chapter on  inflammation of  the aqueous
membrane.   The two cases might be confounded on superficial inspec-
tion: it is important to distinguish them, since the violence of the malady,
and  the danger to the organ, are  much greater in suppuration of the
cornea than in  hypopyon, and a more active treatment is  required in
the former case.  In onyx the inflammation of  the  sclerotica and con-
junctiva is of the most acute character, proceeding commonly to che-
mosis, which is firm from  the effusion  of fibrine.  The  other  local
symptoms and the constitutional disturbance correspond.  The-general
inflammatory affection is much  milder,  and often inconsiderable in
hypopyon.  In  the latter, the yellow appearance is of definite form,
and confined to the bottom of the  anterior chamber, while  in onyx the
figure is irregular, the outline indefinite, and the  appearance may be
found in any part of the cornea.   In  hypopyon the cornea generally
may be little altered, or merely exhibit a dulness or slight greyish cloud;
the matter, on careful examination, will be seen  behind it.   In onyx a
more or less dense whiteness surrounds the yellow effusion, often occu-
pying the entire cornea, while the suppuration comes to its very surface,
so that we cannot discern a  nearly healthy cornea covering the matter.
The level of the matter is  changed when the  position of  the eye is
altered in hypopyon; no such change is seen in onyx.
   Suppuration produces ultimate changes in the cornea and iris, which
are often  destructive, almost always more  or less injurious to vision.
These are, destruction of the corneal substance by ulceration; adhesion
of the iris, and extension of  the weakened and adhering structures into
the opaque swelling of staphyloma;  abolition of the anterior chamber,
and flattening of the front of the eye; opacity of the cornea in various
degree and extent, with or without adhesion of the iris {synechia ante-
rior,) or prolapsus iridis, and consequent displacement or contraction of
the pupil.  The corneal opacity, the adhesion of the iris, and the changes
in the iris and pupil, may be  variously combined ; they may be so related
to each other as to intercept the passage of light, to impair vision, or to
leave it uninjured.  In the most favourable termination of the disorder,
some opacity of the cornea will remain.
   The indications of treatment are, to arrest the local disturbance, or
diminish its  violence; to prevent effusion,  and to promote absorption of
what has  been already poured out.   Free depletion and other antiphlo-
gistic measures  are required  in the outset; these means are to be followed
by the use of mercury.
   Regarding the suppuration of the cornea in the  light of a common
abscess, some have  advised puncture  to let out its contents.  As the
effused matter is thick and  viscid, and usually infiltrated,  it does not
escape on puncture,  so that  the proceeding fails so  far as the object of
discharging  the contents of  the corneal abscess  is concerned.  I  have
not seen any advantage from such punctures.   Mr. Middlemore states
that he has been compelled to puncture on many occasions  in order to
relieve pain, but  without any expectation of saving the cornea.   He
adds that he has seen many bad cases recovered by the  use of mercury;
but that the  same fortunate result has not been obtained in similar cases, 
INFLAMMATION OF THE CORNEA.
337
where the incision alone has been made.*  Mr. Tyrrell says, "When
the abscess is extensive, and the  pain severe, with a distressing sensa-
tion of tension, I consider it proper to puncture the cornea, more with
a view to relieve the suffering than to hasten  the cure; for the matter is
rarely so  fluid as to escape by a small aperture, but ihe larger part
appears to be  removed by absorbents."f  Mr. MackenzieJ observes
that it is a rule generally agreed on not to meddle with small effusions;
that he has frequently punctured  larger ones with the lancet, and sta-
phyloma has always  resulted, while the eye has sometimes recovered
almost perfectly, where  he  had  left large collections  untouched.  He
states afterwards that  large abscesses  must be punctured in order to
relieve the pain, but  that the puncture  must be  repealed several  times.
If the suppuration be extensive, and the  pain very great, puncture of the
suppurated portion may be  tried; the eye will probably be irreparably
injured by the progress  of the malady.   The  evacuation of the aqueous
humour would probably afford more effectual relief.
   By the inflammation, which produces suppuration of  the cornea, its
texture is softened; thus it is found flabby, and does not resist the knife
when an  attempt is made  to puncture it after ulceration  has  taken
place externally, or after the escape  of the matter  into the  anterior
chamber.
   If suppuration of  the cornea  should  assume the chronic  form, and
occur in  an  unhealthy or enfeebled constitution, a different course of
treatment must  be pursued.  Direct depletion  must  be avoided alto-
gether, or employed  sparingly  and  cautiously: local  bleeding will
suffice.   Mild counter-irritation  will be useful.  We  must endeavour
to restore and maintain  general strength  by  suitable  regimen and
tonic  medicines, with  which the milder mercurials may be  com-
bined.
   Inflammation  of the  cornea, especially when spontaneous, causes in
the great majority of  instances enlargement of the vessels, so that
they carry red blood,  and interstitial deposition, rendering the  mem-
brane opaque.   On ihe  first view the inflammation might be considered
chronic,  but  the local  and  general  symptoms  mark  an  acute  affec-
tion ;  and its particular characters, the enlargement and  distention
of vessels, and the opaque change in the part, arise  from its peculiar
structure.
   The complaint begins with  dulness of vision, the cornea being at the
same  time  hazy. It  loses its transparency,  and exhibits a  general
cloudiness, with  increasing imperfection of sight, objects appearing  as
if seen through a cloud  or mist.   This nebulous condition of the cornea,
as it is frequently called, may be general or partial: in the latter case it
is continued insensibly into the healthy structure.  The cornea may be
generally  of a dull grey colour, or like ground glass; it may exhibit the
various "degrees  of change  from haziness to  nebula, or to opacity so
dense as to conceal the  iris and pupil, or to render them quite invisible.
The opacity, which begins at the circumference, and gradually extends,
is  generally  unequal, so as to give a  cloudy or smoky appearance,

 * Vol. i. p. 462, 463.                        t Practical  Work, vol. i. p.236.
 t Practical Treatise, p. 539, 540.
      43 
338
INFLAMMATION OF THE CORNEA.
clearer  portions being interspersed among the more opaque parts, and
vision being more perfect  than  the general appearance of the cornea
would have led us to expect.  The opaque spots are sometimes of a yel-
lowish colour, as if something like matter had been deposited ; perhaps
there is  a kind of suppuration in  such cases. The surface of the cornea
loses its polish, assuming a finely granulated  appearance, as if  it were
covered with fine sand, or  minute drops of dew.   This change, which
commences in the onset of the affection, with cloudiness or mistiness of
vision, gives the eye a very dull  appearance, even before there  is much
general  opacity.  Is this irregularity of surface caused by minute vesi-
cles of the corneal conjunctiva, by expansion of its texture, or by effu-
sion under it ?
  While these changes are proceeding, we shall usually observe an al-
teration in the external vessels of the eye. A few distended trunks may
be seen  in  the conjunctiva, running  towards the margin of  the cornea;
but we find more  constantly  distention  of the deeper  trunks  lying on
the sclerotica.  Their  small and straight branches  run forwards and are
continued into the substance of the cornea.  When  the opacity is partial
or  unequal, this distinction of the deeper vessels is observed where ihe
change  has gone to the greatest  extent.   As the affection proceeds, the
opacity becomes more considerable while the apparent number and the
distention of the vessels are increased.  The circumference  of the mem-
brane assumes a brownish  red tint,  and  appears on first view to be dis-
coloured throughout its  texture.  Closer  examination shows  this ap-
parent discolouration, which represents a band round the cornea, seldom
complete, to arise  from a countless multitude of minute vessels.   The
edge of  the discoloured part  is sometimes regularly defined, sometimes
not: it may be broader at one part than at  another.  It is sometimes
slightly  elevated.  It may  be partial, and, as  it follows the  edge of ihe
cornea  it  has a crescent  shape.  The blood-vessels ramifying in the
cornea  are obviously derived from the  trunks lying on the sclerotica.
The dull brownish red colour of the vessels shows that they are not
superficial. The  conjunctiva often retains its  natural paleness, while
the vessels under it are turgid and the whole sclerotica is covered  by a
plexus of distended  ramifications, which  form a pink zone round the
cornea.  There is a singular contrast in these cases, between the brown-
ish red  circumference, and the opaque interior of the cornea.
   In the more acute cases the conjunctival vessels are distended; not,
however, so  as to  conceal the  changes which have occurred  in the
more deep-seated plexus, and the  sclerotica geneially, has a  rose or
pink tint.  A slight cloudiness of cornea may be produced  and  continue
without visible increase of vascularity.
   Considerable pain and sense of tightness in the  eye, and pain in the
brow or forehead, often accompany the affection, especially in its early
stage, in which we find  white tongue,  headach, and general  feverish-
ness.  There is increased sensibility to light, which is the more remark-
able, as the changes in the cornea  must diminish the quantity  admitted
into the eye:  it must be  remembered, that the sclerotica is involved in
the inflammation, and  that intolerance of light usually occurs when that
membrane suffers.   These symptoms are attended with lachrymation,
especially on exposure to light. 
INFLAMMATION OF THE CORNEA.
339
   The inflammation may proceed with  some rapidity, and be attended
with feverishness.   On the other hand, it is often of long duration, con-
tinuing  for many months;  and  it  does not proceed to  suppuration.
Often, after going through  an acute stage, with pain and  feverishness,
it assumes a more indolent character and is protracted indefinitely: the
disease lasts, but the patient does  not suffer.
   Corneitis may be brought on by external agencies, by cold, damp, or
atmospherical vicissitudes.  More commonly it owes its origin to inter-
nal causes, seeming to come on spontaneously.   It is most frequent in
the young, and seldom seen after  the middle period  of life.   It occurs
in those of  unhealthy constitutions,  especially the strumous;  or  where
the general  powers have been considerably reduced.
   The iris is generally involved,  to  a  greater  or  less degree, in cor-
neitis; it may suffer considerably if the inflammation  be active, and
allowed to proceed unchecked.   Hence arise contraction of the pupil,
effusion of lymph and consequent permanent adhesion of its margin to
the crystalline capsule, and discolouration of the iris.
   Prognosis.—Under proper  treatment, the interstitial effusion  of the
cornea is removed, the membrane regains its transparency, and  vision
is completely restored.   The iris,  however, sometimes exhibits, after
such  recovery, a darker tint, with a little  loss  of brilliance;  and  thus
the eye has a  somewhat dull  appearance.   Under less favourable cir-
cumstances the  cornea loses its transparency, and becomes changed in
various degrees from leucoma to slight nebula.   The iris is dull, and
dark  coloured, the  pupil  adherent, and there  may  be opacity  in  the
opening.*
   Treatment.—When acute, corneitis requires pretty active antiphlogis-
tic measures.  If stimulants and astringents are employed, as they some-
times have been, on account of the  opacity, without proper considera-
tion of the other circumstances, the symptoms are aggravated, and the
recovery is rendered difficult.  The local abstraction of blood by cupping
on the temples, and by leeches, or other antiphlogistic means are neces-
sary.   The loss of blood may be repeated from time to time if the symp-
toms should require.  Subsequently, the use of mercury,  perhaps car-
ried to the length of slightly affecting the mouth, is the most efficacious
means of checking  the inflammation, and restoring the transparency of
the part.  The occasional use of leeches might be combined with this
plan.   Counter-irritation by blistering or by the emetic tartar ointment
will be a useful auxiliary measure.
   As the  complaint is  formed and proceeds  slowly, the influence of
treatment is gradual, and steady perseverance is necessary to  insure
success.   When the  treatment takes  effect, and  especially  when  the
mercury acts decidedly, the  vessels of the cornea contract, and  the
newly-deposited matter is absorbed, the cornea regaining its transpa-
rency, even where it had become generally and rather densely opaque.
It clears first in the  circumference, the favourable change  gradually
advancing towards the centre.
   If the iris should participate in the  affection, there is an additional
reason for the use of mercury. When the constitution is naturally deli-

  * Ammon has represented, in numerous figures, the principal appearances and effects of
corneitis.  Klinische Darsteliungen, pt. 1, tab. 3. 
340
INFLAMMATION OF THE CORNEA.
 cate, as it commonly is in those affected with corneitis, or  where its
 powers  have  been reduced  by disease and treatment, all measures  of
 depressing influence must be avoided as much possible.  Even leeches
 to the eye would not be admissible, unless strongly required by the local
 symptoms.  Mercury  must be cautiously employed in small doses, and
 combined with tonic and strengthening medicines, such as bark or steel,
 with good diet and the other restorative influences.
   Case.—A young woman, of pallid  countenance and delicate frame, about twenty
 years of age, came to the London Ophthalmic Infirmary, complaining of loss of sight,
 in the right eye.  There was considerable general opacity of the cornea,  which had
 destroyed all useful vision, redness of the sclorotic coat, uneasiness  on exposure  to
 light, and increased lachrymation.  S le  said that she had been ill six weeks; that
 she had been under the care of a surgeon in her neighbourhood, and that by his direc-
 tion she had been putting drops into her  eye, which made it  very sore and painful;
 however, as she  was directed  to do so, she  persevered in  using  them.   When she
 showed me the prescription, I found that these drops were a solution of the oxymuriate
 of mercury.   In this case  it was  necessary to take blood by cupping repeatedly, to
 apply leeches several times, to use mercury freely, to put an issue in the temple, and
 to persevere in these measures, variously combined and  repeated,  for a long time before
 the inflammatory action was removed.  The cornea has not completely regained its
 transparency, nor was the sight fully restored until nearly the end of a yeir, during
 the greater part of which time she was using  mercury more or less  actively. In a
 few months she came again to the infirmary, and  said that she had the  sime complaint
 coming on in the leit eye;  she found the sight dim, and had considerable  pain in the
 head; in short, the same symptoms which she had  before complained of in the other
 eye.   We had an opportunity of treating this eye from the first.   We took blood from
 the temple  by cupping, and employed the other treatment I have just particularize),
. and in six or eight weeks the complaint was completely put a stop to, although  the
 cornea was  generally nebulous when she came.  The difference of treatment was
 very striking, and the results were equally so.
    Partial inflammation  of the cornea.—Most frequently inflammation
 affects  the  entire cornea, especially in  young persons.    Sometimes,
 however, about or after the time of  puberty, the affection  commences
 in one spot; other points become  affected  in  succession, and  thus dis-
 ease may gradually extend over the whole.   Pain has been felt in the
 eye;  partial dulness is found at one point near the edge of the cornea;
 a little redness is seen  on the external surface of the eye, corresponding
 to the nebula corneas.  On  close inspection, this  redness proves to be
 seated in the sclerotica, and the conjunctiva is unaltered: enlarged ves-
 sels are  seen on the sclerotica, and we find  minute ramifications extend-
 ing from them on the  cornea.   Another patch of  nebula  occurs, and
 ultimately the whole cornea, or the greater part of it, is affected.
   Case.—A young lady, about  sixteen, of florid complexion and full habit, had an
 attack of external inflammation in the left eye, from which she had recovered under
 active treatment.   She began to complain of the right eye :  some of the sclerotic ves-
 sels were enlarged, and the corresponding portion of the cornea, near  its margin, was
 nebulous.  Active antiphlogistic treatment did not prevent the progress of the inflam-
 mation, and its extension into general inflammation  of the cornea, for which a long
 continued course of treatment, by purgatives, mercury, and  issue, was required.
   In a young boy, of rather pale  and languid appearance, the same progress was
 observed.   He had an attack of external inflammation, which got well, when partial
 corneitis came on, and gradually extended over  nearly the whole cornea.  It was
 accompanied with chronic iritis, and partial adhesion of the pupil took place.  Issue in
 the temple, and mercury, ultimately removed the affection, but  not till after a long
 time.
   In another patient, near thirty years of age, of light complexion and pallid appearance,
 partial inflammation of  the cornea showed itself first, and  fresh portions of nebula
 appeared successively, till the affection became general.  But in this, and  in the laat
 case, the  inflammation was  in  roundish patches, the intervening portions being compa- 
INFLAMMATION OF THE CORNEA.
341
ratively transparent.  The central and most opaque part of these patches had a slight
yellowish cast.  Here too the iris was involved.  The same treatment was success-
ful.
  In a young lady of delicate habit, about twenty-four, patches of opacity showed them-
selves in the lower half of the cornea.   They were small,  roundish, dense, and  yel-
lowish in the centre, and shaded off at the circumference.  After antiphlogistic treat-
ment, mercury and issue were employed.  Considerable benefit was produced, when
the mouth became affected.   The treatment was interrupted, and  relapse occurred ;
it was resumed, the mouth was again afivcted, and the influence was kept up for some
weeks without much  benefit.  The affection, indeed, began to show itself in the upper
portion of the cornea, which had  been previously clear.  I did not witness the termi-
nation of the case.
   Local applications are not of much advantage.  In the inflammatory
period, and when  intolerance exists, fomentations are most comfortable
to the patient.   Stimuli and  astringents are hurtful so long as active
inflammation exists.   When that  is removed, and the complaint  is  be-
ginning to  yield, the vinum opii, or  the four grain solution  of lunar
caustic, may be tried, and  a small portion  of  the mild red precipitate
ointment may be introduced between the lids at night.
   Strumous  inflammation of the  cornea* {corneitis scrofulosa or stru-
mosa.)—inflammation of the cornea frequently occurs in  scrofulous per-
sons ; its local characters and its real nature do  not differ essentially
from  the description  already given ; it cannot, therefore, be regarded as
a peculiar  or distinct affection.  The entire cornea becomes dull and
hazy, and  then exhibits a more or less deep nebulous opacity, the sur-
face having  the sanded appearance already described.  The conjunc-
tival vessels  are not  much  distended; but there is a deep-seated pink
redness, from fulness of the  trunks on the sclerotica, the minute straight
branches of  which form a zone round the cornea:  when the affection is
very active  minute twigs  of the conjunctival  vessels join the  zone,
which has a bright redness  round the  cornea.  A dull  reddish brown
discolouration is seen in the cornea, at its circumference, generally par-
tial.  This depends on an aggregation of minute vessels filled with  blood,
and ramifications are easily distinguished, proceeding from  the  red
zone to such discolourations.   That the latter are  owing  to stagnation
of blood in the minute vessels of the cornea is an opinion expressed  by
Dr. Froriep, for which I see no sufficient ground.
   Lachrymation and intolerance of light are  common to this affection
with ordinary strumous ophthalmia ;  and  it is not usually attended with
pain in the eye or head.
   The constitution suffers;  the pulse being quick,  the skin hot  and dry,
the tongue white, the appetite deficient, and the bowels costive.
   The opacity of the cornea varies in degree.   The pupil can be seen
through it  more ©r  less  clearly in some cases; in  others the iris and
pupil  are entirely  concealed.
   Like other strumous affections, this is obstinate, yielding difficultly to
treatment,  and liable to relapse.
   The iris probably suffers with the cornea, though its condition is con-
cealed by the changes going on in the latter membrane.
  Formidable as this affection appears, when fully developed, it  yields

  * Remarks  on strumous  Corneitis and Iritis, by Mr. James Guthrie, Edinb. Med. and
Surg. Journal, vol. xxix. p. 315. The Dissertatio Medica de Corneitide Scrofulosa of Dr.
R. Froriep, Jenee, ]830, contains a good description of the affection, with some of its con-
sequences, and some excellent figures. 
342
VASCULARITY OF THE CORNEA.
to treatment, and the normal condition of the inflamed  textures is re-
stored.   It may however terminate in leucoma, contracted and adhe-
rent pupil, which may be closed more or less completely by an  opaque
adventitious  membrane, disorganization of the iris, and diminution or
loss of sight.  Under long continuance of the affection,  which must no
doubt be attended with increased secretion of  the aqueous humour, the
anterior chamber is enlarged, and  the cornea  may be even altered in
figure.*
   Treatment.—Abstraction  of  blood is  generally inadmissible, as in
strumous inflammation of the conjunctiva.  The alimentary canal should
be cleared;  and the sulphate of quinine may then be administered with
great advantage.   Mercury may be  combined with this remedy, if ihe
opacily of the cornea does not give  way.   The moistened extract of
belladonna may be smeared on  the brow, to prevent  contraction of the
pupil, and lessen  the irritability  of the eye.   Tepid fomentations are the
most agreeable local application ;  a  little laudanum  may be added to
the liquid.   Mild counter irritation may be employed, if the disease does
not yield to  the means already specified.  Under such circumstances a
local stimulus may be tried, such as the vinum  opii, or a two grain solu-
tion  of the nitrate of silver.
  [The sirup of ioduret of iron and the iodide of potassium are useful internal
remedies.]
   In  the  observations  already  quoted,  Mr. J. Guthrie recommends
emetics and Dover's  powder, to remove the constitutional irritability,
which in general is strongly marked.
  Inflammation of the cornea with vesication.—Under this name Mr.
Tyrrell,  (vol. i.  p. 241.) describes an external inflammation, attended
writh great irritability of the eye, with the troublesome symptoms coming
on in paroxysms, occurring  in  adults whose general health has  been
impaired.   "A partial  nebulous condition of the cornea  exists, in the
centre of which a small vesicle  distended with  fluid may  be perceived,
if the eye be examined during the paroxysm;  otherwise a thin portion
of loose membrane, which is partially separated, much as the cuticle is
after puncture of a cutaneous vesicle."   Local applications are unavail-
ing, and we must depend on general means, among  which the warm
bath has been found particularly beneficial.
               SECTION II.--VASCULARITY OF THE CORNEA.

   The nutrient vessels of the cornea become enlarged in disease, so as to
convey red blood, the slate thus  produced being called  vascularity of
the cornea.  The enlarged vessels may be those of the conjunctival
layer, and consequently superficial; or they may be more deeply seated,
perhaps in the corneal laminae.  A few vessels or fasciculi may be visi-


  * A slight change of this kind is exhibited in  Froriep's Dissertatio, fig. 5.  He al«o
enumerates staphyloma corneae among the consequences of the disease, as well as staphy-
loma sclerotic®, and  staphyloma corporis ciliiiris. The latter changes must be conse-
quences of an affection more general than corneitis.  Considerable enlargements of the
cornea, with and  without partial opacity, are delineated by Ammon, Klinische Darsteliun-
gen, pt. 1, tab. 3, fig. 18—.21. 
ULCERATION OF THE CORNEA.
343
ble, or the whole texture may be reddened by a countless multitude of
ramifications.   This unnatural vascularity may result from  the  direct
excitement of active inflammation ; and the change in question has been
already mentioned among the effects of common external inflammation,
(see p. 333.) of strumous ophthalmia, (Chapter X.) and of inflammation
of the. cornea, (Chapter  XIV.)  The enlarged  vessels contract, and
the vascularity disappears under the influence of the means, by which
inflammation is reduced.   Vascularity of  the cornea is seen more fre-
quently as the  slow consequence of chronic irritation.  This is the case
in purulent ophthalmia, where  it is produced by the  mechanical  irrita-
tion of the diseased palpebral  conjunctiva, (see Chapter VIII. p. 261.)
and in strumous ophthalmia  (see Chapter X.  p. 298.) where the en-
largement of vessels, and the loosening of texture, proceed occasionally
to such an  extent, that the corneal conjunctiva can  hardly be distin-
guished from that of the sclerotic.
  The only question which remains for  consideration is, whether the
effect of the treatment elsewhere described, can be assisted by the ope-
ration of dividing the vessels; for example, by cutting  out a piece of
the conjunctiva round the  margin of the cornea in pannus.  The deep-
seated vessels cannot be divided; the proceeding, therefore, could only
be beneficial where  the enlargement is confined to those of the mucous
surface.  I have seen no decided benefit from it; but there can be no
objection to trying it in a suitable case,  which remains  unrelieved by
a sufficient perseverance in other measures.
               SECTION III.--ULCERATION OF THE CORNEA.

  In its natural structure, consisting of cartilaginous laminae and mucous
membrane, the cornea is  analogous to  the articular ends of bones, in
which  the dense cartilage  is covered by synovial membrane.  Both are
prone  to  ulceration, and  the process in both exhibits this peculiarity,
that  no granulations  are seen and no pus is formed.   It appears as  a
simple process of absorption.
  Ulcers of the cornea occur frequently in inflammation of the external
tunics; in  the purulent and strumous ophthalmias; and I have described
their phenomena, progress, effects, treatment, and  mode of reparation
in the chapters on those subjects.*
  Ulcers of the cornea may be small or  large; superficial, and confined
to the conjunctival layer,  deeper, and affecting the  corneal  texture, or
even penetrating the anterior chamber; inflamed and spreading, sta-
tionary, or healing.
  In the superficial ulcer there is a mere removal of the thin conjuncti-
val layer, producing an appearance like that of excoriation in the integu-
menis.
  When the loss  of  substance extends more deeply, the excavation is
more or less funnel shaped.
  The figure of the ulcer  may be regular or irregular; its surface and
edge smooth or unequal.

  * See  Chap. VII. p. 223; Chap. VIII. p. 240; Chap. IX. p. 275; Chap. X. p. 298; Chap.
XI. p. 308. 
344                  ULCERATION OF THE CORNEA.
     The state of surface left by the separation of a slough, the characters
  of the ulcers while spreading, and  their appearance under  the process
  of repair, are mentioned at pages 223. 273, and 275.
     The ulcerative process in the cornea, as in oiher textures, is an effect
  of inflammation, at least in the great majority of instances:  to represent
  the latter, as produced by the  irritation  of the former, would be to invert
  the order  of occurrences.  The  ulcer, however, being  attended with
  inequality of surface, may be a source of  irritation  to the eye, in the
  movements of the globe and lids.   We employ the same treatment that
  we should  for an inflammation not  attended with ulcer; and, if we suc-
  ceed in arresting the inflammatory  disturbance, the ulcer will soon heal:
  no particular local treatment is required for this symptom.
     When the ulcer is healing,  we shall  find it the  best course to leave
  the case to its  natural progress, employing merely tepid ablution.  See
  pages 258  and 283.  The notion that ulcers of the cornea require the
^ use of lunar caustic has prevailed  generally, and led to injurious prac-
  tice.  In the inflamed and  spreading state  of the sore, such treatment
 v would be most  mischievous:  when the process  of repair is  going  on
  properly, it is, at the least, unnecessary.   Dr. Jacob* says that the caus-
  tic sometimes becomes  perfectly fixed, and constitutes an  indelible dark
  speck;  an  effect which  I  have not seen.   Generally speaking I  have
  found ulcers of  the cornea go on most favourably under the usual anti-
 4 phlogistic  treatment, or such  other general measures as  circumstances
  might require, without the use of local stimuli or astringents.
     When the ulcer is stationary, the affected part has its  natural trans-
  parency ; it may be difficult to discover it when  small.  By placing the
  eye so that the light shall fall on the part,  the inequality of surface is
  soon recognised.  It is sometimes seen as a small round or oval dimple.
  The appearance is just as if a small  bit had been  shaved off with a knife;
  and it resembles exactly the dent  in marbles that children play with.
  Strengthening treatment may be required, when the healthy  processes
  of repair are thus deficient.  It may be useful at the  same  time to use
  mild astringents in solution, such as the sulphate of zinc or nitrate  of
4 silver, not stronger at first than in the proportion of two  grains to the
  ounce.   I never apply the  caustic in substance.
     When the ulcerative  breach has been filled  up, and the surface is
  restored, the cicatrix presents a glistening chalky white opacity, which
  is indelible.  The  ulcer may be surrounded by  a more or less conside-
  rable opaque halo, which  gradually disappears, diminishing the extent
  of the opacity.  If the ulceration have been confined to the conjunctival
  layer, the  surface will  be restored without any  diminution  of  trans-
  parency; should it affect the corneal substance superficially, the opacity
  will be nebulous; it is dense and leucomatous when the cornea has suf-
  fered in its whole  thickness, either  by ulceration or penetrating wound.
  If the latter has  been a  clean cut, and united by  adhesion, as in the ope-
  ration by extraction, union may take place  without opacity, so that we
  cannot discern the  course of the incision.
     I have found  cases of corneal ulceration  peculiarly obstinate and  in-
  tractable, when  the surface of the ulcer has presented, generally or par-
* Dublin Hospital Reports, vol. v. p. 367. 
OPACITY OF THE CORNEA.
345
tially, an opaque white colour, as if it had been covered by wetted chalk,
the attendant ophthalmia not being considerable.  Sometimes such ul-
cers have continued for weeks or months, in spite of every treatment.
I do not know what the peculiarity depends on, but  Dr. Jacob ascribes
it to the application of the acetate of lead, which, he says, " is decom-
posed, and a white precipitate is deposited in the ulcer, to which it ad-
heres tenaciously, and in the healing becomes permanently and indelibly
imbedded in the structure of the cornea."
  I conclude that Mr. Tyrrell, alludes  to  cases of the same kind in
speaking of inflammation of the cornea with  deposition of earthy matter.
He shows clearly that the  appearance cannot be explained by the use
of lead  lotion, and he recommends a weak solution of acetic  or hydro-
chloric  acid.   He represents strongly the intractable  nature of the affec-
tion in some cases.  (Vol. i. p. 246,)
  In obstinate cases of chronic ulceration, which, with little inflamma-
tion, will sometimes  creep  slowly over the cornea, healing  on one side,
while it advances on the other, I have found great benefit from issue in
the temple.
  The  appearance  called hernia  cornece,  or ceratocele, sometimes
attendant on ulceration  of the part, has  been noticed  in  the descrip-
tion of gonorrhoeal  ophthalmia, at page 275.  The  hernial protrusion
of the membrane of the  aqueous humour  forms a transparent vesi-
cle in the  bottom of the corneal ulcer;  this rises  or  protrudes when
the muscles of the globe  act, and subsides  when that  action ceases.
  I have not considered it necessary or advisable  to snip away this
vesicle with scissors, or to apply the nitrate of silver  in substance to the
ulcerated excavation, having found the restorative  process  to go on
quite favourably without such means.   The  application of belladonna
might be useful  to prevent the iris from becoming involved in the mis-
chief.
  A minute opening in the cornea has sometimes remained after ulcer
or wound, giving issue occasionally  to the aqueous humour. It is called
fistula cornea.   Mr. Middlemore (vol. ii.  p.  492,) has seen it as a con-
genital  malformation.
                 SECTION IV. —OPACITY OF THE CORNEA.

  The edge of the cornea frequently loses its transparency, throughout
the whole, or in a part of  its circumference, in elderly persons, at least
in those past the middle period  of life ;  and the  opaque circle, or half-
circle, thus formed, is called arcus senilis, or gerontoxon*   The change
comes on without any redness,  pain, uneasiness, or the slightest impedi-
ment of function, and  proceeds at  length to render the cornea, in  the
part which it occupies, entirely impervious to light.  The opaque circle
is not situated at the veiy margin of the cornea; there is generally a com-
paratively transparent rim between it and the  sclerotic coat.   In some
cases  the opacity is very narrow, in others much  broader; but I have

                * From jji/wv, an old man, and t&£ov, a bow.
       44 
346
OPACITY OF THE CORNEA.
never seen it interfere with vision.   Although it has occupied a consi-
derable portion of the cornea, enough of the central part  has been left
clear for  the transmission of light.   The colour is at first bluish white,
and the  opacity slight; it becomes more  dense, and  chalky white; at
last the loss  of transparency is complete,  and the affected circle is a
yellowish or greyish white, the tint being deeper towards the circumfe-
rence, and gradually shaded off towards the  centre of the cornea.   Of-
ten it occurs on the lower half only ; and sometimes it  exists only in one
eye, or is more considerable in one than in the other.   It occurs much
earlier in some individuals than  in others, being occasionally seen be-
tween  thirty and forty, but  usually not  until  after the  latter age.   No
essential difference has been  found in the structure of the part ;* there is
no  new  growth, nor any deficiency of its  usual  density.   I can  only
compare it to the change which takes place  in the internal coat of the
larger arteries in old persons.   We see opaque spots and patches in the
lining membrane of those vessels, although no disease has been apparent
during life.   In the same way this opacity of the cornea occurs without
any evidence of disease, but merely as a  change incidental to advancing
age.   Beer  would call  it marasmus senilis  cornece, a name which is
objectionable, as implying the presence  of disease, and inappropriate to
a change of which I have  seen an example,  while these sheets are pas-
sing through  the  press, at  the  age of thirty-three.    A puncture or
incision  in  the arcus senilis  heals just  as well as in  any  other  situ-
ation.
  In the dissection of eyes  affected with arcus senilis, a correspond-
ing opaque change has been  found in  the  circumference of  the lens or
capsule, more frequently of the latter.  When the lower half only of the
cornea has been effected, the internal opacity has been confined to the
inferior portion of the lens or capsule.f
  The cornea may be rendered opaque by the application of the chemi-
cal agents called escharotics, such as lime.   This subject is considered
in Chapter III. Section II.

                                OPACITY.

   Opacities of the cornea are generally  the result of disease, being pro-
duced  by inflammation.   New matter is  deposited  during inflammation,
and becomes organized, thus causing the  opaque change.   Therefore
when we see  opacity, we infer that inflammation has  preceded:  and,
generally speaking, the intensity of the  opacity is in  proportion to the

  * "I have often," says Dr. Schon of Hamburgh, " examined anatomically, cornea? affected
with arcus senilis, and found the affected portion changed into a homogeneous, sometimes
fat like (speckartipe) mass, often of considerable firmness. The laminated  structure had
entirely disappeared, the laminse being consolidated inio one mass ; this was more particu-
larly the case with the external than the internal lamina;.  I never found any alteration in
the neighbouring portion of the sclerotica.  When the opacity  has been inconsiderable, it
has been confined to the conjunctival layer."—Ammon's Zeitschrift, vol. i. p. 162.
  t  Ueber den Marasmus senilis der Kapsel und hinse im menschlichen Auge,von Dr. M.
S. A. Schon ; in Ammon's Zeitschrift, vol. i. No. 10.
  This change  in the capsule has been delineated  by Vox Ammon in  his Klinische
Darsteliungen, part i. tab. 11. fig. 1 and  2, of which the former represents an opaque
half circle in the anterior, and the lutler a nearly complete circle in the posterior portion
of the capsule. 
OPACITY OF THE CORNEA.
347
  violence of the preceding inflammation, as is exemplified in the purulent
  ophthalmias, and in the acute corneitis, proceeding to suppuration. This
  however is not necessarily the case, as certain inflammations of the cor-
  nea are characterized rather by the deposition of new  matter, than by
  vascular congestion;  so that considerable general opacity may be pro-
  duced without much external  redness of  the eye, and a nebulous state
  of the membrane is sometimes seen without any other  evidence of  in-
  creased vascular activity.
   The term opacity is a general  one, including all  the changes which
  affect the transparency of the cornea, from a difficultly perceptible film,
  to whiteness like that  of  marble or chalk.   Opacity in its slighter form
  is called  nebula, haziness, or dulness;  there is a milky, cloudy, or smoky
  appearance of the part; a state in  which ihe transmission of light is only
  partially  impeded.  The more dense  opacities extending through  the
  laminas, are called leucoma or albugo*  The term macula is applied to
  small patches or specks.   The popular word for opacity is film.  The
  colour of the opaque part is different  in  different instances ; generally
  speaking, it is bluish white like milk,  or grey; it may be pearly or sil-
  very, even  with a metallic lustre,  or it may be dull.  It  may be a dense
  white, like  that of marble; there is sometimes a yellowish, and occasion-
  ally a reddish tint.   Permanent  enlargement  of vessels is sometimes
  conjoined with opacity of the cornea, and we see one  or more trunks
 containing  red blood ramifying on the part.
   The effect of this morbid condition on  vision will vary according to
 the densily  and position of the opacity.  The slightest film or cloud op-
 posite the pupil  will interfere with vision materially, while the most
 dense  leucoma  near the circumference is uninjurious to sight.   Dim-
 ness is sometimes  caused by a  central cloudiness, so  faint  that  it
 can only  be detected  by close inspection  of the organ  in  various po-
 sitions.
   Opacity may be confined to the external or mucous layer; it maybe
 seated in  the corneal substance, or in the internal serous  membrane; or
 it may extend through  the whole texture.   The opacity is partial in de-
 gree in the  first of  these cases;  it may be general or partial in extent;
 in the third, it is generally partial  both in  degree and extent.  Opaque
 change of the corneal laminas may vary from slight nebula to dense
 leucoma ; and  opacity of the entire  structure may  vary in the  same
 way.
   Treatment.—Our first object  is to arrest inflammation where that  is
 still present.  If  we do this, and wait a little the opacity will diminish
 of itself, the newly-deposited  matter,  which  has  caused  the  opaque
 change, being absorbed, as inflammatory interstitial effusion is removed
 in other textures.   In children the processes of nutrition  and  absorption
 are vigorous;  there is an active removal and  deposition of materials,
 and the changes which the cornea undergoes are very striking; although
 the membrane should  be  so opaque in a child as to render the iris in-
 visible, it will completely  recover  its  transparency, as in the cases re-
 lated at pages  228 and 229.  After reducing the inflammation, and re-
 moving all irritation, after waiting to  see what can be done by the na-

  * heucoma and  albugo, derived respectively from the  Greek  and Latin languages, are
synonymous terms,  heuoma is from aswccc, white, and albugo from albus. 
348
OPACITY OF THE CORNEA.
tural process of absorption, we may adopt further measures for lessen-
ing the opacity.   The effect of counter irritation, with attention  to diet,
and to the state of the stomach and bowels, will often be very consider-
able.   The absorption of the newly-deposited matter  may be assisted,
after these means have been put in force, by the employment of stimu-
lants or astringents; the best of which is a solution of the nitrate of silver,
commencing with gr. ii.  to the ounce of water, and gradually increased
in strength.  This may either be dropped into the eye, or applied to the
opaque part by means of a camel-hair brush.
   Mr. Middlemore (op.  cit. vol. i.  p. 450.,)  recommends the solution of
the oxvmuriate of mercury, in the  strength  of two grains to one ounce
of water, in the treatment of corneal opacity ; also solution of the nitrate
of  silver, three grains to the  ounce, the vinum opii, and an  ointment
containing one part of the citrine  ointment in three.  He  considers it
advantageous to use these several applications in succession, each being
employed for a week  at  a time.
   [A very large number of stimulants and astringents have been recommended
for the removal  of  corneal  opacity.   In  addition to those mentioned by Mr.
Lawrence, we have used with much  advantage, solutions of  the sulphate of
cadmium (gr. i—iv to the oz.,)and of the  sulphate of zinc; the liquor plumb.
subacet. of the old London pharmacopcea, diluted acetic acid, red precipitate and
iodine  ointments, diluted creosote, and finely powdered loaf sugar and  calomel
applied to the part  with a camel-hair brush.
   Dupuytren is said to  have been extremely successful with a mixture of equal
parts of prepared tutty, sugar-candy,  and calomel, reduced to  an impalpable
powder and blown into the eye from  a  quill.   When the opacity was  large
and of long standing, he introduced a  seton in the back of the neck.
   Red precipitate and loaf sugar (one  part of the former to eight of the latter,)
powdered glass  and white sugar, solutions of ammoniuret of copper, carbonate
of potassium, hydriodate of potassium, the bile of various animals, walnut oil, oil
of lemon peel, molasses, &c, &c, &c, have been extolled by different writers
for their powers, but we have never tried them.
  Experiments  have likewise been made on the eyes of animals,  by Bigger, to
ascertain whether the opaque cornea might not be completely removed, and re-
placed by a transparent  one, obtained from another animal, on the principle of
the Taliocotian  operation.   It is  almost unnecessary to add that the results
afford no encouragement to a repetition of the expedient.]
   When  red  vessels  are seen  proceeding  to  the opaque part, their
division has been  recommended.   I have  seen no advantage from this
proceeding.
  [Our own experience, relative to this measure corresponds with that of Mr.
Lawrence.
  Mr.  S. M. Griffiths, states that in Tehran, Persia, an operation is  prac-
tised for the cure of opacity of the cornea, which is  said to be frequently suc-
cessful in improving the transparency  of the cornea, if not always capable of
restoring perfect vision.  The object of this operation  seems to be,  to com-
pletely cut off the vascular  communication, by excision of a circular portion of
the conjunctiva  at a small  distance from  the margin of the cornea, which is
accomplished by fixing  eight small hooks into the  conjunctiva, about a line
from the union of the cornea with the sclerotica, quite round the cornea; the
operator then raises that part  of  the  conjunctiva by pulling these hooks to-
wards him, and  with a pair of scissors he cuts off the portion thus raised, and
completely insulates the conjunctiva covering the cornea, the consequence of
which is the gradual absorption of the opacity  of the part affected, and the 
OPACITY OF THE CORNEA.
349
cornea recovers its  transparency.  The  after-treatment is very simple, con-
sisting merely in the introduction of a small quantity of antimony between the
lids; in fact the result of the operation is  confidently expected to be successful
without any other application.— Transactions of the Med. and Phys. Soc. of
Calcutta, vol. viii. Pt. 1.]
  Some forms of opacity may be remedied, others not.   I shall mention
first such cases as admit of recovery.  A general dulness or haziness,
and sometimes a  thin  nebula  of the  cornea occur in iritis, and other
internal inflammations of the eye; the change appears diffused through
the whole texture.  Often  a more or less thick film covers the cornea
in  the purulent  ophthalmia of infants,  the conjunctival  layer  being
thickened and loosened by the inflammation; the cornea  assumes a pale
greyish colour;  and this appearance frequently extends  over the whole
surface.  Sometimes  it is a white opacity,  so  dense as completely to
hide the iris and pupil.  A general nebulous or more opaque state  of
the cornea is  produced in  corneitis.  There is also nebulous opacity,
often accompanied with some  redness, in strumous ophthalmia.   These
several cases present examples of  impaired  transparency, which admit
of  complete relief; and in all  of them, although the opacity should be
considerable, it may be removed  by the treatment just  pointed out.
Indeed, it is sufficient to arrest the inflammation which  has caused the
opaque change, and the latter  will disappear of itself.  In the first, and
the last two instances, there is general disturbance of the corneal circula-
tion, and interstitial deposition; in the second, the  mucous layer alone
is the seat of change.  The dotted opacity  caused by inflammation  of
the membrane of the aqueous humour also disappears, when the inflam-
mation has been arrested.  (See Chap. XV. Section 2.)
  Another and a denser kind of opacity  arises from inflammation of a
more serious character.  The  change affects the  surface and the cor-
neal laminaj more or less deeply:  it is interstitial deposition under con-
siderable inflammation of the corneal texture.  It  may  exist in various
degrees,  from the slight cloudy appearance of a nebula, properly so
called, to the most dense form of leucoma;  in the  first we find that the
change of structure is confined to the external lamellas of the  cornea,
whilst in the more dense forms the whole thickness of the part has been
altered in structure.   The corneal substance is condensed and hardened,
so that, when the  part is  squeezed between the finger  and thumb, the
laminaD no  longer move on each other, as in the normal state.   These
while and dense opacities may be occasioned by escharotics,  such as
lime, applied to the surface of the cornea, by acute inflammation of the
corneal substance, or  by the effusion of matter, when suppuration has
taken place.   In  the  latter case, the  opacity has  at  first  a yellowish,
and subsequently  a light brownish tint.   These are cases which admit
of partial relief," but not of complete cure.   The extent  of the mischief
is lessened bv the gradual removal of the thinner halo, which surrounds
the  spot of acute inflammation.
  The third description, which does not admit of cure, is the firm white
shining cicatrix of wounds or ulcers.  When an  ulcer has extended
into the corneal  lamina?, the cicatrix  is a permanent white mark;  but
if it should be superficial  merely,  like an excoriation, it may leave no
trace.  A cicatrix is  distinguished by its sharply  defined margin, and 
350
OPACITY OF THE CORNEA.
 shining appearance: the edge of an opacity produced by an interstitial
 deposite is gradually shaded off.  In the dense opacity of the entire tex-
 ture ealled leucoma, the organization is so much changed, that we can
 do no good  by any treatment  as respects the state of the  cornea.   It
 will depend upon the situation of  the leucoma whether  the case may
 be relieved by the  operation for artificial pupil or by the use  of bella-
 donna.
   Mr. Middlemore's opinion respecting  the advantage derivable  from
 surgical treatment in leucoma  is  more  favourable  than that  which I
 have expressed.  " In many cases where dense opacity and leucoma of
 the cornea have been under treatment for many months, I have effected
 very great benefit by applying the strong nitrate of silver ointment every
 day, or every other day: indeed, without the  slightest exaggeration, I
 may state that in those cases in which  the application of this ointment
 can be borne, I have effected as much benefit by a single application of
 it, as the  use of the common stimulating drops has produced in several
 weeks."   Mr.  ivi. combines with this application the administration of
 mercury so as  to maintain slight ptyalism, occasional leeching,  counter-
 irritation  behind the ears or at  the back of the neck, or by means of an
 issue in the temple.*
   Another mode in which the  transparency of  the cornea may be im-
 paired, is by the effusion of blood between its layers, which may take
 place, according to Mr.  Middlemore,  from local  injury, or during
 the  progress  of acute corneitis.   In  the  former case  it is  fluid  at
 first; in the latter it is deposited  in the  solid state.  If neglected, the
 fibrinous substance may become organized, and no  longer within the
 action of  remedies.  The same treatment is required as for inflamma-
 tion and opacity of the cornea  under other circumstances.f
   Congenital opacity of the cornea.—Mr. Ware observes, that  children
 are sometimes born  with eyes remarkably large and  prominent, and
 with an opaque state of the cornea.  This happened in three children
 of the same family.  The opacity in these cases gradually diminished
 after birth, without any applications:  in  two of them, it was quite re-
 moved in  less than  a year;  while in the  third, the alteration was not
 complete until the end of the second year.  Mr. Ware found the cornea
 very prominent in  these  children, who  were  all short-sighted, though
 they bad recovered distinct vision.   In  another new-born infant  both
 eorneae were large, prominent,  and  completely opaque.   At the end of
 nearly three years,  the left cornea  was sufficiently clear to allow the
 perception of all large objects; the opacity of  the right cornea being
 also diminished round  its outer edge, though the greatest part of the
 pupil was  still obscured.   In a  fifth case, both corneas, at  the  time of
 birth, were large, prominent, and completely opaque, the child  in other
 respects being healthy.  At  the end of a year, the cornea of one eye is
 not only perfectly transparent for a considerable space round  its  circum-
 ference, but the pupil can be seen through the diminished opacity which
 remains in its centre; and though the cornea  of the other eye  has im-

  * Vol. i. 452, 453.
  t Ibid, p. 465, 466. This occurrence is represented in Ammon's  Klinische Darsteliun-
gen, pt. i. tab. 3, fig. 5. 
STAPHYLOMA.
351
proved  less, its transparency has  increased, particularly towards the
circumference.*
  I have seen two or three similar  cases, in which the corneal opacity
has diminished  after birth ; but the progress has been very slow, and I
have not known the ultimate event.
                      SECTION V.--STAPHYLOMA.

  The cornea is subject to changes in figure as well as to the alterations
of texture, which impair or destroy its transparency.  The term staphy-
loma denotes an increase of size, with change of figure in the membrane,
(fig. 19.) these alterations being accompanied almost invariably by more
or less opacity;  it is derived from the Greek word Tratpv^, which sig-
nifies a grape.  The name was originally applied to that projection of
Fig. 19.
the cornea, in which its texture, having been
weakened by alteration-  of structure  conse-
quent on the inflammatory process, yields to
the pressure  of the fluids contained in  the
posterior  chamber, and is  elevated  into a
rounded prominence on  the front of the eye,
the iris being  adherent  to its  internal sur-
face, and stretched out  so as to afford it a
thin  general  lining.   The  term  has since
been applied more extensively, having been
given to other tumours of  the front of the eye, and even to expansion
of the coats in other directions.  However, when the term staphyloma
is  used alone, it is understood to denote the affection of the cornea now
under consideration.
   In order that staphyloma should be produced, there  must have  been
inflammation of the cornea, rendering its texture more or less generally
opaque; that inflammation must have extended to the iris, and caused
it to  adhere to the cornea; and the cornea  must have  been weakened
by sloughing or ulceration, so that it  yields to the distention from with-
in, and forms, with the adherent iris,  the staphylomatous tumour.
   The external surface of the staphylomatous swelling is formed  of the
extended and thinned  cornea, of the  aqueous membrane, or of a  tissue
like that of cicatrix covering the iris where  it has been denuded by
sloughing of the  cornea.   This external covering may be so thin  at
some parts, as to  allow the colour of the iris to appear through, giving
the tumour a dark bluish aspect in such  situations.
   The expanded  cornea is  sometimes  thicker, generally thinner than
the membrane in  its normal state.   The aqueous membrane  and the
adventitious pellicle are  as thin  as writing paper, the iris being closely
adherent in such situations.
   The cornea is lined internally by the iris, which is thinned, expanded,
and adherent.  It is sometimes  found to  have given way partially to the
distention, so that openings are  seen in it.
   The interior of the  swelling  is filled with aqueous humour:  it flows
* Tracts on the Eye; London, 1818 ; p. 235-8. 
352
STAPHYLOMA.
out, if a puncture be  made, and  the  part  collapses.   The  crystalline
lens is sometimes contained in the staphylomatous enlargement.
  The morbid distention, which in the great  majority of cases is con-
fined to the cornea, sometimes embraces also the anterior portion of the
sclerotica, the enlargement of the eye-ball being then much more con-
siderable.
  The figure of the swelling is generally tolerably regular;  sometimes
otherwise.  Staphyloma corneae may  be either total or partial; that is,
including the whole, or confined to a part only of the cornea.  The  en-
largement is generally rounded, either hemispherical, or  more nearly
globular;  sometimes it is  conical, the circumference  of the cornea
having yielded less than the middle: hence the distinctions of staphyloma
hemisphericum, globosum, conicum.  The term  staphyloma racemosum
is employed when the tumour is  subdivided  into smaller portions  by
more or less deep fissures, so as to admit of  its being compared to a
bunch of black currants or small grapes.*  See p. 274.
  The foregoing account represents the generally received opinion  re-
specting the mode in which  staphyloma corneas is produced;  and my
own experience corresponds with this opinion.   Its correctness has been
questioned by Mr. Wharton Jones, whose views are clearly detailed in
the following quotation.   " When  destruction of the cornea has taken
place to a certain extent by ulceration or suppuration, the iris protrudes,
' and forms a projection at one part of the  cornea, generally the lower
or lateral.'  This projection  is  at first  merely a bag of the iris distended
by the aqueous  humour;  but by and  by its exposed surface  becomes
covered by an opaque firm tissue, of  the nature of the tissue of cica-
trices ;  and this tissue  is incorporated  at the  base  of the  tumour with
the sound cornea.   The projection, the  mode  of origin [of which] I
have just  described, is a partial staphyloma; it is  not a  distention of
the cornea itself, but a protruded portion of the iris covered by a new
tissue, intended to supply the loss of  substance which the cornea has
sustained.   The mode of origin of a total staphyloma is essentially the
same, but differs only in degree.   The whole or greater part of the cor-
nea being destroyed, as occurs in gonorrhoeal, purulent, and very often
in variolous ophthalmia, as also that of new-born infants, the whole iris
falls forward,  the pupil becomes closed, and the aqueous humour being
thus allowed to accumulate  in the  posterior chamber, the iris is kept
distended in the form of a tumour on the front of the eye.   Its surface
gradually gets covered with  an opaque  cicatrice-like tissue, or pseudo
cornea, which assumes a greater or less degree of thickness, and a total
staphyloma is the result.  Sometimes the central part only of  the cor-
nea is destroyed, a ring of the circumference still remaining; the sta-
phylomatous projection has then the form of a small globe stuck on the
front of a larger."f
  Mr. Jones finds it difficult to understand  how the iris can become
adherent to the cornea; yet partial synechia anterior occurs not unfre-

  * In the first part of his Klinische Darsteliungen, tab  5, 6, and 7, Ammon  has devoted
numerous figures to the subject of staphyloma corneae, exhibiting the varieties of configura-
tion, as well as the changes in the cornea and iris, and the state of the organ generally.
  t Some Observations on the Pathology of Staphyloma, in the hondon Medical Gazette,
vol. xxi. p. 849. 
STAPHYLOMA.
353
 quently, without wound or penetrating ulcer, as an effect of acute cor-
 neitis, and in conjunction with leucoma.  He enumerates various cases
 of disease, wounds, and operations, involving  the cornea, in which  no
 adhesion of the iris takes place.   We cannot hence infer that the iris
 will not become adherent to the cornea, in  the widely different morbid
 conditions of the organ, which lead to the development of staphyloma.
 Mr. Jones has forgotten to explain how, when the whole  cornea  has
 been destroyed, the aqueous humour  can be accumulated in the poste-
 rior chamber, so as to distend the iris into a staphylomatous tumour.
   I  think  it probable that the explanation offered by Mr. Jones is  cor-
 rect, as regards partial staphyloma; though it may be doubted whether
 the iris protrudes nakedly, as he represents, or whether the bulging por-
 tion is covered by the membrane of the aqueous humour.  In the latter
 case, the adhesion of the iris to the membrane, which constitutes with
 him so great a difficulty, must still occur; and the covering of the sta-
 phyloma would be the aqueous membrane in an altered state, and not
 the supposed new tissue.
   Respecting total staphyloma, I  think  the old notion the correct one.
 If it be otherwise, and if Mr. Jones be right, we want proofs; his mere
 assertion is not sufficient.
   What I have observed, after entire destruction of the cornea, is, that
 the bulging iris has gradually receded, and become covered by an opaque
 pellicle; the front of the eye  being  thus permanently flattened.   It is,
 however,  not improbable that the iris, instead of shrinking, may some-
 times be pushed out  by the secretion  of aqueous humour in the poste-
 rior chamber and form staphyloma.   This view of the subject, adopted
 as I think too exclusively by Mr.  Jones, had been  already clearly set
 forth in explanation of certain  cases by the late Mr. Ware, who says,
 " I have sometimes seen the whole cornea sloughed  off during an acute
 purulent ophthalmia, and a white opaque substance gradually effused from
 the ulcerated surface, sufficient to form  a complete cover  to the  iris;
 after which this opaque body has gradually projected in a conical shape,
 until at length it has become so prominent as to hinder the eyelids from
 closing over it."  Mr. Ware adds, " I have at other times seen the pro-
jecting  cornea partly opaque, and partly transparent; the pupil being
 distinctly visible through the transparent part." (Op. cit. p. 271.)
  It has always appeared to me that the aqueous membrane,- and more
or less of  the cornea, have remained  where staphyloma has occurred.
In the  numerous  instances in which I have operated for staphyloma,
the excised portion  has  seemed to me to be obviously cornea, often
of its natural thickness, and exhibiting  partially the smooth internal
surface natural to that membrane.   The external covering of the sta
phvloma,  and the expanded  iris, are perfectly distinct, and often  but
slightly adherent: we do not see the close adhesion, and the blending of
substances which are observed  in cicatrices of other parts.
  When the staphyloma is once established, the enlargement of the cor-
neal  region gradually increases, especially if the eye still suffers from
remains of the previous imflammation, or from any of the various ex-
ternal or internal causes of irritation.  As  the tumour  becomes more
prominent, its surface, which is often irregular, presses unusually against
the eye-lids, which again press  upon  and mechanically irritate the sta-
       15 
354
STAPHYLOMA.
phyloma.   The latter may become so large as to protrude between the
lids, when their margins and the cilia rub against the base of the swel-
ling.  Thus an addition to the great and conspicuous deformity of an
enlarged, misshapen, opaque eye, the patient experiences attacks of in-
flammation, which exert a sympathetic influence  over the other eye,
rendering it irritable and painful, so that the patient cannot use it freely
in reading, writing, or other occupations requiring active exertion of the
organ.
   Under increasing distention of the cornea, it becomes thinned at some
point, and  occasionally gives  way, allowing the  aqueous humour to
escape with temporary diminution  of  the eye.  Frequently the swel-
ling remains stationary after a  certain time, occasioning no inconve-
nience except the deformity.
   Causes.—The changes  in  the  cornea just described are  the imme-
diate  cause of staphylomatous enlargement.   These  changes occur
most frequently in purulent ophthalmia, whether of the infant or adult,
in  gonorrhoeal and variolous  ophthalmia.   It may have  its origin
in  strumous  inflammation,  and perhaps  in  common external  oph-
thalmia.
   Treatment.—We may prevent  the development or increase of the
affection, by removing inflammation, and by guarding the eye against
all sources  of irritation. Occasional evacuation of the aqueous humour
by puncture of the cornea might  aid the beneficial  operation of these
measures.   After  bringing the  eye  into a quiet state by such  means,
solution of the nitrate of silver or oxymuriate of mercury might be ap-
plied, to the morbid enlargement.
   The treatment of staphyloma, when fully developed, is either palliative
or radical.   The former consists  in  removing inflammation, or in di-
minishing the volume of the swelling, by puncturing the cornea, which
may be done with a  cataract knife or needle.  Sometimes by repeated
puncturing, the palliative remedy has been converted into a radical cure,
the globe shrinking, and becoming quiet: however, it will  be necessary,
if the patient be subject to relapses of  inflammation, more especially if
these  should affect the other eye, to resort to the radical treatment.
   This consists in cutting  away the staphylomatous  protruberance with
a cataract  knife.   The lids being held  asunder  by an assistant  so as to
expose the  globe, the operator transfixes the staphyloma with  a hookr
and removes it at one cut  by carrying  the knife through  its base, from
above downwards, a little in front of the sclerotica.   Or the knife may
be passed through the middle of  the basis, then carried  upwards, and
afterwards turned to divide the lower part.  After dividing the upper
portion with the knife, in the way described, it maybe found more con-
venient to cut through the lower part with scissors.   The effect of this
operation is, that the globe shrinks, the coats collapse, and form  a small
tubercle in the orbit, and the lids fall in.  It  has been advised to pass a
curved needle and thread through the tumour, for the purpose of  holding
it more securely, but the tenaculum or hook is quite sufficient.   In se-
parating and fixing the lids,pressure on the globe should  be avoided: if
all the vitreous humour be squeezed out, the tubercle formed by the tu-
nics after their collapse, may be too small to admit of the  adaptation of
an artificial eye.   The front of the globe in its shrunk state, is gene- 
STAPHYLOMA.
355
 rally divided into four portions by superficial sulci, corresponding to the
 insertions of the four recti muscles.   When the first puncture is made
 into the tumour, the contained  fluid  escapes, and that fluid is aqueous
 humour.
   Generally speaking no serious consequences follow this operation, but
 severe inflammation sometimes results, as I have seen in two or three
 instances.  This happened in a medical student, in whom staphyloma
 had occurred from gonorrhoeal ophthalmia.  He found  that he could
 not pursue his studies in consequence of the irritability of the staphylo-
 matous eye and its  influence on the sound one, and he requested  that
 the projection which was by no means considerable might be removed.
 Although he was a person of great firmness, he  complained of  severe
 pain on making the division of  the parts, and soon after the operation
 was finished, very acute suffering came on; the  conjunctiva covering
 the sclerotica, and that of the eye-lids, became the seat of active inflam-
 mation, not distinguishable from the original gonorrhoeal  ophthalmia.
 Violent chemosis and purulent discharge came on, with acute pain in
 the eye and head.   He was bled copiously, and other  measures  of de-
 pletion were put in force, although his diet had  been low some time be-
 fore the operation.   These means did not diminish the  pain, and  it was
 necessary to give opium largely; however, the inflammation subsided,
 and the case recovered.  I have seen one or two other instances of severe
 inflammation after the operation, but in general little pain  or inconve-
 nience is  experienced.  Scarpa speaks also of inflammation happening
 after the removal of the tumour, and he advises the method of Celsus.
 The directions of the latter are much like those of many modern practition-
 ers: he advised the removal of the tumour by deligation or excision.  In
 the former a needle should be carried through the base of the tumour,
 armed with a double ligature, the  ends  of  which  should  be tied above
 and below, so as to embrace the enlarged and protuberant cornea.   In
 the latter  case, he says, we  should cut  away " magnitudo lenticulce," a
 portion of the size of a lentil seed, and not the whole unnatural promi-
 nence. Scarpa recommends that only a small portion of the cornea  should
 be  taken away;  but I see no good reason for deviating from the ordi-
 nary operation of removing the tumour at its  base, inasmuch as  severe
 inflammation  is  an unusual result of  the operation, and referable  to
 something in  the  state of the  individual, and not to  the kind of ope-
 ration.
  [" It occasionally happens," Mr. Mackenzie states, " especially in cases of
 staphyloma attended  with varicosity  of  the internal vessels of the eye, that
 either immediately, or some hours after  the operation,  haemorrhagy takes
 place, both from the eye and into  its cavity.  A bloody, dark-coloured mass,
 of pretty considerable consistence, protrudes to such an extent from the wound,
 that it is impossible  to keep the eyelids shut. The eyeball is painfully dis-
 tended, while the conjunctiva and lids  become greatly ecchymosed.   The
 haemorrhagy into the eye gives rise in some cases  to agonizing pain, and may
 even bring on convulsions.  Under such circumstances, we ought to cut away
 with the scissors the protruding substance, which perhaps is in some cases the
hyaloid membrane injected with blood, but in other cases is nothing more than
a clot of blood, hanging from the front of  the eye.   After this is done, the
bleedino- ceases, and the pain abates.   Left to itself,  the protrusion dies away
in the course of a few days.   The eye is apt in either case to shrink below
the  usual size of a staphylomatous eye after operation. 
356
STAPHYLOMA.
  "It occasionally happens that the opening into the eye, formed by the re-
moval of the staphylomatous cornea and iris, is long of closing, no pseudo-
cornea being present when we open the lids on the eighth or tenth day, and
even for weeks the clear humours lying uncovered behind the gap in the front
of the eye.  At length, however, the aperture contracts and cicatrizes.   Fun-
gous granulations sometimes  sprout from the aperture, requiring  the use  of
lunar caustic.   If the  eye is not kept shut after the operation,  the lens may
come forward and protrude through the wound.  When  this is the case, the
lens should be removed, and the eye kept closed till the cicatrice is formed."]
  When the globe has shrunk in the socket, we  can adapt an artificial
eye to the prominence which remains, and in this way completely re-
move the deformity.   An artificial  eye may be  obtained  to  match
exactly the colour of the sound one.   The resemblance to the natural
appearance is so perfect, that casual observers do not notice the defect.
The artificial eye, which is made of enamel, is a concave kind of shell,
perfectly smooth on  both surfaces.  It is introduced by first pushing the
upper edge under the upper lid ; then by depressing the lower lid, the
lower edge of the eye  slips  into its  place.   The  introduction of this
fereign body does not in general produce any irritation of  the mucous
membrane.  Patients can take  it out and put it in at pleasure; and they
generally remove the eye at  night, which is done  easily by depressing
the lower lid,  and  raising the lower  edge of the eye W'ith a bodkin, or
with the end of  the nail.   When taken  out it should be wiped clean.
The artificial eye moves in harmony with the natural one,  especially
from side to  side;  the motions  upwards  and downwards are not
so well performed.   The muscles  of the globe  are uninjured in these
cases, and remain attached to the  collapsed tunics;  when  the eye has
shrunk they continue to act in  concert with those of the sound  organ,
moving the remaining tubercle, and the artificial eye which is supported
on it.
  In total staphyloma sight is lost, for the cornea is more or less opaque,
and the axis of the eye  greatly lengthened.  If partial staphyloma does
not involve the pupil, or if it should engage only a small portion of the
aperture, a considerable degree of vision, or  even  perfect sight, may
remain.  If it embrace  the entire pupil, or be accompanied with  gene-
ral opacity, it destroys sight altogether. Evacuation  of  the aqueous
humour by puncture of the cornea, and the external application of a
solution of nitrate of silver, may be employed as means of prevention
or cure.   With  the former, I have succeeded completely in  removing
the swelling, and restoring the natural outline of the cornea, the affected
portion of which has presented a  thin semi-opaque  texture, with dark
appearance  from the adhesion of the iris.  If  this partial projection  of
the cornea should be the source of irritation from friction of the lids, or
if it should affect the  opposite eye sympathetically, it must be dealt
with as if the staphyloma were total.  I have never "found it necessary
to resort to excision.  Some cases of partial staphyloma admit of relief
from the operation for artificial pupil.
  Staphyloma pellucidum.—The case is thus called when the cornea
is increased in size, without diminution of its transparency or any other
apparent alteration.   The source of mischief here is probably not in the
cornea, but in some  cause affecting  the anterior chamber  generally.
The subject is further considered in the next chapter. 
CONICAL CORNEA.
357
CONICAL CORNEA.
   Synonymes:—Sugar-loaf cornea;  staphyloma conicum;  staphyloma
 pellucidum conicum; staphyloma corneae totale pellucidum conicum; pro-
 lapsus cornece; ceratoconus; hyperceratosis,* from  vxt% super, and we,*™*)
 in cornu muto; the term is equivalent to hypertrophy of the cornea.—The
 cornea is also subject to a change of figure, in which its regular convexity
 is lost, and it is elevated into a conical protuberance without previous or
 concomitant  inflammation, pain, or  suffer-           Fi  20
 ing, without opacity or indeed  any  visible
 change in its own  texture, or in any other
 parts of the eye.  It becomes conical, and that
 is all we can observe in the case, [fig. 20.]  The
 elevation is sometimes pointed or conical,
 sometimes obtuse or shaped like a sugar-loaf.
 Its situation is usually central; but it may be
 situated a little below the middle line.  This
 state of the membrane has been called sta-
 phyloma, pellucidum conicum, though  it is  a totally different condi-
 tion from that of  staphyloma  properly so called ; we generally call it
 simply conical cornea.  This change of figure begins insensibly, pro-
 ceeds very slowly, and will require several  years to reach its full de-
 velopment.  When we see a patient labouring under this affection, we
 are at first struck with a peculiar brilliance or dazzling look of the eye,
 the light being reflected in an  unusual manner from the altered portion
 of the  cornea.   When we  surveys the  eye  laterally, we see that the
 cornea does not present its natural convexity; that it is elevated into an
 obtuse cone, and that it looks as if a  piece of crystal were placed in
 front of the eye.   The cornea remains perfectly transparent, and there
 is no apparent deviation from its natural structure;  the iris and the
 pupil are natural;  the  external surface  of the eye is perfectly so; in
 short, there is no other  visible alteration  but this change of figure in the
 cornea.
  In the early period of the complaint, it is difficult to ascertain its ex-
 istence ; after a certain  time  we  notice  it from  the before-mentioned
 dazzling reflection  of light.   The change in  the  shape of the  cornea
 interrupts the transmission of light; the  focus is altered and the  patient
 is rendered myopic, or  near-sighted; he  brings objects very close to the
 eye.  The near-sightedness becomes more  and more considerable as
 the disease advances, so that at last the patient can only read at about
 the distance of an inch, and he holds  what he has to read towards the
 side of the eye, not in front of it, the circumference of the cornea being
 the part least  altered.
  When the complaint  has gone to the  length of elevating  the cornea
into  a  decided conical  protuberance, which generally occupies some
years, it will  remain stationary.  The friction  against the  lids some-
times renders the apex  of the  cone opaque.

  * The inaugural dissertation of G. E. Wimmer, de Hyperceratosi, Leipzig, with a litho-
graphic plate, contains a full historical statement  of what  is known on the subject, and
references to all the recorded cases. 
358
CONICAL  CORNEA.
  This change may go on in one eye without the other being affected,
and so little inconvenience does  it occasion at  the commencement, or
even after it has made some progress, that the patient only discovers its
existence  by shutting the sound one,  or by some accidental  occur-
rence.
  Professor Jaeger, of Erlangen, examined after death an eye, in which
this disease had existed.  When the cornea was taken between the finger
and thumb, a depression towards the middle was plainly perceptible sur-
rounded by a thick margin.   On cutting it through, the middle third was
found three times thinner than usual, and not thicker than writing paper.
The exterior two-thirds were thickened, the increase being in the middle
laminae.  The thicker was continued gradually into the thinner portion,
which was about the size of a moderately dilated pupil.*
  Mr. Middlemore had also the  opportunity of examining the eye in a
person who had been affected with conical cornea in an extreme  degree.
Its laminae were less moveable on each other; its circumference was of
the natural thickness, but the  apex was much thinner  than usual, and
opaque on its exterior only.f
  It may be doubted whether the thinning and distention  of the  cornea
at its  centre are owing to  direct pressure  from increased secretion of
aqueous fluid.   Such a cause might be expected to  act on the  cornea
generally, and to be attended with evidences of increased vascular
activity, such as pain, redness, and changes in the state and position of
the iris.
  It occurs  in young and healthy subjects, in whom there is no  consti-
tutional cause to which the  local change can be referred, generally
coming on about or soon after the period of puberty.   I have seen it in
healthy country girls; and it is  more frequent in women than in men.
We must suppose it to be a rare affection, as it is not mentioned in  the
work of Beer; Professor Himly, of Goettingen, had never seen a case
of it.   I have seen several instances, so that it would not appear, com-
paratively speaking, to be of unfrequent occurrence in this country.
  If we do not know the cause of the affection,  we cannot be prepared
to propose any rational  treatment.  I cannot say that I have seen any
plan productive of benefit.   Repeated evacuation of the aqueous humour
and astringent washes have been employed without  advantage. It is
doubtful whether  the latter are even  capable of checking the progress
of the complaint in the early stage.
  During the progress of the complaint, the use of concave glasses will
assist sight; and  if pain should attend the affection, we must have re-
course  to such  local measures as the state  of the organ may seem to
point out.   The eye should  be used sparingly, and blood  may be taken
locally, if circumstances seem to  requireMt.  A young woman from  the
country, who laboured under this affection, had some  symptoms  of con-
gestion in the head, which were  relieved by cupping,  and the sight was
assisted by using  concave glasses.
  An old clergyman, who was the subject of this affection  for nearly
thirty years, was enabled to  continue his duty in the pulpit with tole-
rable accuracy to the time of his death, which happened when  he was
* Ammon's Zeitschrift, vol. i. p. 548.
t Treatise, vol. i. p. 532, note. 
ARTIFICIAL DILATATION OF THE PUPIL.
359
about seventy.   The apex of the cone had become opaque in his case;
the opacity was  diminished by the solution of nitrate of silver; and he
employed belladonna to enlarge the  pupil.
  It was  proposed by Sir William  Adams to perform the operation for
cataract by solution as a  remedy for this affection.  The  refractive
power of the eye is increased by the unnatural convexity of the cornea;
and  his object was, by getting rid of the lens, to counterbalance  that
increased refraction.  I should not think of proposing any such opera-
tion, unless the affection had gone so far as to make the eye useless; and
I should then  expect no good from  it.  The proceeding has not been
employed with advantage in  any instance.*
  Mr.  Tyrrell! says that he has relieved several cases to a considera-
ble extent by altering the  position of the pupil, and  removing it  from
behind the conical centre towards the margin of the  cornea,  where the
membrane is little changed.   He punctures the cornea, with  a broad
needle, close to the sclerotica, at the lower and outer part,  and then in-
troduces a small  blunt  hook to catch the pupillary margin of  the  iris,
which  he carefully draws out of the aperture far enough  to bring the
pupil from the centre to the lower and outer part of the cornea.   The
iris remains embraced  by the wound; the  portion dragged out by the
hook may be cut off with a fine pair of scissors.
CHAPTER  XV.
     DISEASES OF THE AQUEOUS MEMBRANE -AND CHAMBERS.


 SECTION I.--INTERNAL INFLAMMATIONS  OF THE EYE ',  ARTIFICIAL  DILATATION
                             OF THE  PUPIL.


   The internal inflammations constitute a subject  of the greatest  im-
 portance.   With less external appearance of disease, with fewer visible
 marks of inflammation, with less to  excite the  attention of the patient
 or the alarm of friends, than in the external affections already described,


  * A good coloured figure  of the eomplaint is given  by Demours, pi. 57.  fig.  1,
 who states that he and his father had often  seen it, and that the latter had noticed it
 as long ago as 1747.  Traite des Maladies des Yeux, torn. i. p. 316.  Dr. Lyall detailed
 the particulars of four cases, and gave to the affection the name of staphyloma pellucidum
 conicujn, in an Essay which he contributed to the Edinb. Med. and Surg. Journal, vol. vii.
 p. 6.   He afterwards made it  the subject of  his inaugural dissertation, printed at Peters-
 burg in 1816. The affection was also noticed by Leveille, in a note to his translation of
 Scarpa's work on Diseases of the Eye, tom.ii. p. 179. It was particularly described under
 the name of conical formed cornea by Mr. Wardrop, in his Essays on the Morbid Anatomy
 of the Eye, 1808, vol. i. ch. xiii.  He has also given a figure of it in the ninth plate of his
 work.
  These, with some other notices on the subject, are collected by Himly in  his Bibliothek
fur Ophthalmolgic, vol. i.
  t Vol. i. p. 277. 
360
ARTIFICIAL DILATATION OF THE PUPIL.
there is much greater danger to vision.'   Slight alterations in the pupil,
in the transparent media behind it, or in the retina, are sufficient to im-
pair or destroy sight.   These often take place without external redness,
without any changes visible to superficial observation.  The commence-
ment and progress of chronic and  internal  inflammation are frequently
most insidious; the existence of the affection, when confined to one eye, not
being discovered till the change of structure is irreparable, and then only
observed accidentally.  This part of the  subject has  been much  ne-
glected by English writers, until within  a recent period.   It has been
more accurately and  successfully  investigated by the Germans than by
any others: they deserve the merit of having first observed, described,
and discriminated the principal forms of internal ophthalmic disease.
   Inflammation may  be confined to one  of the  internal structures, or
these may be  involved  altogether.   The  close connexion between  the
different internal parts,  and their common vascular supply, are sufficient
to account for the circumstance of inflammation spreading from one to
another,  and indeed make it  difficult to understand how it is so often
limited to one part.   If inflammation commences in  the iris, it easily
extends to  the ciliary body, choroid coat, vitreous humour, and retina;
on the other hand, it will  spread forward to the anterior part of the eye;
so that a case of iritis often involves, in its progress, the greater part or
the whole of the internal tunics, and the external parts also.  Inflamma-
tion beginning in the  retina spreads in like manner to the vitreous tunic,
choroid,  iris, &c.
   The phenomena of inflammation have been most accurately noticed
as they present themselves in the iris, because it is immediately open to
external  observation; hence its history, progress, and treatment are best
understood.  We are not so fully acquainted with the appearances of
inflammation in the retina, choroid coat, and vitreous humour; we can-
not give  so clear and satisfactory an account of choroiditis and retinitis,
as these  affections have been termed, as we can  of iritis.  We labour
under peculiar disadvantages in the pathology of these parts;  their in-
ternal position secludes  them from observation during life, so that we do
not see the actual changes which constitute the inflammatory state; and
we have no opportunity of investigating  these changes after death, be-
cause the affections do not destroy life.   There are hardly any recorded
dissections of such cases in the active state of inflammation.  The few
examinations hitherto  made have been in instances of long standing blind-
ness; hence they have  only shown the ultimate  effects, without eluci-
dating the origin, progress or primary state of the affections.
   Artificial dilatation of the pupil.—This  state of the pupil is one of
the most important points in the internal ophthalmias;  to  preserve its
circular  figure, its natural dimensions, and permeability to light, is our
principal object in most instances.  Here we derive essential assistance
from  that  anomalous and hitherto unexplained power, which  certain
narcotic  vegetables possess, of acting upon the iris so as to dilate  the
pupil.*   Before I describe the internal inflammations, I shall speak of the
effect, which these substances produce on the eye.

  * The influence of belladorna on the pupil had been  observed long ago, and is incident-
ally mentioned, as if  it were  well known in a case of amaurosis, related in Arneman's
Magazin, vol. i.  Reimakus, who saw a striking instance of it, proposes to employ the 
ARTIFICIAL DILATATION  OF THE PUPIL.
361
   The power in  question resides  in the  atropa  belladonna,* (deadly
 nightshade,)  the  hyoscyamus  niger,f  (henbane,)  the lauro cerasus,J
 (cherry laurel,) and the datura stramonium, (thorn apple.)   It is found
 in  the  recently expressed juice of these vegetables, in  an  inspissated
 decoction of them, in  the extract,  or  in  the active  narcotic princi-
 ples, lately discovered by German  chemists, and  named by them  hy-
 oscyamine and atropia.§   There are vegetables,  somewhat analogous
 in their  properties to these, which might therefore be expected to possess
 similar power;  but they  do  not.  This  has  been ascertained of  the
 conium maculatum, aconitum napellus, and opium ;  also  of the digitalis
 purpurea, arnica, rhus radicans, and  saffron.||
   The usual  mode  of proceeding is either to rub the moistened extract
 on the brow, or to drop a solution of it in distilled water into the eye:
 the  last is the most efficacious.   A  scruple of the extract of belladonna
 or of the extract of hyoscyamus should be rubbed down  with an  ounce
 of distilled water; the fluid should be filtered through linen, and two or
 three drops of it should  be introduced between the lids.  When the  ex-
 tract is employed, it should be  brought to the consistence of honey by
 mixture with distilled water, and then copiously smeared on the  upper
 lid,  eye-brow, and neighbouring part of the forehead; after remaining
 for  an hour, it may be washed off.


 application as a means of facilitating extraction of the cataract.  See Baldinger, Sylloge,
 as quoted in the next note. But the attention of the profession was first  expressly directed
 to the subject by Professor Himly, in  some remarks on " Paralysis of the Iris by the local
 application of Hyoscyamus, and the use of this  remedy in the treatment of some diseases of
 the eye," published in his "Ophthalmologische Beobachtungen, Bremen, 1801.  These were
 translated into French, and published at Altona in 1801, under the following title:  " De le
 Paralysie  de VIris par  une  application locale  de la Jusquiame, et de son utilite dans la
 traitement de plusieurs maladies des yeux."  Ehlers, who translated the observations of
 Himly, communicated their purport to Dubois,  who used hyoscyamus to dilate the pupil in
 cataract operations in the following year at the H6pital de Perfectionnement.
  Himly has the merit  of first seeing and clearly explaining the practical utility of  this
 artificial dilatation in various  states of the eye.  It is so important in internal inflamma-
 tions, by preventing contraction of the  pupil;  in the distinction of  cataract from other
 affections; in discriminating  the several species of cataract; in facilitating some of our
 operations, and as a palliative remedy in contractions and displacements of the pupil,  and
 in many cases of glaucoma and cataract, that  its  introduction  into practice by Professor
 Himly may be deemed an important epoch in ophthalmic surgery.
  Mr. Wishart has given a good account of the circumstances connected with this subject,
 historical as  well as practical, in the ninth volume of the Edinburgh Medical and Surgical
 Journal, in a short paper, entitled " Case of congenital cataract, with some observations on the
 means of artificially dilating  the pupil in the operations of extracting and depressing the
 cataract."
  * This effect of belladonna, which was known to our countryman,. Ray, was observed
 in a young man,  who had some of the fresh  juice accidentally applied to the eyes. The
 pupils remained  dilated  for three weeks. See Baldinger, Syiloge Opusculorum, vol. ii.
 1777.
  t The fact was first noticed by Professor Himly, in 1799, in a case where the eyes  had
 been  bathed with  a solution of hyoscyamus: see his Ophthalmologische Beobachtungen,
 quoted in the last note but one.
  X Conradi saw full dilatation of the pupil produced by the external application of cherry
 laurel water, as a remedy for  opacity of the cornea.  Auswahl aus dem Tagebuche eines
prakliscken Arztes, Chemnitz, 1794, p. 23.
  § On the effects of Hyoscyamine and Atropia,  by Dr. F. Reisinger.  Extracted from the
 Medicinisch-chirurgische Zeitung, February, 1826.   Edinburgh Medical and Surgical Jour.
 ual, vol. xxiv. p. 287.
  || See Baratta Osservazioni pratiche suite  principali Malattie degli Occhi, vol. i. cap. 4,
and Benedict Handbuch der  praktischen Augen-heilkunde, vol. i.  p. 7—9.   The latter
 author says that the lactuca virosa and pulsatilla nigricans produce slight dilatation.
        46 
362
ARTIFICIAL DILATATION OF THE PUPIL.
  In the observations just quoted from the Edinburgh Journal, Dr. Rt-i-
sinoer expresses his opinion that a solution of the hyoscyamine or the
atropia would be preferable to the other modes in which these narcotics
have been used for dilating the pupil.   His opinions and experience will
be learned from the following passage:—
  " In the first part of the Bavarian Annals  for Surgery, Ophthalmic
Medicine and Midwifery, I endeavoured to draw the attention of Ger-
man physicians to the narcotic principles  of  belladonna  and hyoscya-
mus, discovered by Brandes and Runge, and  expressed my  conviction
of the great utility to be derived from  these substances in several dis-
eases of the eye, and preparatory to different operations, on  account of
their being stronger and more certain  in their action than the extracts
generally made from these plants.  My expectations appear now to be
realized; for having found leisure to  put them to the test of experiment,
I have obtained the following results:—
  "Hyoscyamine, prepared from the  henbane seed, I found to be an
extremely powerful substance for the dilatation of the  pupil.  A  small
drop of a solution of hyoscyamine (gr. i. to  9fS of  water)  was intro-
duced into the eyes of dogs and cats;  the  eye was scarcely at all irri-
tated in any case, and the pupil was so considerably widened, that, an
hour after the application of  the solution, only a small  ring  of the iris
could be seen beyond the edge of the cornea; and after three hours, the
pupil appeared as large as the cornea itself, without the power of vision
being diminished or any other bad symptoms being induced,  even when
the solution wras introduced into  both eyes.  After three days the dila-
tation of the pupil first began to diminish; and it  was not  before the
sixth day that the iris recovered its natural state.  A drop of a solution
of extract of hyoscyamus, containing five grains of the extract to half a
scruple  of water, produced in the same eyes a considerable irritation
for the space of from five to eight minutes, which was shown by the secre-
tion of tears,  shutting of the eye-lids, rubbing  of the eye-brows with the
feet, &c.; and a much less complete dilatation of the  pupil, which in
dogs disappeared after six or eight, and in  cats after twenty-four hours.
As soon as we learnt  by these experiments, which we frequently re-
peated, that the hyoscyamine did not in its action injure either the con-
junctiva, or any of the deeper-seated organs, as for instance the retina,
I proceeded to apply it on the human eye, and found that a drop of a
solution of one grain of  hyoscyamine, in a drachm  of distilled water,
applied to the eye of a  cataract patient, seventy-one years old, produced
such a dilatation of the pupil, that only a small ring of the iris  was appa-
rent.  The pupil continued dilated seven days, during which time the
old woman could see moderately well, and no irritation whatever was
produced in any part of the eye.  At another time, a drop of a solution
of five grains of extract of hyoscyamus in half a scruple of  water, ap-
plied  to the same eye, produced  a  considerable burning, and only a
moderate dilatation of the pupil after twelve hours.   From other  expe-
riments with  the hyoscyamine, we  obtained  nearly the same results.
The hyoscyamine which was obtained from the stalk and leaves of the
plant irritated the eye  much more, and was less efficacious, than that
obtained from the root."
  When the organ is inflamed and painful, so that it will not bear any 
/
                   artificial  dilatation of the pupil.              363

 direct application to its surface, the moistened extract of belladonna
 should be used ; under other  circumstances, dropping the solution  into
 the eye is preferable, as  being more powerful.  If we wish to produce
 the greatest  influence in the quickest  manner we  may employ both
 methods at the same  time.
   The same substance will enlarge the pupil, when applied externally in the
 neighbourhood of the eye, as to an ulcer of the face,* or tongue,f or when
 taken into the stomach.   In  the case of a boy who had swallowed  a
 teaspoonful of the moistened  extract of belladonna,  supposing it to be
 an electuary, and in  whom a most  alarming effect on the nervous sys-
 tem was produced, both pupils were dilated to the utmost, and continued
 so for two or three weeks.
   The immediate effect of these narcotics is enlargement of the pupil,
 or, in other words, contraction of the iris, which at the same time loses
 its power of motion, so that the pupil remains dilated  even in the strong-
 est light: hence Himly has called it  paralysis of the iris.   The influence
 is generally produced in  half  an  hour, or from that to an hour after the
^ application to the eye, and the dilatation lasts for several hours or even
' some  days.  It is not uniform in all individuals, being  greater in pro-
 portion to the healthy state of the eye, and sometimes  so considerable as
 to reduce the iris to  a  narrow scarcely perceptible ring.  Under such
 circumstances,  vision becomes imperfect, sometimes to an alarming de-
 gree.   This kind of amaurosis, which is analogous in  its cause to the
 momentary dazzling and confusion of sight experienced in passing from
 a dark place into a  strong light, goes off as the action  of the iris  re-
 turns, producing no permanent injury; as soon as the iris recovers its
 power of motion, vision is as  perfect as before.   I believe that the  no-
 tion of the belladonna  being  injurious to visionj is  unfounded.  The
 Germans, however, acting on this notion, use hyoscyamus, which has
 a more feeble and temporary influence.  In this country, the belladonna
 is used almost exclusively, as  the more powerful agent; the suspicions
 of its  injurious influence may have arisen  from its greater efficacy in
 dilating the pupil.  I  have known some instances in which it has been
 employed daily for many years:  it has merely dilated the pupil, without
 injuring sight, or doing harm in any way.   We learn, too, from such
 cases, the important fact, that its influence on the iris is  not diminished
 in the slightest degree by use.   In two patients, of whom  one had
 used  it four  or five  and the  other fourteen  or fifteen years, it dilated
 the pupil just  as well at  the end  as at the beginning of  those  pe-
 riods.
   Patients have occasionally  complained of  pain  or  undefined uneasi-
 ness as following each employment of the belladonna; but it has  some-
 times  appeared to me doubful whether such  sensations were  caused by
the application.

  * Ray mentions in his Historia Plantarum (L. 13. c. xxiii.) that in a woman, who applied
the leaves of belladonna to a cancerous ulcer below the eye, the pupil became dilated after
each application.
  f Langenbeck, Neue Chir. Bibliothek. vol. ii. p. 389.
  t Benedict De Morbis Oculi Injlammaloriis, p. 116; see also his Handbuch, SfC vol. i. p.
7—9. 
364
INFLAMMATION OF THE AQUEOUS MEMBRANE.
         SECTION II.--INFLAMMATION OF THE AQUEOUS MEMBRANE.

  Synonymes: Inflammation of the capsule of the aqueous  humour;
Wardrop.   Inflammation of  the  aqueous  chamber; aquo-capsulitis;
Mackenzie.   Kerato-iritis; Rosas.—This disease, which forms a con-
necting link between the external and internal ophthalmias, has been called
inflammation of the anterior chamber, because the visible changes are
nearly confined to that part.  We cannot doubt, however, that the in-
flammation occupies the posterior as well as  the anterior chamber.   It
is frequently accompanied by hypopyon, that is, by the formation of mat-
ter which collects at the  bottom of the anterior chamber.
  External inflammation, involving the cornea, may extend to the an-
terior chamber, and  thus the iris may become adherent to the cornea;
again, inflammation commencing  in the iris  may spread over the
cavity which contains it, and in this case hypopyon is  sometimes pro-
duced.
  The disease, however, which I am about  to describe, is a primary
affection of the cavity containing the aqueous humour, not extending  to
the more internal tunics,  and  affecting the exterior of the  globe only
secondarily.  I used to see it frequently in children  from two  to eight
years of age, at the London Ophthalmic  Infirmary; it is less  common
in older subjects,  and Mr. Mackenzie probably alludes  to this circum-
stance, when he calls it  a  " rare ophthalmia."  (Op. cit. p. 472.)  Be-
tween the membrane of the  aqueous  humour and the serous membranes
there is analogy of structure and disease.  Both  are equally prone  to
adhesive inflammation, that is, to the effusion, under various appear-
ances, of the matters called albumen or coagulating lymph, and to their
subsequent transformation into  preternatural  adhesions,  or  adventitious
membranes; and  such effusion, when it is interstitial, may cause opacity
in both instances.
  Symptoms.—The cornea loses  its transparency,  exhibiting at first
general dulness, then nebulous opacity more or less considerable; often
there is an ulcer on its surface.  The anterior chamber looks cloudy;
but it is difficult to decide whether this appearance is owing to the state
of the cornea  or  to a change in the aqueous  humour.   There is some,
but not considerable external redness: it is chiefly in the form of a pink
zone round the cornea.   The colour of the  iris  is altered, it loses its
brilliancy and  fibrous  character, and becomes  dark and  dull.  The
whole surface, or  at least the inner circle, assumes a  reddish brown
tinge, and the pupillary margin becomes thickened.  This reddish colour
of the iris is more remarkable in blue or grey eyes.  The pupil is rather
contracted.  An effusion of yellow  matter takes place into the anterior
chamber.   There is  a  sense of tightness and fulness in the organ, and
the patient complains of pain and aching in the eye and forehead; but
this affection often happens in subjects who  are too young to express
their feelings.   Lachrymation  and increased sensibility  to light exist in
greater or less degree.  There is a white tongue, with some feverishness;
these and the pain are confined to the commencement of the affection;
so that, when  the  symptoms above described are fully developed, the
patient is free from uneasiness, and opens  the eye to the light without 
INFLAMMATION OF THE AQUEOUS MEMBRANE.           365
 any appearance of intolerance.  The progress is not very rapid; and it
 goes on for several days without the child suffering much.
   Mr. Wardrop, who calls the disease inflammation of the membrane
 of the aqueous humour, represents  that the opacity is seated on the
 internal surface of the cornea, and that it consists chiefly of small round-
 ish specks, which give the part a mottled appearance.  I do not know
 whether this affection, as I have  described it in  children,  ought to be
 considered as included in  his account of  the subject, which seems to
 have been  drawn from the adult, and to include  many of the cases
 usually called iritis.   In the latter, I have recognised the accuracy of
 Mr. Wardrop's description, but I have not seen this particular modifi-
 cation of opacity in the child,  in whom the cornea seems to suffer gene-
 rally.  It is enough to know practically that the opacity, whatever may
 be its seat, will disappear,  when proper means have  been  adopted to
 remove the  inflammation.
   Another question has  arisen respecting the effusion into  the anterior
 chamber, whether it is rightly named pus.  Mr. Wardrop calls it albu-
 men, considering it to be the same as that  poured out on the iris, which
 causes adhesions.  In the  cases I have described, the pupil does not
 become adherent.
   Treatment.—The  affection  is  easily controlled:  it yields readily to
 simple measures.   We begin with leeches and aperients, and then pro-
 ceed to the mild administration of mercury.   A grain, or half a grain
 of calomel,  or two grains  of hydrarg. c. creta, combined with one or
 two grains of James's powder, should be given twice, or, if necessary,
 three or four times in the twenty-four hours.  Counter-irritation is sel-
 dom necessary.  Under  this plan, which  may be continued for a  few
 days, the inflammation is soon removed, and  the matter speedily disap-
 pears.   Local means are of little service; occasional fomentation with
 the poppy decoction, or warm water, will  suffice.
   If this disease should occur in children of scrofulous constitution, the
 symptoms will be somewhat modified.  The pain and  intolerance of
 light will be more  marked. It would be right to  administer mercury
 more cautiously, and to combine it with tonics, such as the sulphate of
 quinine; or it may be omitted altogether, although its efficacy in check-
 ing effusion, and thus preventing change of structure, makes it a desirable
 remedy in such cases.  The occasions are rare, in which it is not admis-
 sible in small doses,  and in  conjunction with such other  means as the
 state of the patient may require.
   The characters of the affection are more distinctly marked, when it
 occurs in the adult.   They are; 1st. increased external redness in the
 form of a pink zone round  the the cornea.  A narrow white line inter-
 venes between the zone and the  cornea, and  red vessels do not extend into
 the latter.  2ndly,  Hazy or nebulous state of the cornea, more or  less
 dense,  with completely  opaque,  circumscribed, greyish, or yellowish
 white specks or dots, not exceeding the size of a pin's head, in greater
 or smaller number.   The haziness or nebula, with the opaque spots, are
 seated in the aqueous  membrane,  the latter being albuminous effusions
on its surface, similar to  what occur in other serous membranes when
inflamed.  In other respects the cornea is unaltered;  the corneal sur-
face has  its  natural  polish  and moisture,  and the  laminae  retain their 
      /
3G6            INFLAMMATION OF THE AQUEOUS MEMBRANE.
 transparence.  The latter point is clearly ascertained by careful inspec-
 tion, and especially by looking at  the eye obliquely, when the situation
 of the opaque change on the aqueous surface of the membrane will be
 readily recognised.  Similar albuminous depositions may be sometimes
 discovered on the surface of  the iris.   These circumstances are most
 distinctly seen in the early period, and when the affection  is confined to
 the aqueous membrane.  As the disease  advances, the opacity becomes
 more considerable, and the  cornea suffers more generally.   3rdly, A
 turbid state of the aqueous  humour, with or  without shreds of  lymph,
 has been generally enumerated among the symptoms.  I do not doubt
 that the secretion is altered, but I have not been able to convince my-
 self of the fact by direct inspection ; the difficulty arises from the cloudy
 state  of the cornea.  4thly, Dulness and change of colour in the iris,
 especially in  its inner  circle, which has a general  dull brownish  red
 tint, although the  exterior  circle may have  its  normal  blue or grey
 colour.   Slightly contracted, misshapen,  and  motionless pupil, of which
 the edge may be  thickened, and  partially adherent, with albuminous
 effusion into the opening.  Sometimes the iris and pupil are little altered;
 or their state may  be concealed by the condition of the cornea.  5thly,
 Imperfection of vision, from dimness to  loss of all useful sight.  6thly,
 Pain of the brow, with sense of fulness and tension.  The latter feeling
 must be referred to increased secretion of the aqueous fluid, which dis-
 tends  the anterior chamber, and is said even to increase the prominence
 of the cornea.   Increased sensibility to light, with lachrymation.  7thly,
 Puriform or more  consistent effusion into the anterior chamber, under
 the  form of hypopyon, is seen occasionally, but less  frequently than in
 younger subjects, and with  more acute inflammatory symptoms. It is
 said that  blood is occasionally effused into the anterior chamber, and
 even converted into hypopyon.*  The appearance of pus is sometimes
 preceded by partial reddish  discolouration of the cornea,  by  increased
 opacity at  some point, or by changes considered to  denote ulceration
 of the cornea on its aqueous  surface.f
   Constitutional disturbance  of febrile character in some degree, or dis-
 order  of the digestive organs, may  accompany the development  of the
 affection; or it may be unattended with  marked general indisposition.
 The character and progress of the disease may be acute or chronic.  In
 the  former  case, with more redness, in which the conjunctiva partici-
 pates, there will be considerable  pain, intolerance, and  lachrymation,
 and vision is soon seriously impaired.  In the latter, which is  more fre-
 quent, the local symptoms are  mild, the pain  and intolerance slight, or
 absent, while the disorder lasts for a long time, or relapses after appa-
 rent improvement.
   Diagnosis.—The position and dotted or mottled character of the opa-
 city, with the natural state of the corneal  substance and surface,  distin-
 guish this inflammation from  corneitis, where the opaque change is more
 uniform, where it  occupies  the whole  thickness  of the  membrane,
 making the  surface irregular, and giving  it a  sanded appearance.   In
 the latter the vascular zone comes to the very edge of the cornea, and

  * Beobachtungen und Bemerkungen uber die inflammatio tuncia,  humoris aquei von Dr.
Wedemeyer; Langenbeck's neue Bibliothek, vol. iv. st. I.
  t -Mr. Tyrrell's Practical Work, vol. i. p. 318. 
                INFLAMMATION OF THE AQUEOUS MEMBRANE.             367

red vessels enter the membrane; not so in the former.  The pains, in-
tolerance of light, and lachrymation, are greater in corneitis.  The cor-
nea is clear, and the anterior chamber in a natural state in most cases
of iritis, where the  most striking phenomena are found in the iris itself,
and the vascular zone round the cornea.
  Under proper treatment the affection is easily arrested, especially in
its early stage; the transparency of the cornea is restored, the iris  and
pupil  regain their normal state, and vision becomes  perfect.  Corneal
opacity in various degrees, adhesions of the pupil, closure or obstruc-
tion of the opening by  adventitious membrane, and  injury or  loss of
sight, are  the probable  consequences  of  neglect or injudicious treat-
ment.
  The general plan of treatment includes antiphlogistic means, more or
less active, according to  the  character of the attack and the state of
constitution, the use of mercury to arrest the effusion of lymph  and
cause absorption of that already deposited; counter-irritation by blister
or tartar emetic ointment, and fomentation.  The  vinum opii may be of
use in the chronic stage.
  In the following case, the affection, which had been of long duration,
with loss of all  useful vision, was soon arrested, with complete recovery
of sight.
  Case.—On the 30th of May, 1826,1 saw a young woman of twenty, who looked per-
fectly well, and stated that she was so. She had sometimes suffered from pains in the
limbs,  which had never been sufficiently severe to confine her.  About a year before
she had experienced severe pain in the head.  Her left eye began to be affected the pre-
ceding Christmas: it was painful and occasionally blood-shot, but not very red. Sight
was dim: it had been impaired for the preceding two months.  I found general hazi-
ness of the cornea, with several  small roundish opaque dots, particularly towards the
centre; these were obviously on the internal surface of the cornea.  The opacity was
sufficient to obscure the view of the iris, and especially of the pupil, which  appeared
contracted and adherent; but I could not determine the latter point.  There was slight
redness of the sclerotica round the margin of the cornea, and some pain on the same
side of the head.  There was no useful vision; and the patient was quite unable to
read.   I could discover no cause for the disease.   (Twelve ounces of blood from  the
nape by cupping; a dose of calomel and jalap; pil. hydr. g. v. every night; to abstain
from fermented liquors.)  3rd June.  Improved: (to take the pill night and morning.)
3rd July.  The treatment has  been continued to the present  time with great improve-
ment.   The  pain and redness are gone: the general haziness of the cornea has disap-
peared, and the dots are lessened.   The iris and pupil are now clearly seen: the former
is altered in colour, being lighter than that of the sound  eye.   The pupil is contracted,
and rendered irregular  by small white adhesions, but otherwise clear.  She can read
a small print with  ease.
  In a case seen by Mr. Mackenzie (Op. cit. p. 471,) the spots appeared
and disappeared at  different points of the cornea, even in the space of a
few hours.
  I saw a  lady of  full habit, between fifty and  sixty, in whom there
was general haziness of the cornea with dotted opacity all over.   Sight
was lost.   The inflammatory stage had completely subsided.   She had
recently employed stimuli, which had made ber worse.
  [The best marked  case we have seen of inflammation of the membrane of
the aqueous  humour,  was the following:
  Eliza Williams, a coloured woman, aged twenty, applied at the Pennsylvania
Eye Infirmary, April 6th, 1826.  Her  sight had been growing dim  for several
days, and she suffered slight pain in her eye.   On the  most minute examina-
tion, no change from a healthy state could be perceived, except perhaps an ex- 
368
HYPOPYON.
tremely faint dulness, situated at the posterior part of the cornea, the cornea
itself being evidently unaffected.  After some days a small spot became evident,
and was shortly followed by two others, differing both in situation and appear-
ance from the opacities produced from inflammation of the cornea.  They were
deep-seated,  and evidently produced by the  effusion of lymph on the inner
surface of the cornea, giving it the appearance  of being mottled with  white.
The margins of these spots were well defined, and the lamina of lymph so thin
as not to  produce perfect opacity.  These spots remained permanent.]
   The aqueous membrane  may be  the  seat of  inflammation, not pre-
senting the appearances just described, causing  increased  secretion of
aqueous  humour, distention of the cornea, and enlargement of the ante-
rior chamber.   There is a red zone round the cornea, probably dulness
of the latter, obvious increase of the anterior chamber, sense of disten-
tion, with pain of the eye  and head.   The complaint goes on for a long
time, and perhaps ultimately causes  diminution or loss of sight.   If the
affection is obstinate, and the  patient's sufferings considerable, it may
be advisable, in addition to antiphlogistic and mercurial  treatment with
counter-irritation, to evacuate  the aqueous humour by puncture of the
cornea.
  A gentleman was under my care with inflammation of the eye, accompanied with
enlargement of the anterior chamber.  He was about twenty-five, of good constitution,
and in good health, except as far as regards the eye.  The latter, of which  he states
the vision  to have been always imperfect, became inflamed while he was on duty, as a
naval officer, in the Mediterranean.  The  disorder continued with more or less vio-
lence between one and two years, and obliged him  to return to England.  At first
view the globe seemed enlarged, but I could discover no increase of size, except in
the anterior chamber, which contained about three times the usual quantity of aque-
ous humour.  There was external redness  of the eye, chiefly in the sclerotica, round
the margin of the cornea; the latter being a little  nebulous at its circumference.  The
iris and pupil were nearly natural in appearance,  size, and movement.  The lens was
opaque.  Increased redness, with pain of the eye and head, came  on occasionally; but
in general there was no uneasiness.   The active congestion was removed by cupping,
low diet, and aperients.  ] then evacuated the aqueous humour, and repeated the pro-
cess four or five times.  The  eye became quite quiet; but the patient left London,
and I did not hear how the case terminated.
         section in.—hypopyon, {Eiter-auge of the Germans.)

  The  term hypopyon or hypopyum (from  wo, under, and wt/ev, pus)
designates the  presence in the anterior chamber  of  a yellow matter
usually called pus, which  it closely resembles in colour and general ap-
pearance, as well as in its inflammatory origin.   I  have mentioned this
as  an occasional  effect  of  the  disease  last  described, in which the
inflamed membrane of the aqueous humour pours out the matter.   More
frequently it proceeds  from the  bursting of a corneal  abscess, when it
is seen in conjunction with more or less opacity of the cornea and acute
inflammation of the external  tunics.  Abscess of the iris, breaking into
the anterior chamber,  may produce hypopyon,  which  may also  occur
in iritis not proceeding to suppuration, in inflammation of the internal
tunics,  and in general inflammation  of the globe; the circumstance
common to the latter three affections, and leading to the occurrence of
hypopyon, being inflammation of the membrane lining  the chambers of
the aqueous humour.   When matter is  effused behind the iris, as well
as in front, the case is called  empyesis oculi, which is equivalent to sup- 
HYPOPYON.
369
 puration of the eye.  Hypopyon, then, is not to be regarded as a peculiar
 disease of  the eye;  like the formation of matter in other parts, it is the
 occasional result of various inflammatory affections.*
   The matter of hypopyon, being heavier than the  aqueous humour,
 sinks to the bottom of  the anterior chamber, forming a  collection, of
 which  the superior surface is a horizontal  level line, while the inferior
 boundary, being formed by the margin of the cornea, is crescent shaped.
 Sometimes the upper line is not level; the matter is in lumps, and ap-
 pears heaped up.  This is particularly the case in  abscess of the cor-
 nea, where we see  occasionally a stratum  of  thick matter continued
 from the aperture to the collection below.   In some instances the puri-
 form fluid changes  its level, when the  head is moved to one side; but in
 general it  is too thick and  viscid.   Sometimes,  when  the inflamma-
 tion is  violent, and  the matter in heaps, an admixture  of blood in small
 quantity is seen.
   It is  hardly necessary to  observe,  that  the inflammations, in which
 matter  is effused  into the anterior chamber, must be treated on the same
 principles as other ophthalmia?; that we must depend principally on an-
 tiphlogistic treatment and the use of mercury for preventing the occur-
 rence,  or arresting  the progress of hypopyon.   The only question that
 remains is, whether the presence of matter  behind  the cornea requires
 any particular course of proceeding; whether we ought  to follow the
 practice that has been usually recommended, of puncturing the cornea
 to evacuate the matter, on the supposition of its presence being injurious
 to the parts with  which  it is in contact.
   The  practice of a late eminent oculist was very singular.   He treated
 hypopyon  with powdered sugar  blown  into  the eye,  with vinum opii,
 leeches, blisters and washes.   If the quantity of matter be large, or if
 it should increase instead of diminishing, it will be  necessary, he says,
 " without delay, to  make an   incision  through the  inferior part of the
 cornea, in order to  discharge it.   This incision  will be best performed
 in the manner used for dividing the cornea, in the  operation of extract-
 ing the  cataract."  He adds, that the opening in the cornea may close
 and the matter collect again; the best mode of  preventing which is to
 take care that the first incision shall be sufficiently large; but if it should
 happen, the cornea  must be again opened, and so on toties quoties.  The
 perusal of this extraordinary advice prepares us, in some measure, for
 what follows.   Delay in performing the operation  above recommended,
 " may issue in the total  destruction of the cornea, and, of  consequence,

  *  The  division  of hypopyon into the true and  the spurious may be discarded, as not
 resting on any satisfactory grounds.  Beer gives the epithet true to that which is produced
 by acute  inflammation of the eye, accompanied  with fever; while he says that the false is
 an effusion of puriform fluid not produced by true inflammation.—Bibliotheca Ophthalmica,
 vol. i. p. 53,  Richter enumerates five kinds of true hypopyon; four of them are various
 suppurations of the cornea, the fifth  and principal is formation of matter  in the chambers
 from  acute inflammation.—Anfangsgrunde, vol. iii. § 79—87.  He then specifies three
 kinds of spurious hypopyon; 1st, effusion of matter into the  anterior chamber without in-
 flammation; 2ndly, from  metastasis,  as in suppressed clap; 3rdly, from abscess of the cor-
nea bursting  internally,  § 90—91,  Benedict calls true hypopyon  an effusion from the
inflamed  iris, without abscess or ulcer; false, the consequence of abscess in the iris,
Handbuch, vol. i. p. 390.  True hypopyon, according to Juengken, is  inflammatory abscess
of the globe; false, is  a collection, in the chambers, of matter from an ulcer or wound of
the cornea, or an abscess of the iris.—hehre, p. 404—6,
      47 
370
HYPOPYON.
the irrecoverable loss of sight."  " In this last and worst stage of the
complaint, should it unfortunately have arisen to this height, nothing re-
mains but to open a way for the  discharge of the morbid matter,  toge-
ther with the vitiated  humours, either by making a large aperture side-
ways through  all the tunics of the eye, or, if the diseased state of the
cornea make it necessary, by removing the whole of its  anterior por-
tion."*
   Richter!  recommends the evacuation of the matter by incision of
the cornea, as the best mode of treating hypopyon.  He says that u as
the matter is tough and thick, the incision must not be small.  It must be
exactly like that for the extraction of  the cataract; but it need not be
quite so large.   It is  enough  to  divide  the  cornea in one-third of its
circumference."!
   Langenbeck§ and Bededict|| follow  the same practice.
   In his early writings, Beer^T recommended letting out the matter: he
appeals to his great experience,  and will hardly condescend  to notice
objections.  " Any one," says he, " who has successfully and completely
cured by incision so  many cases as  I have, will not think it worth while
to hear or read, and  much less to refute such objections."   Subsequent
observation induced  him to change his opinion completely, and to re-
probate  the incision  in equally  strong  terms.   " When matter shows
itself in  the anterior chamber, the surgeon must on no account think of
opening  the cornea;  for the eye would certainly be much injured."  I
am sorry to say that the treatment he recommends  is quite as objec-
tionable  as the  discarded operation: it  consists of dry warmth to the
part, laudanum  dropped between the  lids, and blisters, combined with
calamus aromaticuy,  naphtha, opium,  and  in urgent cases bark !' ■
   ScARpAft judiciously advises active antiphlogistic treatment, observing
that the  matter  will be  absorbed after the  inflammation has been re-
moved ;  and he rejects  the operation because it aggravates the inflam-
mation, and gives rise to greater evils than the  hypopyon itself.
   Waether rightly observes that the operation  for hypopyon should
not be thought of until the  secretion of matter in the corneal  abscess
has ceased, or the inflammation of the chambers is at an end.JJ   If he
had proceeded to say that it is then unnecessary, he would have spoken
more consistently with  his own principles; for he shows how actively
absorption goes on in the anterior chamber.   He  chooses for the ope-
ration  the very period  when, in consequence of inflammation having
ceased, nothing is wanting to complete the cure but a little time for ab-
sorption, and when the effused matter, according to his own description
of its viscid, dirty-yellow, half-dried  and lumpy state,§§ could not be ex-
tracted without difficulty.
   I lay it down as an invariable  rule not to puncture the cornea in hy-

  * Remarks on the Ophthalmy, §c. 5th ed. p. 74—76, and Cas.es 5 and 6.
  t Anfangsgrimde, yol. iii. § 92.                            t Ibid, § 99.
  § Neue Bibliothek, yol. i. p. 182.
  || Handbuch der Augenheilkunde, vol. i. pp.  359 and 393.
  IT Bibliotheca ophthalmica, t. i. pp. 41 and 98.              ** hehre, vol. i.  p. 430.
  tt Treatise, p. 267 and following.
  tt Merkwurdige Heilung, Sfc. pp, 18 and 66__69.
  §§ Merkwiirdige Heilung, fyc. p, 69. 
PUNCTURE OF THE CORNEA.
371
popyon.   Inflammation must be  arrested  by suitable  means, and  the
effusion will be rapidly absorbed.  If the matter increases, depend on it
that the inflammation continues.   Can  an incision of the  cornea be
considered a good remedy for inflammation ?   It is much more calcu-
lated to increase  than diminish the local disturbance; and as a means,
merely of getting rid of the matter  it  is unnecessary, because the  ab-
sorbents are very competent to that duty.  I  never saw an instance of
hypopyon in  children,-where the puncture'of the cornea was necessary,
or even justifiable.  These cases invariably do well  under the treatment
I have described.  I have seen the anterior chamber punctured for  hy-
popyon  in the adult, but never with any beneficial result that might  not
have been obtained without  it.   These reasons  are  sufficient  against
the practice.  There is still another, namely, that the matter is so thick,
it will not in general come" out.   I suppose that the believers in its nox-
ious properties would  endeavour to squeeze or scrape it out.*  The only
exception  I make to the general rule of not puncturing  the corriea is in
the case of  general  suppuration of the globe;  but here  the  eye is
lost, and our object is merely to relieve the patient  by giving exit to the
matter.
           SECTION IV.--EVACUATION OF THE AQUEOUS HUMOUR.

   In  connexion with this question of  opening the cornea to let out the
 matter of hypopyon, I shall mention the subject of puncturing it to dis-
 charge the aqueous humour, as a remedy in some inflammations, and
 in certain states of the cornea.  We are indebted to Mr. Wardrop for
 this ingenious proposal, which was  suggested to his active mind  by a
 singular phenomenon in the dead eye, which I have mentioned in des-
 cribing the anatomy of the organ, viz. the milkiness of the cornea, pro-
 duced by squeezing the globe, and the return of its transparency when
 the pressure is removed.f  It immediately occurred to  him, that vascu-
 lar distention of the internal tunics during life, might cause a similar
 general cloudiness of the cornea, and that this could be removed by that
 diminution of the contents, which escape of the aqueous humour would
 produce.   In trying it with this view, he found it a source of so much
 relief to the patient that he was led to employ it extensively in various
 cases, where there  is tension of the globe; and he has found results so
 advantageous as to induce him to continue the frequent use of the plan,
 although it does not appear  clearly that it has  ever had  any marked
 effect in remedying opacity.  Relief of  pain, removal of the sense
 of tightness, diminution in the size  of the  blood vessels, and improved
 vision are the effects of the operation, when it acts beneficially.

  * " When an opening  is made in the cornea to let out the matter of  hypopyon, we be-
 come sensible of its tough viscid nature; for a part only escapes at the moment, while the
 more consistent portion is discharged gradually, sometimes not without the assistance of
 art."—Benedict, lib. cit. p. 393.
  t Observations on the effects of evacuating the Aqueous Humour in inflammation of the
 eyes; and on the changes produced in the transparency of the  cornea, from the increase
or  diminution of the contents of  the eye-ball.—Edin. Med. and Surg. Journal, vol. iii,
p. 5(J. 
372
PUNCTURE OF THE CORNEA.
  It may be performed either with a narrow cataract knife or a broad
needle: the instrument should be introduced near the margin of the cor-
nea, with its flat surface parallel to the plane of the iris, and carried on
till the point enters the anterior chamber, when it may be turned on its
axis, particularly if it be a needle, to facilitate the escape of the fluid.
It should be immediately withdrawn, as soon as  that is accomplished,
care being taken to remove it before the iris can  fall against it.   The
knife is the best  instrument for this purpose, as it makes a larger aper-
ture, the sides of which will  separate so as to allow  a repetition of the
discharge, if the chamber should become again distended. The chief
difficulty of the  operation arises from the painful state of the inflamed
organ, which is  aggravated by the pressure necessary for keeping the
lids  open to expose  the ball.   The  upper lid should be fixed by the
fingers of an assistant, or by Pellier's speculum.  The operator presses
down the under  eye-lid, with the fore and middle fingers  of one hand,
and applies their points over the tarsus, so  that they  touch the  eye-ball,
and can make such pressure  as may be necessary to steady it: or, the
patient being placed on a low seat, the surgeon may stand behind  him,
fixing the upper  eye-lid and globe with the fingers of one hand, while he
makes the puncture with the  other.
  Mr. Wardrop recommends the operation in gonorrhoeal and purulent
ophthalmia, whether  of the newly-born infant or adult, in cases where
the membrane secreting the aqueous humour is inflamed,  in inflamma-
tion of the external proper tunics, in staphyloma, and in  prolapsus iridis,
in inflammation  consequent on  injuries, in  some  kinds of opacity, in
some cases of ulcer, and in all instances of hypopyon.   In the latter, he
says that it is sometimes necessary to make an incision nearly equal to
that for the extraction of the lens.  I must observe, that he does not
recommend it,  in any instance, as the  sole or principal, but only as
an auxiliary measure of treatment; and that he by  no  means  proposes
it, in the severe  forms of inflammation in which he has used it, with the
view of superseding  the antiphlogistic  measures, which  are obviously
required in such cases.
  The paper of  Mr. Wardrop in the fourth volume  of the Medico-Chi-
rurgical Transactions,* like every thing he writes, is interesting and in-
structive ; it contains a valuable series of  cases.  I must, at the  same
time, candidly state, that my opinion of the operation is by no means so
favourable as his.  I  have tried it in some instances, but with so  little
benefit, that I have not been induced to persist in the  practice; and  I
have been the less inclined to do so in severe inflammations of the organ,
because the  ordinary antiphlogistic  treatment  enables us to control
them.   I think so highly of  Mr. Wardrop's knowledge and judgment,
and rely so implicitly on all that he relates, that  I doubt my own  con-
clusions when I   find  them at variance with  his experience.  Let me
observe, however, that although the puncture, regarded as an operation,
may be spoken of lightly, it is not so trivial as to induce  us to perform
it, unless with decided expectation of benefit.  It is often difficult  to
fix  the  eye for  any operation, and the  pain and  irritability of  severe


  * On the effects of evacuating the Aqueous Humour  in inflammation of the eyes, and  in
some diseases of the  cornea, p. 142. 
AFFECTIONS OF THE CHAMBERS.
373
inflammation do not make this easier;  the swelling of the eye-liqjs in
some instances offers a serious obstacle.   Cases have occurred where
the instrument has  been  carried as far as the  pupil, in which the
lens and iris have been pushed forcibly against it, and cataract has been
produced ;  an event which, indeed, is chargeable to unskilfulness, but its
possibility must be taken into  account in estimating an operation pro-
posed for so great a  number of affections: (see page 166, note.)  The
puncture has not been injurious in any case where I  have practised it.
  Mr. Macgregor* performed the operation twenty-three times in puru-
lent ophthalmia with results so favourable as to induce him to recom-
mend it strongly.  He says, "it is to be regretted  that this operation is
not more frequently performed; for I am convinced that many persons
have lost their sight from rupture of the cornea taking place in front of
the pupil, which a timely and judicious  performance  of this operation
might have prevented."
  MuELLERf  speaks favourably of the  puncture, which he had per-
formed eighteen times in cases of purulent ophthalmia.  LangenbeckJ
thinks well of the proceeding on the faith of three or four cases in which
he had recourse to it.
  Benedict regards it as the principal  measure  in  the treatment of
iritis,§ considering it applicable only where inflammation has affected
both chambers.  He employs  it in every period of acute  and subacute
iritis, with or without hypopyon, when  bleeding and  other means have
failed to relieve.  It  must be repeated as often as inflammation and pain
return;  three, four, or more times.||
  Rosas^F has found it injurious in acute iritis.
  I believe that it is  but little practised  at the present moment, either in
this country or in  Germany.
  SECTION V.--EFFUSION OF BLOOD AND OTHER MATTERS INTO THE ANTERIOR
                              CHAMBER.

  Effusion of blood into the chambers  of the eye has been technically
denominated hcemophthalmus.   I  have  already mentioned this  as an
effect of injury in Chapter III. pages 149—152 and 160.   Blood is also
occasionally effused, in  conjunction  with matter in hypopyon, and in
iritis.  I have seen it poured out into the  anterior chamber alone, as an
effect of inflammation.
  This effusion is sometimes vicarious of menstruation.   " I have seen
says P. F. Von Walther,** " a considerable quantity of blood effused
into the anterior chamber, so as to form a true hcemophthalmus, in many
cases of acute ophthalmitis.  This happened particularly in one instance,
where the affection occurred regularly  at the monthly period, and sup-
plied the place of the suspended menstruation."
  The following case is in some respects analogous:—
  "  Louisa Martin, aged forty-five, ceased to menstruate during three months without
inconvenience.  She had suffered some injury of the eyes in early life from small-pox,

  *  Transactions of a Society, &c. vol. iii. p. 59, 60.
  t Erfahrungssatze, p. 147.   X Neue chir. Bibl. p. 177.   § Handbuch, vol. i. p. 409, 410.
  ||  Ibid, p. 408.            V Ibid, vol. ii. p. 446.     ** Abhandlungcn, p. 395. 
374
AFFECTIONS of the chambers.
and had always had weak sight.  To these  symptoms had lately been added some
appearance of incipient cataract, and within  the last twenty days she had been afFected
with an acute and permanent pain on the right side of the head, with throbbing.  Be-
sides this, however, there was no change in the habitual state of her eyes till the night
of the 28-9th of August, when  she experienced a sharp pricking m  the right eye,
giving the sensation of a foreign body, which she endeavoured to get rid of by rubbing
the part.  In the morning she found that the sight of that eye was lost.  She applied
fomentations of rose water, and afterwards cold spirits and water, without avail.  On
the sixth of September she was admitted at La Charite.  The  ball of the eye was
slightly tumefied;  the vessels of the conjunctiva injected; the cornea of the affected
side more prominent than the other, and perceptibly softer, (!) behind it was seen an effu-
sion of blood, occupying the lower part of the anterior chamber, changing its place
with the movements of the head, and rising to a level with the edge of the pupil. The
headach and pricking continued but slightly.  The pulse was natural, but there were
night sweats.
  "As this patient exhibited at  the same time signs of gastric disturbance, an emetic
was ordered on the 7th, which was the only treatment adopted till the 10th, when an
astringent wash was prescribed; but, as  yet, the blood  effused  has not been reab-
sorbed."*
   The vicarious nature of the sanguineous effusion  into  the anterior
chamber  was  unequivocal in  an interesting  case  recorded by Mr.
Tyrrell in his practical work, vol. ii. p. 40.
  A girl of delicate constitution, between fourteen and fifteen years old, had suffered
for a long time from internal inflammation of the eyes, which had rendered the irides
dull and discoloured, the pupils adherent, and vision very imperfect.  Considerable
improvement had been  accomplished by a long course of treatment; but  active mis-
chief again occurred.   There was great internal redness, with pain and tension, and
aUnost total loss of sight. The anterior  chamber  of one eye was filled with dark
blood.  Under antiphlogistic treatment these symptoms disappeared in three  or four
days.   They returned  twice at monthly intervals.   Means were now successfully
adopted for inducing menstruation, which had not occurred previously; and there was
no subsequent effusion into the anterior chamber.
  In some rare  instances  blood has  been poured  out in this situation
without previous injury or inflammation, or any recognizable morbid
state of the  organ.   A  remarkable  example is related  by Professor
Walther.   In a healthy young peasant, wTho saw well with both eyes,
blood  came into  the anterior chamber, as he was working  at harvest,
much  heated, and  in  a bending position.   Subsequently  the effusion
would occur in consequence of any considerable exertion, or indulgence
in drinking, especially when the  head was held  down.   Walther saw
the blood appear, first  in small quantity, then gradually increase till it
reached the level of the pupil.  It would disappear completely in eight
or ten minutes.   When the effusion was considerable, it was attended
with pain  and tension of the globe.   The blood appeared to come from
the posterior chamber.f
  In an analogous  example related  at  length by Mr.  John Bell,J the
effusion occurred in the first instance, in a gentleman of twenty, in con-
sequence of violent exertion in  running; and had recurred  repeatedly.
IVJore pain was experienced than in  the former case, and the absorption
of the blood was not accomplished until after many days.   Vision at last
began to  suffer,  and it seemed probable that  sight might be lost.

  *  hondon Medical Gazette,  vol. v. p. 123.  From the  French periodical called ha
Lancetle.
  t  M'trkwurdige Heilung eines Eiteraugrs, p.  61.
  t Principles of Surgery, Jtu. vol. iii. p. 270. 
AFFECTIONS OF THE CHAMBERS.
375
  Ammon  relates an instance of spontaneous sanguineous effusion in
the anterior chamber of a diseased eye. {Zeitschrift, vol. i. p. 103.)
  The appearance of pus in the anterior chamber, under various cir-
cumstances, has  been already described under the name of hypopyon.
  The effusion of lymph in the chambers of the aqueous humour, which
occurs in  inflammation of the  iris, see Chapter XVI. § 1, has  been
technically called Hypolympha.
  It has been  supposed that milk, or a fluid  nearly resembling it, is
poured out sometimes into the chambers of the eye, and the name of
hypogala has been given to the case.   I do not consider that the fact is
as yet established by sufficient evidence.  Rosas, however, admits it,
and says that it occurs under the following circumstances, viz. in suck-
ling women, when the secretion of the breasts is suddenly interrupted
or suppressed ; or in other individuals, of either sex and every age, who
take milk  diet, and are exposed to disturbance of the cutaneous func-
tions.  Handbuch, vol. ii. p.  671.
  Beer  says, that he has seen spherules of quicksilver in the anterior
chamber three times in venereal patients.  Repertorium, vol. ii. p. 97.
   section vi.--enlargement of the cavity containing the aqueous
             humour; dropsy of the anterior chamber.

  I have seen the chambers  unusually large, with the  cornea transpa-
rent or  slightly  nebulous, as a  congenital malformation, in children
otherwise healthy.  The subjects of  this defect have  either seen very
imperfectly, or been  blind.   Juengken says that he knows a Swedish
family, in which seven brothers are affected with congenital  dropsy of
the anterior chamber, while the parents and two sisters have  no defect
in their eyes.   Lehre von den Augenkrankheiten, p. 541.
  I was consulted by a patient in whom  the anterior chamber was en-
larged, so as to contain about three times the natural quantity of clear
aqueous fluid, the cornea being perfectly transparent, and the pupil filled
with an opaque  adventitious membrane, as the  consequence of acute
internal inflammation, which had destroyed sight.  The eye  had been
in the same state for some years.
  Lono- continued strumous inflammation of the cornea is attended with
increased secretion of the aqueous humour and enlargement of  the an-
terior chamber;  the  latter  change  being produced partly by  greater
prominence of the cornea, partly by the  iris yielding to the pressure of
the accumulating fluid.  When the  inflammation is at an end,  the eye
presents a natural appearance in all other respects, but the  dropsy of
the anterior chamber remains.   Near-sightedness  is produced,  but vi-
sion is otherwise perfect.  In a case of this kind there may be nebulous
opacity of the cornea, with more or less  imperfection of sight.  I have
seen this state of the eye remaining long  after the cessation of strumous
inflammation:  I am unable to state whether it is ever  removed, in the
course of years, so as to restore the natural proportions of the anterior
chamber.
  Staphyloma may be considered as dropsy of the posterior  chamber;
for the tumour formed by the  expanded cornea and iris  is filled with 
376
IRITIS.
aqueous humour.  (See Chapter XIV. § 5.)  We may probably regard
in the same light the bulging of the iris, accompanied with absorption
of the sclerotica round the cornea, occasionally consequent on severe
and long-continued strumous iritis.
   When the disease which has produced increased secretion of aqueous
humour is at an end, and the enlargement of the cavity containing it is
not considerable, we can do no good  by surgical interference.  Should
inflammation still exist, with  painful distention of the globe, should the
enlargement be troublesome by its magnitude, or should it be attended
with occasional attacks of inflammation  exerting an injurious sympa-
thetic influence on the sound eye, palliative relief  may be afforded by
puncture of the cornea; under circumstances of greater inconvenience
and urgency, a larger opening may be made in the part, with the view
of accomplishing more effectual and permanent diminution.
   Mr. Middlemore has seen instances in which the cornea, retaining its
perfect transparency, has  assumed the globular  form, with  imperfec-
tion of vision.   (Vol. i. p. 439, note.)   He mentions also two examples
in which undue development of the cornea existed.  In a young man,
the cornea, although perfectly transparent, had increased to three times
its natural size, the iris  and anterior  chamber being  enlarged in  the
same proportion, while the other parts of the eye were  of normal mag-
nitude.   The same change was  beginning in the opposite eye.   The
other example occurred in an infant after small-pox.   The diameter of
the cornea of one eye was twice  as great as that of the other.   Vol. i.
p. 546.
                       CHAPTER  XVI.

                     DISEASES OF THE IRIS.

                  INFLAMMATION OF THE IRIS ; IRITIS.

   Inflammation of the iris was, I believe, first described by John Adam
Schmidt, professor at  the Josephine Academy in  Vienna, who  desig-
nated it by the term  Iritis.  His Essay,* published in 1801, contains an
excellent description, which has not yet  been surpassed, of inflamma-
tion of the iris, and its various  results.   To  some of these, he acknow-
ledges that his attention had been directed by his teacher and  friend,
Professor Barth,! who founded  the school of Ophthalmic Surgery at
Vienna, and raised it to a high degree of excellence.  When the clear
account of the penomena, progress and consequences of iritis, contained

  * Uber Nachslaar, und Iritis nach Staaroperationen,  4to. A good analysis of this Essay
may be seen in the first volume  of the Quarterly Journal of Foreign Medicine and Sur-
gery; the intelligent writer gives a general account of  the views entertained by the Ger-
man practitioners on the subject of iritis.
  t Page C2 of the last work quoted, note. 
iritis,                            377
in the work of Schmidt, is contrasted with the entire ignorance which
then prevailed, in this and other countries, on the  same subject, we shall
become sensible how far the Germans have preceded all other  nations
in cultivating the ophthalmic department of medicine.  It appears inci-
dentally that Schmidt was acquainted with the syphilitic and  other forms
of iritis, although he  has  spoken of the  affection generally, and more
especially for the purpose of illustrating some of the consequences which
occasionally follow operations for cataract.   Inflammation of the iris is
not mentioned in the third  volume of Richter's  Elements of Surgery,
which was published in 1795, and treats of diseases of the eye; it is not
alluded to in the first edition of Beer's work* on  diseases of the Eye,
which appeared  in  1792.   In his second and enlarged  edition,! which
is quite a different book from the first, Beer has treated the subject at
considerable  length;  and the Germans in general have been well ac-
quainted  with iritis and its varieties since the appearance of Schmidt's
Essay already quoted, and through the practical lessons afforded in the
admirable ophthalmic  school  of  Vienna.
        SECTION I.—GENERAL ACCOUNT OF IRITIS AND ITS TREATMENT.

   General character of iritis.—The chambers of  the aqueous humour,
 having a smooth membranous lining, which exhales and absorbs a watery
 fluid, present a striking analogy to the serous cavities.  A similar corre-
 spondence is observed in their diseases; inflammation being generally at-
 tended in the former, as it is in the serous membranes, by the  effusion
 either of albuminous fluid or of coagulating lymph.  The peculiar struc-
 ture and the  situation of the affected part will, perhaps, account satisfac-
 torily for our  not being able to recognise  in iritis the  combination of
 circumstances,  which  is  usually considered to constitute  the state of
 inflammation; viz. swelling, redness,  heat, and  pain.  The inflamma-
 tory  process, however, is unequivocally characterized  by its  effects;
 that is, by altered secretion,—by  effusion on the surface or into the
 texture of the organ; and by impaired function.
   The effused matter, which  is found under various circumstances and
 appearances, is called indiscriminately by the  not very precise  term of
 cougulable lymph.  Besides changing  the  colour  and general  appear-
 ance of the iris, it thickens and consolidates this delicate texture, thus
 impairing and destroying its motions, rendering it at first sluggish and
 afterwards motionless; it causes  adhesion of the iris, particularly at
 its pupillary margin, to the surrounding parts; it  alters the form and
 size of the pupil, contracting or entirely obstructing that aperture,  with
 more or less  injury, or complete loss  of  sight.  Thus iritis belongs  to
 the class of adhesive inflammations.  The increased action in the ves-
 sels of the part, by which the changes just enumerated are produced,
 is attended by an enlargement of the vascular trunks and ramifications

  * hehre der Augenkrankheiten, Vienna, 2 vols. 8vo. 1792.  The observations on venereal
inflammations of the eye in this work are quite unworthy of the celebrity which BttER  af.
terwards acquired in this department of surgery ; they are either vague and unsatisfactory,
or erroneous. See vol. i. sect. 425—437.
  t The two volumes of the second edition were published separately, in 1813 and 1817,
       48 
378
IRITIS.
on the sclerotic coat, and, consequently, by preternatural redness of the
eye, to which are usually added increased sensibility to light, and lachry-
mal  discharge.
  Change of colour in the iris.—The change of colour which the organ
undergoes, is  one of the most striking characters of iritis.   A light
coloured iris assumes, under inflammation, a yellowish or greenish tint;
occasionally, it is distinctly yellow;  and, if  the  eye be blue, a bright
green is sometimes seen.  Generally, however, the tint, whether yellow
or green,  is  of a  dull and muddy cast, and darker  than in the sound
state.  In case of the iris being naturally dark-coloured, it is less altered
under inflammation, presenting merely a reddish tinge.  Together with
these changes of colour, there is a  complete loss of its  natural bril-
liancy ; it becomes dull and dark, and the beautiful fibrous arrangement,
which characterizes it in the healthy state, is either confused or  entirely
lost.  These changes, which  are rendered particularly obvious by  the
contrast  between the inflamed  and the  sound eye, commence in  the
pupillary margin.   In an early period, the very edge of the pupil  alone
may be affected ;  the internal circle then becomes altered in colour, and
thickened; and afterwards, the change spreads gradually to the external
or ciliary edge of the iris.   This alteration of colour is produced by
effusion into the texture of  the organ: and the particular tint is  such as
would arise  from  blending with the natural colour of the iris that of  the
lymph, which  is yellowish or brownish.
  Effusion of lymph ;—its various  appearances.—The deposition of
lymph in iritis shows itself under various forms: 1st, Its effusion into
the  texture  of the  iris  causes the changes  of colour just described.
2ndly, It may be  deposited  in a thin layer, covering a larger or smaller
surface.   In this  way, the edge of the pupil first, and  subsequently  the
lesser circle of the iris, assume a reddish brown or rusty colour in  the
beginning of the affection.  The discoloured part has a rough villous
appearance, when closely  inspected; and we  shall generally find, on
careful examination, more particularly on looking at the part sideways,
that  slight elevation and irregularity  of surface  are  produced  by this
new  deposite.  Sometimes the  stratum of lymph has a light yellowish
brown or  ochry tint, and a loose villous texture, rising into obviously
prominent masses.  The rusty colour is the most common, and is  ob-
served particularly in blue irides: the other is seen in the orey, or  the
mixture of grey and orange.   This kind of deposite is generally con-
fined to the inner  circle of the  iris; but the outer circle is usually, at  the
same time, more or less discoloured and dull.   3rdly, The  lymph may
be effused in distinct masses, that is in small drops or tubercles of a yel-
low, yellowish, or reddish  brown  colour; sometimes they have a red
tint,  which may be  light or deeper, bright or  more dull.  They vary
in size from  that of a pin's head to a split-pea.  Often there is only one,
there may be  two, or more.   They may be  deposited on the edge of
the pupil,  or in any part of the anterior surface of the iris.  When  the
inflammation is  very active,  and  has been  neglected or improperly
treated, the lymph is sometimes secreted so abundantly, as nearly  to fill
the anterior  chamber; in which case  it has a light dirty yellowish tint,
and  often a looseness of texture,  with semi-transparency.  4thly,  As
the iris swells or is pushed forwards in the anterior chamber, its surface 
IRITIS.
379
 being sometimes partially concealed by a thin cloud, while the cornea
 is losing its  transparency, suppuration may take place, and a  true ab-
 scess of the iris may be produced.  At one or more points a small bright
 yellow, whitish or reddish yellow prominence slowly arises from the sur-
 face of the iris;  assuming a regularly rounded surface.  It breaks and
 pours out matter, which sinks  to the bottom of  the anterior chamber,
 and forms hypopyon.  Little shreds of the yellow cyst, after  hanging
 from  the iris for several days,  at last disappear.*  5thly, Effusion may
 take  place into the anterior chamber under the form of hypopyon.
 6thly, Under violent inflammatory action,  blood  itself is sometimes
 effused; it may be seen alone, or mixed,  in a coagulated state, with the
 tubercular masses of lymph, or with the yellow abscesses.  I have seen
 such  effusion of blood where the inflammation has not been of the most
 violent kind.  7thly, Lymph may be poured out from the margin  of the
 pupil  or the uvea, so as to agglutinate them partially or  generally to
 the capsule of the  crystalline.   A mass  of lymph  sometimes  fills the
 pupil.   More commonly, a thin greyish  web or  film  stretches across
 the opening, which loses its clear black colour, and  has a cloudy ap-
 pearance.  Lymph may be effused  in  considerable  quantity  into the
 posterior chamber, and  make its way through the pupil into the anterior
 chamber; it may cause  a bulging of the sclerotica, or penetrate that
 membrane, and  form a tumour under the conjunctiva.!  I have  lately
 seen an instance of the last  description, in a tailor,  who had eruptions
 and inflammation of the eye  after a chancre.   These symptoms got
 better, but the eye relapsed in consequence of the patient resuming his
 occupation prematurely.  I found the iris  nearly in  contact with the
 cornea; some red vessels were visible in it.  The lower and inner half
 of the anterior  chamber was  filled with semi-opaque light yellowish
 lymph;  and a small portion of coagulated blood was seen  near the
 ciliary edge of the iris.   Lymph of similar appearance was partially
 visible behind the pupil, towards the nasal side.  On the same side  of the
 globe, the conjunctiva was raised into a tumour about the size of a pea;
 and from the appearance of its contents, through the  membrane, there
 could be no doubt  that they consisted of lymph.  Such was the  state
 of the eye at the end of about three months.  When I saw the patient
 again, after an interval of five or six weeks, the globe had begun to
 shrink :  the conjunctiva oculi was intensely red, the cornea opaque, with
 a reddish  tinge, so that  lymph in the  anterior chamber could be dis-
 cerned through it with difficulty, and the protrusion  of the conjunctiva
 continued of the same size, the  brownish yellow lymph that it contained
 being more distinctly visible.
  The external swelling in these cases has  sometimes a yellowish ap-
 pearance on its most  prominent part, from which, in  conjunction with
 the intense redness and violent pain  of the eye, it has been supposed that
 suppuration of the globe had occurred; and  the part has been punctured,
 under that notion.  I once did this in the case of a lady, whose eye was
 destroyed by syphilitic inflammation: neither matter nor lymph escaped

  *  The abscess of the iris is well represented by Beer in  hehre, tab. 2, fig. 1. Tab. 1.
fig. 6; tab. 2, fig. 4—5; and tab. 3, fig. 1, are excellent views of iritis in other forms.  Other
representations of iritis will be found in Mr. Wardrop's Essay, pi. 8, and in Mr. Tyrrell's
 work, pi. 3.
  + Cases illustrating these occurrences are detailed in my Treatise on the Venereal Dis-
eases of the Eye, pp. 216, and 223. 
380
IRITIS.
from the opening.*  A case, in which a similar attempt was made with
the like result, is related  in the posthumous work of Mr. Saunders,! and
illustrated  by a coloured figure  of the organ.  It  may, I believe, be
asserted, that suppuration never takes place in  syphilitic iritis; that the
inflammation, however violent, is always of the adhesive kind ; and that
the changes, to which it  leads, are produced by the  effusion of lymph.
Nor, indeed, have  I seen  general suppuration of the globe as an effect of
iritis in any form.
  The effusion into the texture of the iris, which  causes a general change
in its appearance,  and the reddish brown discolouration of the inner cir-
cle, with thickening of the pupillary margin, are generally the first altera-
tions observed  in  this inflammation; they may take  place separately,
but are usually conjoined.  In a case, which was of rather a chronic
type, the greater circle  of the iris retained nearly its natural colour,
while the lesser was reddish brown or  rusty-coloured. In  another, the
whole iris, which was naturally blue, had become dark, dull, and muddy,
while the pupillary margin and inner circle were  of a rusty brown. As
the inflammation proceeds, the tubercular masses appear: thus in one
case the whole iris was dull and discoloured, the inner circle being of a
rusty brown, and a large mass of reddish lymph  was deposited on  it;
in another, the irides were so  discoloured, dark, and muddy, that  their
natural appearance could not be estimated; the inner circle rusty brown;
the edge of the pupil thick and villous; while about one-third of  each
was covered by a  prominent mass of bright reddish brown lymph.  In
the  most violent degree, large effusion  takes place into the  anterior, or
posterior chamber, and the pupil.
  The progress of the  affection was  clearly marked in an instance,
where  proper treatment was neglected; we seldom see it so distinctly,
as the complaint is usually arrested by the  means we adopt.  In this
patient, the iris, at the end of nine days, and on the 16th August, had
completely lost its  blue colour, and had a dull, muddy appearance, with-
out any trace of the natural fibrous structure: the inner circle was red-
dish brown, while, in the  outer, this tint was mixed with  a  dull yellow-
ish  colour.   On the 20th, a mass of light-coloured lymph was effused,
and the general discolouration was more striking.   Another effusion
took place on the 27th.   The two portions were united on the 30th, and
increased to one light brownish yellow deposition, covering the lower
half of the iris.  On the  21st  Sept. the inflammation, which  had  been
removed, recurred, and lymph was again effused, increasing in quantity
to the 25th.   In the following  March, nearly the whole anterior cham-
ber was filled with lymph.
  Since the several  modifications of effusion depend on the degree of
inflammation, and  not on any difference in the nature of  the process,
we  see  them combined together in  greater or smaller number accord-
ing to the stage which the affection has reached,  and the effect of the
measures which have been adopted.  Occasionally, however, we  may
observe that the inflammation, although violent  and of long standing, is
characterized by general discolouration, alone,  or  with the addition of

  *  The particulars are detailed by Dr. Farre in a letter to Mr. Travers :—See Coopeb
and Travers's Surgical Essays, pt. 1, p. 93—96.
  t  Treatise on some Practical  Points, Sfc. 2nd ed. pi. 1, fig. 3; and p. 213. 
IRITIS.
381
 a thin stratum of lymph on the inner circle of the iris; while, in some
 instances, the tubercular deposition of lymph takes place with hardly
 any other observable change in the iris.*
   When the complaint has been treated properly at an early period, it
 is soon brought to a  conclusion, and several of  the effects  above de-
 scribed are  not produced.   We have the opportunity of observing these
 phenomena  where the disease has been neglected and left to its  own
 course; where it has been  injudiciously treated, or  aggravated by in-
 temperance and other irregularities. Thus we often meet with instructive
 pathological studies in those, who present themselves for relief at charita-
 ble institutions. The disorganizing effects of the disease, when thus left to
 itself or mismanaged, present  a striking contrast with the favourable
 progress and recovery of cases properly treated, enabling us to estimate
 the effect and appreciate the importance of such  treatment.
   In carrying on the processes and changes just described, the circula-
 tion of the iris is excited,  and  we cannot doubt that its vessels are en-
 larged.  They may  be  occasionally seen, especially  with the aid of
 magnifying powers, filled with red blood.
   Motions of the iris, and state of the pupil.—The motions of the iris
 must be seriously impaired by the changes just described, more particu-
 larly by the interstitial effusion of lymph.  It moves sluggishly at the
 commencement of the inflammation; and when effusion has taken place,
 its movements are entirely suspended, the preternatural connexions by ad-
 hesion concurring with the change of structure in producing this effect.
 The pupil, consequently, cannot exhibit the ordinary variations in size;
 it is contracted, and it becomes smaller and  smaller in  the progress of
 the affection.  At the same time the effusions of lymph and the adhe-
 sions change the figure of the opening, rendering it angular,  and often
 extremely irregular.  Together with other changes, the pupil sometimes
 undergoes an apparent alteration in situation, its edge being fixed at
 one or more points, and free elsewhere.  The margin of the aperture is
 thickened, and has a villous or spongy appearance in the beginning of
 the disease,  presenting a strong contrast to the thin, sharp,  and well de-
 fined edge which  naturally belongs to it.  The effusion of lymph into
 the aperture, which has been  already noticed, destroys its clear black
 colour, and  gives it a dull, cloudy appearance.
  Increased redness of the eye.—There is more or less external redness
 of the eye, in the form of a red band round the cornea, deeper-coloured
 and abruptly terminated in front, gradually shaded off behind; the cir-
 cumference  of the globe being comparatively clear.  In the commence-
 ment of the  affection, the  anterior part of the sclerotica exhibits a pale
 pink redness, and the vascular trunks, which lie on this membrane, are
 seen, of a deeper pink tint, under the conjunctiva, which is then unal-
 tered.   The pink tint of the inflamed sclerotica and of the trunks lying
 on it, which is observed in all inflammations  of  the  membrane, is pro-
 bably owing to their being covered by, and consequently seen through,
 the conjunctiva.   These vessels  advance in nearly straight lines from
the circumference of the globe, ramifying towards the front, and are lost

  *  The cases illustrating the various points in this and the preceding paragraph, will be
found in my Treatise  last quoted. 
382
IRITIS.
in the pink zone.   The redness of the sclerotica, and the distention of
its trunks, increase as the affection proceeds.   The vessels of the con-
junctiva soon  become partially enlarged towards the  anterior part of
the eye; they are distinguished, by their scarlet colour, from those lying
on the sclerotica;  they subdivide minutely, and their fine ramifications,
which are crowded together, combine with the pink redness of the scle-
rotica to form the  vascular zone round the  cornea.  The  minute ves-
sels terminate abruptly in front, probably passing under the edge of the
cornea to the iris;  generally the  zone does not come to the very  edge
of the cornea; a narrow white line intervenes.   This may extend round
the whole circumference of the cornea, or be  confined to the inner and
outer sides; it is always broader and more conspicuous in the latter
situations.  This phenomenon is explained by the mode in which the scle-
rotica overlaps the cornea.   The congestion in the former membrane,
and in the vessels lying on it, reaches, in these cases, only as far as the
situation where the iris is attached on the  inside; the thin portion of
the sclerotic, which passes externally beyond this situation remains free;
sometimes, however, it participates in the excitement, and then the white
line is not seen.
  The limits of the zone are clearly marked  in  front, while it is gra-
dually shaded  off  behind.  It differs in breadth  in different instances.
It is of a vivid red in acute iritis, when fully developed, the circumfe-
rence of the globe being paler as  the conjunctival vessels are less dis-
tended.   When, however, the inflammation exists  in  its most violent
degree, all the external vessels of the globe participate in the excitement,
giving to its whole visible surface  a uniform fiery redness.  The red
zone lasts as long  as the  inflammation of the  iris continues, and disap-
pears when that is  removed; its origin, progress, degree, and termina-
tion, manifestly depending on the iritic affection.
  The whole iris is usually the seat of inflammation, but not necessarily
so; one point only may be inflamed, and then  the redness of the sclero-
tica is confined to the part opposite to the inflamed portion of the iris;
again, when the iris is inflamed generally, it  sometimes happens  that
the excitement  is more violent in one  part, and the external redness will
be greater opposite to that part.
  State of the cornea and aqueous humour.—The phenomena of the dis-
ease show that an  intimate vascular connexion exists between the scle-
rotica, the cornea, and the iris, although the arrangement and the com-
munications of their vessels in the healthy state of the organ, are not
yet clearly explained.  Hence it  happens that active  inflammation  in
either of the latter parts  causes vascular distention and redness  of the
sclerotic, while inflammation originating in that membrane may extend
to them; the latter event, however, is less frequent and  regular than the
former.  When the sclerotica is inflamed, as it is in an acute attack of
iritis, change may  be anticipated in the state of the cornea.  General
haziness occurs at  first;  this  is aggravated, as the case proceeds, and
nebulous opacity comes on when  the  inflammation is violent and  long
continued.   This  change affects the  cornea generally, in most cases;
there may be more considerable partial opacity with the general hazi-
ness  or nebula.   Sometimes, but rarely, there is ulceration of the  cor-
nea.   These corneal affections add to the imperfection  of sight caused 
IRITIS.
383
 by the changes in the pupil.  Under the existence  of  inflammation  in
 the surfaces, which secrete the aqueous humour, we might expect that
 this fluid would be altered in its properties, and become  turbid.   We
 have, however, no clear evidence on this point.   In considerable and
 active inflammation of the iris, with the cornea remaining clear, we can
 see no change in the  aqueous fluid: when the cornea becomes hazy  or
 opaque, we can hardly  expect to discern it.
   Intolerance  of light, and pain.—There is generally  some, and  often
 considerable intolerance in the beginning, and in the early progress  of
 the affection; together with increased lachrymation, the tears flowing
 freely on exposure of the eye to light.   These symptoms are probably
 owing to the participation of the sclerotica  in the affection; and they
 continue, although the quantity of  light  admitted  into  the eye is con-
 stantly diminishing, in  consequence of  the changes produced in the
 pupil and the  cornea.   This was exemplified in a  case which  1  have
 related in my Treatise on the Ven. Dis. of the Eye, p. 259, where the
 distress  was experienced on  approaching  the light, although  it was
 doubtful whether the  patient could  distinguish light from darkness, ex-
 cept from this circumstance.
   There is generally more or less  pain  from the commencement, the
 degree varying according to the acuteness of the attack.  It may  be
 considerable, with burning  sensation and  tension; deep-seated in the
 globe and orbit, extending to the head, and so severe as to prevent rest
 entirely.  Thus, in one case, there was no rest for three or four days  in
 consequence of unremitting and  most severe pain in the organ, and over
 the brow, and intense general headach.   On the other  hand, it may be
 slight, even when  considerable effusion of lymph and loss of sight have
 occurred.  Thus,  in another instance, the iris of the left eye was in con-
 tact with the cornea,  the sclerotica was bulged by effusion of lymph be-
 hind  the iris, and  sight  was destroyed : these changes, however, had
 been  produced by  inflammation of chronic character, and accompanied
 with so little pain as not to interrupt rest.   In two cases the local appear-
 ances were those of the most acute inflammation: in one of them  there
 were large effusions of  lymph in both eyes, with the highest degree of
 vascular turgescence: yet these  patients did not  complain, and  even
 when questioned, said that they had no pain.  In  another patient, al-
 though a mass of  lymph was  effused on the iris of the right eye, the
 patient not only had experienced no pain in the organ, but was not  even
 aware that any disease  existed  in it.  (Op. cit. p. 270.)   Patients often
 complain of great pain in the temple, brow, or cheek, as if it were seated
 in the bone.   In some cases the pain is most severe at night.
   Dimness of sight occurs in the commencement of iritis.  The changes
 in the pupil and cornea  render vision more and more imperfect, so that
 the patient ultimately cannot see the largest print, discern objects, or
 even distinguish light  and darkness.
   General symptoms.—There is great variety in the degree of constitu-
 tional disturbance.   In its most acute form, iritis is attended with se-
vere febrile symptoms;  with headach, restlessness, and  want of sleep;
with  full  and strong pulse; white  tongue, thirst, loss of appetite, and
costiveness.   Often, however, even in cases that would be termed acute,
such symptoms exist only in a slight degree,  or are entirely wanting. 
384
IRITIS.
  Progress and extension of the inflammation.—During the occurrence
of the changes just described, which might be divided into two stages,
that of  congestion and that of effusion, the  iris swells, or appears to
swell;  that is, it approaches towards the cornea, becoming  convex in
front, diminishing the anterior chamber, and sometimes having its sur-
face puckered and irregular.  Is this an actual  swelling of the iris, real
thickening of  the  part from interstitial deposition 1 or mere protrusion
by the  swelling of parts behind, by the effusion of lymph, or by aqueous
secretion ? Dissection has not yet elucidated these questions: for opportu-
nities  do  not  occur of ascertaining the  state of the  iris in the  active
period  of inflammation, by examination after death.   In dissecting eyes,
which  have suffered from iritis, long after the inflammation has ceased,
we  see sometimes considerable adventitious formations behind the iris,
showing that there must have been, originally,  large effusion of  lymph
into the posterior chamber.  Does this protrusion of the iris ever occur,
except  in  conjunction with  adhesion of the entire pupillary margin,
and consequent intercepted communication between the two chambers?
I rather think not; but cannot speak positively.
  If the progress of the affection be not checked, it  does not remain
limited to its  original seat in the iris.   At first it  appears on the very
border of the  pupil;  then shows itself on the inner circle;  and  subse-
quently extends to  the outer  circle, presenting the combination of symp-
toms already described.  Supposing it to go on without interruption, it
passes  from the ciliary circumference of the iris to the corpus ciliare,
the  choroid coat and retina, with increase of pain and fever, and ulti-
mately with irrecoverable loss of vision, from  change of structure in
the  retina. At the same time the mischief is propagated forwards ; the
cornea becomes more opaque, the conjunctiva more inflamed, and great
external redness is added to all the other symptoms, so that the case
which  was at first simple  iritis, becomes ultimately  ophthalmitis, or
inflammation involving the external and internal tunics generally.  The
question naturally occurs, whether the inflammation, when thus propa-
gated to the posterior tunics, presents in them the same characters as in
its original seat;  that is, whether it is attended by effusion  of lymph?
I have never  had an opportunity of  dissecting an eye in this state of
disease, nor are any such dissections recorded.   The escape of  lymph
through the sclerotica,  which has been  already  mentioned, and the
bulging of the globe at some distance behind the cornea, in cases where
it is disorganized by this inflammation, which certainly is not owing to
suppuration, would lead us to suppose that the question ought to be an-
swered in the affirmative.   Sometimes the internal tunics suffer gene-
rally from the beginning; and vision is impaired, although the pupil may
remain clear.  The term iritis, implying that disease is confined  to one
texture, is not properly applied to such cases.
  Effects of iritis—gradual recovery.—The effusion into the texture,
or on the  surface of the iris, like the  interstitial deposition which pro-
duces swelling of other inflamed parts, is removed by absorption when
the  inflammation is at an end.  Under favourable  circumstances, that
is, when the  inflammation  is recent, and proper  treatment has been
adopted, the iris  may be completely restored, recovering its natural
colour, brilliancy, and  power of motion.  This restoration  may take 
IRITIS.
385
 place equally whether the organ should have been simply discoloured,
 whether suppuration should  have commenced in the form of yellow
 abscess, or effusion of lymph should have taken place, either in a thin
 stratum or in tubercular masses.
    Change of texture and colour in  (he iris.—Where the inflammation
 has been more violent, and of longer duration, we shall find that it has
 produced  serious changes of structure, which come under our observa-
 tion when the active excitement has subsided.  The eye may be  flat-
 tened anteriorly, if the iris should have become adherent on  both sur-
 faces: but these are not ordinary consequences  of iritis.   I have seen
 dropsical  enlargement of  the anterior  chamber {hydrophthalmus ante-
 rior) with closed  pupil,  and staphyloma  scleroticae, as results of the
 disease.
    When the  disorder has been  of acute character, affecting the entire
 iris, and particularly after  repeated attacks, serious  disorganization  is
 the consequence.   The  colour and  texture are  so much  altered, that
 the normal appearance of  the iris is lost.  The pupillary margin is ad-
 herent to the capsule of the lens;  the iris no longer forms a level parti-
 tion between the two  chambers, but is elevated into a convex protube-
 rance, which  is puckered  in various places.-   It  has commonly a dull
 leaden colour, with dark spots in various  number, and an intermixture
 of white, apparently tough fibres.   Usually this kind  of change is gene-
 ral ;  it may be partial,   it  has not yet been  ascertained whether the
 iris be thickened  in these cases, or pushed forwards by a secretion be-
 hind.*   Sometimes the  iris  ultimately becomes  thinner  and  lighter
 coloured than in the normal state.   The cornea may be clear, or more
 or less opaque.  Vision is irrecoverably lost; for, whenever the inflam-
 mation is  sufficiently violent to produce such  changes, it will be found
 to have extended to the retina, and to  have rendered it insensible.
   In other cases the effects are less considerable; but the continuance
 for some weeks of slighter inflammation will produce permanent change
 in the texture of the iris,  causing alteration of its colour, which may be
 lighter or darker than the healthy tint, diminution of its lustre, and con-
 fusion of its fibrous structure, so that it presents a striking contrast to
 the sound iris.  Sometimes it is  marked with  small dark specks; some-
 times  it has,  almost throughout a  dull leaden  hue.  These organic
 changes concur with the adhesions of  the pupil in lessening or destroy-
 ing the motions of the part.  In the iris, when thus seriously disorgan-
 ized, vessels  carrying red  blood are occasionally visible to the naked
 eye, in greater or smaller number.
   In a  case of acute syphilitic iritis, with  a large effusion of lymph, the
 part of the iris which had been covered by the lymph was left, after its
 removal, of a  dark black  colour.   It was a little elevated above the
 level of the iris, and of triangular figure, with the basis at the pupil, and

  * Dr. Klemmer, of Dresden, represents this state of the membrane as thickening and
 consolidation from interstitial effusion of lymph occurring in parenchymatous iritis.  He
 has not ascertained this by direct examination  in the human subject, but has found the
 iris thus thickened in the eye of an ox.  To this mere thickening from inflammatory effu-
 sion, he has given the name of iridoncosis, as if it were a distinct disease; and has described-
 it in that point of view with tedious minuteness.  Die Iridoncosis, ein wcnig bekannter
 Ausgang der Iritis parenchymatosa ,* in Ammon's Zeitschrift, vol. v. p. 203;  with five
figures.
       49 
386
IRITIS.
the apex at the edge of the cornea.   Vision was perfectly restored in
this case.
  Adhesions of the pupil.—The lymph effused in iritis, like that poured
out on the surface of an inflamed serous  membrane, soon becomes or-
ganized, producing  adventitious  structures  of a  permanent character.
Thus, when the inner circle oNhe inflamed iris has regained its natural
appearance by the progress of absorption, the edge of the pupil is found
preternaturally fixed to the crystalline capsule.   The whole pupillary
margin may be thus fixed.  A tubercle  of  lymph effused on its  edge
will leave an adhesion  including one half, one third, or one fourth of the
circle.  The pupil may be closely attached at one or more points, the
rest being free.  More commonly the connexion is  effected by slender
threads, one, two, or more, long enough to allow some motion;  there
may be many of these fringing the whole opening.   Such adhesions are
dark coloured; that is, they are of the same colour as the edge of the
pupil  or the uvea, partaking, like other adventitious formations, of the
nature of the surface which produces  them.
   Under suitable treatment, in an early stage, adhesions of the  pupil
are sometimes detached, leaving behind, at least,  in some instances,
black marks  on the capsule, which I believe are permanent.  These
marks escape notice in consequence of the  blackness of  the pupil; they
are, however, sometimes detected on close examination with a strong
light on the eye.   I have seen a complete circular series of such marks,
which I discovered while accidentally examining the eye with the sun
shining upon it.  The  patient  had laboured under iritis; and the pupil,
which had been fixed  to the  capsule in its whole circumference, was
completely liberated by the means employed.
   Adhesions  of the pupil are sometimes whitish  or greyish, not being
coloured by  the  pigment.  The difference  probably arises from the
lymph being effused from the anterior surface, or iris properly so called,
in the one case, from the pupillary margin or uvea in the other.
   The changes now described must  necessarily affect  the  figure and
motions of the pupil.   It is generally contracted; and  it  may exhibit
every variety  of form, being in different cases oval, angular, shaped like
an hour-glass, stellated, or otherwise irregular.  Mere alterations of
figure are not injurious to vision; which is just  as good with the most
irregularly shaped pupil as with a circular one;  and we often see per-
fect vision with great  and permanent contraction of this  aperture.  It
must  be understood, of course, that the retina is uninjured, and that the
pupil, however irregular  or small, is clear.  By  the  adhesions now de-
scribed, the motions of the iris are impaired or entirely lost.
   Adventitious membrane in the pupiL—If the lymph thrown out into
the pupil, and lying on the crystalline capsule, be not soon absorbed, it
becomes organized, and forms an opaque adventitious meinbrane adhe-
rent to  the capsule and to the pupil,  and corresponding in  size to the
dimensions of the pupil at  the time of effusion.  The opacity of this new
production is greatest in the centre, and gradually shaded" off towards
the circumference.  In the contracted state of the pupil, it fills the whole
aperture; but, when the edge of the iris  is withdrawn, it is surrounded,
partially or entirely, by a clear  black margin, and the iris is  found to
be attached to it by one or more adhesions, which may  be either close, 
IRITIS.
387
or in the form of  short black or whitish threads.   These  adhesions
sometimes divide the clear portion of the pupil into  small roundish or
irregular apertures.  In such cases, the pupil does not change under
variations in the quantity of light; it is usually necessary to apply bella-
donna in order to  expose the clear part of the opening, and the adhe-
sions which connect its margin to the adventitious membrane.  If the
effusion should have occupied the pupil and margin of the  iris only par-
tially, the adventitious membrane will be found towards one side, not in
the centre, the edge of the pupil being fixed to it, and thus drawn out
of its regular line, while the rest  of the opening is  natural.   This state,
which has been called imperfect  closure of the pupil  {atresia iridis im-
perfecta,) is  attended with greater  or less injury  of  sight.  Although
the patient may have no useful vision when the aperture is contracted,
he may be able even  to read if a little enlargement can be procured by
the influence of belladonna.
   Closure  of the  pupil, {synizesis  a Greek word,  o-fvr£j?o-/s-, collapse,
sinking in; atresia iridis, i. e. imperforate state  of  thex iris.)  When
large effusion has taken place into the posterior chamber, it is organized   '
into a dense opaque substance, to which the entire  circumference of the
pupil is  closely fixed, the  opening itself being greatly contracted, or
actually  shut, and sometimes removed more  or less from  the centre of
the iris.  By this complete closure of the  pupil {atresia iridis perfecta,)
the communication between  the two chambers is destroyed, and the
passage of light into  the eye  almost entirely intercepted, with  corre-
sponding loss of sight.   By means of the adventitious membrane  thus
produced, the uvea may be rendered generally adherent to the crystal-
line capslile; and there may be a free anterior chamber: or the iris  may
have been previously pushed  forwards and in  contact with the cornea,
so as to lessen or destroy the anterior chamber.*
   Atrophy of the globe, and fluidity of the vitreous humour.—When
large effusion has  occurred into both chambers, and when lymph  has
been deposited behind the iris in such quantity as to cause bulging of
the sclerotica, or to escape through that  membrane and raise the  con-
junctiva  into a swelling, it will be completely removed by absorption,
when the inflammation has ceased.   But the  internal  parts of the globe
are so altered in structure, that it becomes flaccid, and reduced in  size
{atrophia bulbi.)   This change sometimes occurs after complete closure
of the pupil.   A fluid state of the vitreous humour  {synchisis) and  con-
sequent softness of  the globe, may take place  after  acute syphilitic  iritis
of long standing, without shrinking in size or atrophy.
  Impaired vision.—When the inflammation has extended to the poste-
rior tunics, although it should have been  arrested  by  proper treatment,
it often leaves behind imperfection of sight in  various degrees; and this
may take place in cases of chronic, as well as of acute character.   In
an instance, where the inflammation was treated  rather  actively, and
lasted a month, several thread-like adhesions of the  pupil were produced,
and  the  opening was contracted, but quite  clear.   The patient could

  * Von Ammon has taken great  pains to delineate the  phenomena and effects of  iritis.
Twenty-three figures are devoted to this subject in his Klinische Darsteliungen, pt.  i. tab.
14, and others in tab. 15.  His Commentalio de Iritide, 4to. 1838, has two plates on thin
subject with eighteen figures, representing the appearances on an enlarged scale. 
388
IRITIS.
read in a good light, but found a mistiness and dimness before the eye.
Both eyes were affected in another patient, the inflammation being of a
decidedly chronic character in the right, with very slight redness, and
no heat or pain.  At the end of ten  weeks the pupil, which was clear,
was fringed by short dark adhesions, and  the patient could only make
out large print with  difficulty.   His sight was afterwards improved,
but he could not read a small print by candle-light.  In  two instances,
adventitious membranes were formed in the pupils, leaving, however, in
the dilated state, sufficient marginal openings of  clear  black colour for
the purposes of vision: one of these patients could distinguish the letters
of middle-sized  print;  but  vision was much  more imperfect in  the
other.
   After the apparent cure of the disorder, the eye sometimes remains
preternaturally sensible to external influences.   It will  become red, and
water, with some pain, on exposure to cold and damp, or after exertion.
This is more particularly observed when the inflammation has been con-
siderable, and has lasted long, in consequence of neglect or injudicious
treatment; and thus the patient  may experience repeated and trouble-
some relapses of the affection.
   Causes.—The causes of iritis  are the same as those  of other ophthal-
mic inflammations.  In the first  place, direct injuries,  such  as wounds
and various surgical operations, particularly those  of cataract and arti-
ficial pupil.  Secondly, over exertion, as in the long employment of the or-
gan on minute or bright objects: in this way it may occur in those, whose
occupations are attended with  continued  exertion  of the sight.   We
cannot point out how it happens  that the same kind of injurious influ-
ence should, in one instance, produce iritis, in another, affection of the
retina.   We observe, however, that iritis is easily  excited in unhealthy
states of the constitution, such  as the gouty and  rheumatic, and  that
produced by syphilis.   Observation discloses the fact, that in these cases
there is a strong disposition to disease in certain textures; but no satis-
factory reason can be  assigned for the iris being included among these,
unless the observations on gonorrhoeal and rheumatic ophthalmia should
be considered  as elucidating the subject.   See pages 289, 290 and  326.
   I have heard it asserted that iritis  never occurs with obvious effusion
of lymph, except under the unsound states of constitution already speci-
fied.  In corroboration of this remark, I may observe  that iritis is  rare
in young subjects, in whom these states of constitution do not exist; it
is comparatively uncommon before puberty.  The iris  may become
affected by extension of inflammation from the external tunics under
neglect or improper treatment; but I am speaking of primary iritis, that
is, of inflammation commencing in that part, which is a rare affection
in young persons.  I have seen some instances of  the disease, accom-
panied with tubercular effusions  of lymph in children ; but the patients
have exhibited obvious marks  of unhealthy constitution;  and  a few
examples have come under my notice of iritis in infants not apparently
unhealthy, where closure of the pupil has taken place from effusion of
lymph.
   The same external circumstances, such as cold, wet, particular states
of atmosphere, which  are capable of exciting gout and rheumatism in
other forms, may bring on iritis in the predisposed; but it often appears
jn. such subjects without any obvious local agency. 
IRITIS.
389
  In the same way, syphilitic iritis generally appears to us as the simple
offspring of the morbid poison.  The only reason we can assign for its
occurrence, is the previous existence of primary syphilis, or, to use the
ordinary language, the contamination of the body by the venereal poison.
When we come to understand the nature and operation of that change,
to which syphilitic affections of the throat, skin, bones,  and other parts
owe their origin, we  shall  probably  be able to explain the occurrence
of syphilitic iritis.  It may occasionally happen, as some have repre-
sented, that cold, wet, and  other  external influences will immediately
excite the complaint in those who are already disposed to it by having
previously contracted syphilis;  but  it appears, in  most cases, without
any assignable external cause.
  According to Beer, syphilitic inflammation of the eye may arise in
two ways.  External influences, even though slight in degree, and such
as would  probably be uninjurious  to  a person in  good health, will, he
says, excite inflammation of the eye in a  syphilitic person.  This may
at first be a rheumatic or a traumatic inflammation, and may be trans-
formed in two or three days into syphilitic iritis; or, particularly if the
constitution be thoroughly affected with lues, syphilitic  iritis appears at
once under its proper character.  This last he calls primary or genuine,
the former secondary syphilitic iritis.*  I  have  not seen this metamor-
phosis of disease; nor do 1 believe that there is any ground for the dis-
tinction.
   Whether iritis  is caused by the use of mercury.—An opinion has par-
tially prevailed that the use of mercury is capable of producing iritis;
if so, it is both  bane and antidote;  for we know that  it will  cure the
disease.   Some have considered that syphilitic iritis, as well  as other
secondary symptoms, either are rendered more frequent  and severe by
the employment of this remedy, or owe their very existence to it; while
others have spoken of iritis generally as  being caused by it.  I have
seen no instance  of iritis, of whatever kind, in which there has appeared
to me any reason for ascribing the occurrence of the complaint to this
cause.  In nine of the cases related in my  Treatise on  Venereal Dis-
eases of the Eye, p. 165, iritis  came  on where no  mercury had been
taken previously  to its appearance; and in some of them the complaint
was severe and produced consequences injurious to vision; in nine others,
mercury had been administered only in small quantity, and the mouth had
not been made sore; and there is  not one in the whole list in which the
remedy had either been employed for a long time, or affected the system
severely.   Iritis occurred in some of the cases which had been treated
by Mr. Rose and Dr. John Thomson  without mercury.!  Dr. Ekstrom,
of  Stockholm, informed me that he had seen many similar instances in
the patients of an institution where the use of mercury in syphilis had
been entirely abandoned for a long time.   Iritis took place in a woman,
who had contracted syphilis from suckling  a  diseased infant, and had
taken no mercury .J

  *  hehre, vol. i. § 547,548.
  t Medico-Chirurgical Transactions, vol. viii. p. 361; and Cases 17—19. Edin. Med. and
Surg. Journal, vol. xiv. p. 91.
  X Medico-Chirurgical Review, August, 1829.—The patient had suckled the child of ano-
ther woman, who was  known  to have had the venereal disease.  The child, about six
weeks after birth, had ulcers of the mouth and blotches on the trunk, and when  in this 
390
IRITIS.
   Prognosis.—This is favourable when the affection is recent, and con-
 fined to its original seat in the iris.   Continuance of the inflammation is
 attended with increasing contraction of the pupil, with augmented effu-
 sion of lymph, and with its organization into those adhesions and adven-
 titious opaque  substances, which, together with the contraction of the
 pupil, so frequently injure or destroy sight.  In the progress of the affec-
 tion, further injurious consequences arise: the inflammation extends to
 the posterior parts of the globe, including the retina, with the greatest
 danger to  vision; also to the cornea, which  may become more or less
 opaque.
   We  need not entertain  apprehension for  the  result, if the changes,
 however considerable, are confined to the iris.  The inflammation may
 be arrested; and then extensive alterations of colour, large effusions of
 lymph, and great contraction of the pupil, will be removed.  The mere
 quantity of effusion is of little moment.
   Before pronouncing the prognosis,  we should closely examine the
 organ in order to decide the question whether the posterior tunics are
 involved.   The state of vision  alone will not determine the point: the
 changes in the cornea and pupil may impair sight considerably, so that
 the patient may be unable to distinguish objects, and  may be reduced
 to the mere power of discriminating light and darkness, in cases where
 the function of the organ is ultimately restored.  Indeed, a considerably
 impaired state of vision is  sometimes found where the cornea is clear,
 and the pupil not visibly obstructed, and yet the sense is recovered; so
 that even affection of the retina is not necessarily a ground of unfavour-
 able prognosis.   The case is hopeless when we find a change of colour
 in the  whole iris, with considerable contraction of the  pupil and an
 opaque substance in  it,  with intense external  redness, great  and deep-
 seated pain, and complete  extinction of sight.  I have not seen vision
 recovered  when  large effusion  has taken place  behind  the  iris, more
 particularly if it should  have caused bulging of the sclerotica, or  have
 made its way through that membrane.  Great contraction and general
 adhesion of  the pupil, a protruded and puckered s'ate of the iris, are
 very unfavourable circumstances.   Considerable imperfection of  sight
 may be removed if the inflammation be recent, but not if it be of long
 standing.   Cases differ so much in the degree of disturbance, and the
 rate of progress, that we  can  hardly  speak  of definite  periods.   We
 confidently expect  to  arrest the inflammation and  remove  its effects
 when iritis has lasted a fortnight or three weeks;  and we often succeed
in cases of a middle kind as to severity, at the end of a  month.  In a
 case, where the  inflammation had  existed six weeks, and the  patient
 could not make  out large  print without much difficulty,  complete and
permanent  recovery wras effected.   In another, where inflammation of
active character had gone on for six weeks, the recovery of  sight was
nearly perfect.   Much improvement of sight was  accomplished  in a
third, although the affection had lasted nearly ten weeks.  We  must

condition it was applied to the patient's breast. Soon afterwards, a sore formed near the
nipple, with a smooth and slightly excavated surface, thin  discharge, indurated basis, and
great pain : a  gland in the axilla swelled to the size of a chestnut.  In seven weeks, no
mercury having been used, either internally or locally, iritis of the left eye came on. It
yielded speedily, as did the primary symptoms, to calomel and opium, under which the
mouth became sore. 
IRITIS.
391
 take a combined view of the activity and duration of the inflammation
 before we decide on the probable termination.   The power of treatment
 is great: much good is  often done  in unpromising cases:  we  must,
 therefore, take care not to form hastily an unfavourable opinion, and
 thus neglect means by which sight might be improved.
   Treatment.—The three principal objects which we have in view, namely,
 to arrest the inflammation of the organ; to prevent the further effusion
 of lymph, and promote the absorption of that which has been already
 poured out; and to prevent the contraction of the pupil, may be accom-
 plished by antiphlogistic  measures, by the administration of mercury,
 and by the use of belladonna.
   Antiphlogistic means, particularly loss  of blood.—It  can  hardly be
 necessary to enforce at length the propriety of resorting immediately to
 active treatment when violent  inflammation attacks the delicately or-
 ganized internal parts of the eye.  Whenever,  therefore, the inflamma-
 tion is acute, with great vascular congestion, severe pain, and constitu-
 tional disturbance;  when we have reason to fear that inflammation may
 extend from the iris to the posterior tunics, and more particularly if we
 should suppose that such extension has already occurred, we must im-
 mediately adopt active antiphlogistic  treatment in all its parts; that is,
 we must bleed generally and locally, repeating  the evacuation until the
 inflammation is subdued, clear the alimentary canal by an active purge,
 following it by  saline aperients and  the tartrite of  antimony, put the
 patient on low diet, guard the eye from all injurious external influences,
 and  keep the  body at rest as well  as the affected organ.  When the
 disorder  is  less violent, the local abstraction of blood  by cupping or
 leeches will supersede the use of the lancet.   The latter, however, may
 be advantageously employed in  many instances, which, from the  dura-
 tion  of the complaint and  the local symptoms, would not be considered
 as of the most acute kind.  General depletion  may be had recourse to
 with propriety whenever there  is feverishness,  particularly if the pulse
 be full and strong.  I must observe, however, that the absence of such
 symptoms does not  contra-indicate venesection.  If the local complaint
 be serious, and threaten mischief to the organ, the treatment may pro-
 perly begin  with loss of blood  from  the arm,  unless  there should be
 objections in the particular circumstances of the case:  in the progress
 of the affection we should not hesitate to repeat the depletion whenever
 the state  of the part, or of the  system, or both,  call for it.
  Mercury.—The measures now described lessen the  violence of the
 inflammation, remove or greatly diminish the agonizing pain in the part
 and in the head, moderate the accompanying general  excitement, and
 thus  give great relief to  the patient.   But they fail,  at  least, in  many
 instances, to accomplish the second  object.  We  frequently  see, after
 large and repeated bleeding, that the action of the capillary vessels, the
 essential agents- of  the mischief, continues: the effusion of lymph goes
 on, and leads to the alterations of structure, which have been already
 described.  Some further  power is necessary to put a  stop to this dis-
organizing and destructive process, and that power is afforded by mer-
cury, not however when employed as a purge merely, nor in those small
doses, given at considerable intervals, which have been called alterative,
but in such a way as to produce quickly a decided effect upon the sys- 
392
IRITIS.
 tem.   The  mercurial action, when thus effectively and speedily pro-
 duced, cuts short the inflammation, and puts a stop to the effusion  of
 lymph, when that which is  already effused  will be absorbed; thus, it
 not only prevents further changes, but remedies those already produced.
 The redness'of the eye diminishes, and sudden relief is experienced by
 the patient; the lymph, in whatever form it may have been effused, be-
 gins to lessen, and is soon removed; the distinct masses are  absorbed;
 the adventitious layer is removed from  the pupil; the colour of the iris
 is restored last.   The red zone round  the  cornea  begins to  look pale,
 and soon disappears.  Small doses of mercury are  quite inadequate to
 the production of these changes, and  I do  not know how it has hap-
 pened that such  doses have been  called  alterative, for they certainly
 will produce no alteration in a decided inflammatory attack of this kind;
 while, on the contrary, if any such effect is  to be caused by mercury,
 it must be employed freely.  After the  loss  of blood, either  from the
 arm,  or  locally  by  cupping  and leeches, and after clearing out the
 bowels by purgative medicines, the use of mercury may be commenced;
 and the best way of employing it is in the combination of calomel with
 opium, two, three, or  four grains of the former with  one-fourth, one-
 third, or half  a  grain  of the latter, every eight, six, or in urgent cases,
 every four hours.  In this plan  of  proceeding, the  influence of the re-
 medy on the system will soon be perceived.   Under particular circum-
 stances, blue pill, the hydrargyrum c. creta, or mercurial frictions, may
 be employed instead of calomel.
   [When it is desirable, as is often the case, to continue the use of antiphlogistic
 measures at the same time that we are endeavouring to establish the mercu-
 rial action, we have given with much utility, calomel combined with nitrate of
 potassa and tartar emetic.  The usual proportions are the following.   R. Calo-
 mel, gr. viij—x, Potass. Nitrat. 3j.  Antim.  Tart. gr. j TT[ Div. in Chart. No. viij.
 One to be given every four hours.]
   Two important questions  present themselves respecting the mode of
 conducting  this  part of 'the treatment; first,  to what  extent mercury
 should be used;  and secondly, how long it should  be continued.  The
 more  powerful  its  action on the system, the more effectually does it
 control the disease, putting a stop to the excitement of the capillary
 circulation, diminishing the size of the distended vessels, preventing the
 further effusion of lymph, and its organization into those new structures,
which are so injurious to sight.   Sometimes these ends  are not accom-
plished by a slight action on the mouth, when a more powerful influence
will quickly do  the business.  Full salivation, quickly produced, cuts
 short recent disease, as if by a charm.   The remedy may then  be sus-
pended, and its  effects allowed to subside slowly, which will  take two
 or three  weeks:  it will not be necessary to  give any  more  mercury.
Although  the disease yields more quickly and effectually to a powerful
mercurial action, it will be sufficient, in general, to make the remedy
sensible in the mouth.   In cases of longer standing its  influence is not
so quickly effectual.   We must persevere until the lymph is absorbed,
until the natural colour of the iris returns, the red zone round the cornea
is gone, and vision is restored.  This will require four, six, or eight weeks
in some instances.  A longer time is usually necessary  in relapses and
second attacks, than on the first occurrence of the complaint.  I attended 
IRITIS.
393
a gentleman for an attack of syphilitic iritis, in which the disease was
of chronic character; it yielded slowly, and was well in six weeks.   It
recurred in consequence of premature exposure to cold, and the patient
was obliged to  keep the house for twelve weeks in a state of salivation,
recovering perfect  vision, which  has  continued unimpaired from that
time, now many years ago.
   The question will naturally occur, why  this affection should require
a different treatment from other inflammations?  whether iritis may not
be cured by simple  antiphlogistic means ? and whether the employment
of mercury be absolutely necessary ?   To the  latter there can be  no
hesitation in giving a  negative reply.  Iritis may go through its course
and come  to an end without any treatment; but, when thus left  to itself,
it often produces effects more or  less seriously injurious to vision, such
as contraction and adhesions of the pupil, obstruction of the opening by
adventitious membrane, and large  effusion  behind  the iris, with total
loss of sight.
   Again, the affection may be controlled and  brought to a conclusion
by the common antiphlogistic means.*
  Case.—A patient, thirty-two years of age, was admitted into St. Bartholomew's
hospital, under my care, on the 1st of October, 1829, with superficial sores  round the
orifice of the prepuce, and superficial ulceration of  the velum palati and tonsils.  He
was ordered  to take a  blue pill night and morning, and the  compound decoction of
sarsaparilla; and to apply the black wash. On the 7th, his mouth  not having been
affected by the mercury, the right iris became inflamed; the  attack was not severe,
nor attended with much pain.  Sixteen ounces of blood were taken from the  temple by
cupping, and  active aperients were  administered.  On  the 9ih there was a tubercle
of yellowish brown lymph on the iris, with dimness of sight.   The cupping was  re-
peated to the same quantity. On  the 14th  twelve leeches were applied to the temple;
and he left  the hospital on the  19th perfectly well; the eye had  recovered com-
pletely.
   In another case, where both eyes were inflamed, active antiphlogistic
treatment was employed, and the patient  became very pale and feeble
from the loss of blood.   The right eye recovered, but the inflammation
continued in the left, with  increased  pain  and lachrymation, and  pro-
gressive diminution  of vision, until  mercury was exhibited and carried
to the extent of ptyalism.
  In general, however, simple antiphlogistic treatment is not so effectual,
as it  was in the foregoing  case, in arresting the  effusion of  lymph.
Hence,  when we trust to such  means  only, although  the inflammation
may not be violent,  the pupil will contract, and lymph will be  thrown
out: the disease may be checked and subside, leaving the organ  ap-
parently recovered, but the adhesions and  adventitious membranes re-
sulting "from the organization of the newly deposited  substance will per-
manently injure vision.  Many years ago I treated a case of iritis in St.
Bartholomew's Hospital without  mercury: the  inflammation   was re-
duced by cupping, bleeding, and  other corresponding measures, but  a
partial opacity of the crystalline capsule in the centre of the pupil, with
imperfection of sight remained.
  Durino- the time that I was surgeon  to the London Ophthalmic Infir-
mary, I frequently saw patients  who had been treated by common means,

 * «' In seven cases of eruption, attended with iritis, which have  occurred to my observa-
tion, the disease has been cured without the use of mercury."—Dr. Thomson in  the Edin.
Med. and Surg. Journal, vol. xiv. p. 91.
       50 
394
IRITIS.
and in whom general  disorganization of the iris, contracted, closed or
partially adherent pupil, obstruction of that aperture by adventitious or-
ganizations, and loss or serious injury of sight, had resulted from inflam-
mations that might have been checked by mercury, without leaving any
permanent ill consequence.  I may observe that iritis, of whatever kind,
is an  affection easily managed; that  it rarely fails  to  yield to proper
treatment even when the case has been originally neglected; and that
the serious effects just detailed  are chargeable to injudicious manage-
ment  only.  A strong contrast  to  such cases is afforded by those, in
which mercury is properly administered;  the  cure  in the latter being
rapid and complete, and the occurrence of ptyalism being in general
attended with  the most decided improvement in all the symptoms.   In
this latter respect the  action of mercury exerts a  much  more marked
influence over the complaint than the  loss of blood.  In  numerous in-
stances, which have come under my observation, the continued progress
of the inflammation until the system was brought under the influence of
mercury, the immediate cessation of pain and the corresponding dimi-
nution of all the other symptoms as soon as the mercurial  influence was
established, have afforded, the most  unequivocal  proof of the great
power which the remedy possesses over the complaint
   In  comparing the progress, effects, and treatment of iritis with those
of other inflammations, our attention  is chiefly directed to the effusion
which takes place from the inflamed texture, to its influence on the pupil,
and to the paramount importance  of stopping that  effusion, and pro-
ducing the absorption of the newly deposited substance.   A very small
quantity of lymph  thrown out in  the  pupil, and then organized, may
impair or destroy sight.  A similar occurrence in any other part would
be of no consequence.  Effusions  take place  into  the serous cavities,
leading to the  formation of  adventitious membranes, or  unnatural  ad-
hesions, without any subsequent injurious influence on the functions of
the parts.  Interstitial deposition occurs in other organs with  similar
results.
   The good effects of the  mercurial  treatment appear  most  obvious
when it has been resorted  to after the failure of other measures.   I have
seen it rapidly effectual in many cases after active antiphlogistic means
had been employed  without success.  I was consulted, in the year 1822,
by a gentleman labouring under iritis, who had undergone considerable
depletion during three weeks.  He had been bled twice, freely leeched
and purged, and kept on low diet, the use of mercury having been care-
fully avoided under  the notion that  his constitution, which  was supposed
to be  scrofulous, would  not  bear it.   He had  become very pallid and
feeble, without experiencing  any amendment  of the local complaint.
The sight, on  the contrary, had grown more  and  more  dim.   There
was a red zone round the cornea, which was hazy;  the iris was dis-
coloured and dull; the pupil adhered above and  below, so as to have
the shape of an  hour-glass placed horizontally, and vision was so dim
that no print could be distinguished.  Under the use of the hydrarg. c.
creta and belladonna, with a more generous diet and wine, the disease
was speedily stopped; the adhesions gave way,  so that the  natural figure
of the pupil was restored, with perfect vision.
  Two opposite opinions  are entertained  respecting the comparative 
IRITIS.
395
 efficacy and advantages of the simple antiphlogistic, and the mercurial
 treatment of iritis.  Some, placing unlimited  confidence in the powers
 of  mercury, assert "that  the  mercurial action alone, when properly
 kept up, is sufficient  to  subdue the ophthalmia iridis in  its most acute
 stage ;"* while  others dreading the injurious  effects of  the remedy on
 the constitution, discard  it entirely in these cases, believing that other
 antiphlogistic means are  capable of accomplishing  all  that is required.
 I cannot adopt either of  these views.  Although mercury alone, or, at
 least, in conjunction with purgatives and restricted  diet,  will often cure
 iritis, I have  seen many instances in which the sufferings of the patient
 have been  protracted, and the organ has experienced  serious injury
 from the continued progress of the inflammation, when the use of mer-
 cury has not been preceded or accompanied  by the loss of  blood.  A
 striking example of this kind is related in my  Treatise on ihe Venereal
 Diseases of the Eye, p. 208, which contains many other  cases of acute
 iritis greatly  relieved in their most urgent symptoms by active depletion.
 The danger of trusting to  the  antiphlogistic  treatment  alone has been
 already sufficiently explained.  The  practical conclusion, therefore, at
 which I have arrived after  ample experience of the complaint, under
 every variety of treatment, is, that  iritis generally and the  syphilitic
 form of the complaint particularly, will be most advantageously treated
 by the successive or combined employment of antiphlogistic means and
 mercury; that this plan will give the  quickest relief, will most effectu-
 ally arrest  the inflammation, restoring the iris to its healthy structure
 and functions, and will  afford the best security against  the return of
 the disease.
  Although there are few, if any instances, in  which medical treatment
 acts more beneficially or certainly than when  mercury is employed for
 iritis, the remedy  must  not be employed indiscriminately.  In deter-
 mining on its use,  and  selecting the form and  dose, we must be guided
 by various considerations of individual peculiarity, diversity of consti-
 tution, state of general health and  constitutional power.   Sometimes it
 disorders the stomach and bowels, disturbs the circulation,  causes want
 of rest and loss of appetite, and  must therefore be discontinued.  Under
 such circumstances the local complaint is not  benefited;  perhaps it will
 rather be aggravated.  Effects of this kind are likely to be produced in
 those of weak constitution,  especially the strumous.   Where health is
 already impaired, or wrhere  general weakness  has been  brought on by
 previous disease and treatment, the free use of mercury will often disa-
 gree, and our expectations of benefit to the  local  complaint are  not
 realized.  In some of the cases now alluded to, the use  of the remedy
 must  be  abandoned;  in  others it  may be  employed cautiously and in
 small doses, the strength  being at the same time supported by good diet,
 tonic and strengthening medicines, and the general influences favourable
 to health.
  Small doses of  mercury have sometimes been of service when the
 use  of the remedy in larger quantities has failed.  Between  one and  two
 years ago I attended a ladv with internal inflammation of the left eve,

  * Dr. Farrf,  in his  Prefatory Observations  to the posthumous work of Mr. Saunders;
2nd edition, p. 38. 
396
IRITIS.
manifested chiefly by changes in the iris and impaired vision, to which
was added slight increased vascularity of the external tunics.  She em-
ployed calomel and opium freely so as to make the mouth very sore, and
kept up the effect for some weeks.  The complaint yielded at first; it then
became stationary, and afterwards  got worse.   Ultimately vision was
extinct, and the cornea became generally nebulous.  In a few months
after this unfortunate event, disease of  similar  character  showed  itself
in the right eye with impaired vision.   Remembering how she had suf-
fered from mercury on the former occasion, she said she had determined
not to  use that remedy again.  I was not surprised at her determination,
but at  the same time strongly recommended her to employ it in  small
doses,  and to  go on with it  for a considerable  time, taking her usual
diet and exercise.  She took one grain  of the hydrarg. c. creta twice a
day, and sometimes only once, for  five months, with the effect of pro-
ducing and keeping  up slight swelling and  redness of the gums.   The
disease was arrested, sight perfectly restored, the health, strength, and
appearance decidedly improved.
   The hydrarg. c. creta  is the mildest and most eligible form of the
remedy, where we fear that mercury may disagree.   Its efficacy as a
mercurial  is often  underrated.   When  administered  in  the dose of
two or three grains  three times a day, it often makes the mouth sore:
and I  lately saw a powerful effect produced, in a robust person, by
twenty grains given  in the dose of  two grains and a half three times a
day.   Swelling of the tongue,  gums, lips,  cheeks, and jaws  came on
with profuse ptyalism.   These  symptoms  continued with little abate-
ment for about three weeks,  and the effect had not completely gone off
at the end  of six weeks.
   The strumous constitution is a reason, not for objecting altogether to
the use of  mercury,  but for employing it cautiously, and in conjunction
with auxiliary measures of a strengthening  kind.
   In some cases, where  mercury has disagreed, or where, after a fair
trial, the affection of the eye has either  not improved  or got worse, I
have lately employed, with  excellent effect, the  iodide of potassium,
giving three or four grains  in  tw7o or three ounces  of the compound
decoction of sarsaparilla, three  times a day.  The beneficial operation
of the change  seems  analogous to what we  observe from the same suc-
cession of remedies in certain cases of venereal disease.
   Mercury is  used with the greatest effect in the active  period of the
inflammation,  and in the  acute form of the complaint.  It  is desirable
to determine the time, after which it can no longer be administered with
benefit; but this is a  difficult point.  The question  of practical impor-
tance is, whether there is any advantage in using it after the active pe-
riod is passed?  In  many such  cases  I  have  employed  it with  great
benefit to vision : I speak of instances in which  pain, redness, and every
indication of vascular excitement had disappeared, where the iris had
regained its natural character, and  the apparently permanent effects of
inflammation had  been produced, such as organized adhesions, and con-
siderable imperfection  of sight.   In  many instances, where several
weeks  had elapsed from the supposed recovery  of the  organ, and where
mercury had been used almost without expectation of advantage, it has
nevertheless been of  service, and has essentially improved  vision.  In 
IRITIS.
397
such cases, therefore, it is  best to make trial of this powerful remedy.
As ihe circumstances are  not urgent, the mercurial influence  may be
slowly produced; but it will be necessary to keep up the effect for some
weeks.
  The local employment of mercury has been recommended in addition
to its internal use.   A weak solution of the oxymuriate has been used
as a lotion; and the red precipitate ointment, also in a mild form, has
been introduced between the lids.  Such local stimuli are obviously in-
admissible in the active stage of the inflammation;  and I  believe that
they are of no use as  mercurials, at  any period.  One mode of using
the  remedy locally is often of much service.  When patients complain
of severe pain over the orbit at night, the mercurial ointment, combined
with opium may be  rubbed on the neighbouring integuments of the fore-
head and temple, with great alleviation of suffering.   Eight or ten grains
of the ointment, with two  grains of finely-powdered opium, should be
well rubbed in before  the time at which the nocturnal pain is expected
to recur.  A larger proportion of both ingredients  is sometimes used.*
By  this mode of proceeding, for which we are indebted to the Germans,
the  attack of  pain will generally be prevented.   The benefit, however,
is confined to the relief of  this particular symptom : mercurial frictions
on the brow do not arrest  the inflammation as the internal use of the
remedy does.
  Belladonna.—The artificial dilatation of  the pupil must be combined
with the use of mercury in order to prevent that contraction to which
there is so strong a tendency in iritis. Belladonna and the other narcotics
do not exert their power when the iris is actively inflamed, and the dis-
ease not yet checked.   The application, however, although it may fail
to produce the desired effect, does  no  harm, especially if it be confined
to the surrounding skin, and not actually dropped into  the eye: perhaps
it may even be advantageous by preventing further contraction.
  The use of belladonna is of great importance, not only in preventing
further diminution of the pupil, but because the contraction of the iris,
under its powerful influence, is capable, where adhesions have already
taken place, if the effusion be recent, of elongating them, and sometimes
of separating them entirely, so as completely to liberate the pupillary
margin.   But the belladonna cannot  do this alone: two conditions are
necessary to the accomplishment of the object; the case must be recent,
and with the employment  of the belladonna we must produce as quickly
as possible a full  mercurial effect on the system.  Under these circum-
stances, I have seen the whole edge of the pupil detached from the cap-
sule of the lens, to  which  it had become  adherent; and, in proof that
adhesions had  previously  existed,  the capsule  has  exhibited a circular
arrangement of black spots, marking their number and situation.  These
marks, of which the dark colour, like that of the adhesions, is derived
from the pigment of the uvea, are permanent, so far as my observation
goes.
  Adhesions of the pupil  prevent its dilatation more or less completely,
according to their number and nature.  A general and close attachment


  * Juenoken mentions 20 to 30 gr. of the ointment, with 10 to 15 gr. of opium for each
friction.—Handbuch, p. 272. 
398
IRITIS.
precludes all change in the dimensions of the aperture, but partial adhe-
sions only affect that part of the iris in which they are situated, so that
when the edge of the iris is fixed only at certain points, the pupil may be
dilated in the intervals, and then has' a more or less irregular shape. A
close adhesion prevents all contraction in the corresponding part of the
iris; but  when the preternatural connexion is formed by slender threads,
the iris may still move in a limited  degree.  Belladonna and the other
narcotics are capable of dilating the pupil in many instances, where the
iris is no longer affected by variations in the  quantity of light.  But
the permanent condensation  of this delicate texture by the effusion of
lymph under violent  inflammation, when allowed  to proceed uncon-
trolled, renders it altogether incapable of motion ; consequently, in such
cases, the narcotics have no effect on the pupil.
   Operation of mercury.—We  know so little  of the mode in  which
medicines produce their effects generally, that  it need not surprise us if
we should be unable to explain satisfactorily the beneficial operation of
mercury in the treatment of iritis.  Its influence is not confined  to  the
syphilitic form of  the disease,  but extends equally to the idiopathic.
Although the general  opinion  is  well-founded that the full effect  of  the
remedy is less advantageous in the iritis  of  rheumatic and gouty per-
sons, I have often found it necessary to use it freely in such cases, more
particularly those of the rheumatic kind,  and have so  employed it with
decided  benefit,  while its more moderate  employment in  alterative
doses is generally resorted to with advantage in all arthritic cases.
   The subject receives no elucidation from what we know of the effect
of mercury  in syphilis.  Indeed  the latter is quite as obscure as its influ-
ence in iritis.   After it has been used  for three centuries with a confi-
dence in its specific powers  almost complete and general, we now find
its efficacy doubted by many,  while others ascribe several of the symp-
toms called syphilitic to the noxious influence of the remedy.  Putting
these doubts, however, out of the question,  and supposing the ancient
faith and doctrines to remain  unshaken,  what  information do we gain
when we are told that mercury  cures syphilis by its specific power; or
that mercury causes an action or a disturbance in the constitution which
destroys the action  of the morbific poison ?
   The case of iritis is particularly favourable for studying the influence
of mercury, because the transparency of the cornea enables us to  see
what is going on  in the diseased structure.   We can observe the alte-
rations caused  by disease, and the changes  effected by our treatment.
In this way we discover that  mercury, when employed in the manner
already described, puts a stop to that increased action of the capillary
vessels, on which the effusion  of lymph depends.  A circumstance so
striking could not fail to attract notice as soon as the  diseases of  the
eye were closely observed;  thus we find Beer  strongly recommending
the employment  of mercury in  internal  inflammations of the  eye  ex-
pressly on this ground.  " I know," says  he, " no remedy so capable of
preventing hypopyum and  opacity of the parts  essential to vision, in
genuine acute ophthalmia, as mercury."*  Again, in the second volume
of the same work, he observes, " that no remedy is  so  efficacious as
* Bibliotheca Ophthalmica; Vienna, 1799, I. i. p. 55. 
IRITIS.
399
mercury in the most acute inflammation, and in preventing suppuration
and the exudation of lymph, proper evacuations of blood being premised.
I promote its excellent effects in obstinate cases, by mercurial friction
on the superciliary region; and since  employing  this method, I meet
even in the acutest cases, with no suppuration,  nor with cataracts from
lymphatic exudation."*
  The late Mr. Saunders employed mercury in syphilitic iritis only as
an anti-venereal remedy.  In his Essay " on Inflammation of the Iris,
and the Influence of Belladonna to prevent the  consequent Obliteration
of the Pupil," he says, " But this state of the  iris (inflammation, with
effusion of  lymph) sometimes arises from syphilis.  Then the general
plan of treatment here proposed (the  antiphlogistic) must be changed
for the specific  remedy, and mercury must be vigorously exhibited if it
be proposed to  obviate the effect of inflammation, which is the same
whether the inflammation be general or specific."f  His friend and col-
league, Dr. Farre, was led, from observing  the influence of the remedy
in syphilitic iritis, to employ it in other forms of the disease; and his ob-
servation of its great power in arresting inflammations of this texture,
led  him  to ascribe to it a general  property of  controlling  increased
action of the  capillary vessels.   In the observations prefixed  to the se-
cond edition of Mr. Saunders's  posthumous work, he says, " The cer-
tainty with which  the mercurial action arrested the  deposition of coa-
gulable lymph in  syphilitic inflammation of the  iris, led  the editor to
give this  remedy a fair trial in simple inflammation of the iris, in which
the disorganizing process by the adhesive inflammation is precisely the
same, however  it may  differ from the former in its exciting cause.  The
result of  the trial has  perfectly satisfied him that the mercurial action
alone, when properly kept up, is sufficient to subdue the ophthalmia iridis
in its  most acute stage.  Although  the  full  action of mercury is often
efficient in arresting that disorganization of the various parts of the body
which results from the gradual deposition of coagulable lymph within
their insterstitial textures; yet the free abstraction of  blood is still essen-
tial to prevent its bolder and more immediately destructive effusions in
phlegmonous  inflammation.  It is, however, too low  an estimate of the
operation of mercury to  consider it only as a specific against syphilis,
or as  an evacuant  and  promoter of certain secretions and excretions,—
it powerfully  alters the action of inflamed  arteries,  more especially in
respect to the effusion of coagulable lymph, which it,  in various degrees,
controls, or even altogether suspends."};
  Masses of  lymph quickly disappear from the surface of the iris, and
the interstitial deposition  into  its texture is speedily removed  under the
mercurial action.   Hence mercury  has been supposed to possess  the
power of causing absorption.   I rather think that it  has no such direct
operation, and that the removal of these depositions takes place in con-
sequence of the inflammation, to which they owe their  origin,  being
arrested.   Thus the effused lymph was immediately absorbed, as soon
as"the inflammation had  been stopped,  in the case related at  page 393,
although the mercurial treatment was not adopted.  I never saw it dis-

  * Lib. cit. t. ii. p. 85.     t A Treatise on some Practical Points, Sfc 2nd ed. p. 66,
  X See the work last quoted; Preface, pp. 38 and 39. 
400
IRITIS.
appear more quickly under any circumstances.   In the same way tume-
faction from interstitial effusion, whether in the cellular membrane, or
in any organ, is soon dispersed, when the increased action which  pro-
duced it  is subdued, although no mercury may have been employed.
Again, fragments of cataract, effused  blood, and pus are rapidly re-
moved from the anterior chamber without any use of mercury.*
   Local applications.—The use of belladonna, and frictions of mercu-
rial ointment with  opium  on the forehead, which have been  already
mentioned,  hardly come under the denomination of local applications,
in the ordinary acceptation of means  applied to the eye itself.  From
these we  cannot expect much benefit in a serious affection of parts com-
paratively internal.   Warm  fluids, such  as the poppy fomentation, or
tepid water, to which  a little tinctura  opii, or extract  of  belladonna
might be  added, will be found most agreeable to the patient, who may
however use cold applications, if he  should find them more  comfort-
able.
   The use  of blisters is not advisable in the active period of the inflam-
mation.   They add to the excitement, instead of lessening it, particularly
when applied near to the inflamed organ.   They are seldom  necessary
in the treatment of iritis; but they may be employed occasionally, when
the violence of the inflammation has been lessened, if the disease should
be stationary, and the eye should  continue  irritable.
   Use of vinum opii and blisters in the chronic stage.—After the symp-
toms of active inflammation have  been removed, and  sight  has been
restored,  the eye sometimes continues  preternaturally red and irritable;
it will not bear exertion, or exposure  to strong light, and attempts to
use it bring on pain.  The vinum opii may be employed with advan-
tage in such cases;  blistering is  also serviceable.   The  latter remedy
may be resorted to when pain continues after the diminution or removal
of the other symptoms.
   Precaution against relapse.—Relapse of  disease is a frequent occur-
rence in iritis.   The eye, although apparently recovered, will  not bear
exertion,  exposure, or the excitement incidental to irregularities in diet.
The use of  mercury, too, leaves  the constitution unusually  susceptible
of external influences.   The  injurious effects of premature  return to
ordinary  occupations and  habits  is often seen in hospital patients, who
get tired  of restraint  and  leave  such institutions as soon as they feel
themselves relieved.  Hence it is  necessary to pursue steadily a proper
course of medical treatment  and general care, until the organ has com-
pletely regained its normal condition.
   Oil of Turpentine.—Mr. Hugh  Carmichael,  of  Dublin, has lately
recommended the oil of turpentine in iritis generally, and more particu-
larly in the  syphilitic form of the  affection.!  He appears to place  the
greatest confidence in the efficacy of mercury, speaking of " its almost
unerring powers over the inflammation of the iris," p. 25, and admitting
"that in the  treatment of disease generally, an instance wherein a remedy

  * For fuither observations on the  use of mercury in other  affections, see my Treatise
before quoted,  pp. 198—203.                                       J
  t Observations on the Efficacy of Turpentine in the Venereal and other deep seated In-
flammations of the Eye, with some Remarks on the  Influence of that Medicine on the Sys-
tem, accompanied by Cases; 8vo. Dublin, 1829. 
IRITIS-
401
is more successfully employed cannot perhaps be adduced, p. 26:" but he
recommends the turpentine in instances where mercury is inadmissible, in
consequence of its occasional injurious influence,  or of the  debility pro-
duced  by protracted disease.  The following extract  will show the
mode in which  the treatment was conducted.
  " I use the turpentine in this complaint in drachm doses, given three
times a-day.   Its  disagreeable flavour  and nauseating effects 1 have
found best obviated by almond emulsion.   This circumstance it  is very
necessary to attend to, the medicine being so unpleasant, that if its taste
be not in some way disguised, it is difficult to depend  on patients taking
it with  the necessary regularity.  In the formation  of the emulsion, if
double the quantity of confection directed in the London Pharmacopoeia
be employed, that is, two ounces  to the half pint of  water, it answers
the above objects much  better; the residuum  may be  removed  by
straining.
  " With an  emulsion so made, the  following is the  formula I  now
generally adopt:—H. Olei terebinth, rectificat. ^\. Vitellum  unius ovi.
Tere simul et  adde  gradatim, emulsiones amygdalarum 5i'v.   Syrupi
corticis aurantii iii.  Spiritus lavandulae conipositi  5iv.  Olei cinna-
momi guttas tres vel quatuor.  Misce, sumat cocblearia larga duo  ter
de die.
  " In  a few cases  it has been  necessary to  increase the quantity of
turpentine to an ounce and a half, or two ounces, in the above mixture,
the other ingredients being proportionally diminished, so that a'drachm
and a half or two drachms of it may be taken each time;  but in gene-
ral, when administered to the extent directed in this  formula, it  has
very seldom indeed failed, though extensively tried, and in very urgent
cases:  the instances  of its failure  shall be presently noticed.
  " The stranguary, so frequently induced by the internal use  of tur-
pentine, is obviated  by the  usual means—flax-seed  tea and camphor
julep: when very urgent, the medicine maybe suspended for  a time.
The tendency to  acidity in the stomach, which it  sometimes  causes,
is relieved by the addition of carbonate of soda to the mixture; ten or
fifteen grains to the eight ounces will be sufficient; some patients have'
said, the taste was further disguised by this addition.
  " When the local  inflammation is high, and acute  pain is present in
the eye  and side of the head, theJ abstraction of  blood from the temple
by cupping, or  from  the more immediate seat of the  disease by leech-
ing, may be resorted to:  the  same practice is adopted where mercury
is  used.  Nevertheless I have frequently,-when  these symptoms were
very urgent, relied solely on the turpentine  mixture, and with the most
decided and expeditious  relief;  indeed, in some instances, where the
pain and hemicranium existed as acutely as they are, perhaps, at any
time to be met with, patients  have declared  they were  considerably
relieved after they had taken it once  or twice, and  that its subsequent
exacerbations were lessened in a  very remarkable degree.  It  is in  the
former cases I have generally found it necessary  to follow  up the bleed-
ing by  increasing the quantity of the turpentine.
  " It is highly necessary to observe, that the  condition of the bowels
will require attention: the beneficial effects of the medicine appear to
       51 
402
ACUTE AND CHRONIC IRITIS.
be in certain cases suspended when constipation  is present, and are
called forth, as it were, when this is removed." p. 9—11.
  The cases related by Mr. Carmichael exhibit  the powers of  the re-
medy in a favourable light.   In several well marked instances of syphi-
litic iritis, the pain, redness, and other symptoms were quickly removed,
effused lymph was soon absorbed, and vision  restored  under  its influ-
ence.  In other instances it was less successful.
  As the result of some trials of the remedy  by  Mr. Guthrie, it is re-
ported, that "in  some cases it has succeeded admirably;  in others it
has been of little service; and in some unequal to the cure of  the com-
plaint."  London Medical Gazette, vol. iv. p. 509.
  I have had no  experience of this remedy in iritis.
  [Our  experience with this article, though not very extensive, is sufficiently
ample to satisfy us that the turpentine is a valuable remedy in certain cases of
iritis; not as a substitute for calomel in all cases, but rather in those where there
are objections to the use of the latter.]
                 SECTION II.--ACUTE AND CHRONIC IRITIS.

   The disease, which 1 have now described generally, is not a  uniform
affection, always pursuing a certain course, and marked by the same
symptoms; we recognise  distinct forms of the complaint, with impor-
tant differences in the phenomena and treatment.
   Acute and chronic iritis.—Cases differ much in the severity of the
symptoms, in the rapidity of progress, and in the entire duration.   Se-
rious mischief may occur in a few days ;  or weeks may elapse without
permanent change of structure or injury of  sight.   Hence the distinc-
tion of acute and chronic iritis;  or  the  three-fold division adopted by
some writers, of acute, subacute, and chronic.  There are indeed nume-
rous gradations;  but in this, as in other cases, it is sufficient to mark
the difference of character generally: we cannot attempt to give a name
to each degree.
   The acute form of the disease  {iritis acuta) is seen in robust persons
of full habit, where a  powerful  cause has acted  on the organ; more
especially if the case has been neglected at the commencement, or the
cause has continued to act.  Here we shall find bright external redness,
great distention  of vessels, rapid and general change of colour in  the
iris, contraction of the  pupil, effusion  into its  aperture, dulness of the
cornea, loss of sight, agonizing pain of the eye, severe headach, consi-
derable fever, with want of sleep and restlessness.  In a few days vision
is irreparably destroyed.  In one case, at the end of four or five days,
the natural colour of the iris was completely lost, the pupil filled with
lymph, and  vision reduced to the mere power of  distinguishing light
from darkness.   In another patient, within a few days, the iris had be-
come so dark and discoloured, that its  natural colour could not have
been determined; a mass of reddish-brown lymph was deposited on it;
the pupil was irregular, contracted, and motionless; and it was doubt-
ful whether the patient could distinguish light and darkness.  The blood
drawn from the arm in  both these cases had a firm buffy coat.
  As examples of slower  progress  {iritis subacuta)  I may mention a 
ACUTE AND CHRONIC IRITIS.
403
 case, in which vision was not seriously impaired at the end of six weeks,
 although  the iris was discoloured, and two  masses of lymph were ef-
 fused ; a  second, where there wasdiscolouration, but the patient could
 still make out print after six weeks; and a third, in which  the disease
 had  lasted nine weeks, yet tolerable vision  was  recovered.  Another
 patient had iritis of the left eye in a rather acute form.   I observed in
 the right eye a stratum of light yellowish lymph of loose texture, cover-
 ing one half of the inner circle  of the iris;  there was  no redness, no
 pain, nor  diminution of sight, and the patient was not conscious that his
 eye was affected.
   The disease  sometimes  arises so  slowly, proceeding  to  effusion of
 lymph and its organization into adhesions, to diminution  or even loss of
 sight, that no visible vascular distention occurs, no alteration is  observed
 in the eye, no pain is felt, and  the  patient even  discovers the existence
 of the disease accidentally  {iritis chronica or lenta.)
   Case.—A lady of twenty-five, tall, with light hair and irides, who had been in the
 habit of spending much time in needle-work, had experienced for some months before
 she consulted me, dimness of sight in  the right  eye, which had come on  gradually,
 without pain or redness, except that the  eye had been a little bloodshot for a day or
 two in the very beginning, after which the appearance went off.  For the previous six
 weeks she had been judiciously treated  by  a physician:  venesection, leeches to the
 temple, aperients, and mercury, carried to the length of salivation, had.been employed.
 There were three adhesions  of* the right pupil, scarcely discernible in its natural state,
 but rendered obvious by the use of belladonna: all useful vision was lost in this eye.
 Two adhesions existed  in the left eye, and  vision was dim.  No pain or redness had
 ever been noticed in this eye.  The irides,  pupils, and  all visible parts of both  eyes
 were perfectly natural in all other respects.
   Case.—A young lady of delicate frame and constitution, of great information and
 accomplishments, who habitually devoted a  large portion of her time to music, read-
 ing, drawing, and fine  needle-work, found, on looking at  a picture  with the left eye
 shut, that she had lost the sight of the right.  She had experienced no uneasiness in
 it; there had been no redness, nor any other change to attract the notice of her friends.
 A gentleman, since dead, who had great reputation in  this department of practice,
 was consulted.  He said that the eye had probably been originally defective: and in
 answer to an inquiry on that subject, he observed that there was no necessity for re-
 striction in the use of the other eye.  As this opinion, which accorded with the incli-
 nation of the patient, was acted upon, the left eye soon became diseased, and the case
 was placed under my care.   I found inflammation of the left iris, with adhesion of the
 pupil, slight external redness and some pain. In the right eye, the iris was slightly
 altered in appearance, and the pupil fringed with slender dark adhesions;  the aper-
 ture itself was clear, but vision was extinct.  A mild antiphlogistic treatment, followed
 by the use of mercury, restored the sight of the left eye: it was necessary to continue
 the mercurial course for some weeks, although  the patient's friends had in the first
 instance entertained great apprehensions of the remedy, on account of her delicate
 constitution and supposed consumptive tendency,  A relapse took place at the end of
 a year, when the employment of mercury was again successful, but not till after it had
 been used fur many weeks.   In  a  third relapse, the patient again used mercury, not
 so much from the recommendation of her medical advisers as from  her own  conviction
 that it was the only means of restoring her  sight.  She  employed  it by friction, and
 persevered for five months  before vision was restored.   These unusually long  and
repeated mercurial courses produce none of the anticipated injurious effects on health.
Disease returned again, and  at last destroyed all useful vision.  It is now  more  than
twenty years since I first attended this patient; and she is better  in constitutional
strength than she was at that time.
  Extension of inflammation to the posterior tunics is most to be feared
in acute iritis; but,  that the  chronic  form of the disease is not exempt
from  this danger, is rendered evident by  the  two foregoing histories. 
404
SYPHILITIC IRITIS.
                    SECTION III.---SYPHILITIC IRITIS.

  Iritis is called idiopathic, when it occurs from mechanical injury, or
other immediate influence on the part, in persons of healthy constitution.
The yellow abscesses already described, and  the  hypopyon resulting
from their bursting, are  said to  belong more particularly to the acute
idiopathic disease.   The sympathetic forms of the affection  are those
which it assumes in unhealthy states of constitution.
  I consider the syphilitic to be  the most frequent description of iritis:
it is indeed very common, and as unequivocal  a consequence of syphi-
litic infection as any other symptom of the disease, although Mr. Hun-
ter* and Mr.  Pearson! were not only unacquainted with it, but have
expressly denied the existence of any affection of the eye as dependent
on  the venereal poison.   It is a secondary symptom, taking place in
the constitutional stage of the disorder.
  Although sometimes occurring  alone, it is  more commonly accom-
panied by other secondary symptoms, such as eruptions, ulceration of
the throat and mouth, pains  of the limbs, and  swellings of the perios-
teum.   It. is seen  in conjunction with papular,  scaly, tubercular,  and
pustular  eruptions.   As it belongs to  the earlier  class of  secondary
syphilitic affections, it sometimes shows itself, like  the other symptoms
of that class, before the primary disorder is cured.J
  It is rarely seen as a symptom of  syphilis in infants: numerous chil-
dren labouring under this  disease have come under my observation,
but iritis has occurred in  two instances  only.  In one of them, there
were excoriations and ulcerations round  the  anus.   The  iris had  lost
its  brilliancy,  and become dark-coloured; the pupil was slightly con-
tracted, and there was some redness of the sclerotica.  On the other case
I was consulted by  letter from the country.   The  father had had  pri-
mary venereal sores before marriage.   In a few  weeks after birth, the
child had an eruption all over the body, wasted, and seemed on the point
of dying.  It got well under the use of mercury in very small quantities.
In a few weeks more, severe inflammation of  the eyes came on: mer-
cury was employed in the same manner; the inflammation was arrested,
but the child remained blind.  I saw it some weeks after.  Both pupils
were fixed, and moderately contracted.  An opaque body, which was
not a cataract, was seen behind one;  the other was  clear.   Both eyes
were blind.
  I have seen one instance in which syphilitic iritis, or rather syphilitic
inflammation of the internal tunics, occurred as a secondary symptom,
in conjunction with scaly eruption, after the infection of a chap on  the
hand by  the contact of discharge from a sore in delivery.
   Syphilitic iritis may be either acute  or chronic.  It is frequently, but
not invariably accompanied with effusions of lymph in masses or tuber-
cles of a reddish or yellowish brown colour.
   Beer  seems to regard these depositions of lymph  as analogous to the

  * Treatise on the Venereal Disease, p. 324.
  t Letter to Mr. Briggs in his translation of Scarpa's Treatise, p. 164—166, note.
  X The cases related  in my Treatise on Venereal Diseases of  the Eye, illustrate the
various points referred to in this paragraph. 
SYPHILITIC IRITIS.
405
condylomatous excrescences which appear on the organs of generation
and the neighbouring parts in some venereal cases.   I do not see the
anology.  " When effective and appropriate treatment is not adopted at
this critical period of the  disease, other much more  important pheno-
mena present themselves, if it be a case of pure genuine syphilitic iritis.
On the pupillary, or on the ciliary margin of the iris, or on both, there
are formed reddish brown, knotty elevations, which become larger and
larger, and appear on close  examination with a glass, very similar in
structure to those condylomata, which are called cristas galli."*
   It  has been  represented by Beer  and others,  that the pupil seems
drawn upwards  and  inwards, or  towards the  root of the nose: it is
displaced in this direction sometimes, but not constantly.   Its form and
situation depend on the effusions of lymph.
   The pain is chiefly nocturnal: the patient may have hardly any un-
easiness during the day, even  although the attack  be acute, and  the
external redness considerable;  but, as evening comes on, or soon after
bed-time, the pain, which is usually seated in the brow, begins, and  ar-
rives  at such a  pitch as  to  prevent  rest, going off  again completely
towards morning. Where pain exists  constantly,there is amarkedexa-
cerbation at night.
   I have not seen the appearances described by Beer in  the following
sentence : " Lardaceous (speckige) ulcers  frequently appear at the same
time  both on the cornea and on the white of the eye; while gummata,
or true tophi, which quicklv pass into the state of ulceration, form on
the edge of  the orbit, particularly in the neighbourhood of the frontal
sinus and at the root of the nose."   Lehre, vol. i. §  580.
   Diagnosis.—The  tubercular depositions of lymph, the reddish brown
discolouration of the iris on its inner circle, the nocturnal exacerbations
of pain, which  is felt either  in a much slighter  degree  or  not at al
during the day,  the angular disfiguration of the pupil, and  its occasional
displacement towards the root of the nose, together with the previous
occurrence of syphilis, and, in most  instances, the  concomitant exist-
ence  of other  syphilitic symptoms, clearly designate this kind of iritis
and distinguish  it from other forms of the affection.  The local symp-
toms  alone are not sufficient, in all cases, to  establish the distinction;
for we sometimes see merely a general discolouration of the part, such
as might occur  in idiopathic or arthritic iritis.  In one patient the com-
plaint exhibited  all the characters of  the latter affection, including the
white rino- between the red zone and  the margin of the cornea;  and the
state  of the  iris was similar in another.  Under  such doubtful appear-
ances, the age  of the patient, with the previous and concomitant  cir-
cumstances,  will not fail  to elucidate the nature of  the  affection.   In
idiopathic iritis  there is no distinct deposition, or it occurs as a  yellow
abscess, with the addition of hypopyon if the abscess breaks.   Such yel-
low  abscesses are seldom seen in  syphilitic iritis.   Lymph is  effused
from  the margin of  the pupil in the arthritic species, but not deposited
in a distinct form, and the adhesions  are generally white.  Both in the
idiopathic  and  arthritic  iritis the  pupil  generally retains its circular
figure and central position in the iris.
* hehre, vol. i. p. 558.  The appearances are well represented in tab. 2, fig. 
406
ANTHRITIC IRITIS.
    Although  the effusion of  reddish,  brownish, or  brownish-yellow
 lymph on  the iris, in the adult, clearly  shows the case to be venereal,
 1 have seen analogous appearances in several instances, both of young
 children and  infants, in whom no suspicion of syphilis could be enter-
 tained.
    The treatment falls under the general rules already laid down.


                     Section iv.—arthritic iritis.

    Inflammation of the iris is a common affection in the rheumatic and
 the gouty.  The circumstances  characterizing  it  are, in addition to
 some local peculiarities, the  temperament  of the individual,  and the
 previous occurrence, or present existence, of rheumatism or gout.
    In describing gonorrhoeal inflammation of the external  proper tunics
 of the eye, and rheumatic ophthalmia, I have mentioned that the inflam-
 mation occasionally extends to the iris.   Rheumatic iritis thus produced
 is  not a serious affection.
    The following is an example of simple rheumatic iritis.
   Case.—A man, tbrty-one years of age, who has been subject to occasional pains of
 the limbs from exposure to cold in his occupation, that of a waterman and fireman, but
 otherwise healthy, became my patient on the 14th of July, 1831, for an inflammation
 of the right eye,  which had existed three days.  The symptoms were external redness,
 chiefly in the sclerotica, and in the form of a zone round the cornea; dulness of the
 iris; pupil rather contracted and irregular; dimness of vision; intolerance of light, and
 pain shooting across the head.   Cupping, leeching, blister, Plummer's pill and colchi-
 cum were tried in succession, without much benefit.  On the 3rd of August the sul-
 phate of quinine  was given; two grains three times a-day, and the emetic tartar oint-
 ment was rubbed on the back  of the neck.  The symptoms  rapidly subsided, and he
 was discharged on  the 7th.  No effect of the complaint remained except a slender
 adhesion or two of the pupil.  He was readmitted on the 15th with a similar attack in
 the left eye.   The quinine and the tartar emetic ointment were now  immediately re-
 sorted to, but without advantage. The vinum colchici was then administered in the dose
 of half a dram every six hours with some advantage.  Cupping, leeching, and blister
 were employed.  He then took a  dram of the  vinum colchici every six hours, under
 which the symptoms quickly yielded, and he was quite well on the 7th of September.
   In persons of  gouty habit inflammation often attacks the iris, and is
 usually of an  acute character.   Uneasy sensations are experienced in
 the neighbourhood of the eye;  pains occur about  the  forehead, brow,
 and orbit, extending to the side of the head.  Redness of the sclerotica
 comes on with pain of  the eye, intolerance  of  light and lachrymation.
 It has been observed by the  Germans, that  in  consequence of the  re-
 peated motions of the lids, which become red and a  little swelled, a
 small quantity  of white froth or foam collects on their edges, particu-
 larly towards the angles.   With  increase of the  local symptoms, the
 iris is now obviously involved; it becomes  dull and discoloured, the
 pupil  is contracted, but preserves its central situation, and it is fixed at
 one or  more points to the capsule.   The complaint is attended with
 headach and feverish disturbance of the system.
  The red zone round the  cornea does not  advance  to the very edge
of the latter; but a narrow white ring is left between them.   This white
border is often partial, being  observed  more especially  towards  the
angles of the  eye.  It  has been  remarked by the  Germans, that the
colour of the zone in anthritic iritis is more dull than in  the other forms 
anthritic iritis.
407
 of the  affection, that  it is sometimes even livid, and  that  the  vessels
 occasionally exhibit a  kind  of varicous enlargement.  After a violent
 attack of this kind, with great diminution  of  sight, the symptoms sub-
 side, the eye recovers, and vision is completely restored, the iris being
 connected to the capsule by adhesions of white colour.  The inflamma-
 tion returns  again  and again, and we are surprised  to  see  the  eyes
 recovering so completely as  they do  after  these repealed attacks.  A
 gentleman whom I  saw labouring under severe arthritic  iritis, told me
 that  his  eye had been inflamed fourteen  times, yet vision was unim-
 paired, though there were in  each eye adhesions connecting nearly the
 whole pupillary  border to the capsule.   In each attack fresh  effusion
 takes place; the pupil  is more and more contracted, and at last  filled
 entirely with an opaque adventitious membrane.  Even now, although
 sight  is  destroyed,  the texture of the iris is  in many cases  but  little
 altered.   Sometimes one violent attack closes the pupil, or greatly con-
 tracts and fills it with a densely opaque plug.  Sometimes gouty inflam-
 mation, when severe and long  continued, causes complete disorganiza-
 tion with puckering and tubercular projection of the iris and extinction
 of sight.
   When this violent local inflammation occurs, as it frequently does, in
 persons of plethoric habit and robust constitution, abstraction of blood
 by venesection  and cupping, and other suitable antiphlogistic measures
 are urgently necessary.  In  older persons, whose powers are reduced
 by frequent gouty attacks, if there is active local mischief, with heat of
 head, white tongue  and thirst, and full pulse,  the indication for deple-
 tion  is  still obvious.  The  antiarthritic remedies, as  they are  called,
 which are either stimulant or narcotic, can only add to the  mischief.
 This  remark, however, does not apply to colchicum, which may be
 employed alone, or in  combination with purgatives.
  [We have used with great  advantage in this form of iritis, colchicum com-
 bined with purgatives, in the form of Scudamore's draught, and with the addi-
 tion of the oil of turpentine.  Our  formula is the following:—R. Magnes.
 Sulph. 5ss. Magnes. Calc 3ij« vin Rad. Colchici  3j—3ij, ol. Terebinth 3j—
 3ij, syrup cort. aurant, (or some other agreeable sirup) 5j. Aq.  carbonat.  5vij<
 Dose one to two ounces, two, three, or four times  a day.]
  I believe that  arthritic iritis neither requires nor admits that free use
 of mercury, which  is so advantageous in other forms of the complaint.
 I have seen  cases  in which  mercury, carried to salivation, has  been
 injurious rather  than beneficial.   Calomel is useful as a purgative, par-
 ticularly in  combination with antimony;  and,  after the  bowels  have
 been evacuated,  mercury may be  given  in  the alterative  form, such as
 Plummer's pill once or twice a day, with  mild aperients.  Sometimes
 we are obliged to use  the remedy more freely, and  we do  it  with ad-
 vantage.
  Abstinence from  all  stimuli in diet,  and attention to the state of the
bowels, are  points of obvious necessity.  Counter irritation by blister,
or preferably by the tartar emetic ointment, may be employed with ad-
vantage after depletion.  Tepid fomentations are the best local means.
The Germans recommended dry warmth, and opiate frictions to the
forehead, using for  the latter purpose opium moistened with saliva  or
mucilage. 
408
SCROFULOUS IRITIS.
   Since repeated attacks of arthritic iritis  must either seriously injure
or destroy sight, it is  of importance to adopt preventive measures;  to
enforce such regulations of diet and mode of living as will remove that
plethoric state of the system which exposes it to the attacks of gout.
   I subjoin two  cases to illustrate the  nature of the affection.
   Case.—In the summer  of 1829, I saw a gentleman, forty-years of age, of sanguine
temperament and stout frame.  He led a dissipated life at Oxford, where he drank port
wine very freely.  At the age of twenty-two he had  a severe attack of gout, that is,
painful affection of the feet, knees, and other parts, which lasted several months. This
induced him to leave off port; but, having  an excellent  appetite, he has been accus-
tomed to eat largely, and  to drink beer and  other liquors.   Since his arthritic affection
he has had ten attacks of  inflammation  in the right eye, and the left suffered on two
occasions.   At one time he had no inflammation of the eyes for  three years; and  in
that time he had swelling, with some pain  of the right  hand.  With  this exception,
he has not suffered in the  joints or limbs since his first illness.  The iris of the right
eye is of a dull leaden colour, irregularly tuberculated on its surface, and in contact
with the cornea, except at its central portion, where the pupillary margin, being adhe-
rent to  the capsule,  seems depressed. The globe is hard to the  feel, and vision is ex-
tinct.  About one-half of the circumference of the left pupil is connected to the  capsule,
by white adhesion.  Vision is perfect.   From this gentleman's description, the various
attacks of the eye seem to have been highly inflammatory.  For some time after the
last inflammation of the right eye he felt a flow of blood to the head,  and uneasiness of
the eye after every meal.
   Case.—A gentleman, fifty-two years of age, of spare habit, has nearly lost the sight
of both  eyes by arthritic iritis.  He has  been subject to  rheumatism all his life.  His
father was gouty, had chalk stones, and  died of gout in the stomach.  A brother lost
his sight from repeated attacks of iritis; and a sister is rheumatic.  The eyes of this
gentleman have been inflamed about, a dozen times, each return having been preceded
and accompanied by rheumatic ailments. He had repeated inflammation of both eyes,
from September, 1827, to  September, 1828, with rheumatism all over the body.  The
iris of the left eye is bulged, tuberculated, and thoroughly discoloured;  the vessels are
varicous, and sight is destroyed.  In the right the iris is convex, and  nearly in  contact
with the cornea, the pupil is fixed by a  white adhesion, and  enough sight remains to
enable  him to find  his way about.   This gentleman  had an attack in the right eye
recently ; the local and general symptoms were  inflammatory ; three cuppings on the
temple, to eighteen, sixteen, and fourteen ounces were necessary.

   Scrofulous iritis.—The inflammation which begins  externally, under
the usual character of strumous ophthalmia, or corneitis, sometimes ex-
tends to the iris, and even to the more  deeply seated parts of the  globe.
It is preceded and accompanied by such  change in the state of the cor-
nea, as prevents  us from  observing  what is  going on in  the anterior
chamber, so that we sometimes do not know that iritis has existed, until
We see its effects on the subsidence of the inflammation.  I believe that
scrofulous iritis will seldom be seen as a primary and separate affection.
The presence of this  complication,  should its existence  be recognised,
does not require any departure from the principles of treatment applica-
ble to  strumous ophthalmia generally.
   I have to observe, in  conclusion, that the several kinds  of iritis  are
not different diseases,  but modifications of one  and the same affection.
Although the form of  the malady  is more or less different in the various
species of iritis, the nature and effects of the disturbance  are nearly the
same,  and there is no  difference in the principles of treatment.   In dis-
tinguishing to which division a particular case ought to be  referred, we
are often guided  by the history and  concomitant circumstances  rather
than by the local appearances, and thus  the difference  turns  out  at last
to be in the exciting cause, and not  in the nature of the  malady.   The 
                        affections of the iris.                    409

differences of form are, however, often striking enough; and the exam-
ple of  the skin would be sufficient to teach us that  inflammation may
present itself under very various aspects in the same texture.
  The distinctions I have pointed out  will be found, I think, sufficient
for all  practical purposes.   They have, however, been carried  further,
without, as far as I can understand, any  useful result in pathology  or
treatment.*
                        CHAPTER XVII.

          MALFORMATIONS, AND VARIOUS AFFECTIONS OF THE IRIS.

   Congenital deficiency of the iris {Irideremia.)—Sometimes  the iris is
 entirely deficient, vision being at the same time imperfect, frequently so
 much so, as hardly to answer any useful purpose.   I  have lately seen
 two infants a few months old, in whom this  congenital  peculiarity  ex-
 isted.   They were supposed to be  blind, and  brought  to me on that
 account.    I  could  observe no other defect  except  the absence  of
 iris.  They did not bear exposure to  light well.  In  one I thought
 that I could observe a reflection of light at one part, as if there had been
 a narrow rudiment of  iris.   The parents of these infants had  no defect
 in the eyes.
   In Ammon's Zeitschrift, vol. i. No. 4, mention is made of three sisters
 born without iris.  The father has only a rudiment of iris at the lower
 margin of  the  cornea.   The full light of day is offensive  to  him, and
 his sight has become impaired lately, so that he makes out  even large
 letters  with difficulty.   The eldest daughter,  now twenty-eight, was
 born without irides, always experienced  intolerance of  light, and saw
 imperfectly. She has lost one eye by inflammation, which was followed
 by total staphyloma.  The second daughter, aged twenty-one, with com-
 plete deficiency of the iris, cannot bear the light, and is troubled by  re-
 peated ophthalmia?, with increasing imperfection of sight.  The young-
 est daughter, thirteen years old, has clear black pupils; but, like her  sis-
 ters, has not been able to read and write.
  Another instance, in which the hereditary transmission of the con-
 genital  defect is seen still more remarkably, will be found in  the same
 periodical.  Christian  Kbhl, born of  healthy parents, was the first  of
 the family, and  the only one  of  eight brothers, in whom  this defect  ex-
 isted.  He was  annoyed by  light, and pursued his occupations  in  the
 dark.   He had  eight children, of whom three boys inherited this defec-

  * The Commentalio de Iritide of Professor Von Ammon is an elaborate description of
 iritis in its various  forms.  He first describes traumatic iritis.  Subsequently he distin-
guishes irilis generally into three modifications ; 1st, serosa anterior or superflcialis; 2ndly,
parenchymatosa; and 3rdly, serosa posterior or uveitis.  Under the first head he speaks of
scrofulous, rheumatic, and cachectic  subdivisions. The simple forms of parenchymatous
iritis are  the syphilitic and arthritic; but he mentions, as complicated cases, iritis syphili.
tico-mercurialis, syphilitica arthritica, syphilitico scorbutica, scrofuloso-syphilitica, psorica,
and plicosa.
       52 
410
AFFECTIONS OF THE IRIS.
tive formation.  The eldest of these has four sons now living; the iris
was absent in all  excepting the  second, in whom  a segment of the
membrane exists.   The second son had  a son, whose  eyes, as well  as
those of his  children, are normally constructed.   The third  son died
a  few  months after  his  birth.   The eldest of the  four children  of
Christian Kehl's eldest son had  a  son whose eyes were well formed
The second who had the segment of iris, had, 1st, a well-formed boy;
2ndly, a girl with deficiency of the  iris, who sees clearly in  twilight.
The third had two children ;  a daughter with deficiency of the iris and
constant motion of the eye-balls,  and a  malformed child.  The fourth
had a well-formed child.   The several  individuals above-mentioned  as
affected with this malformation, see near objects clearly, but distant ones
very indistinctly, excepting one, who has good distant sight.  The eye-
lids are habitually half closed, so  that light enters the eyes by a narrow
slit.  The vessels of the ciliary body and choroid  coat are not seen. No
particular movement of the eyes is observed.  The interior of the globe
is black-brown or black-blue, and shining.   No reflection of light is ob-
served from the interior.   Strong light is painful, and makes them hold
the eyes down.*
  Baratta-}- saw complete congenital deficiency of the iris in both eyes
of a youth aged  twenty-two.  There  had been  great  weakness  of
sight from birth.  He distinguished distant objects very imperfectly; near
vision was rather better.   When  this person was seen again at the end
of  a year, he had cataracts.   In  one eye the lens was of natural size
and steady in its position, with a black  circle  round it of a line  in
breadth, through which the patient had good sight. The other cataract
moved backwards and forwards, reclining  backwards when the head
was erect, and coming against the cornea when he stooped.J
  Coloboma^ iridis.—Another original  peculiarity in the iris  consists
in a fissure of its lower portion, and a consequent prolongation of the
pupil to the margin  of the cornea.  This natural  defect, which is not
very uncommon, was  first  expressly noticed by Professor Walther,||
although it had been previously observed; he gave it the name of colo-
boma iridis.   The  sides  of the  fissure are sometimes perpendicular,
sometimes a  little inclined towards  each other  below, so as to make
the lower portion of the pupil triangular.   I  am acquainted with a youth
in whom this  natural  defect  exists, his eyes being well formed  in all
other respects, and vision being perfect.  No deviation  from the nor-
mal structure exists in the eyes of his parents, brothers, or sisters.  Von
AmmonTI examined after death the eyes  of an individual in whom this

 * Gutbier, Diss, inaug. de Irideremia, seu defectu Iridis Congenito. 1834.  In Von Am-
mon's Zeitschrift, vol. v. p. 78.
 t Osservazioni pratiche, vol. ii. p. 349.
 X  Von Ammon has represented an eye, in  which the iris  was  entirely deficient, and
a capsulo-lenticular  cataract had  formed.  Klinische Darsteliungen, pt. 1. tab.  10,
fig.  7.
 § The Greek word, xoac/^x, meaning defect or mutilation, was applied to fissure of the
eye-lid.
 II  Ueber einen Usher nicht beschriebenen, angebornen Bildungsfelder der Rtgenbogen-
haut, in Graefe u. Walther's Journal, vol. ii. p. 601.  The  various recorded  cases are
referred to by Sciion in his Pathologisehe Anatumie des menschlichen Auges, p. 70.
 *  Zeitschrift, vol. i.  No. 5, with figures.  In the work and plate of  Von Ammon just
quoted, there are three figures of eyes affected with  coloboma iridis and cataract.  Figs.
5, 6, and 13. 
AFFECTIONS OF THE IRIS.
411
 peculiarity existed.   There was a rising of the sclerotica along the mid-
 dle line on the under surface, and towards the back part of the globe.
 Corresponding to this external rising, there was a fissure of the choroid
 and retina, from which a rising fold was continued in front along the cor-
 pus ciliare, where it took the place of ciliary processes.   An impression
 in the lower part of the viterous humour corresponded to this fold. The
 lens had not quite its regular figure below.   This defect is said to have
 occurred on the upper, inner and outer, as well as at the lower part of
 the iris.  I have seen it in the latter situation  only.
    Change of colour in the iris.—Sometimes the iris undergoes change
 of colour without any other indications of disease.  A  lady, thirty-five
 years of age, of dark complexion, black hair, and dark irides, had passed
 eleven years in hot climates.  When I saw her, the right iris had been
 slowly changing in  colour for two years, and had acquired a dull grey
 tint.  There had been no inflammation, pain, nor other assignable cause.
 The iris moved properly, the pupil was natural, and she could read the
 smallest print, but complained of dimness.   Another lady, of fifty-eight,
 has a bright dark brown iris in the right eye, while the left is light grey
 and rather dull.  There is also  a firm lenticular cataract in  the latter
 eye.  Both eyes were originally very dark.   The colour of the left iris
 changed twenty years ago without inflammation, pain, or diminution of
 sight.  The cataract has existed eight years.
   I have several times seen change  of colour in the iris in conjunction
 with capsulo-lenticular cataract.  In a person of twenty-five, who has
 opacity of the capsule, with  incipient opacity of the lens, the sound eye
 is orange, inclining  to yellow, while the other is a dull bluish grey.  In
 another, the right iris  is very dark ;  the left, with capsulo-lenticular ca-
 taract, is light grey.  There has been no inflammation.
   Spotted iris.—Dark brown spots of roundish figure and various num-
 ber, seldom exceeding the size of a pin's head, are frequently seen on
 the iris. They are often met with in eyes that are not quite sound; but
 they occur also  where there has been no disease, nor any diminution  of
 vision.   They do  not belong to  the original structure of the iris, for
 we do not see them in young subjects; and  in most individuals they do
 not occur at all.  They are met with about or after the middle period
 of life.
   Prolapsus or procidentia iridis.—The iris floats loosely in the aqueous
 humour.  When an  opening is made in the cornea by wound, sloughing,
 or ulceration, that fluid escapes, and the iris passes out at the aperture,
 forming a kind of hernia,  more especially if pressure be made on the
 globe by its muscles, or if the parts in front are pushed forwards by in-
 flammatory congestion in the posterior tunics.  The tumour formed by
 the protrusion is called sometimes staphyloma iridis.  If the cornea be
 completely penetrated, as in wounds and some ulcers, the protruded iris
 is  naked and forms a dirty-looking  brownish or greyish irregular and
 ragged prominence.   If the membrane of the aqueous humour remains
 entire, it gives a smooth covering to  the prolapsed iris.   The protrusion
of the whole iris, after general slough of the cornea is called staphyloma
racemosum; a small prolapsus, forming a brownish tumour, as large as
a fly's head, is called myocephalon, and those of larger size have received
the names of clavus, or helos, and melon.   The  progress and result of 
412
AFFECTIONS OF THE IRIS.
the protrusion  are described  in  Chapter  IX. on gonorrheal ophthal-
mia.
  The treatment consists in removing the inflammation; no specific
measures  are required  for  the  prolapsus.  We cannot remedy that,
whether it has occurred in the case of wound or ulcer.  It would not
come out unless there were pressure from behind ; we cannot restore it
in opposition to this force, and  the attempt would  only aggravate the
mischief.  The employment of belladonna, at an early period, might be
of use in some cases.
  If the tumour should not  subside,  when the  inflammation  has been
removed, if its friction against the lids should cause renewed irritation,
it has been  recommended to  touch it with  lunar  caustic scraped to a
point for the purpose, both  of reducing the  tumour, and of furthering
the adhesion of  the  protruded  part  to the corneal aperture.   This
application must be used  cautiously,  since it may not only fail to do
good, but  be absolutely injurious.  I  do not  use  the caustic, having
found that the prolapsus recedes  when inflammation  has  been quieted.*
If the protrusion were large, it might  be expedient to puncture the part,
so as to let out the aqueous humour, and thus  lessen the tension of the
globe.   A small quantity of a strong solution of nitrate of silver might
then be  carefully applied with a camel-hair brush.
  [The pressure of the aqueous humour, tends to protrude more and more of
the iris, until sufficiently firm adhesion is established between this  tissue and
the edges of the opening in the cornea, to counteract that force.  The stretch-
ing of the  iris—its strangulation in  the  opening of the cornea—and the fric-
tion of the  lids against the prolapsed portion, are so many sources of irritation
which it is very desirable to remove.  By snipping off  the  part of the iris
which protrudes, the aqueous humour escapes and relief  is afforded;  but this
is only temporary, for the iris  soon unites, the aqueous humour is regenerated
and the evil is renewed. We have been accustomed, therefore, in these cases,
to apply a  point of  nitrate of silver to the  protruded portion  of the  iris, by
which it is made to shrink, adhesion between it and the edges of the wound in
the cornea  promoted; and we are persuaded that by this course the  sufferings
of the patient and the period of cure are abridged, and that less distortion of the
pupil occurs than when antiphlogistics alone are trusted to.
  The following case illustrates this practice:
  Rosannah M'Nally, aetat. 8, was admitted into Will's  Hospital November
8th, 1838,  with prolapsus iridis of the right eye.  About two weeks previously,
whilst attempting to untie a knot in her  shoe-string  by the aid of a fork, the
instrument slipped, and a prong penetrated the cornea of her right eye, towards
the lower and outer portion, at about a line  and  a-half, or  two lines from its
junction with the sclerotica.   Some inflammation followed, which resisted the

  * My opinion and experience on this subject coincide with those of Demours, who ob-
serves, that " la petite portion de Piris, pincee entre les levres de Pouverture de la cornee,
s'atrophie et se perd  peu-apeu."  Respecting  treatment, he says, " apres de nombreux
essais, je  me suis apercu que tout ce  qui provoquait l'augmentation de la phlegmasie etait
nuisible,que Pon devait, sans s'arreter acetepiphenomene, s'atUcher acombattreles causes
qui lui ont donne  naissance, en un mot, qu'il ne fallait rein faire a la hernie de Piris,
quelle que soit la cause qui lui ait donne lieu, et que les efforts seuls de la nature, lorsqu'ils
n'etaient  point contraries,  suffisaient pour la faire disparaitre en quelques semaincs ou en
quelques mois, selon sa situation, son volume, et la gravite des causes qui lui ont donnl
naissance."
  " Pour moi, une  gueMson obtenue par le  nitrate d'argent fondu, est une guerison ob-
tenue malgre' Pemploi  de ce caustique.  La nature  est  si habile!  Elle  resiste avec
tant d'e'nergie & Paction des mauvais moyens."—Traite des Maladies des Yeux, torn. i. p.
302—304. 
AFFECTIONS OF THE IRIS.
413
homely applications made and continued when admitted in the hospital.  The
iris at this time protruded, forming a small dark tumour, and the iris was drawn
towards the wound, rendering the pupil oval.
  The inflammation was first subdued by venesection, saline purgatives and
the usual antiphlogistic treatment;  and the prolapsed  iris was  then touched
with nit. argent.  Under this treatment, the pro-          fig. 21.
lapsed portion of the iris  shrunk, and eventually
the  wound  healed, and  the  patient  was  dis-
charged cured, on the  19th of December.  There
remained, however, permanent  adhesion of the
iris  to  the cornea, at the seat  of  the wound,
and the pupil was irregular, (see  fig. 21.)  Her
sight was, however, excellent,  and  the motions
of the iris, though limited, were not entirely de-
stroyed.]
  Prolapsus  iridis may cause unfavourable changes in the pupil, so as
either to impair or destroy vision.  The figure of the opening may be
rendered oval or elongated; the pupillary margin may be drawn out of
place so as  to contract or close the opening.  If, in  addition to such
displacement and contraction, there should be opacity of the neighbour-,
ing portion of the cornea, vision will be rendered very imperfect, or en-
tirely destroyed.   Sight may not be injured by a small protrusion  near
the margin of the cornea, above or on either side  of the pupil; while if
it take place towards  the centre, it may involve  the  entire pupil, and
thus cause blindness.   The pupil may be  closed  in consequence of a
prolapsus  at the edge of the cornea.   There may be two or more
protrusions, not only lessening the size of the pupil, but drawing it into
the form of a narrow  slit.
  The changes in the figure of the pupil, and in the state of its margin,
and the adhesions, which the iris contracts to the neighbouring  parts,
are considered  in Chapter XVII. on iritis.  The  adhesion of the  uvea
to the crystalline capsule  {synechia posterior) caused by iritis, and  that
of the iris to the cornea, which is at the same time generally opaque, in
common and purulent  ophthalmia, or after prolapsus  {synechia ante-
rior,) cannot be remedied by operation.  In these cases, however, espe-
cially if complicated with contraction of the pupil and the  formation of
adventitious membrane in its aperture, we  are often able  to render es-
sential service by the use of belladonna.   A small dilatation  will some-
times extend the edge of the pupil beyond the corneal opacity.  Even
in cases where  there is an adventitious membrane in the pupil, and its
margin appears at first sight adherent  throughout, it  has been often
found, on  applying the belladonna, that a small  portion of the  open-
ing has remained  free, and capable of dilatation, with great improve-
ment of si<*ht.   We ought not, therefore, to consider these  cases irre-
mediable; and  I  have often  been surprised  to find how well  patients
could see'through a  minute pupillary aperture.  I have  seen  patients
enjoyino- tolerable  vision, when the opening in the iris has not  been
larger than a small  pin's head.   In  these cases, if we find that the use
of belladonna will give the patient vision, or improve it, we must  em-
ploy it once in  twenty-four hours, to keep up its  effects  permanently.
This is the only remedy in some instances; others may be relieved by
making an artificial pupil.
 
114
AFFECTIONS OF THE IRIS.
          FUNGOUS EXCRESCENCES FROM THE IRIS AND CILIARY BODY.


   The following two cases occurred in the practice of Mr. Saunders.
  Case I.—Fungous excrescence from the iris and corpus ciliare, ulcerating and
 discharging: spontaneous cure, and atrophy of the globe.—In a girl ten years old,
 who was brought to the London Ophthalmic Infirmary, " the sclerotica was unusually
 vascular, but not inflamed.  The vessels were large and serpentine.  The iris, retired
 from its situation, seemed to be twice as far from the cornea as is natural.  The pupil was
 dilated, and the iris contained many distinct red vessels.  The cornea, the aqueous,
 crystalline, and vitreous humours were  at  this time transparent. In the course of a
 few weeks the crystalline  became opaque; the iris, covered with lymph, and as red
 as if injected, advanced towards and touched the cornea; shortly, a  blue excrescence
 was thrown out at the superior part of the eye, at that part of the sclerotica which unites
 with the ciliary ligament.  It increased rapidly, and became as large as  the anterior
 portion of the globe.  This tumour ulcerated; for a long time a thin watery fluid was
 discharged, then pus, and lymph, which trailed out through the aperture.   After some
 months this aperture closed, the eye-ball, much reduced in bulk, became tranquil, and
 even retained some vestiges of the cornea,  the blue excrescence being totally extinct.
 During the process there was nothing like  acute inflammation, and the pain was very
 trivial."*
  Case II.—Fungous growth proceeding from the iris: spontaneous cure.—" In
 1809, a boy about three years old was brought to the infirmary.   On the inferior part
 of the iris, a small patch of lymph  was deposited, the pupil was not  influenced by it,
 but varied as usual. There was no ophthalmia, nor any irritability from  exposure of
 the organ to light.  In a fortnight the mass of lymph was so much increased, that it
 occupied the inferior half of the anterior chamber.  Now a process of organization
 commenced in the lymph, and an action analogous  to inflammation was set up in the
 cornea; it became turbid and vascular, the  iris and cornea wasted, a blue mass arose
 in the situation of the ciliary ligament, which, together with the whole of the cornea,
 ulcerated or suppurated, and an ill-conditioned and very luxuriant fungus shot forth.
 By degrees this fungus diminished,  and finally the eye-ball healed."t
   Mr. MackenzieJ  has quoted from  a German work§ a case of fungous
 excrescence  from the iris, in  a weakly child, affected  at  the same time
 with caries of the foot.  A white elevation began at the pupillary, and ex-
 tended gradually to the ciliary edge  of the iris, approaching at the same
 time to the cornea.   After a considerable time the tumour was so much
 increased that it seemed likely to implicate the whole organ, and removal
 of the front of  the  eye-ball was  proposed.   The patient was not seen
 again  for  a year, when the globe had become atrophic, and the cornea
 constituted a white  cicatrix.
  From this and the  two preceding cases we may derive a salutary
 caution against  proceeding hastily to operation in such affections.   It
 may be confidently  expected  that the active disorder exemplified in the
 first two instances will  come to a natural conclusion  under mild anti-
phlogistic treatment, aided perhaps  by the moderate  use of  mercury.
In the more  chronic disease,  a  similar  natural termination  may be
looked for, under the  strengthening  and restorative  plan of diet  and
medicine, which is calculated to raise and uphold constitutional power.
  Mr.  Middlemore  mentions  fungoid growths  arising from prolapsed
 portions of iris,  and curable by nitrate of silver.*
  He  saw two small fungoid productions arising  from the iris, which

  * A Treatise on some practical points relating to Diseases of the Eye, &c.2d edition, p.
143» 144.                                 t Ibid, p. 144,145.
  X Practical Treatise, ed. 3, p. 602.
  § Jahrliche Beytrdge zur Vervollkommnung der Augenheilkunst, vol. i. p. 37.
  II Treatise, vol. i. p. 721.               as                r 
AFFECTIONS OF THE IRIS.
415
was in other respects quite healthy.   They were removed by mercury
administered internally, so as to produce its specific action.*
  Mr. Wardrop met with an  example of bleeding excrescence  from
the iris.  It was small, though of long standing, and extremely vascu-
lar ; for it often  bled profusely without any external cause, and would
quickly fill  the anterior chamber with blood.f   Mr. Middlemore heard
of a  similar case, in which the  swelling went away under the use of
mercury. J
  Tumours growing from the iris.—Some  years ago, in  a boy about
eight or nine years of age, I saw an apparently simple vascular growth
of a light brown colour,  equal in size to a large pea, proceeding from
the iris, without much redness or pain, and without opacity of the pupil.
It had caused ulceration  in the cornea, and thus appeared externally.
As the young patient was removed to his  residence in the country, I
did not witness the progress or termination of  the  case, but I was  in-
formed that the tumour subsided after a time, and that the eye shrunk
into its socket.   Mr. Mackenzie mentions the formation on the iris of
tubercles, which  he regards as scrofulous.   The eye generally becomes
atrophic in such  cases.§
  A boy had the cornea  injured by a particle of hot iron, which lodged
in the iris, causing severe inflammation, which was removed with diffi-
culty ; he recovered good vision.   Some months afterwards a cyst was
formed on the injured  part of the iris, without pain, and  acquired the
size of a pea.  It had a  rounded figure, and shining white surface.  It
was removed in  the London Ophthalmic Infirmary,||
  A similar cyst formed  on the front of the iris in a girl, some months
after the eye had been injured by a beard of corn.  As it  increased,
inflammation of  the eye was excited,  and thus excision became neces-
sary,  which was performed by Mr. Tyrrell.^!
  Mr. Mackenzie** saw a semi-transparent cyst formed on the iris in
consequence of a wound.   It did not increase, and gave no pain; it was
therefore left alone.
  Mr. M.  saw another case, in which a cyst, apparently originating in
the posterior chamber, came gradually through the iris, increasing in
size, and being painful.   It was punctured through the cornea, when a
little fluid escaped, and the cyst collapsed.  The  puncture was twice
repeated, and the cyst  did not fill again.  Vision was not injured.-f-f
  Myosis is a name given to unnatural contraction of the pupil.   This
is a frequent consequence of iritis, being usually accompanied with ad-
hesions, and irregularity  in the figure of the opening, and occasionally
with adventitious meinbrane obstructing it more or less  completely.  In
some  instances the imperfection  of vision, caused by  this state of the
pupil,  may be remedied or alleviated by the use of belladonna.
  Individuals, who employ their eyes  habitually on minute objects, often
have small pupils, yet  see  perfectly well;  and this state of the pupil
sometimes exists, where we see no cause for it.   Under such circum-
stances, the motions of the iris are limited.   Contracted pupil is some-

  * Treatise, vol. i. p. 722.                        t Essays, vol. ii. p. 49.
  X Treatise, vol. i. p. 722.                         $ Practical Treatise, p. 602.
  || Mr. Tyrreix's Work; vol.  i. p. 3G8, pi. 3, fig. 6.      1 Ibid, p. 3G9.
  «* Practical Treatise, ed.  3d, p. 602.               ft Ibid, p. 604. 
416
AFFECTIONS OF THE IRIS.
 times seen in conjunction with impaired vision.   The use of belladonna
 has but little effect on the opening, and does not improve vision.   The
 prospect is unfavourable in such cases.
   Mydriasis denotes the opposite or preternaturally dilated condition of
 the pupil.  Most frequently this is a symptom of amaurosis, and conse-
 quent on disease of the retina.  It has sometimes followed injury of the
 head, being then probably caused by affection of some part within the
 cranium.  As a temporary state, it is produced by the external appli-
 cation or internal use of certain narcotics.   (See Chapter XV. § 1.)
 It occurs, with  other symptoms, as an  effect of disease  affecting the
 nerve of the third  pair.  Such cases are alluded  to at p. 73.  It is some-
 times, but  rarely, seen without any other evidence of disease in  the
 organ.
   Mydriasis, when it exists alone,  or in conjunction with paralysis  of
 the muscles  supplied by the motor nerve, implies the existence of dis-
 ease in the ciliary system of nerves.   It is  usually connected with dis-
 order of the digestive organs.
   As the  dilatation  of the pupil is permanent, strong  lights  have a
 dazzling effect  on  the eye.   Distant objects are seen better than those
 which are near; but vision altogether is indistinct.   Sight is improved,
 so that patients can even read, by  looking through a small hole in a
 card; and this  circumstance distinguishes simple  mydriasis from the
 dilated pupil of amaurosis.   Convex glasses will improve the sight  of
 near objects.  Irritating applications to the surface of the eye are  said
 to cause contraction-of the pupil with improvement of sight.
   Curative proceedings must depend on what we  can discover respecting
 the nature and cause of the affection.  These points are obscure where
 mydriasis is the sole symptom.   In  such a case we shall often find the
 source of mischief in the digestive organs.   The employment of elec-
 tricity has been suggested.   A portion of blackened card, with a small
 central opening, corresponding to the natural size of the pupil might be
 fixed into a frame, and worn as a spectacle.  The  prognosis is favour-
 able in these cases.*
   [We have seen some cases in which the application to the eye of a few drops
 of a collyrium of acetate of strychnia, instantly contracted the pupil, so that the
 patients, who previously could not  distinguish letters  an inch long, were able to
 read promptly from  a book printed in type of the size  of the body of this work.
  M. Serres, of Uzes, employs a fine point of nitrate of silver which he applies
for a second to the cornea near its junction with the sclerotica,  and he reports
 some cases cured by this method.!
  Dr. Kochanowski, of Warsaw, relates a case cured by Ergot given in the dose
of three grains three times a-day, gradually increased  to twenty grains.  At the
 end of a few days the pupil had recovered its normal dimensions and the iris its
 natural contractility.}]
   Tremulous iris.—The  iris sometimes  loses its natural tension, be-
 comes flaccid, and oscillates backwards and forwards, when the globe
 is moved, like a rag in a bottle of water.   This movement is sometimes
 considerable and obvious; in other instances slighter, so that close ob-
 servation is necessary to  detect  it.   There is no apparent change  of

  * Such a case is related in the hondon Medical Gazette; vol. xxii. p. 68.
  [t Archives Generales, June, 1828, p. 307.]
  [1 Ibid, Nov. 1838, p. 351.] 
FORMATION OF AN ARTIFICIAL PUPIL.
417
structure.  The pupil does not contract and dilate, or only slightly, and
in sympathy with that of the other eye.  It is often combined wTith cata-
ract, which may exhibit a similar oscillation or vibration.  Vision is
generally lost or very imperfect.   In  a  few instances I have seen the
iris  tremulous, and that to a great degree, after the operation for cata-
ract, with good vision.
  The more frequent cause of the tremulous motion is a fluid state of
the  vitreous humour, under which the  natural support of the iris by the
parts behind is lost, so that it waves backwards and forwards when the
globe  is moved, in obedience to the impulse of the contained fluid.  As
this condition of the humour indicates disease of the internal parts in-
cluding the retina,  the tremulous state of the iris is  regarded as  a most
unfavourable  symptom.   When it occurs after cataract operations, it
probably depends on increase of the aqueous humour.
  I  may  be seen after serious injuries, and in other cases where we do
not  ascertain that  the vitreous humour is in a fluid state.   The cause is
obscure under such  circumstances.  The  affection itself is in all cases
irremediable.
                       CHAPTER XVIII.

              FORMATION OF AN ARTIFICIAL PUPIL.

         SECTION I.--GENERAL AND PRELIMINARY CONSIDERATIONS.

   When vision  has been destroyed or impaired by contraction, closure,
 or displacement of the pupil, or by such changes combined with obstruc-
 tion of the opening by an adventitious membrane, or an opaque capsule, or
 with synechia anterior, or with opacity of the cornea, relief may be given
 by enlarging the natural pupil, by making a new aperture for the passage
 of light through the iris, or by a combination of both these proceedings.
 The various methods employed for these purposes are called the ope-
 rations for artificial pupil, {conformatio pupillce artificialis; coremor-
 phosis, from z°?*> pupil, and ^o^ou-^-, formation.)
   Although the first attempts of this kind were made in the earlier part
 of the last century, the operation was not  much practised till towards
 its very close; since which period so much attention has been paid to
 it, so many  persons have investigated and attempted to improve it, that
 the methods of proceeding, and the instrumental apparatus, are perhaps
 more diversified than in any other  surgical operation.  The latter  cir-
 cumstances  are partly accounted for by the differences in the states of
 the eye  requiring operative assistance, partly by that  desire of pro-
 ducing something new, which often leads us to neglect what is simple and
 sufficient, for more complicated, but less advantageous proceedings.
  The changes in the state of the eye, requiring the formation of an
artificial aperture, through which light may gain  admission into the in-
       53 
418
FORMATION OF AN ARTIFICIAL PUPIL.
terior of the organ, are numerous and various, and cannot all be com-
prehended under the common expression, closure of the pupil; although
such closure, or rather obstruction of the aperture, direct or indirect,
must exist whenever the operation is required.  Some of these changes
are seated in the cornea, others in the cornea and iris;  several in the
iris alone;  some in the capsule  and lens as well as  in the iris; while
others involve at one and the same  time, the cornea, iris, capsule, and
lens.
  Although we speak of the operation for artificial pupil in the singular
number, a mere glance at the subject will suffice to show that no  one
operation can be suited to the various morbid conditions of these several
organs, which  interfere, more or less seriously, with the passage of light
into the posterior part of the  globe.  It is not our object to compare the
various proceedings with the view of finding which is generally prefera-
ble ; the attempt at  devising any one method that would  be  applicable
in all cases, would be manifestly  absurd.  We must  carefully examine
the several states of the organ, in order to determine which mode of
proceeding may be preferable in each instance.
             STATES OF THE EYE, REQUIRING THE OPERATION.

  The following are the conditions of the organ to which the operation
for artificial pupil is applicable.
   1. Simple closure of the  pupil, consequent on acute  iritis, without
opacity of the lens or capsule.   This is a rare occurrence; and it must
be difficult to ascertain  that the lens and  capsule have undergone no
change.
  2. Closure  of the pupil by  an  adventitious  membrane, {occlusio
pupillce lymphatica.)   Such a state may be the result of the different
operations for cataract; that  is, of extraction, depression, reclination,
or the operation by absorption;  or it may remain after iritis, when it
occurs from internal causes, as in the idiopathic, arthritic, or syphilitic
kinds.
  3. Closure of the pupil, with  adhesion of its margin  to an opaque
capsule, the lens being at the same time generally, if not always, opaque,
{occlusio pupillce cum synechia  posteriori.)   This is a consequence of
iritis.
  In the cases now enumerated, the  cornea and anterior chamber are
usually natural, and the fibres of the iris are more or less on the stretch.
  4. Contraction or closure of the pupil, with synechia anterior, from
prolapsus iridis,  either  through wound or ulcer of the cornea.  A pro-
lapsus near the centre of the cornea may include the whole  pupil, and
thus completely  destroy sight.   In such a case the cornea is leucoma-
tous in its centre, transparent in the circumference;  the  fibres  of the
iris are stretched from the  ciliary margin to  the  edge of the leucoma,
and either in contact with the transparent portion of  the cornea or sepa-
rated from it by  the smallest interval.  The entire pupil may be involved
in a prolapsus more or less near to the circumference of the  cornea, or
at its very edge; the fibres of the iris are tightly  stretched between the
opacity and the  most distant part of the corneal margin, and a  larger 
FORMATION OF AN ARTIFICIAL PUPIL.
419
 anterior chamber is left in the same situation.   If the prolapsus should
 have included a part only of the pupillary margin, or a portion of the
 iris  near the pupil, the aperture may be merely displaced, or contracted
 and altered in figure, yet the passage of light through it may be more
 or less effectually impeded by the opaque cicatrix, which remains after
 the  wound or ulcer has  healed.   If a large portion should  have been
 protruded, the fibres of the iris must be tightly  stretched from the cili-
 ary margin to the situation of their adhesion to the  cornea;  they  are
 more or Jess tense in all  cases of contracted or  closed  pupil from pro-
 lapsus iridis.
   5. Contraction or closure of the pupil from partial staphyloma.
   6. Obstruction  of  the  pupil by  central  leucoma, the  iris and other
 parts being natural.  The  effect on vision of central corneal opacity
 will vary according to its extent.   If  it is  small, for instance, not  ex-
 ceeding one-third  of the  diameter of the cornea, the patient may enjoy
 good vision when the pupil is dilated either in  a  moderate light, or by
 the use of belladonna;  and an operation would   not then be advisable.
 If the leucoma should extend to two-thirds of the  diameter, there will
 be no useful vision, and an operation will be required.
   7. Obstruction of the pupil by synechia anterior and partial leucoma.
 The anterior adhesion  may embrace the whole  pupillary margin, with
 complete  obstruction  by the  accompanying leucoma, and blindness.
 The adhesion maybe partial, and the obstruction of the contracted and
 misshapen pupil may be  partial also.   The effect on vision will depend
 materially on the  situation of the adhesion, and  of the leucoma; if they
 are  above the natural situation of the pupil, or on either side of it, they
 may not interfere much with vision; if below, the  effect will  be more
 injurious.  In partial synechia anterior, the pupil may sometimes be so
 much enlarged by the use of belladonna, as to give good sight.
   8. Central leucoma, with closed pupil,  or synechia  posterior, and
 opaque capsule.
   9. Partial opacity of the cornea, with synechia anterior  and cata-
 ract.
   I  have never seen the  congenital closure of the  pupil from continu-
ance of the membrana pupillaris, {imperforatio pupillce,*) which is men-
tioned bv  some writers.

  * "I believe," says Beer, "that I have hitherto  seen  only  once a truly congenital
closure of the pupil, that is, an  iris remaining completely imperforate after birth.  In the
sixth week the pupil had become open without any interference of art. I have, however,
seen  in  newly-born  infants, when a few days old, closed pupil; but careful inquiry has
shown, in all such instances, that it was the consequence of irilis, produced in a few hours
after  birth, by exposure to strong lights, and neglected."—hehre, vol. ii. p. 190, note.
  Juengken enumerates it among the conditions of the eye  requiring operation, adding
that it is of very rare occurrence.—Die hehre von den Augenoperalionen, p. 628.
  So  far  as  my researches have gone, there is no evidence of the membrana pupillaris
having ever been found perfect  even a few  days  after birth; and I believe that no record
exists of  any case in which an operation has been performed on it.  Dr.  Jacob gives the
following account of its disappearance:—" The  period now approaches when it is to dis.
appear;  this occurrence takes place, according to my observations, a short time  previous
or subsequent to birth.  In every instance where I have made the examination, I have found
the membrana pupillaris existing in  a greater or less degree of perfection  in the new-born
infant; frequently perfect without the smallest breach, sometimes presenting ragged aper-
tures in several places; and, in  other instances, nothing existing but a remnant hanging
across the pupil like a cobweb.   I have even succeeded in injecting a single vessel in the 
420               FORMATION OF AN ARTIFICIAL PUPIL.

  Diagnosis.—Before we undertake to form an artificial pupil, we must
satisfy ourselves that the morbid state of the organ cannot be remedied
by any other means.   Opacities of the cornea may often be diminished
by external applications.  The adventitious membrane closing the pupil
may be lessened by absorption in recent cases.   The use of belladonna
may improve sight, or even render it perfect in partial  synechia, ante-
rior or posterior.
  The operation merely provides for the admission of light into the eye:
it will not  restore sight unless the organ be  in other respects healthy.
A  careful  inquiry is  therefore necessary to  ascertain  that no olher
change has taken  place in the eye capable of frustrating the success of
the operation.  The various conditions of the organ, enumerated above
as requiring the formation of an artificial pupil, are mostly the conse-
quences of  severe inflammation, either external or internal.  This in-
flammation may not have been confined to the cornea, iris, and capsule
of the crystalline; it will be found, in many instances, to have extended
to the nervous structure of the eye, or to other parts of the organ.  We
must  ascertain whether the  loss of vision  is produced by the changes in
the pupil only, before we  think of forming a new opening for the  pas-
sage of light.
  Our first step  then must be  a careful  examination of the organ,  in
which attention  must be directed to the condition of its various compo-
nent parts.  The colour and texture of the iris must be observed; these
are changed by inflammation, and the alteration may be  detected by
comparing  the affected with the sound eye.  A blue or grey iris may.
exhibit  a greenish or yellowish discolouration; a brown one may be-
come of a  dull bluish or leaden colour; the unnatural tint may be gene-
ral, or in  variously sized  and  shaped spots or patches.   The fibrous
texture may have disappeared, and  whitish  threads may  be  seen  in
various parts of the iris, with the spotted discolouration just mentioned.
The natural brilliancy of  the organ is gone.  Under such changes the
texture of the iris loses its natural softness and contractility; it becomes
tough, thick, and incapable  of motion.  In other instances it is unnatu-
rally thin and semi-transparent.  If the inner circle only be changed  in
colour, it  is not of  much consequence;   but if the alteration extend
through the whole iris, it is  unfavourable.   If change of texture should
be equally extensive, and  occupy the whole of the greater or ciliary
circle, it is probable that the inflammation extended beyond  the iris, and
that the ciliary body and  other  posterior parts of  the  globe have  suf-
fered.   We must observe whether the iris preserves its natural position
and uniform surface, or whether it bulges forwards, and is elevated into
tubercular  projections,  separated  by intervening constrictions.  If it
form a convexity in  the anterior chamber, pushing against the cornea
at its  outer circle,  and drawn in at the pupil, which adheres in its whole
margin; and if its surface be puckered and irregular, it will have been
so changed in texture, as  to render the operation impracticable; while
the retina will have undergone such alteration as to make the  opening,

membrana pupillaris of the ninth month.  Where I have examined it in subjects who have
lived for a week or fortnight after  birth, as proved by the umbilicus being healed, I  have
uniformly found a few shreds still remaining."—Medico-chirurgical Transactions, vol, xii.
p. 515, 516, 
FORMATION OF AN ARTIFICIAL PUPIL.
421
even if one could be formed, totally useless.  Simple bulging of the iris,
without change of colour or texture, does not absolutely contra-indicate
the operation;  though, as it implies  a  diseased state of parts behind, it
is an unfavourable circumstance.   The pupil is  closed when the iris is
thus pushed forwards, and the bulging  may depend  on accumulation of
aqueous fluid behind.   The effect of opening the pupil with the needle,
and thus re-establishing the communication between the two chambers
may be tried in such a case, if the state of the retina should  hold  out
any encouragement to an operation.
   The globe should have its natural size and consistence, being neither
enlarged by dropsy, nor shrunk and flaccid from atrophy.   No benefit
can be expected from the operation if there  should be either  hydroph-
thalmia, or a soft and diminished globe.
   Softness of the eye-ball, without diminution  of bulk, especially if ac-
companied by  a tremulous  state of  the iris, denotes synchisis, or disor-
ganized vitreous humour, with which insensibility of the retina is usually,
but not necessarily, connected.  If the state of vision should be favour-
able, the operation may be undertaken in such a case, although  the
flaccidity of the organ may occasion  additional  difficulty in the execu-
tion, and the chance of benefit is small.*
   Absorption of the sclerotica in the neighbourhood  of the corpus ciliare,
giving the globe a bluish or leaden colour  at that part, staphylomatous
protrusions  of  the sclerotica,  and a varicous state of  the external  ves-
sels, indicate serious disorganization of the internal parts of the  globe,
with insensibility of the retina.
   We must examine further whether the retina  possesses a  clearly
marked sensibility to light; for without that  no benefit can be expected
from the operation.   It might be supposed that closure of the pupil, with
opacity of the  capsule, would  prevent the passage of light  to the retina,
and thus deprive us of direct evidence respecting its sensibility.   How-
ever, light is transmitted in sufficient quantity for this purpose.   If the

  * Sir William Adams speaks more favourably of these cases.  " When the vitreous hu-
mour is transparent, its partial or total disorganization does not appear  materially to affect
vision.  For after  the caiaract has  been removed, or the artificial pupil formed, vision
appears to be equally good, as if no such morbid change had taken place."—Treatise, on
Artificial Pupil, 8fc. p. 117.
  " In several  cases, where from  the fluidity of the vitreous humour, it has escaped so
abundantly during the operation, through the puncture made by  the needle, as to occasion
almost an entire collapse of the coats of the eye; yet, after its regeneration, the patient's
vision has been restored as perfectly as is usual after the operation for cataract."—Ibid,
p. 117, 118. .
  " Even when so much of the vitreous humour is absorbed, as  to occasion a flaccid and
diminished condition  of the eye, I have in several instances operated with perfect success,
both in the removal of cataract, and  in the formation of an  artificial  pupil.  Indeed, the
success which  has attended the operations for artificial pupil  in these morbid states of the
eye has frequently excited my surprise. For in several  cases which have scarcely offered
a sufficiently favourable prospect to justify the performance of an operation, but which, at
the urgent  importunity of the patient, I have executed, almost contrary to my judgment,
the happiest results have nevertheless been obtained.  In the case of a young lady who
had been for many years a patient of the late Mr. Ware, I actually refused, from the soft
state of her eye, to operate upon it.  But encouraged by my success upon cases of a simi-
lar kind, I again sent for her to town to undergo the operation for  artificial pupil, which
in one eye terminated in the most favourable manner, the patient being enabled to see the
minutest objects.  An artificial pupil  was formed with equal  success in the other eye, but
the retina had lost  its sensibility."—Ibid, p. 119, 120. 
422
FORMATION OF AN ARTIFICIAL PUPIL.
 pupil be closed, and the lens and capsule opaque, the patient can still
 distinguish light from darkness, if the retina is  unaffected.   If the pa-
 tient, therefore, cannot  make  that distinction, we may conclude that
 the eye is amaurotic, and the operation consequently hopeless.  In many
 of  the  conditions requiring the operation for artificial pupil, a much
 greater degree of vision  exists.
  These various points must be inquired into, that we may inform the
 patient whether an operation is likely to be successful or otherwise.   It
 is our duty to represent to him accurately the state of the case.   We can
 recommend the operation only where we think that it will be of advan-
 tage.  Some states of the eye, however, are unfavourable without being
 hopeless.  Under such circumstances, the patient may be inclined to try
 the experiment of a doubtful operation, rather than submit without  an
 effort to permanent blindness.
  The presence of external or internal inflammation, in  any degree,
 absolutely contra-indicates the operation, so long as it continues.  When
 the organ is thus excited, the additional irritation of mechanical vio-
 lence would aggravate  the inflammatory disorder, and thus  probably
 increase the evils which  the operation  was designed to remedy.
  A good state of health is  necessary to the  success  of the operation,
 which must not be thought of so long as any constitutional disease, such
 as gout or rheumatism is in activity.
  " The formation of an artificial pupil," says Beer, " without reference
 to the particular mode of proceeding, is indicated in those cases only,
 in which the blindness is caused merely  by the closure or  the obstruc-
 tion of  the normal pupil; when the  sensibility to light is unequivocal;
 when no other deviations exist  from  the  natural form and structure  of
 the globe, which might render the operation extremely difficult or im-
 practicable; when the previous inflammation has been lona: and com-
 pletely terminated; when the patient is, in other respects healthy, and
 does not  show even  any marks of previous scrofulous, syphilitic, or
 arthritic disease; and when, moreover, he is  completely blind  in both
 eyes."  (Lehre, vol. ii. p. 196.)   From the previous statement respect-
 ing sensibility to light, it is obvious that the last observation is not to be
 taken strictly, but that it must be understood  as importing the absence
 of useful vision.
  Prognosis.—A serious  wound is inflicted in this operation on the most
 sensible texture of the eye; considerable inflammatory re-action may
 be expected, and  the results cannot be estimated with much certainty
 beforehand.   Generally speaking, the necessity for the operation arises
 out of disorders originally inflammatory; and the eyes, on which it is
 performed, having suffered much from wounds or violent inflammations,
are rendered more susceptible of injury,  and more likely to suffer from
future attacks.   Hence it is difficult to determine the probable conse-
quences of an operation.  " We cannot," says Juengken, " satisfy our-
selves respecting the state of the posterior structures, particularly in the
cases in which the natural pupil is completely  closed.  Instances occur
in which we conclude with  great probability that the vitreous humour
and retina are healthy; yet it turns out afterwards that they are not so.
 I have observed cases  of the kind, in which, although there was a distinct 
FORMATION OF AN ARTIFICIAL PUPIL.
423
 perception of light, the posterior parts of the globe were altered in tex-
 ture as the result of  the operation proved.*
   The operation is often performed on eyes, in which the lens has been
 already lost; while we are frequently obliged to make  the new pupil in
 a situation disadvantageous for vision.   These are two sources of im-
 perfection in the subsequent state of the sense.
   The new opening is not susceptible of those changes in its dimensions,
 which occur in the normal pupil.  On this  point, Mr. Gibson says, " I
 have paid considerable attention to the state of the artificial pupil, after
 the  eye has quite recovered, in order to ascertain whether the fibres of
 the  iris possess any power of  motion, so as to alter the size of the new
 opening; but have never  been able  to detect any thing  similar to the
 contraction and dilatation of the natural pupil."f
   Again, there are often niceties and difficulties in the execution of the
 operation, which are increased by the  involuntary motions and unstea-
 diness of the patient.   Hence we must  be very guarded in our promises
 as to the result of the proceeding.   In  some rare instances, in which
 the  eye has not suffered much, in which the lens and capsule are entire,
 and not injured by the operation, perfect sight may be restored.   But,
 generally speaking, the result of this proceeding is tnuch less favourable
 than that of cataract operations.  In many instances, the patient must
 be contented if he should be able to see large objects, and to find his way
 alone.
   Mr. Gibson observes, that "the degree of vision restored by an opera-
 tion of this kind, is not quite so  perfect as that which  succeeds the re-
 moval of a cataract.  In most  cases, however, when the  cornea has
 been perfectly transparent to the full  extent of one-third of its diameter,
 the  patient has been  able  to read tolerably small print.   In looking at
 any thing, the direction  of the eye and position of the head are some-
 what  altered,  and the object viewed  is  not held directly before the
 eye.   Thus the artificial pupil, when  formed towards the external angle
 of the eye, is turned  by the motion of that organ more towards the in-
 ternal  angle, so as to  bring that side of  the eye somewhat forwards, and
 to produce a squint.  And when an object, as a watch, is taken into the
 hand to be  viewed, it is not held, as  in the natural state of the eye, di-
 rectly  before the  observer, but a little to one side.   This alteration in
 the direction of the eye, and in the situation of the object viewed, is evi-
 dently the result  of experience;  for a person having an artificial pupil
 situated towards the external angle  of the eye, can discern  an  object
 placed directly before him ; but  he sees it indistinctly, as another per-
 son,  whose  eyes  are  perfect, discerns  objects inaccurately which  are
 placed aside whilst the eye is directed to objects before him. The reason
 of this appears to be, that the rays of light passing from oblique objects, or
 entering the eye with great obliquity, do not reach the retina in suffi-
 cient quantity to  render Vision  distinct.  This indistinctness the patient
 attempts to  remove, by placing the object in different situations, and by
varying,  at  the same  time, the  position  of the eye and head, until he at
* hehre, von den Augenoperationen, p. 361.
t Practical Observations on the formation of an Artificial Pupil, p. 49, 50. 
424
FORMATION OF AN ARTIFICIAL PUPIL.
 length discovers the exact position of the eye and object most condu-
 cive to distinct vision.  (Lib. cit. p. 47—49.)
    The prognosis is more  favourable in proportion as the imperfection
 or loss of vision is simply dependent on obstruction of the pupil, and as
 the iris itself, the cornea,  and other parts of the organ are sound.   The
 best cases, therefore, are those of central leucoma  with healthy iris and
 unadherent pupil, of partial synechia anterior, and of pupils contracted
 or closed from prolapsus  of  the iris through the wound  or ulcer of the
 cornea.  In those which are usually the results of common inflammation
 affecting the external tunics, if we  except the changes requiring  the
 operation, the globe is perfectly healthy.  Closure of the pupil  after
 operations for cataract is  also a favourable case, especially after extrac-
 tion : in the serious internal inflammation, which sometimes follows de-
 pression and reclination, the posterior tunics generally are often involved.
 Iritis  and other internal inflammations do not come on in  healthy con-
 stitutions.  Hence, when  the pupil has been closed under such circum-
 stances, the operation itself may cause a return of the original disease
 with renewed effusion of lymph.  The prognosis is bad when the iris is
 changed in colour and texture throughout, and still wrorse if it is also
 convex on-Jts anterior surface, tuberculated and puckered.
   The prospect of benefit  from the operation is influenced by the extent
 of the organic changes in the cornea and iris, which render it necessary.
 It is better in proportion as more of the cornea remains transparent, and
 more  of  the iris and pupil unadherent.   If the clear portion of the for-
 mer, and the free part of the  iris, are less than one third of the whole,
 the result will be doubtful.
   Position  of the artificial pupil.—The  situation  and size of the  new
 opening must be taken into consideration.  The nearer it is to the cen-
 tre of the iris, the better will the patient see:  the more it  approaches to
 the circumference, the  more imperfect will vision be,  both because the
 rays of light fall on a part of the retina naturally  less sensible, and be-
 cause the patient must learn to squint more or less, in order to bring the
 eye into the best direction  for vision.
   A further reason against making an  artificial pupil at the greater cir-
 cumference of the iris, is derived from the position of the ciliary processes,
 the anterior extremities of  which are placed behind this part of the iris,
 and would therefore partially obstruct the new7 opening.  This  point has
 been particularly insisted  upon by Scarpa.   " Another rule," says he,
 "no less important to be followed in these cases, is, that the lateral pu-
 pil, although necessarily instituted in the semi-diameter of the iris,  be
 always at a sufficient distance from the corpus ciliare, that  this  part
 may not render the  operation  useless by intercepting  the passage  of
 light through the new pupil.   All, who are acquainted with  the struc-
 ture of the eye, know that  the corpus ciliare, with its processes, is  pro-
 longed from the ciliary  ligament to the  circumference  of the capsule of
the crystalline lens behind the  great margin of the iris, extending  to
about a fourth of the length of the  semi-diameter of the membrane,
from this ciliary ligament towards the centre of the iris.  Every artifi-
cial pupil, therefore, which is not made at such a distance from the great
 margin of the iris, and consequently from the  corpus  ciliare,  that the 
FORMATION OF AN ARTIFICIAL PUPIL.
425
apex at least of the triangular aperture may correspond directly to the
circumference, which would have been occupied by the capsule of the
crystalline, must be  useless.*
  In general, sight will be better, the larger we can make  the  new
pupil.  The artificial opening has in most cases a disposition to contract
or close:  it is formed in a part where there is no natural aperture, and
as attempts are generally made to repair the consequences of injury, we
may expect that the new opening in the iris will become smaller after
the operation.   The iritis  consequent on the  injury increases the con-
traction, which  sometimes proceeds  to entire closure.  " The perma-
nency of  the artificial pupil," says Mr. Gibson,  " appears to me to de-
pend principally upon the size of the opening, and healthy state of the
iris and contiguous parts of the eye, at the time of the operation.  When
the artificial pupil has been made almost  as  large as the medium size
of the natural one, and especially when the part of the iris removed has
included its border, I have never seen any  disposition in the opening to
close.  When, however, a mere narrow slip has been removed ;  when
the iris, from  previous inflammation, has  become more vascular than
natural, or when it is complicated with adhesions to the capsule of the
crystalline lens, in such cases its closure has occasionally taken place."f
  The prognosis is most favourable when  the purposes of the operation
are accomplished by a simple clean cut of the iris; forcible detachment
of it from the ciliary body, with laceration, protrusion, and strangula-
tion of the part, is a more serious kind of injury, from which inflamma-
tion is more likely to result.
  Previous considerations.—When one eye is sound, it is not advisable
to operate on the other.  Vision, with an  artificial pupil, is imperfect,
compared to natural sight; hence the patient continues to  use his sound
eye, so that he is no better off afler the operation than  he was  before,
even if it  should succeed.  The  apprehension  has been expressed, that
the imperfect sight on the operated side might confuse that of the good
eye.J
  When the  sight of one eye has been irrecoverably lost, our decision
respecting the  propriety of performing the operation for artificial pupil
on the other, must be regulated by the degree of its vision.  If the pa-
tient can  see large  objects, and  find his way without a guide, it would
be hazardous to operate, because blindness sometimes results from the
operation, particularly  where the  eye has already been  seriously and
repeatedly diseased.   If there is no  useful sight, the experiment may
be tried, as the  patient cannot be rendered  worse.
  " When both  eyes," says Mr. Gibson, "have happened to be similarly
affected with opacity of the  cornea, I have found it of little use to the
patient, to form an artificial pupil in each.   For when the vision of one
eye, after the operation, is more  perfect than  that  of the  other, the
patient (as in many cases of defective vision) acquires the habit of using

  *  Treatise, &c. p. 312, 383.
  t  Practical Observations on the formation of an Artificial Pupil, p. 47.
  X  "To form an artificial pupil in one eye, when the other is perfect,  is quite superflu-
ous, by no  means advantageous  to  the patient, and  therefore a thankless undertaking.
After such an operation, the patient would be obliged to keep the eye closed, in order to
see well, because its axis does not correspond to that of the other."—Beer, hehre, vol. ii.
p. 196, note. I  doubt the correctness of the latter statement.
       54 
426
FORMATION OF AN ARTIFICIAL PUPIL.
the more perfect eye, and entirely neglects the other.  When, therefore,
I meet with defect in both eyes from opacity, I select the more perfect
for the subject of an operation."*
   The situation  of the new pupil is often determined by the  nature of
the case;  as the artificial opening must be made opposite to such part of
the cornea as retains its transparency.  Certain positions, however, being
more advantageous  than others, are to  be preferred, when we have  a
choice.  The middle of the iris is the best place, as the axis of the new
opening then corresponds to that  of  the natural pupil.   When a lateral
opening is to be made, in consequence of the circumference of the cor-
nea only remaining  transparent,  the nasal  side of the iris  should be
chosen on the level of  the natural pupil; then comes the temporal side.
The normal place of the opening is nearer to the nasal than to the tem-
poral edge of the cornea;  the axis  of  vision, therefore, with a pupil in
the former situation, coincides more nearly with that of the perfect eye,
than when it occupies the latter place.   The next best situation is the
lower and outer part of the iris, after which comes the lower; but the
optic axis then  deviates widely from its natural direction.   The  least
favourable position is  above; for a pupil is not  of much use here, as
the upper  eye-lid interferes with it, so that the eye must be turned down-
wards, and even then sight is imperfect.
   When circumstances permit, Mr. Gibson prefers the external angle
of the eye for the new  pupil, alleging, " that instruments can be used in
this part with more facility than  in any other part of  the cornea; and
every advantage is at the same time derived from the operation.  When
this part of the eye has been found opaque,  I have formed the pupil, in
several cases both at the inferior  part of the  cornea, and towards the
internal angle of the  eye.   I did not, however, observe, that my patients
saw at all more  distinctly; on the  contrary, when the artificial pupil
was formed towards the interna]  angle of the eye, the sight in my opi-
nion was  less extensive; the nose appearing in some measure to curtail
the field of vision.  I  prefer, therefore, the operation at the external
angle in all convenient cases; and if the patients  are  enabled to read
with more certainty  by this mode than any other, they can have  little
reason to  be dissatisfied with the slight squint of which it mav be produc-
tive.f"
   The reasons for making the artificial opening  large have been al-
ready mentioned.  In the majority of cases we should  make it as large
as we can: in some few instances we must  be  on our  guard not to
make it too ample.  JuengkenJ says, that it will  never be too large if
it extends to one-third of the diameter of the iris.  Rosas§ observes, that
in order to secure  a permanent opening of sufficient magnitude, the new
pupil ought to be  made rather larger than the middle size of the nor-
mal one;  that it would be improper to make it much larger, and to ex-
tend it beyond one-third  of the iris, since the impulse of light would be
too powerful, and would destroy the sensibility of the retina.
   Since the changes of structure, requiring the operation for artificial
pupil are generally caused by severe or repeated inflammations, which

       * Lib. cit. p. 51.                          t Lib. cit. p. 50, 51.
       X hehre von den Augenoperationen, p. 635.
       § Handbuch, vol. iii. p. 333. 
FORMATION OF AN ARTIFICIAL PUPIL.
427
  leave the organ more susceptible of future  attacks;  and since the vio-
  lence inflicted on the iris in the operation is a serious exciting cause of
  inflammatory disorder, we should  omit  no  precaution  calculated  to
  prevent its occurrence.  We must  carefully prepare the patient before,
  and  watch the case  closely, after the operation.   The observations on
  these points,  in reference to the operation  for cataract, are equally ap-
  plicable  to  that  of  artificial  pupil:  the  only difference is, that  the
  greater probability of inflammation requires greater care in  the latter
  instance.
    Various operations.—The differences in the states of the eye, which
  render the formation of an artificial pupil necessary, require correspond-
  ing diversities in the mode  of accomplishing the purpose.  The combi-
  nations of the various derangements already specified are so numerous,
  that  almost every  case  presents something peculiar  and  individual.
  Hence the methods, which  have either  been  practised, or devised  and
  described, are very numerous.   Mr. Guthrie mentions nearly fifty in
  his work* on this subject; and the list might now  be augmented.  I do
  not  deem it necessary  or advantageous to  enter   into all these details,
  and  shall therefore confine  myself to the general plans of proceeding
  without considering all the  modifications which may be required in par-
  ticular cases.

   * A Treatise on the operations for the formation of an Artificial pupil; London, 1819.
 Also, hectures on the operative surgery of the Eye, 1827.
   The following works may be  consulted:—Gibson, Practical observations on the forma-
 tion of an artificial Pupil, &,c. London, 1811.  Sin William Adams, Practical Observations
 on Ectropium, on the modes of forming an Artificial Pupil, &c. 1814. Silt William Adams,
  Treatise on  Artificial Pupil, in which is described  a series of improved operations for its
 formation, &c. 1819.   Observations on the operation for Artificial Pupil, illustrated by
 cases and engravings; by E. Rvan, M.D. in the second  volume of the Dublin Hospital re-
 ports and communications in Medicine and Surgery. J. A. Schmidt, Ueber Pupillenbildung
 mittelst Einschneidung der Iris {coretotomia) mittelst Ausschneidung der Iris (coretonecto-
 mia) und mittelst Ablosung der his (coretodialysis} nebst einem Zusatze von K. Himlt;
 in Himly und Schmidt's Ophthalmologische Bibliothek,  vol. ii. p. 1. Beer, Ansicht der sta-
 phylomatosen Metamorphose des Auges, und der kunstlichen Pupillenbildung, Wien, 1805.
 Nachtrag.  1806. Beer, Lchre der Augenkrankheiten, vol. ii. section iii. chap. ix.  Lan-
 gf.nbeck, Ueber Pupillenbildung, in Neue Chir. Bibl.vo\. i. 197.  Nachtrag zur kunstlichen
 Pupillenbildung,  ibid,  p. 676. Sghlagintwfit, Ueber den gegenwdrtigen  Zustand  der
 kunstlichen Pupillenbildung in  Deutschland; Miinieh, 1818.   Wagner de  coremorphosi
 sistens brevem methodorum ad Pupilla artificialis  conformation em hucusque adhibitoium,
 adumbrationem, S(C. Brunswick, 1818.  Krohn de Iridodialysis operations, instrumentisque
 inea adhibendis;  IJerlin, 1826, 4to.  Assalini, Ricerche suite Pupille artificiali con cinque
 tavole incise in rame e colorite; Milan, 1811, 4to, 2nd  edition, 1^*18.   Donegana, Delia Pu-
 pilla artificiale ragionamento corredalo di osservnzioni, e rami; Milan, 1809, 8vo.  Quadri
 annotazioni pratiche sulle Malattie degli Occhi; Naples, 1819, 4to.  Wagner, Kritxsche Re-
 vision der neueren  Verhandlungen iiber die kunstlichen Pupillenbildung in (»raefk und
 Walther's Journal,  vol. iii. 1822.  Juengken, hehre von den Augenoperationen; Berlin,
 1829.   Kap. 22.  Rosas, Handbuch, vol. iii. § 390—442.
   In his Chirurgische Kupfertafeln, Dr. L. F. Von Froriep has delineated all the various
 instruments hitherto devised for the operation of artificial pupil, and has given other figures
 relating to the same subject.  Several instruments used in incision and excision of the iris
 are represented in Plate 193, Part 39.   The numerous figures of Plate 199, Part 40, relate
 to the operations by excision and separation.  Plates 228 and 229, in Part 45, arc devoted
to the same subject.   Plates 270, iu Part  53, exhibits the instruments employed by Lu-
sardi, and described in his Memoire sur la Cataracte conginiak, &c. Paris, 1827.  The
Plates above  mentioned contain also numerous figures representing the appearances of the
pupils before and  after  operation in several cases.  The methods of operating are  men-
tioned at  more or less length in the description of the figures. 
428
FORMATION OF AN ARTIFICIAL PUPIL.
OPERATIONS.
Fig. 22.
   There are three principal methods, viz, incision, excision, and separa-
tion, to one or the other of which, or to a combination of them, all the
proceedings hitherto proposed, however apparently  various, may be re-
ferred.

section n.—operation  by  incision; koretomia, (from  *»?»,  pupil, and
                       Toy-n, section;) iridotomia.

                     Synonymes: Corotomia, coretotomia.

   Method of Cheselden.—Cheselden has shortly mentioned, in the Phi-
losophical Transnctions, a proceeding which he adopted in two instances
of closed pupil following the operation  of depression.   He introduced a
narrow knife, or, as he calls it, " a sort of needle, with an edge on one
side," through the sclerotica, as in the  ordinary operation of couching,
and then brought it forwards, through  the iris  into the anterior cham-
                                ber.   " This done,"  says he,  ",I  turn
                                the edge of the needle, and cut through
                                the iris as 1 draw  it  out."*
                                   [Fig. 22, represents the artificial pupil,
                                in Cheselden's first operation.  It is copied
                                from the figure given in the Philos. Trans.,
                                (fig. 67.)  The artificial pupil, as will be
                                perceived, is formed  above the centre of
                                the iris, and  this  was done to  avoid the
                                lens, as Cheselden did not  know how low
                                he might have depressed it in the opera-
                                tion of couching,  which had  led to the
                                closure of the natural pupil. In his second
                                case, for reasons which he does  not men-
tion, he formed the artificial pupil below the centre of the iris.l
   Wenzel's operation.—Baron Wenzel, having employed the method of
                        Cheselden without success, adopted  a  different
                        proceeding, in which incision of the iris  was per-
                        formed through the cornea, and was combined
                        with excision.    He made  an opening of the cor-
                        nea with  the cataract  knife, as  in extraction;
                        but  after  puncturing this part, he carried the
                        point of the knife through the iris, then brought
                        it out again into the anterior chamber at a short
                        distance from the point of entrance, and subse-
                        quently completed the corneal section,  as in ex-
                        traction,  thus  at the same time dividing  the
                        iris, so as  to make a small flap, [fig. 23,] which
                        is then cut off  by  a  small  scissors introduced
                        under the cornea.  {Treatise  on  the  Cataract,
translated by  Mr. Ware, sect. 27.)
Fig. 23.
J
  * Philos. Trans. No. 402, p. 451.  Philos. Trans, abridged, vol. vii. p. 493.  The two
pupils, which are elliptical and transverse, are represented in figs. 67 and  68.  Fig 69
represents the eye  with the  instrument carried through the sclerotica.  The latter figure 
FORMATION OF AN ARTIFICIAL PUPIL.
429
  Janin's operation.—Janin tried the operation of Cheselden unsuccess-
fully.   The fibres of the iris did not retract, so  that  the incision which
he had made appeared as a simple line; he says  that the wounds  cica-
trized completely.  Having accidentally wounded the iris with the scis-
sors in operations of extraction, he found  that the openings thus made
did not close, and that they did  not subsequently interfere with vision.
Hence he was induced  to adopt  a new  method of forming artificial
pupils.  He opened the lower half of the cornea, as in extraction.   Then,
elevating the flap of that membrane, he introduced  under  it a  curved
scissors,  one end of which was pointed.   He  penetrated  the iris with
this pointed end,  about one line from its greater  circum-   -p\g. 24.
ference,  then carried the  instrument  directly upwards, and
half a line from the original pupil towards the external angle,
and divided the iris by closing the blades  of the scissors, so
as to form an opening about two lines and a half in extent.
He adopted this  proceeding successfully in  many instances,  c||  ^
which he has detailed.*   In some  of  them cataract  existed,   §
which he extracted through the new pupil.
   Operation of Sir W.  Adams.—The formation  of an arti-
ficial pupil by incision  through the  sclerotica, which had
fallen completely into disuse,  was  revived and  improved by
Sir W.  Adams, who  devised  for the purpose a  very small
knife, which he calls an iris scalpel, [fig. 24, c]  It is less
than a line in width, with a straight  back  and sharp point.
The edge is convex towards the point, like that of a scalpel,
and cuts back towards  the  handle for about  three lines.f
The iris scalpel  may be made  still narrower than  is men-
tioned above,  [fig. 24,  d.]  In  his last work  on  artificial
pupil, Sir William thus  describes his  mode of employing the
instrument.  The  patient is seated, the upper  lid raised by
an assistant, while the  lower is depressed, and the  globe
fixed by the operator.  " The iris  scalpel  already described,
with its  edge turned backwards, must be introduced through
the coats of the  eye at  their  external part, about a  line be-
hind  the iris, and  in the  transverse  diameter of the latter
membrane.  The point of the instrument should then be made
to penetrate through the iris, into  the anterior chamber, in
a line with its central diameter, and somewhat less than one-
third of  the width of that membrane, from its ciliary mar-
gin.  The iris scalpel is  then to  be carried cautiously through
the anterior chamber, towards  the inner  canthus, keeping
its edge in contact with the iris (in order to  prevent the
point from piercing the internal part of the cornea) until it
has traversed more  than two-thirds of the width  of the  iris, when  it

is repeated in the Anatomy of the Human Body, tab.  36, fig. 1, p. 317. In the explanation,
Mr. Cheselden, says, "This operation I have performed several times with good success;
indeed, it  cannot fail when the operation is well done, and the eye no otherwise diseased,
which is more than can be said for couching a cataract."
   * Memoire sur VImperforation de riris, dans lequelon indique le moyen qu'on doit em.
ployer pour faire une overture a cette tunique, lorsque la pupille est detruite ; in Memoires
et Observations anatomiques, physiologiques et physiques sur Vail.  1772, p. 177—205.
   t Sir W. Adams has given two views of this instrument in  his Practical Observations  on 
430
FORMATION of an artificial pupil.
 should, with great care, be drawn  backwards, almost out of the eye,
 making the most delicate  pressure with  the edge of the  instrument
 against the iris, lest  it should be  detached from  the  ciliary ligament.
 If the division  of the iris is not effected to a sufficient extent, during the
 first effort, the iris scalpel should  be  again carried forward, and with-
 drawn  in a similar manner.  This is to be repeated as often as may be
 necessary to eflect a division of the iris, to the extent of a third part of
 its diameter.   In my work, published in 1812,1 directed that two-thirds
 at least of the extent of the transverse diameter of the iris  should be
 divided, in order to guard against  the supposed disposition of that mem-
 brane to re-unite;  but abundant experience of the  favourable results of
 this operation, which have since  occurred in my practice, has convinced
 me that no such apprehension need be entertained, and that a division
 of one-third the extent of the diameter of the iris, is sufficient.  Indeed,
 so far is there  from being a disposition in  the newly-formed pupil to
 close again after it has  once been established, that the very reverse is
 the case; for the radiated fibres  sometimes contract in a greater degree
 from delay; whereby the artificial pupil is proportionably enlarged.  In
 the species of case now under consideration, an almost immediate con-
 traction of the radiated fibres of the iris usually takes place, after  that
 membrane has been divided, which produces a new pupil of  a sufficient
 size for all the purposes of vision."  A Treatise on Artificial pupil, &c.
 1819; p. 34—36.
   In order to  avoid  the long ciliary artery, the  sclerotica should be
 pierced a little above  or below the middle transverse line of  the eye.
   Incision of the iris, according to this description, seems a simple  af-
 fair ; it  is not however always easily accomplished.  When the lens has
 been previously lost, as  in  closed  pupil consequent on cataract opera-
 tions, or if the  vitreous humour should not possess its usual consistence,
 the iris, being unsupported,  is not divided, but yields to the pressure of
 the knife, and is carried back into  the vitreous humour; if the pressure
 be increased, it easily separates from the  ciliary ligament.   Hence it
 is necessary to  draw  the edge  of the  knife along the surface of the
 iris with as little pressure as possible, and to repeat this movement, until
 the purpose  is accomplished.   In so doing, care must be  taken not to
 enlarge the opening   in the sclerotica, as  the vitreous humour might
 escape through it.  When the texture of the  iris is healthy, and more
 particularly if its fibres are on the  stretch, it is easily divided; the edges
 of the incision retract immediately, and leave an oval  opening of good
 size.  If the iris be thickened and  hardened by, previous disease, and if
 it should be still further strengthened by adhesion to a thick and tough
 capsule, its division by means of the  iris scalpel, may be impracticable.
 When, however, the iris is thus changed in structure, it will usually be
 found that the retina has been involved in the mischief, and consequently
that an  operation is not advisable.
  If there should be an opaque capsule adherent to the iris, one and the
same incision will divide both.  If the new  pupil should be more or less

Ectropium, &c. plate 3, fig.  1 and 2.  [Fig. 24 c. is copied from  the original figure above
referred to.  This instrument is too large; d, represents the blade of a similar knife of a
better size.] 
formation of an artificial pupil.              431
obstructed by the capsule, it may perhaps admit of division or detach-
ment by the iris scalpel.
   When the closed  pupil  is complicated with cataract, Sir W. Adams
recommends that the capsule and lens should be freely divided with the
iris  scalpel.   " The larger portion of the fragments should  then  be
brought into the anterior chamber, and the remainder left between the
edges of the divided iris, so as to prevent their reuniting by the first in-
tention."   (Lib. cit. p. 38.)  In this complicated proceeding, consider-
able violence is offered to  the  organ, and the iris is  also subjected  to
pressure, a description of  injury which generally causes  inflammation
of the membrane.  I consider it preferable to leave the  cataract in  its
place for absorption, and if necessary, to depress or break it up further
in another operation, after the lapse of some time.
   Maunoir's mode of  incision.—<The method of performing incision of
the iris, by means  of scissors, which was practised by Janin, was
adopted and improved by J. 1\ Maunoir,* of Geneva, who has described
it in two memoirs.  It  was approved and  strongly recommended by
ScARPAf in the last  edition of his work  on  diseases of the  eye, from
which I have drawn the following description of it, as being more clear
and connected  than  that given  by its author.   " In  order  to attain  the
object proposed, this learned and  expert oculist has had scissors, [fig.
25,] made of a delicacy and  fineness hitherto unequalled in the con-

                               Fig. 25.
 struction of surgical instruments.J The blades of the scissors are slightly
 inclined to the handle, (at an angle of 140°.)  The upper blade or that
 which is designed to pass through the anterior chamber of the aqueous
 humour between  the concavity of the cornea and the iris, terminates in
 a small button.  The lower blade for perforating the iris and  advancing
 along the posterior surface of this membrane, has a very sharp  point


  * Memoires sur V Organisation de Vlris et ^Operation de la Pupille artificielle, Paris 1812.
 Memoires sur les Amputations, ('Hydrocele du Cou, et VOrganization  de Vlris; Geneve,
 1825.  Observations and cases relating to the Operation for Artificial Pupil; in a hetter
from M. Munoir of Geneva, in the Medico Chirurgical Transactions, vol. vii. p. 301.  Fur-
 ther Account of the Result of an Operation for forming an Artificial Pupil; Medico-Chir.
 Trans, vol. ix. p. 382.
  t Treatise on the principal Diseases of the Eyes; chap, xvi.; on the Artificial Pupil.
  X Mem. sur VOrganization de Vlris, &c. fig. 14. Scarpa's Treatise, pi. 3. fig. 8 and 9. 
432
FORMATION OF AN ARTIFICIAL PUPIL.
similar to that of a lancet.  The thickness of the two blades united does
not exceed  than  of an  ordinary fine probe.   The mode  of operating
with  it, as is  practiced by  Professor Maunoir  with  great  success, and
which has  been  advantageously repeated  in this hospital, is  as fol-
lows.
   " The patient being placed horizontally with his head a little raised,
a position no  less commodious in the operation for the extraction of the
cataract, than the formation of the pupil, and supposing the cornea  to
be perfectly transparent, and the capsule and lens in the case of cata-
ract to have been completely removed from the axis of vision, an inci-
sion is made in the cornea  at its  lower or lateral segment, as may  be
most convenient, of half the extent of  that which is usually made for
the extraction of  the crystalline lens.   Through this small opening  in
the cornea, the scissors are to be introduced closed, with  the flat part
in a line parallel to the transverse diameter of the iris;  and as soon  as
the point of the instrument has advanced near to the great margin  of
the iris, that  is to  say, nearly opposite the small incision  made in the
cornea, it is gently opened, and inclined in such a manner that the infe-
rior pointed blade may perforate  the  iris,  and run along the poste-
rior surface of that membrane, until  the  small button of the  upper
blade  has  reached the  part where the cornea  and sclerotica  unite.
The iris is then to be  divided in  its transverse diameter by a single
stroke passing as nearly as possible through  its centre.  This incision
          Flo-,  26.            being executed, another is to be expeditiously
                           made, so far diverging from the first that the
                           two incisions may form in the centre of the
                           iris a  triangular flap of the figure of the let-
                           ter V, the apex being precisely in the centre
                          of the iris and the base near  its greater mar-
                          gin," [fig. 26.]—"On opening the eyeoperated
                          on five or six days after, the apex of the tri-
            angular space is found.to have retracted towards iis base,
  ^m^     leaving in the  middle of the iris an  artificial pupil of the
 ^L/^k    figure of a parallelogram, [fig. 27.] or of a crescent, with
 wT\^§P    me  cornua  directed to the great margin of the iris, when
 ^%l!P^    the apex of the divided portion has not  completely  shrunk
 Fig. 27.     towards its base."*
  According  to M. Maunoir, the triangular portion of the iris, included
between the two incisions, sometimes retracts immediately and suddenly.
In the first  case  on which  he operated, he says, " A very interesting
circumstance  occurred immediately after the second incision ; the flap or
portion comprised between the two incisions rolled itself  up, or  appeared
to do so, like  the  spring blind of a window-carriage, leaving at the mo-
ment  a free opening for the passage of light."!
  When partial opacity of  the cornea exists with synechia  anterior, the
mode of proceeding is a little altered.   " To  remedy this morbid state,
it is necessary to  have the scissors  of  Maunoir  made with  the points of
both blades terminating in a  button.  A small  incision being made  in

  * Treatise, &c. p. 378—380.  Figures of pupils formed in this way are given in the two
French publications of M. Maunoir already  quoted. [Figs. 26 and 27  are copies of them.]
  t Mem. sur VOrganization de I'Iris, p. 38.
 
FORMATION OF AN ARTIFICIAL PUPIL.
433
 the cornea at the most commodious part, according to the rules before
 laid down, and the scissors introduced closed, an attempt is to be made
 to  free  the adhesion,  which  the  iris  has  contracted to the  cornea
 by them; which, if it is effected, the natural pupil in general  re-
 covers its former situation  and size; but, if the adhesion of the iris to
 the cornea is very firm, the operation is to be completed in the follow-
 ing manner.  One of the blades, by means of the small button, is intro-
 duced within the contracted natural pupil, and conducted behind  the
 posterior surface of the  iris, until the other blade, defended in the same
 manner,  has reached the confines of the cornea with the sclerotica.  The
 iris is then to be  divided in the  form of the letter V, without at all  in-
 juring either the  capsule or lens, both of which have  preserved  their
 transparency.  It is asserted by some able operators, and men of care-
 ful observation, that in this case a simple incision alone is requisite, in
 order that the  pupil may recover its proper size, and maintain it, pro-
 vided, however, that such incision strictly include the orbicular muscle
 of the natural pupil." (Lib. cit. p. 384, 395.)
   If the  closed pupil should be complicated with cataract, it is recom-
 mended  that the  opaque lens and capsule should be cut through by  the
 scissors, together with the iris;  and that the fragments of the lens should
 then be extracted.  The practicability of dividing the lens in this man-
 ner may be doubted; but, if the cornea and anterior chamber be nearly
 in their normal state, the incision of the former might be made large
 enough to allow  of the lens being removed  through the artificial pupil.
 This object was  successfully accomplished in two of the cases  related
 by M. Maunoir in the Medico-Chirurgical Transactions, vol. vii.; also
 in another instance detailed in vol. ix.
   When the fibres of the iris are tense, as in closed pupil after cataract
 operations, or from large prolapsus, and the texture of the membrane
 is at the  same time healthy, the double incision  will  not be necessary.
 A single vertical or horizontal incision will suffice; the  edges of the cut
 will retract so as to leave a pupil of sufficient size.
   The method by incision is best adapted to the  cases in which the an-
 terior chamber and cornea are in the normal state, and the lens has been
 removed; that  is, to closed pupil after cataract operations; also to con-
 traction  or closure of the aperture  from prolapsus near the circumfe-
 rence of the cornea.  M. Maunoir employed this proceeding in cases
 of leucoma with  synechia  anterior; it  is practicable, if a considerable
 portion of the cornea be still transparent, not otherwise.
  [M. Maunoir's  method of operating for artificial pupil is based upon  his
 views of  the structure of the  iris;  and it is impossible fully to understand  the
 former, without a knowledge of the latter, which we  will therefore  briefly  ex-
 plain.
  M. Maunoir conceives that he has discovered in the iris two orders of mus-
 cular fibres; one radiating,  occupying the larger circumference of the iris, and
the contractions of which enlarge the pupil; the other arranged circularly,
 forming the margin of the pupil, and the contractions of which diminish this
opening.   This discovery  of  the direction of the muscular fibres of the iris,
M. M. maintains furnishes us the most important indication for the incision of
the iris, which is always to be made perpendicular to the fibres, for it is by this
mode  alone, he says, that we can hope  to make a wound in the iris, which will
       55 
434                formation of an artificial putil.
not unite, and by whieh a simple incision will change into a more or less ellip-
tical opening. (Mem. sur YOrganization de lTris, p. 68, 31.)
  According to his views if the .radiating fibres be divided transversely through
their middle, the equal contraction of their two ends will widen the incision so
as to make an elliptical opening.  If these fibres be divided transversely near
their ends either at their ciliary or pupillary border, the longer portion of them
being capable of greatest contraction, the opening will be more or less semi-
elliptical.   If the circular fibres be  divided  transversely, and at the same
time  a  fasciculus  of the radiating  fibres be  separated  by two incisions,
forming a triangular flap, the apex of which is  formed by the incision  at the
margin of the pupil, (see fig. 26,) the  contraction of the circular  fibres will
widen the opening at the apex of the triangle, and the contractions  of the radi-
ating fibres at the same time will draw the point of the flap towards the  ciliary
margin and  thus we shall have an opening  of  the figure of a parallelogram.
          Fig. 28.          (See fig. 27.)  The great aim then of" M. Maunoir
                          is to  divide the fibres of the iris  in  such  a way
                          that their  contractions  will  have most effect  in
                          enlarging the opening.
                             In  his first case, a.man named Ceraoreau, M.
                          Maunoir after opening the cornea,  as described
                          (p. 432)  introduced his scissors and made an in-
                          cision in the upper portion of the  iris, dividing
                          transversely the  radiating fibres near their junc-
                       The former contracting, left a semi-elliptical  open-
                          ing.  (See fig. 28.)
                             In  a woman  named Yetre, M. Maunoir di-
                          vided the circular  fibres transversely, separating
                          a cone  of the radiating fibres by two incisions  at
                       ^  the same time, as just described, (see fig. 26,) and
                       I  a pupil was formed  which is  represented in
                       $  fig. 27.
                             Mr.  Mackenzie  in  his  admirable Treatise
                          gives  a  different  mode of  making  the  flap;
                          but it must be evident from what we  have said,
                          that incisions made in the direction represented
                          by him, (see  fig. 29,) would not be in accord-
                          ance with the views of M. Maunoir, nor  would
             there result from such incisions, according to those doctrines, a
              pupil of the form  which he delineates. (See fig. 30.)
                Nevertheless we have little doubt  that  in some cases, the
             operation described by Mr.  Mackenzie might succeed, and
             it would be available where M. Maunoir's would not.]
tion with the circular.
          Ficr. 29.
Fig. 30.
section hi.—operation by excision ; corectomia (from  m§*>, pupil, and
                     tKrofi.il, excision;) iride.ctomia.

                         Synonyme: Coretonectomia.
  The object of this proceeding is to form an opening for the passage
of light by cutting out a portion of the iris.   What is thus removed may
include a part of the natural pupil,  or not.   The excised portion may
be taken from the centre, or towards  the circumference of the iris ;  in
other terms, the excision may .he centr.al or lateral.   The operation  of
�3571603 
FORMATION OF AN ARTIFICIAL PUPIL.               435
 Wenzel, already described, (see p. 428,) is a modification of central ex-
 cision.  Arneman* proposed to cut out a circular portion with the con-
 cave  scissors; and complicated  instruments,  in which  scissors and
 hooks  have  been  combined,  have  been devisedj I  do not  know
 whether they have been used, by others.!
   BeerJ made a small incision in the cornea, introduced a fine hook
 or a toothed forceps into the anterior chamber, seized  the  iris, drew it
 out, and then cut off the portion thus displaced with scissors.
   Gibson's operation.—Mr. Gibson's proceeding was nearly the same as
 that of Beer: it was modified  according  to the different  states  of the
 eye requiring the  opera- Fig. 32.           Fig. 31.         Fig. 33,
 tion.   He used, besides a     m
 cataract knife for opening    I
 the cornea, a  small  hook;
 [fig. 31,] a  pair  of small
 forceps, [fig. 32,] and  iris
 scissors with one or both
 ends blunt, [fig. 33.]   The
 most  favourable case is
 central leucoma of the cor-
 nea, with the pupil  unad-
 herent, and  the lens  and
 capsule transparent. " The
 first step of the operation is
 to  secure the eye-lids, as
 in  the operation for  ex-
 tracting a  cataract.   A
 puncture is then to be made
 in the cornea with a broad
 cornea-knife, within  a  line
 of the sclerotica, to the ex-
 tent of about three lines.
 All pressure  is now to be
 removed from the eye-ball,
 and the cornea-knife gent-
 ly withdrawn.  The con-
 sequence of  this is,  that a
 portion of the aqueous hu-
 mour escapes, and the iris
 falls into contact with  the
 opening in the cornea, and
 closes  it like a valve.   A
 slight  pressure must now
 be made upon the superior
and nasal part of the eye-
ball, with the fore and mid-
dle  fingers of the left hand,
<irp
liri
  * System der Chirurgie, vol. ii. p. 199.
  t Kunstmann in Graefe und Walther's Journal, vol. i. p. 519.  Reisinger, Meine
Hakenscheere zur Bildung kiinstliche Pupillen, und ihr Sehicksal; in the Baiersche An.
nalen, B. I. St. i. p. 121, Tab. 3, fig. 1—7.
  f Ansicht der staphylomalbsen Metamorphose des Auges, &c. p. 114. 
436
FORMATION OF AN ARTIFICIAL PUPIL.
till  at length, by an occasional and gentle increase of the pressure, or
by varying its direction, the iris gradually protrudes, so as to present a
bag of the size of a large pin's head.  This  protruded portion must be
cut off with a pair of fine curved scissors, and all pressure at the same
time removed; the iris will then recede within the eye, and the portion
which has been removed will leave an artificial pupil more or less cir-
cular.
  " It sometimes happens, that the whole breadth of the iris to the bor-
der of the natural pupil is  protruded and removed this way.  This I
consider is rather an advantage, because it ensures a large pupil, though
generally one which is oblong in  its shape.  I have found, however, the
mere circumstance of shape to  be of little consequence in this operation,
and always to be sacrificed to the  object of size.  It may also be  re-
marked, that the opening has no  disposition to  close,  when, in forming
the artificial pupil, the border of the natural pupil is divided.   It occa-
sionally happens, also, that  as soon as the knife is removed, the muscles
of the eye-ball act with violence, and project a small staphyloma or bag
of the iris through the incision.  If this bag be not large enough to form
the new  pupil, the iris must be further protruded by gentle pressure."*
  The incision in these cases should be  made close to the edge  of  the
sclerotica, more especially  when  the transparent border of the cornea
is narrow, that the opacity sometimes  following  the  wound may  not
encroach on that part of the  membrane through which the light will
pass into the new pupil.  The corneal opening should not exceed  the
size mentioned above.  The  protruding  portion of  the iris should be
seized with a small forceps, [fig. 32,] and snipped off as quickly as pos-
sible : it may be previously drawn out further, if the prolapsus should  not
be sufficient.  If the opening, as first made, should not be large enough,
the  iris may be again drawn out by means of the small hook, [fig. 31,]
and another portion removed.
  Adhesion  of the iris to the opaque cornea require some modifications
in the mode of operating.   If one half of the pupil should adhere, the
portion next to the transparent part of the cornea generally remains free.
One or two  points of adhesion may be separated by the knife  employed
to open the  cornea, or by the  iris scissors, [fig. 33,] so as to disengage
the  pupil partially or  entirely.  Considerable adhesion will prevent a
protrusion of the iris sufficient for our purpose.  In that case, we must
introduce the small  hook, [fig. 31,]  seize the unadherent border  of  the
pupil, draw it out through the puncture of the cornea, and cut off a suf-
ficient portion with the curved scissors. (Op. cit. p. 56, 57.)  When the
pupil is generally adherent," the point of the cornea-knife is to be passed
through the cornea in the usual way, and is to be directed to those adhe-
sions, the division of which will most effectually tend  to render the  iris
free, for the subsequent part of the operation.  Care must at the same time
be taken to avoid undue pressure on the  eye-ball, that the  aqueous  hu-
mour may not escape before that object is accomplished ; for otherwise,
the  cornea and the adhering iris will become flaccid, and the adhesions
will be much more difficult to separate.
  Having separated some  part of the iris from its connexion with  the
cornea, and consequently made an aperture in it, the  next step will be

    * Practical Observations on the Formation of an Artificial Pupil, <yc.  p. 39—41. 
FORMATION OF AN ARTIFICIAL PUPIL.
437
 to remove a portion of it in a convenient situation. If the iris appear suffi-
 ciently loose, the hook, [fig. 31,] may be first introduced through the punc-
 ture in the cornea, and a gentle attempt may be made to draw out a suffi-
 cient portion from the eye, to be cut off with the curved scissors.  [Fig.
 33.]   If this be found  impracticable,  the  iris must be  removed within
 the eye with the iris scissors.  [Fig. 33.]
   In using these small scissors, they are to be introduced shut and flat,
 through the aperture in the cornea ; and  at the place where the artifi-
 cial pupil is to commence, a small opening is to be made with them in
 the iris.   Through this opening, the blade of the scissors, which is at-
 tached to the long  handle and  has a blunt point,  is to be conducted
 between  the iris  and crystalline lens by  opening  the scissors a little.
 The other blade is to be passed between the inner surface of the cornea
 and the iris, until their points reach a little beyond the border of the iris,
 where it has been separated from its adhesions. This portion of the iris
 is then to be divided, and the flap thus formed may generally be easily
 removed  by another snip or  two with the scissors.  By this means an
 artificial pupil of a triangular or oblong shape will be made, which may
 easily be  enlarged by the use of the  scissors, if it should  appear too
 small."   (Ibid, p.  66—68.)
   The iris scissors may be employed in the way just described, in those
 cases of partial pupillary adhesion, where we cannot draw  out the iris
 with the  hook.  The operation by detachment and strangulation  is,
 however, more  suitable to the last two mentioned cases; and the use of
 scissors within the eye in the way just described can hardly be regard-
 ed as a practical proceeding.
   Mr. Tyrrell employs a more simple and easy melhod of changing
 the position of the pupil, when its margin is unadherent, or of making
 a new opening when the normal pupil is closed by adhesion to the cor-
 nea.   He employs a broad  needle and a fine blunt hook, with a long
 bend.  The preferable situation for  the new pupil is downwards and
 outwards. The needle pierces the cornea close to its margin, and makes
 an opening just  sufficient to allow the introduction of the hook.  It should
 be carried fairly into the anterior chamber and then withdrawn so  as to
 prevent free escape of the aqueous humour.   " The hook should be
 passed with the bent limb towards the cornea, or forward;  and then it
 should be carried as far as the aperture of the pupil; and, the extremity
 of the instrument being introduced through the pupillary space, the bent
 part of the hook should be directed backward, by half rotating the han-
 dle of  the instrument between the  finger and thumb.  The  pupillary
 margin of the iris should next be caught by the hook, by pressing the
 point gently towards the  surface of the lens, at the same time that the
 instrument is carefully withdrawn.  When, however, the bent part  of
 the instrument is withdrawn as far as  the opening in the cornea, its pas-
 sage will generally be  impeded while the  point is directed backwards,
 as when  catching the margin of the iris: it is then again necessary to
half rotate the handle, so  as  to direct the  bent limb forwards;  but, in
doing this, the instrument must not be  allowed to recede from the open-
ing in the cornea, or the iris may slip from the hook.   The hook being
directed forwards, and still retaining hold of the pupillary margin of the
iris, should then be withdrawn through the corneal puncture, bringing 
438
FORMATION OF AN ARTIFICIAL PUPIL.
with it part of the iris; and sufficient of the membrane should be brought
through the opening in the cornea, to effect  the  desired change in
the pupillary aperture of the  iris."   The piece of  the iris drawn out
may  be cut off with a fine pair of scissors.   (Op. cit. vol. ii. p. 500—
502.)
   If the pupil  should be partially adherent  to the  cornea, and conse-
quently diminished,  the hook may produce a fissure instead of drawing
the iris out.  It may then be necessary to perform a second operation,
in which the hook is passed into the fissure, and  draws out one or  the
other edge, according to circumstances, so as to enlarge the new open-
ing sufficiently.  (Ibid, p. 504.)
   If the adhesion to  the cornea should have  completely closed the natu-
ral pupil, Mr. Tyrrell carries the broad needle, after  perforating  the
cornea through the  iris close  to the place of its  adhesion, taking care
that the point of  the instrument shall not be  directed  backwards.    He
introduces the blunt  hook into  the opening thus made, seizes  and with-
draws the iris,  as in  the former case.   (Ibid, p. 510.)
   The use of the blunt hook is particularly important  in order to avoid
wounding the capsule or  the lens, when they are  perfect.   When the
operation is successfully accomplished, the patient  regains  perfect  vi-
sion, sometimes, however, requiring the aid of convex glasses.
                 SECTION IV.—OPERATION BY SEPARATION.

 coredialysis (from *«^, pupil, and SiuXutis-, loosening or separation,) irido-
                                DIALYSIS.

                   Synonymes: Corodialysis; Coretodialysis.

   The object of this operation  is to  form an artificial pupil by sepa-
rating the iris, at some part  of its greater margin, from the ciliary liga-
ment.  The method  at  first proposed, consisted of simple separation:
subsequently, it was found necessary to strangulate the iris, when sepa-
rated, in  an aperture of the  cornea, or to cut away a  portion of it.
   The operation of Scarpa and Schmidt.—The idea of this operation
occurred about one and the  same time to two celebrated men, Scarpa,*
of Pavia, and J. A. Schmidt,! of Vienna, who tried it in several cases,
and published the results of  their experience without any knowledge of

  * Saggio di os&ervazioni ed esperienze sulleprincipali Malattie degli Occhi; small folio, .
Pavia, 1801.  Cap. xvi.  The last  case detailed in  this  chapter was communicated by
Signor F. Buzzi, of Milan, and gives the history  of a closed pupil consequent on extraction,
in which he formed an artificial pupil by separation, in the year 1788.   He used the com-
mon spear-shaped cataract needle, which he introduced through the sclerotica, as in de-
prcssion. He perforated the iris from behind in  its  upper part, about  a line above  the
closed pupil, carried the instrument parallel to the anterior  surface of the iris, and then
directing its point  downwards and backwards,  detached  the iris  for  at least one-third
of its circumference, on which the anterior chamber became filled with blood. There
remained an oblong artificial pupil,  and the patient was able to read and write with cata-
ract glasses. Osservazione 62, p. 212, 213.
  t  Ueber Pupillenbildung, Sfc, in  Himly und Schmidt's Bibliolhek, vol. ii. Stuck 1, p. 1.
Jena, 1803.  This essay, in which six cases of the operation are detailed, was read at the
Josephine Academy in Vienna, on the 21st of September, 1802. 
FORMATION OF AN ARTIFICIAL PUPIL.
439
 each other's proceedings.  They had observed how easily the iris sepa-
 rates from the ciliary body, so that when  it is seized with  a pair of
 forceps in the dead  subject, even near the pupil, it  gives way at the
 ciliary margin.   They had  seen  it separated in the same way  in the
 living eye from violence, as in smart blows with a  whip, or other simi-
 lar accidents; from  injury in extraction or depression, and  even from
 the dragging of the iris in cases of large prolapsus.
    Scarpa used his slender curved cataract needle,  and introduced it at
 the external angle of the eye, two lines behind  the margin of the cor-
 nea.  He carried it behind the iris until its point had reached the  upper
 and internalpart of the  ciliary margin, which  he  then  perforated  so
 that the point  of the instrument  should be  just visible in the anterior
 chamber: if it were further advanced, it would become engaged  in the
 substance of the cornea.   The needle was now carried downwards and
 outwards, moving in a line parallel to  the anterior surface of the iris,
 so as to detach a portion of its margin from the ciliary ligament.  When
 this detachment had been partially effected, he lowered the point  of the
 needle  to the inferior angle of the artificial opening, and  extended the
 separation to the requisite length  by dragging  the iris towards the tem-
 ple and backwards.  If  any opaque  substance  should be seen in  the
 new opening, he advises that it should be detached with the needle, and
 carried into the anterior  chamber.  (Lib. cit.  p. 208, 209.)
    Schmidt says, that for ten years he  had formed artificial pupils  in
 several instances  annually, by the method both of Janin and Wenzel;
 but that even where  he had reason to expect favourable results, he had
 been disappointed in seven or eight out of every ten cases-   The  cause
 of failure was generally the effusion of lymph, and  the consequent for-
 mation of an adventitious opaque  substance in the new openings:  (Lib.
 cit. p. 23, 24.)  The following facts awakened his attention to the pos-
 sibility of forming artificial pupils in  another  way.   In 1792 he saw a
 coachman, whose left eye had been struck with a whip six months be-
 fore.  The iris was  separated from the ciliary ligament to a consider-
 able extent on the nasal side.  The natural pupil was collapsed, {con-
 sidentia, synizesis pupillce,) with a cataract behind it.  The new  open-
 ing, which was of a clear black, contracted and dilated  according to
 the degree of light, so that the patient enjoyed  clear and distinct vision.
 In  1795, a  similar instance occurred in a youth of  sixteen, who had
 been struck on the eye by a hard ball.  A  considerable detachment of
 the iris  on the  temporal side had ensued, with collapse of the  pupil and
 cataract.   Through  the artificial opening, which was clear, and con-
 tracted, and dilated -like a natural pupil, the smallest objects  could be
 seen distinctly.  In 1797, an officer received a severe injury of the eye
 from a shot.  The iris was separated at its lower part and torn through
 so that  the laceration and the  normal pupil formed one large opening,
 occupied  by an opaque lens, below which  the  posterior  chamber was
 clear.  This patient  took up  a book, closed  the sound eye, and read
 small print.*

  *  Lib. cit. p. 27—29. Several other cases of unnatural pupil consequent on accidents,
in which the iris had been detached from the ciliary body, are quoted by Himly, ibid, p.
5Q__52. Janin has four instances of similar separation in his Observations et Disserta- 
440
FORMATION OF AN ARTIFICIAL PUPIL.
   In his first attempt, which was in 1802, Schmidt made an opening in
the cornea, seized the  iris with forceps, and thus separated it from the
ciliary ligament, (Lib. cit. p. 30,31.)  He afterwards adopted a proceed-
ing almost exactly similar to that of Scarpa, (Ibid, p. 41.)
   The separation of the iris from the ciliary body has sometimes been
effected  by means of  a curved needle, or a hook, introduced  through
the cornea.*
   Subsequent experience induced Scarpa to think less favourably of the
operation by separation, which he seems from the following passage in the
last edition of his work, to have abandoned  altogether.   " Experience,
to which all theory is subordinate, has since convinced me that, indepen-
dently of the  mode of operating which I proposed, being inapplicable, of
which I was aware, to the greater number of cases of complicated closure
of the pupil, I was also mistaken with regard to the most material point
in the operation, that is,  the permanency of its  success;  as I have since
found that the marginal pupil or opening which  is formed by the detach-
ment of the greater circumference of the iris from the ciliary ligament,
from being oval, becomes in process of time, filiform, and consequently
useless."   (Treatise, &c, translated  by Mr. Briggs.  Second  edition,
p. 368.)
   This closure  of  the unnatural opening caused by detachment of the
iris is exemplified in the case of John O'Brian, related at p. 164 of the
present work.
   Professor Rosas justly observes, that " the objections  to  the  detach-
ment of  the iris through the sclerotica are so obvious, that they were
soon  observed  and appreciated by the proposers of the  method.   The
very extensive  injury inflicted  on an organ already weakened  in most
cases  by serious previous  disease, the unavoidable destruction of the
lens, the  great difficulty of bringing the needle into the anterior chamber
exactly at  the ciliary margin of the iris, the almost inevitable passage
of the needle into the cornea, the difficulty of effecting an adequate de-
tachment of the iris from the painful nature of the process, and the con-
sequent unsteadiness  of  the patient, and the subsequent  closure of the
newly-formed pupil in spite of all precautions, are disadvantages belong-
ing to the operation of Schmidt and Scarpa, which seriously diminished
its value  in the estimation of well-informed and  unprejudiced surgeons."
           THE OPERATION BY DETACHMENT AND STRANGULATION.


  As the simple separation of the iris from  the ciliary ligament cannot
be depended on for the formation of a permanent opening, except per-

tions sur le itecollement de VIris  consideree comme conligue, et non continue a la Choroi.de.
He observes that Horn of Dijon had found by repeated trials in human eyes and those of
animals, that the iris, when held with forceps and gently drawn, separates easily from the
choroid without injury to either part. Mtmoire, fyc, sur Voeil, p. 415.
  * Bonzel in Hufeland und Hari.es Journal der practischen Heilkunde, January, 1815.
Wagner de Coremorphosi, p. 36, 1818.  Langenbeck Neue Chir. Bibl. vol. i. p. 221.  Beer
performed  iridodialysis from the front; but he pierced the sclerotica, and carried the needle
into the anterior chamber on the temporal side of the eye.   Nachtrag zu seiner Ansicht
der staphylomalosen Metamorphose, <Src.  This proceeding has not been repeated by other
operators;  nor can it be considered worthy of imitation. Himly had also separated the
iris from the front, having carried his needle through the adventitious membrane by which
the pupil was closed.  Ophthalmologische Bibliothek, vol. iii. st. 2, p. 160. 
FORMATION OF AN ARTIFICIAL PUPIL.
441
haps in the case of its being  effected in the upper  part, because expe-
rience teaches us that the  detached iris  generally resumes its  former
position, either soon after the separation, or at a  rather later  period,
particularly during the inflammation, it is necessary to adopt some fur-
ther means for maintaining the artificial aperture.  Langenbeck pro-
posed for this purpose the strangulation of the detached iris in the wound
of the cornea; while Assalini cut off the prolapsed portion, after drag-
ging it through the cornea.
  Langenbeck's operation.*—This plan of detaching the iris {iridodi-
ulysis) by  means of instruments introduced through a wound of the
cornea, and then strangulating the detached portion in the aperture had
been called iridenclcisis, from ipir and eyxteta, to  lock in  or confine.
It consists in  making an opening in the cornea; in detaching the iris by
means of a hook, or some other instrument introduced into the anterior
chamber through that wound; in drawing the detached  portion through
the corneal wound,  and leaving it there as a prolapsus, so that it may
become permanently  fixed  to the cornea, and thus  prevent the subse-
quent closure of the new pupil.
  The first step  in the operation, that of making a small opening in the
cornea, may be conveniently  accomplished by means of Beer's cataract
knife.  This  wound must be  large  enough to allow the passage of the
hook; but it should not extend beyond that size, otherwise we shall not
succeed in  strangulating the iris.  It may be one and a half or two lines.
  The incision should be distant from the point at which the  separation
of the iris  is  to be effected, by one half the diameter of the  cornea at
least; some advise that the distance should be three-fifths of the diame-
ter.   If the wound of the cornea should be nearer to the new pupil, its
cicatrix may interfere with the transmission of light through the aper-
ture ; if it  be further, too large a detachment of the iris will be neces-
sary, and the extent of injury to the organ will be thus increased with-
out any object.
  The situation at which the detachment of the  iris is to be effected,
will determine the place and  direction of the small opening of the cor-
nea.  If the new pupil is to  be  made on the nasal or temporal side of
the eye, the cornea must be opened in its middle by a vertical incision;
if at the upper or lower part,  the incision must  be horizontal, and a little
above or below the middle.   If the circumstances should require it, the
incision may be  made in a  leucomatous portion of the cornea.
  The point of the  knife directed at a right angle to the surface of the
cornea must be carried through it into the anterior chamber: the handle
must then be depressed, so  as to bring the blade into a  direction nearly
parallel to the surface of the iris, in which it is to be pushed on  until an
opening is formed of the size already mentioned.  The point of the knife
should then be moved a little  towards each angle of the wound,  so as to
make the division of  the internal laminae equal in extent to that of the
external.   The instrument  should then  be withdrawn quickly, so as to
prevent the escape of the aqueous humour.
  A great  variety of  contrivances have been employed for the purpose
of seizing and detaching the  iris.  On this subject, Juengken has sensi-

                   * Neue Chir. Bibl. vol. i. p. 224—240.
       56 
442
FORMATION OF AN ARTIFICIAL PUPIL.
bly observed, " that amidst the multitude of instruments invented, mo-
dified, and changed, often very ingeniously, for the purpose of iridodi-
alysis, the most important point has been  "overlooked, namely, that for
holding the iris securely, the kind of instrument is of less consequence
than the place at which the part is  seized.   I confess that, until instruct-
ed by repeated experience, I had not sufficiently appreciated this circum-
stance.  The texture of the iris is very  different at  its pupillary and
ciliary margins.  In the  former it is fine, delicate,  and so  soft that
instruments easily tear out without separating  the iris from the ciliary
ligament.  In the latter it is of firmer texture,  so that the finest instru-
ments  will hold when fixed in it; and  the nearer we  come to the mar-
gin, the more easy  is the detachment.
  When the lens and its capsule are in the normal state, we run the less
risk of injuring them the nearer we fix  the  instrument to  the ciliary liga-
ment, because the vitreous humour  is behind the latter part, and not  the
crystalline capsule.  Hence, for performing iridodialysis that instrument
is best suited, with which we can come nearest  to the  circumference of
the iris, so  as to seize it close to the ciliary ligament; and no one
can deny that a simple  fine hook, is the best for this  purpose.  If,
however, the iris should have  become changed in  texture, and soft
throughout, no kind of hook will answer  the  purpose,  whether single,
double, or covered; our resource, then, is  to seize the iris with forceps,
and thus effect the detachment.  It has been objected to the simple hook,
that its point may pass between the corneal laminae and become en-
tangled.   This may equally happen with any other instrument, if atten-
tion  is  not  paid  to the  direction  in  which it is carried through the
wound of the cornea.   It is a great mistake to  suppose that the per-
formance of  iridodialysis  is more difficult with  the simple  hook than
with other instruments: on the contrary it  is more easy,  when the mode
of employing it is well understood."   (Die Lehre von  den Augenopera-
tionen, p. 656, 657.)
                    Fig-  34.                         The  hook  must
                                                be carried through
                                                the  wound of the
                                                cornea at right an-
                                                gles, like the knife,
                                                the convexity of the
                                                curve  going  first,
                                                and  the point fol-
                                                lowing.   When   it
                                                has entered the an-
                                                terior chamber, the
                                                handle  should  be
                                                depressed, so that
                                                the  hook  may  lie
                                                flat  between  the
                                                cornea   and  iris,
                                                with its point down-
                                                wards, and in this
                                                direction it must be
                                                carried on to the
 
FORMATION OF AN ARTIFICIAL PUPIL.
443
very margin of the iris, when it will be nearly concealed by the edge of
the sclerotica.  It must  now be turned, so that the point may be di-
rected against the iris: it may then be fixed by gentle pressure, and af-
terwards drawn a little back, so that the hooked portion of the iris may
be safely placed in the concavity of the instrument.  When  we find that
the iris is securely seized, the hook must be turned flat again, but with
its point directed  upwards,  that the iris may not slip  off.  The  point
should indeed be directed a little towards the cornea, to avoid the lens,
if it be present.  We now detach the iris by drawing the  hook back-
wards through  the wound of the cornea very slowly and carefully, [fig.
34.]  In carrying it out of the eye we must  give the instrument  the
same direction  as  that in which it entered.  The convexity of the hook
must be drawn out through the inferior angle of the wound, and the point
will then pass without any risk of catching in the wround.  Having con-
veyed  the hook with  the iris safely through the wound, we continue to
draw it gently in the same direction, until we have got an artificial pu-
pil  of sufficient size.  We  now cease  to  draw the iris, and observe
whether it remains fixed in the wound of the cornea.   If it does so, we
detach the hook and  the operation  is finished.
   The new pupil becomes filled with blood, which  begins to flow when
the detachment of  the  iris commences, and soon  occupies  the whole
anterior chamber.  The cases are, rare in which  the effusion is incon-
siderable, and still more uncommon  where it  does not occur  at  all.
This hemorrhage, which proceeds from the external arterial circle of
the iris formed by the primary branches of the long ciliary arteries, has
no unfavourable influence on the result of the operation.  The blood, as
in other effusions into the anterior  chamber from accidental  violence,*
is removed by absorption in  a few days.
   Reisinger's double hook,  or hooked forceps, for  detachment of the
iris.—The iris is sometimes torn by the hook, instead of being detached.
To avoid this inconvenience, Dr. Reisinger,! of Landshut, devised  an
instrument formed  of two  branches united like those of forceps,  [fig.
35, «.]   Each of these terminates in a small hook, [as seen in the side
view of one of the branches, fig. 35, 6.]  When the branches are pressed
together, the two hooks, having the  same  size and direction, lie close
together, so as to form a single hook:  when the pressure is discontinued,
they separate again.   This instrument, with its branches approximated,
so as to form a single hook,  is carried through  the wound of the cornea,
into the  anterior chamber, and  pushed on like the simple hook to  the
ciliary ligament.   It  is now partially turned, so as to direct its point
against the iris, when the discontinuance of the pressure on the branches
allows the  two hooks to separate:  they are then fixed in the  iris in  the
same way as when the simple hook is employed.  The branches, being
again  pressed together, hold the portion of iris included  between the
  •See p. 149, 150.  In a case where the iris  had been thickened^ by inflammation, Dr.
Rvan made an artificial pupil by incision, according to the  method of Sir. W. Adams.  The
anterior chamber became obscured by an effusion of blood, which was completely absorbed
on the third day.—Dublin Hospital  Reports, vol. ii.p. 364.  The anterior chamber became
filled with blood in another instance, after the  operation of incision.  The effused blood
was completely absorbed in twenty hours.—Ibid, p. 368.
  t Dorstelluwr eines neuen Verfahrens, die Mastdarmfistel zu unterlinden, und einer
leichten und sichern Methode kunstliche  Pupillen zu bilden  Aug-burg, 1816. 
444
FORMATION OF AN ARTIFICIAL PUPIL.
two hooks in the manner of forceps, while the hooks fixed in its  sub-
Fis. 35.
             stance render the hold still more secure.   The instrument
             is now to be turned so as to lie flat against the cornea, with
             the  convexity downwards and the points upwards; it is
             then  to be carried back through  the wound steadily and
             gently, so as to effect a sufficient detachment of the iris.
                On this double hook, or hooked  forceps of Reisinger,
             Professor Rosas* makes  the following remarks:—" No-
             body, who  has tried this plan, can have failed to observe,
             that the use of the  double hook is  attended with greater
             difficulties,  and yet presents  fewer  advantages, than the
             simple  hook of  Langenbeck.   That the  iris may be se-
             curelv seized and detached, the points of the instrument
             mustbe turned directly backwards, so that the iris can-
             not be hooked near enough to its circumference,  and the
             lens is generally seized at the same time.   These incon-
             veniences are  avoided with  the single hook, which can
             be entered obliquely into  the ciliary margin of the iris.
             The instrument, strictly speaking, does not act as a double
             but  only as a  single  hook, for when its  branches  are
             opened, they will be found to have separated the fibres of
             the iris, so that there is a mere empty space between them.
             In unsteady patients there will be a greater danger of the
             instrument  becoming entangled, or  the iris escaping, than
             with the simple instrument.   We cannot rely on  its  ac-
             tion as forceps in giving a firmer hold  of the iris."
                Unless the  opening  in the cornea be  carefully made,
             and similar attention  be paid  to  the  other steps of the
             operation, the  fine hook employed for seizing and detach-
             ing  the iris may become entangled in  the sides of the
             wound, or within the anterior chamber.   To obviate this
             risk, various complicated instruments-j- have been  devised,
             with contrivances for covering the point of the hook, or
             at least placing it in such a situation as to prevent it from
             catching in the parts along which it passes.   I agree with
             JuengkenJ  and Rosas,§ in preferring  the  simple hook to
             any of these complicated instruments.
  Operation by  separation and  excision.—When  the  iris  cannot be
strangulated in the wound of the cornea, either in consequence  of the

  *  Handbuch der theoretischen und praktischen Augenheilkunde, vol. iii. § 429.
  t  The.-e instruments have been designated by the  names coreoncion, or coroncion (from
jeepo, pupil, and cync;, hook,) also iridoncion.  Langenbeck: first employed one of the kind;
see his Beschreibung eines von mir erfundenen  Instrumenlcs, die Coretodialysis zu ver-
riehten, in the  Neue  Cliir. Bibl. vol. i. p. 454 and  676.  The instrument  employed by
Graefe is described by Juengken, in Das Coreoncion, ein Bcilrag zur kunstlichen Pupil-
lenbildung; Berlin, 1807.  Sre also Schi.agintweit, Ueber den gegenwdrtigen Zustand der
kunstlichen Pupillenbildung in  Deutschland; Munich, 1818; in which he describes, under
the name of Iridankistron,an instrument  very similar to the coreoncion of Graefe. Wag-
ner, de Coremorphosi.  Dzondi, Geschichte des  klinischen Instiluts zu Halle, 1818, and
Beschreibung eines neuen  Instrumentes,  &c.; Halle, 1819.  The instrument proposed by
Embden, in liis Diss, de Raphiankistro, fyc.  Gottingen, 1819, is a combination of a hook
with a lancet-shaped needle. The  former, which lies  close on the latter, can be protruded
and  withdrawn again.
  X  hehre von den Augenoperalionen, p. 656.               § Lib. cit. p. 365, note, 
formation of an artificial pupil.
445
opening being too large, or of the iris having been rendered incapable
of extension by disease, the portion which has been drawn out of the
anterior  chamber  may be cut off with scissors.   This operation, in
which excision is united with separation has been called Iridectomedia-
lysis.   Assalini,* who first employed it, used a small forceps of pecu-
liar construction for  seizing and detaching the  iris, introducing the
instrument into the anterior chamber through an opening previously
made in the cornea.   The simple hook,  which can be employed with a
smaller division of the latter part, is preferable.
  " Although," says Professor Rosas,  " I do not approve Assalini's
method  of operating, I think that iridectomedialysis, when performed
in a proper way, possesses advantages  both over simple detachment,
{iridodialysis,) and over detachment with strangulation {iridencleisis.)
The operation is performed more  quickly, not requiring, as the latter
operation does, a small and oblique wound of the cornea, nor  being at-
tended with falling back and repeated dragging out of the iris.   Closure
of the newly-formed pupil is less likely.  Inflammation and suppuration,
or effusion of lymph, occur  more rarely than in  the other modes of
iridodialysis.  The wound heals more quickly, and the corneal cicatrix
is less extensive and  conspicuous than  in iridencleisis.   These advan-
tages have led me  to employ the operation for many years, in the man-
ner recommended  by  Langenbeck, for cases in which the detached por-
tion of iris cannot  be  strangulated in the cornea.   Still I am of opinion,
that its advantages are not equal to those of Maunoir's plan of incision,
or excision, as practised by Wenzel and Beer;  and, therefore, that its
employment must  be restricted to  cases in which these  methods are
not applicable.  Such are obstructions of the pupil by central leucoma
of the cornea, by accumulation of lymph in and about the aperture, and
by a universally adherent cataract.  The following are  the considera-
tions which make  me think the operations last mentioned more advan-
tageous than the iridectomedialysis.
  1. The lacerated wound inflicted in this operation, as in all kinds of
iridodialysis, is a  much more serious  injury  than  the simple cut of
incision  or excision.  2. The lens  is  more endangered  than  in iri-
dectome, so that often we have to treat  subsequently a cataract caused
by the operation.  3.  Inflammation,  suppuration, and effusion of lymph
are much more frequent  after this operation.  4. The cure is more te-
dious ; since the separation is generally  followed  by copious effusion of
blood into the anterior  chamber, the removal of which  by absorption
occupies some time, during which it  impedes vision.   5.  The marginal
pupil, formed by iridodialysis, is much less useful than one produced by
incision or excision in the centre of the  iris, or near it; since the rays of
light falling on the  margin of the cornea are much less  serviceable for
vision than those which go  through  its middle.  Moreover, the ciliary
processes projecting into the posterior  chamber, occupy a part of the
opening, so  that, although the patient is obliged to squint, vision is still
very feeble.  6. Iridodialysis can  never be performed with advantage
where the patient still sees with one eye.   7. For the reasons already
given,  vision is less lasting  than  after the  other  methods.   (Hand-
buch, vol. iii. § 431—433.)
* Ricerche sulle Pupille artificiali. Milan, 1811. 
446
formation of an artificial pupil.
   The operation by separation  may be  performed in all the cases re-
quiring the formation of an artificial pupil, to  which neither incision nor
excision  is applicable; and in  those, where another operation having
been previously performed, the opening has since closed ; in central leu-
coma covering more than half the diameter of the cornea with general
synechia anterior;  in opacities with partial adhesion, where the trans-
parent portion of cornea is so  situated as not to  allow of excision.
   The combination of excision with detachment is often preferable to
the operation of iridencleisis.  The former must be adopted where stran-
gulation cannot be effected ; also in large synechia anterior, or partial
staphyloma, where only a third  or fourth part of the iris remains  free.
It is a preferable method where  we expect the operation to be followed
by considerable inflammation, as we avoid  the  irritation which might
be expected from pressure on  the prolapsed iris.   When we intend ori-
ginally to perform iridectomedialysis, the opening in the cornea should
be rather larger  than the operation of  iridencleisis.   This  opening is
made in the opaque part, when the case is synechia anterior, occupying
half or two-thirds of the cornea.  We may be  able to direct the knife
in such a way  as to detach partially the adherent iris, and  thus make
way for the passage of the hook into the anterior chamber:  otherwise,
on opening the leucomatous cornea in the  adhesion, we penetrate the
posterior chamber; the hook  must then be  introduced behind the iris,
and carried through the membrane from behind forwards, for the  pur-
pose of detaching it.   Great  caution will then be necessary to prevent
the point of the hook from becoming entangled in  the cornea.   When the
detachment has been effected, the iris should not be dragged through the
wound until the operator has the scissors ready close to the eye for cut-
ting it off immediately.  In this and many other cases, where the sur-
geon must employ both his hands in the manoeuvres of the operation, the
care of the eye-lids must be confided to an assistant.
   The operation for artificial  pupil is simplified  when the lens has  been
previously removed from the eye.   In  the majority of instances, how-
ever, it is still present,  either transparent or opaque.  It is important, in
the former case, to adopt a mode of proceeding, in which no injury  shall
be offered to the lens or its capsule.  This object  is secured in the opera-
tion of excision according to  the method of Gibson, and in the use  of
Mr. Tyrrell's  blunt hook.  Incision of the iris, with the  scissors  of
Maunoir,  blunt at  both  ends, is not quite  so  safe; and  detachment
through the cornea (coredialysis) is still  more dangerous.  If there  be
cataract, it will be advantageous to adopt a  mode  of operating, when
circumstances will admit, by which the lens may be removed  from the
axis of vision at the same time that the new pupil is formed.   This  may
be accomplished by the operation of Wenzel, and by Maunoir's method
of incision.   The lens might  be depressed, or  broken up and left for
absorption, in Sir Win. Adams's mode of incision.   It is, however,  dan-
gerous to add  this violence to  the injury which the organ necessarily
sustains in the formation of an artificial pupil.  In such cases, therefore,
as well as in  others where cataract is present, it will perhaps be safest
to leave the opaque lens in its  situation, from which  it may be  removed
afterwards by depression or absorption.
  [It has been observed, (p. 428,) that there are three principal methods of ope-
rating for artificial pupil, viz. by incision, excision, and separation.  In one case 
formation of an artificial pupil.
447
 we have operated by a proceeding which cannot be strictly referred to either
 of these, and which, for want of a better term we shall call by distortion, the
 pupil being drawn aside or distorted, without any incision, excision, or sepa-
 ration of  the iris.
   The subject of the  case was a young man named  John Kane, who had both
 eyes injured whilst engaged in blasting rocks, in March, 1840.  In August of
 that year, he was admitted into Will's Hospital with central opacity of both cor-
 neae, adhesion of the upper edge of the iris to the cornea of the right eye; and the
 pupil of the left eye closed by a mass of lymph.  He was submitted to the usual
 treatment for the removal  of the opacity  of the cornea, and of the lymph from
 pupil, and the former was so much lessened by the following spring that it was
 believed useful vision might be obtained with the left eye, if the opaque matters
 which closed the pupil were removed.   Extract of Belladonna around the eye,
 and mercury given to salivation having failed to accomplish this, Dr. Fox with
 a needle inserted in the sclerotica broke up the lymph and lens, and after twice
 repeating the same operation, the pupil was cleared and the patient discharged
 with his sight much improved.  It the fall of 1841, he applied to be  again ad-
 mitted into the hospital stating, that though his sight was much improved, it
 was not good enough to enable him to work at his ordinary labour, and begged
 that something further might be done.  I did not feel justified in attempting any
 operation upon the left eye, as it would involve  a risk of destroying what had
 been gained, which the chance for further improvement did not justify.
   The right eye was, however, in a dif-                Fig. 36.
 ferent condition.  The lens was trans-
 parent and the pupil clear; and whilst
 there was  dense opacity of the centre
 of the cornea,  the lower  portion was
 perfectly clear, excepting a few very
 minute points where it had been burned
 by grains of gunpowder.   The  upper
 edge of the pupil adhered, as already
 stated, to the cornea.   (See fig. 36.)
   The pupil could be slightly dilated
 with Belladonna so as somewhat  to im-
 prove the  sight, but not sufficiently to
 enable the patient to  see even as well  with it as he  could with the other eye.
 In consultation with my colleagues, I therefore determined to attempt an  ope-
 ration for his relief.
   The one which first suggested itself, as best suited to this case, was that of
 Gibson; but the risk of wounding the anterior  capsule  of the lens  with the
 hook, and  also  the danger of effusion of lymph from the margin of the incision
 of the  iris, rendering the capsule opaque, and  closing perhaps the new pupil,
 presented  objections to it.   Reflecting on the general occurrence of prolapse of
 the iris in wounds of the cornea with consequent synechia anterior and drawing
 aside the pupil, (see fig. 21,) and that if the  pupil were thus drawn towards the
 lower margin of the cornea  by a simple  wound of  this coat, every thing that
 could be desired  would be attained, and at  little risk;  I decided to  operate in
 conformity with these views.
   This I accordingly did on the 28th October, 1841,  in the presence of my col-
 leagues, Drs. Littell, Fox  and Parish, the house surgeon Mr. S. L. Hollings-
 worth, and Drs. Pepper, Neill, Sic.  The patient being laid on his back on a table,
 the lower lid of his right eye was depressed by Dr. Fox, whilst I raised the upper
 lid with the two fore fingers of my left hand, steadying the ball with  the third
finger.   I  then  with a properly constructed cataract knife incised the cornea
near its junction with  the sclerotica, commencing a little below the middle and
 
448
formation of an artificial pupil.
Fig. 38.
 extending so as to divide nearly one fourth of the circumference of the cor-
 nea.   The knife was carried steadily and rather quickly forward, to prevent
 the escape of aqueous humour before the completion of the incision, as its
 sudden discharge would favour the prolapse of the iris.  The moment the inci-
 sion was completed the knife was withdrawn; at the same instant the aqueous
 humour was evacuated at a gush;  and the lids were allowed to close.  The
 gush was even greater than I had hoped  for, so much so, that at  first I  sup-
 posed some pressure must have been made on the eye, which was not, how-
 ever, the case.  After the lapse of a minute or two, the lids were separated and the
 iris found prolapsed so as to draw the lower edge of the pupil quite to the in-
 cision.  I felt satisfied that the iris would adhere to the cornea at the wound
 forming  at this point,  synechia  anterior, and  determined  contrary to  the
                 fig- 37.              opinion of all present to trust  to this
                                     taking place.  The patient was placed
                                     in a dark room, and putupon a restrict-
                                     ed diet.  The result j ustified my confi-
                                     dence; adhesion formed, no inflamma-
                                     tion occurred, the  patient was soon
                                     able to bear the light;  his vision im-
                                     proved, and I was told  a few days
                                     since, that Kane was  at the  hospital,
                                     and stated that his  vision in  that eye
                                     was almost as good as  ever.  The ac-
                                     companying figure, (fig. 37,) represents
                                     the form of the artificial pupil.
          I had intended, should the iris not have been prolapsed spontaneously,
         to draw it out with a small blunt hook which I had prepared by bending
         a small Anel's probe; (see fig. 38,) and such an instrument may be oc-
         casionally required. But I believe that in the large majority of cases if
         the  knife used be  a good one,  and the incision  properly made, that
         the iris will either be  forced out by the gush of aqueous humour, or
         prolapse soon afterwards from the pressure of the humours.  I  am not
         sure  that  a  punctured wound would  not answer equally well, and
         propose trying it on a fitting occasion.
          This operation, is suitable to a number of cases, and in such it pos-
         sesses advantages over those usually resorted to.]
   Formation of an artificial pupil in the sclerotica.—When the entire
 cornea has been rendered irremediably opaque by leucoma, Autenrieth
 proposed to attempt the formation of an artificial pupil in the sclerotica:
 that is, to remove a portion of the sclerotic and choroid  coats, near the
 edge  of the  cornea, and thus expose  the vitreous  humour, in the hope
 that  the wound might be covered by a  transparent pellicle, through
 which light enough might  pass into the eye for imperfect vision.  After
 experiments  on  animals, Autenrieth tried  it  on the human subject.*
 The operation  (which  has been called  scleroticectome)  has  been  per-
 formed  without an useful result by BEERf and Mr. Guthrie.J  Professor
 Ammon§ has given a history of all that has been done and written on the

  * L. Schmidt Diss, de Papilla artificiali in sclerotica aperienda; Tubingen, 1814.
  t J. S. Webek, Dis. inaug. sislens observationes quasdam in Coretodialysin et Pupillam
 in sclerotica aperiendam; Tubingen,  1817. R.;Sas, Hundbuch, vol. iii. p. 380.  He mentions
 that the operation  had been unsuccessfully performed by Riecke, and quotes  the authority
 Rosner, Diss, de Papilla artificiali; Tubingen, 1823, p. 46 and 47.
  X A Treatise on the Operations for the formation of an Artificial Pupil; p. 205.
  § Die Sclenctomie oder die kunstliche Pupillenbildung in der Sclerotica nach eigenen Er.
fahrungen und Operationsvcrsuchen dargestellt.  Zeitschrift, vol. i. p. 183. 
affections of the choroid coat.               449
subject, and has detailed in three cases in which he tried the proceeding.
The operation has also been performed by Dr. Ullmann,* of Marburg.
No advantage seems to have been gained in any of these operations.-
CHAPTER XIX.
AFFECTIONS OF THE CHOROID COAT, RETINA, VITREOUS HUMOUR, LENS, AND
                            CAPSULE.
              SECTION I.--AFFECTIONS OF THE CHOROID COAT.

   We have seen in  a previous chapter that inflammation commencing
 in the iris will extend, sooner or later, to the other internal structures
 and that it  may ultimately  affect  the whole organ.  The posterior
 tunics, particularly the choroid and retina, may be primarily inflamed:
 the disease may be confined, for a longer or  a  shorter period, to its
 original  seat; or it may spread to the contiguous and connected struc-
 tures, and to the iris.
   As the choroid and retina are out of sight, and their diseases do not
 terminate  fatally, we have not  the same direct and  clear evidence
 respecting the seat and nature of the malady in choroiditis and  retinitis
 as in iritis.   This deficiency is  more  sensibly  felt  in the case of the
 choroid  than of the retina.  From its  high vascular organization, we
 should confidently expect that it would be frequently the seat of conges-
 tion or inflammation; and  it probably may be  so.  But direct proof is
 wanting.  The opaque sclerotica completely conceals it; and its disor-
 ders are not  manifested by peculiar functional symptoms, as in the  case
 of the retina.  The latter  membrane  indeed,  from its close vicinity,
 must suffer when the circulation  of the choroid is deranged; impaired
 vision will  be one of the  most important evidences of such disturbance;
 and hence it  may often be difficult to  distinguish between the diseases
 of the two  tunics.
  Mr. Mackenzie published some remarks on inflammation of the  cho-
 roid in the twelfth volume  of the London Medical Gazette, p. 18;  and
 he has considered the subject at greater length  in the last edition of his
practical treatise, Chapter XII. § 24, under the  denomination of sclero-
tica-choroiditis.
  He says  that it is rare in children; that the subjects of it are usually
adults, and more frequently females  than males.   There is no  general
external  redness; but one or more of the arteries derived from the mus-
cular branches are enlarged,  and end in a broad lash  of  small vessels
near the edge of the cornea.  Under these vessels the  sclerotica is
thickened and altered in colour. There is displacement of the pupil,

                    * Ammon's Zeitschrift, vol. ii. p. 123.
       57 
450
AFFECTIONS OF THE CHOROID COAT.
the iris being drawn towards the affected portion of the choroid.  The
iris may be involved in the  disease, or remain sound.  Partial opacity
of the  cornea towards its edge is an  occasional  symptom.   There is
intolerance of light, lachrymation, impaired vision, with pain,  sometimes
slight, sometimes extremely severe.
  Serious changes in the  state  of the eye may be produced by choroid-
itis; viz. staphyloma scleroticae, effusion of fluid between  the sclerotica
and  choroid, or between the latter and the retina, and general dropsical
enlargement of the globe.
  Mr. Mackenzie advises active antiphlogistic treatment in the begin-
ning of the complaint, including profuse and  repeated blood-letting, fol-
lowed by  free leeching.  On  mercury he  places little  reliance; but
he strongly recommends the arseniate of potass, in  small doses, begin-
ning with the  thirty-second part  of  a grain, in the form  of  pill, thrice
daily.  Under this remedy, he  says, "I have had the satisfaction, in a
number of instances, to observe the varicose  vessels to shrink, the  blue-
ness to become whiter, the tumour of the sclerotica and choroid to fall,
and  the patient's health and vision  to improve."   He considers that
the favourable effect on choroiditis of a remedy known to exert consi-
derable influence on some obstinate cutaneous diseases, corroborates the
analogy, in certain points of structure, between  the choroid and the
rete  mucosum.
   Mr.  M. also advises puncture of the sclerotica and choroid, to evacu-
ate fluid effused internally, in the chronic stage of the complaint.
  Observation and reflection have induced Mr. Tyrrell to believe that
disorders of the choroid coat are of  frequent occurrence,  and to assign
to them an important place in  ihe pathology  of the eye.   He gives the
following enumeration of  the affections, to which he considers that the
tunic is liable.   1st. Partial  distention of its vessels, disturbing the retina
by pressure.   2nd. Permanent  partial preternatural dilatation or  vari-
cosity of  its vessels, affecting the retina.  3rd. Temporary congestion,
affecting the vascular structure, generally or partially, and  disturbing
or destroying  the power of  the retina.   4th.  Acute or chronic  inflam-
mation, extending  to the iris and sclerotic by vascular connexion, or af-
fecting  the deeper  tunics and humours of the globe by morbid deposite.
The latter is considered to  be most  frequently fibrine, more rarely se-
rum. (Vol. ii.  p. 13.)
  To the three states  first  mentioned, Mr. T. refers the various forms
of muscae, whether temporary  or permanent, with the partial  imperfec-
tions of sight coming  under  the head of impaired vision.   There is no
direct evidence of morbid change in the circulation of the choroid; the
symptoms  are subjective,  not objective.
  Choroiditis is most frequently chronic, and preceded by muscas or im-
paired vision, on which more serious  imperfection of sight supervenes,
generally as a mist, cloud,  or  network, gradually increasing, and ter-
minating ultimately, but in  general  slowly,  in blindness.  The whole
course of the affection is usually of very chronic character.   In  its pro-
gress, the iris becomes dull,  and sluggish ; the pupil is at first contracted,
and  then  rather dilated.    More  considerable changes  occur  subse-
quently ; alteration of colour, thickening, and adhesion of the pupillary
margin, with loss  of  transparency in the crystalline capsule.  Occa- 
AFFECTIONS OF THE CHOROID COAT.
451
 sionally the iris is little altered.  The only other external appearance is
 slight redness, round the margin of the cornea.  Staphyloma scleroticae
 and effusion  within the globe, are effects of the disorder.
   Acute choroiditis, which generally supervenes on the chronic form of
 the affection, is characterized by dull throbbing pain, with sense of ten-
 sion and tenderness of the globe; rapidly advancing imperfection  of
 sight in  the shape of dark gauze or mist, with grey or dark spots; dull
 redness of the eye from congestion in the vessels of the  sclerotica, and
 changes in the iris and pupil.   The  affection extends to the retina and
 vitreous humour with  irremediable blindness.  Staphyloma scleroticae
 may result, or the opposite condition of softness and flaccidity of the
 globe.
   In a patient, who had experienced  repeated attacks of the disease,
 and had suffered for a long time, Mr.  Tyrrell found after death the
 choroid coat of a fawn colour, softened, and covered internally by a thin
 layer of fibrine; albuminous fluid effused between the choroid and retina;
 the latter membrane covered irregularly by a deposite of fibrine, thickened,
 opaque, thrown into folds, and preternaturally firm; the iris thickened,
 softened, and adherent; the vitreous humour of serous consistence.*
   Mr. T. represents that choroiditis occurs usually in persons under the
 middle  period  of life, and that it is  not uncommon in the infant. It is
 most frequent in those of scrofulous constitution; and more so in females
 than in males.   He adds, that it is not common as a primary disease,
 either in the acute or chronic form.
   From the intimate vascular connexion between the iris  and choroid,
 inflammation soon extends from the one to the other.  Hence choroidi-
 tis may be easily confounded  with iritis.  In the former, disturbance  of
 vision precedes  the changes in the iris and  sclerotic, and  amaurosis  is
 often nearly complete  before increased  action is apparent in the latter
 tunics.   The changes  in the  iris are not  in proportion to the loss  of
 power in the retina.   In iritis, extensive changes may occur in the iris,
 with increased redness of the  sclerotica, and even of the conjunctiva,
 with but little imperfection of vision.
   Mr. Tyrrell has found choroiditis to be connected  with general de-
 bility in nineteen cases out of twenty.   Hence he advises nutritious diet
and tonic medicines, such as bark, the mineral acids, sarsaparilla, steel,
in conjunction with small doses of mercury, using the latter more freely
when the state of the iris and of vision indicates considerable and ad-
vancing disorganization.   In the small number of instances, where  in-
creased fulness of the  vascular  system is present, loss  of blood may be
cautiously  employed as a preliminary measure.
   Mr.  Tyrrell recommends that in the cases, which he regards as ex-
amples  of  choroiditis, the use of mercury should be tried, even where
complete amaurosis has existed for some time, provided the globe be  in
other  respects  healthy, the pupil  generally or'partially  clear, and the
age and  power of the  patient favourable.  He adopted this course in a
strong man, thirty-eight years of age, who had been amaurotic for seven
years, and had lost the perception of  light.   The pupils were clear, but

  * Ibid, p. 74.  Various morbid conditions of the choroid are delineated by Von Ammon
in his Klinische Darsteliungen, pt. i. tab. 15, fig. 20—24; and tab. 16, fig. 8, 9,10,15, 16,
17; also in several figures of tab. 19. 
452
INFLAMMATION OF THE RETINA.
adherent at many points, the irides discoloured and dull, and the patient
had the vacant stare of a blind  person.  He was  put  under mercurial
treatment with a nutritious diet: the free action of  the remedy was
maintained for sixteen weeks, with the daily discharge of a pint and a-half
of saliva.   Belladonna was applied night and morning.  The adhesions
of the pupils gave wTay, and the  openings regained their natural figure;
the natural colour and brilliancy of  the irides was restored; vision im-
proved gradually, and became at last quite perfect.*
  Von AMMONf  has described  inflammation of the orbiculus ciliaris,
which, according to his description, closely resembles inflammation of
the anterior chamber.   Whether or  no inflammation in any case com-
mences in this part, is a question of observation and experience.  We
cannot  doubt that  disorder, if  it  should thus originate, would  spread
quickly, forwards and backwards, to the continuous membranes, so that
the affection would  become more general.   I have  seen partial  elevation
of the sclerotica, round the margin of the cornea, in conjunction with
other symptoms of  internal inflammation.  This symptom has yielded,
with others, to the usual treatment of such inflammations.
  Deficiency of pigment.—As age advances, the quantity of pigment in
the choroid is diminished, and  the  membrane at last becomes pale.
Hence the pupil presents a grey appearance, so  nearly resembling that
of cataract, that on the first  view we may mistake it  for that disease.
By looking at the pupil laterally  we  immediately discover that the lens
is not opaque; and  the unimpaired state of vision will  prevent  us from
confounding the case with cataract.  A greenish, or  yellowish green
discolouration of the pupil is  sometimes seen in elderly persons without
imperfection of sight.  The  cause not yet ascertained, may  be some
change in the  choroid, or in the  transparent media.
          SECTION II.--INFLAMMATION OF THE RETINA : RETINITIS.

  This affection is not of uncommon occurrence, though the membrane
js so  completely concealed  from our  view, that  we  cannot speak of
retinitis with the same confidence that we do of iritis.  We often meet
with cases, in which there  can be no  doubt  that inflammation  of the
retina is the cause of the symptoms.  Dimness of sight  and pain in
various degrees  are the  early symptoms: the pupil is at first contracted,
and afterwards enlarged.
  RosasJ  rightly observes  that  the  affection does not usually extend
over the whole retina;  he says  that it is found, on examination after
death, to  be confined to the neighbourhood of the  yellow spot.  He
adds, that under favourable circumstances it often leaves behind a tem-
porary or  permanent weakness of sight, while in worse cases it leads to
amaurotic blindness,  from effusion of lymph, varicous change of struc-
ture, or even ossification of the retina, and adhesions of it  to the neigh-

 * Ibid, p. 79.
 t Rust's Magazine, yol. xxx. p. 240.  Von Ammon has represented the  external appear-
ance of the eye in this inflammation, and the changes produced by the disease in the orbi-
culus ciliaris, in the Klinische Darsteliungen, pt. i. tab. 8, fiV. 4, 5, and 12.
 X Handbuch, vol. ii. § 780. 
INFLAMMATION OF THE RETINA.                   453
bouring parts.   I have often  seen it entirely removed by active  treat-
ment in the early stage, without any permanent injury to vision.   The
nature and treatment will be best illustrated by a  few cases.
  Case.—Retinitis from exposure to heat and light.—A young woman, of florid com-
plexion and full habit, came to the  London Ophthalmic Infirmary, complaining that
she had lost the sight of one eye. She was cook in a family, and occupied for several
hours daily before large fires, supporting her strength by free living.  The pupil was
slightly dilated, the iris motionless; a faint and scarcely perceptible pink tint was ob-
served  in the sclerotica near the cornea.   Vision was dim  and had been so  for three
days.   There was headach, flushed countenance, heat of skin,  whitish tongue, and
thirst.   I  considered the case to be pure  retinitis,  and  to  afford a favourable oppor-
tunity for showing whether the affection could be arrested by antiphlogistic treatment.
At that time (now many years ago,) I did not possess the knowledge of  the powers of
mercury in inflammation  of the retina, which subsequent experience has given me.
I directed a full bleeding from the  arm, free purging, low diet, repose  of the organ,
and general rest.   At the end of two days the sight was worse; cupping and blister
were now ordered, but there was no improvement at the  end of two days more.   I
now determined  on trying mercury, and ordered two grains of calomel every four
hours.   Before the remedy had affected the system, vision was quite lost, or at least
reduced to the mere power of distinguishing light from darkness.  Full salivation,
which took place  in about a week from the first application  of this patient at the In-
firmary, suspended all the symptoms; sight immediately improved and was soon com-
pletely restored.
  Case.—Retinitis from the same causes.—A young woman, twenty-four years of
age, came under my care in the spring of 1831.   She was a cook, and employed  much
before  fires; she ate meat twice a day, took two pints of ale daily, and sometimes gin
and water.  She  had lately experienced headach, and now complained of dimness of
sight, for which she  had  been bled and purged.  The iris  was slightly and partially
discoloured, and its pupillary margin adhered at two points to the capsule.  The pupil
was clear, sight was dim, so that she could not read.  There was pain over the  brow,
and no external redness.   I ordered abstraction of blood from the temple by  cupping;
two grains of calomel, with one-third  of a grain of opium  every eight hours.   The
mouth  soon  became sore, and  vision  improved.   Plummer's pill, night  and morning,
was now substituted for the calomel and opium, so as to keep up a certain  influence
on the  system.  In three weeks the patient was able to return to  her  situation with
perfect vision.
  Case.—Retinitis from a stroke  of lightning.—A young man of irritable  habit,
standing at a door under a lamp-iron, during a  thunder-storm, on the 2nd of August,
1832, was struck by lightning, fell  backwards, and was convulsed for some minutes.
He said that the lightning appeared to enter his eye with a scorching sensation.  Mr.
Wheble, of Waltham Abbey, who saw him, and had charge of the case,  bled  him from
the arm with great relief.  Another flash of lightning produced a slighter attack; but
the sight returned.   During the night vision  was completely lost.  On  Friday  morn-
ing there was no redness, nor any unusual appearance of the eye; the iris was motion-
less, and the patient could not even see the sun.  He could, however,  open the lids,
and move the eye.  A blister was applied to the back  of the  neck, and three grains of
calomel, with some Dover's powder, were given night and morning; in  two  days, the
calomel was given every  four hours.  The lids became spasmodically closed, and  the
patient could neither open them nor move the eye.   On Thursday, the 9th of August,
he suddenly jumped up from a sofa on which he had been sleeping, with a  most vio-
lent pain, similar  to that of the first attack.  This lasted about five minutes.   Similar
paroxysms occurred every five or ten minutes for two hours, when he suddenly opened
the eye, and saw light.  Most intense pain, similar to that experienced  at the time of
the accident, now came on, and he writhed in agony.  Light was intolerable, even
though the eyes were carefully covered.   The  pain  went off" in the night, and sight
returned.   It has gradually improved, but is  still (August 28) very weak, so that he
cannot use the eyes at all, without the protection of  blue glasses.
  Case.—Retinitis caused by lightning.—An interesting case of retinitis, with tem-
porary  loss  of sight, caused by lightning-, is recorded in  the second volume of the
London Medical Gazette, p. 58, 59.  Jane Humphreys, eleven years old, was stand-
in<r on  the 6th of  May, 1828, in a school-room,  with her left side toward the window, 
454
INFAMMATION OF THE RETINA.
 when a storm came on, and the room was strongly lighted up by a flash of lightning,
 which produced instantaneous loss of sight in the left eye, with tingling  pain  in the
 globe.  As the pain  increased during  the following days, Mr.  Mayo was sent for.
 Repeated leechings on the temples, blisters behind the ear and on  the  back  of the
 neck, and mercury, so as to affect the mouth,  were employed by his directions: under
 this treatment there was visible daily progress towards recovery.
   The symptoms on the llth of May, were sense of heat in the eye-ball and tender-
 ness on pressure ; inability to  raise the  upper lid; extreme sensibility to light, when
 the eye-lids were held open; vision almost extinct.   There was  no increased red-
 ness, nor any change in the transparent media.  Pain  and tightness  across the fore-
 head ; throbbing in the head ;  white tongue; frequent pulse.
   May 20th. Objects could be distinguished ;  total want of power to raise the  upper
 lid; she could bear the light when the lids were opened.
   24th. The power of the levator palpebrse superioris was restored.
   27th. Although the left eye appeared sound, and was used habitually with the other,
 it was weaker than before, and somewhat painful  when exercised.  She could read
 ordinary print with it when held near to the eye, or  distinguish a pin and pick it up
 from the ground; but the faculty of distinguishing colours was lost.   In a yellow silk
 handkerchief, spotted  with scarlet, she could point out the spots; but they  appeared to
 her black, and the ground less black. She described white paper  as a shade of  black,
 and the leaves and petals of a rose as a deeper shade.
   Case.—Elza Radley, sixteen years of age, with light hair and eyes, was admitted
 into St. Bartholomew's under my care, on the  1st of August, 1826.   The left eye is
 kept half closed,  but she can raise the upper  lid.   When  brought to the  window for
 examination of the  complaint, she closes both eyes, apparently experiencing a pain-
 ful impression from  the light.  The retina of the left eye is totally insensible, so that
 she could not distinguish the situation of the window when brought  near it.  There
 is slight redness of the sclerotica.   The  pupil, like that of the other eye, is rather con-
 tracted, but the irides move naturally.   There is considerable pain in the  head, and a
 dull expression of countenance.  Opening medicine has been taken, and the tongue is
 clean.   She first noticed the defect of sight four days ago, when it was attended with
 headach:  both symptoms have increased to the present time.  The sight was pre-
 viously good.   (Sixteen ounces o£blood  by cupping from the hack of the neck.)   2nd.
 Opening medicine;  afterwards 2 gr. of  calomel, with one-third of a  grain of opium
 every six hours.  4th. Sight was improved yesterday, and  is now restored, (continue
 the medicine.)   8th. The calomel  and opium were left off yesterday; the mouth had
 not been affected.  She is discharged quite well, the left eye opening freely, and the
 countenance much improved.
   Case.—George Winston,  aged  twenty-seven, a carman,  and accustomed to drink
 freely, went to bed well on the 29th of July, 1826.  Towards three in the morning he
 felt great pain in the right eye, and he found himself blind with that eye when he got
 up on the 30th.  When he came to St. Bartholomew's Hospital  on  the first of August,
 there was slight redness of the sclerotica; the size and  motions of the pupil were
 nearly as in the other eye.  The access of light was painful, and he could not read large
 print.  There was headach ; pulse 84 and soft; bowels confined.  (Venesection and
 opening medicine immediately;  then calomel and  opium every six hours.)  2nd.
 Thirty ounces of blood were taken, when fainting ensued.   Sight much improved;
 pulse more  full and strong; (cupping to 16 oz.)   Aug. 4. Mouth sore, and sight per-
 fectly recovered.  In three or four days more he left the hospital.
   The following case, which  was completely relieved by antiphlogistic treatment, is
 interesting, because the appearances of constitutional debility, combined with the fail-
 ure of power in the retina, might have  been  regarded as indicating  the propriety of
 tonics and stimulants.
   Case.—Retinitis from over-exertion of the eye.—M. Gibbs, twenty-three years of
age, tall, with pallid countenance, and the appearance of general feebleness, found the
 sight of the left eye become dim, after complete confinement within  doors, and close
attention to needle-work.  The occurrence was preceded by dizziness, and attended by
 headach, and severe pain in and around the orbit.  Leeches were applied a few times,
to the amount of eighteen, and a blister behind the ear;  she was also put under a gentle
 mercurial course till her mouth became rather sore.   She continued to  use  the eye,
 which grew worse, and the vision of the right began also to suffer.   She therefore
 came under my care  at St. Bartholomew's on the 26th of August, 1830.  At this time 
INFLAMMATION OF THE INTERNAL TUNICS.
455
there were a  few  red vessels in the sclerotica of the left eye, giving it a pink hue.
The pupil was of the same size as in the other  eye, and the iris acted feebly.  She
could barely distinguish light from darknrss. There was frequent headach, with deep-
seated pain in the orbit, especially at night.  The right eye was dim, so that she
could not  read small print.  She has not menstruated for the last two months, and
has been quite irregular since the eye was first affected, now four months.  (Cupping
behind the ears'to 12 oz.  Pil. hydrarg. g. v. mane et vespere quotidie.)  31st. Less
headach and pain; vision not improved. (Pil. ferri c. myrrha g. x. omni nocte.)  Sep-
tember 1.   Cupping on the temples to 12 oz.  5th. Vision of the right eye nearly per-
fect, that of the left improved ; the redness of the sclerotica has disappeared.   (A blis-
ter between the shoulders, to be dressed with savine cerate.)  On the llth, she was
attacked with partial inflammation of the left pleura,  which required leeching, cup-
ping, and antimonial medicines. 20th. The pleuritic attack has subsided, and the pain
of the side has disappeared: she is considerably reduced by the treatment. The head-
ach and orbital pain are gone, and the vision of the left eye is perfect, so that she
reads the smallest print with facility.
  A  considerable  portion of the  cases included under  the head  of
amaurosis are affections of the retina; states of congestion, chronic in-
flammation, or functional disorder.   This subject will be considered se-
parately.  Medullary or fungoid disease  of the retina will  be spoken of
under " Malignant Diseases of the Eye."
     SECTION III.--INFLAMMATION OF THE INTERNAL TUNICS GENERALLY.

   Internal ophthalmia.  Ophthalmitis interna idiopathica, Beer.  Oph-
 thalmitis posterior totalis, Rosas.—Pain in the organ and impaired vision
 are the  principal characteristics; there  is but little external redness  in
 the early stage, and often there is  not much throughout the affection.
 The pain is deep-seated, of a dull aching kind, with a sense of pressure
 and tension, and often with a feeling of  heat;  it increases in intensity,
 and is aggravated by exposure to light, by using the eye, or by circum-
 stances that excite the  circulation, or produce determination towards
 the head.  It extends  from the globe to the orbit,  and soon spreads  to
 the brow, the occiput, the side of the head, or the head generally.  Dim-
 ness of sight comes on with the pain, and in severe cases sight is some-
 times speedily extinguished.   At this period the external appearances of
 disease are not considerable; there is a  little redness of the sclerotica
 round the cornea.  The pupil may be either contracted, the iris moving
 quickly, or the  latter may be sluggish, and the former rather dilated.
 The first is the earlier stage, denoting excitement of the retina, while the
 latter circumstances indicate more advanced  affection, with  impaired
 sensibility of  the nervous structure.
   The patient is feverish; there is heat of skin,  thirst, white tongue,
 disturbed circulation, and restlessness.
   With  the continuance of the complaint, the  inflammatory symptoms
 are more developed and obvious.  The sclerotic redness increases, and
 forms a  bright red zone round the cornea.   The  iris changes colour
 and expands, the pupil contracting towards the centre, losing its clear
blackness, and becoming filled with a  web  of  lymph, effused from the
thickened margin.  The sight becomes more and  more imperfect, and
is  soon lost.   This happens from the inflammatory  excitement and con-
sequent change in the retina; it takes place before  the entrance of light 
456
INFLAMMATION OF THE INTERNAL TUNICS.
 is mechanically impeded by the changes in the pupil.   After vision is
 entirely lost, sparks,  flashes, and  various luminous appearances may
 still be perceived, and even be troublesome to  the patient.
   In the second stage, with increased external  redness, pain, headach,
 and fever, the pupil closes, sight having  been  previously lost.  The iris
 becomes convex,  being pushed forwards towards the cornea, so as to
 diminish or destroy the anterior chamber.  Suppuration occurs, matter
 is effused in front of the iris, constituting hypopyon; blood is sometimes
 mixed with it.   Now the internal and external tunics are fully involved,
 and the appearances  are those of general ophthalmitis.
   The results of such an affection are, closed pupil with the formation
 of an adventitious membrane, insensibility of the retina from change of
 structure consequent on violent inflammation, contraction  and partial
 obstruction of the pupil, the function of the retina being impaired, the
 capsule and lens opaque.  Resolution  may occur, with vision more or
 less impaired, or with complete recovery of sight.
   The complaint is  seen  both in  the  acute  and chronic form.  The
 latter is the most  frequent, and a  long  time often elapses between the
 early symptoms of muscse with slight dimness, and the occurrence of
 blindness.
   Prognosis.—When disease attacks the nervous structure, in which
 vision immediately resides, and the pupillary aperture  through which
 light enters the  organ, the case cannot  be  otherwise  than serious, re-
 quiring that the  history and causes of the  complaint, the state of the
 organ, and the condition of the constitution, should be investigated with
 great care.
   The prospect is favourable in the beginning, and is  less and  less so,
 in proportion as  time  elapses.   The state of the  retina, as indicated by
 the degree of vision, and the condition of the iris and pupil, are the most
 important  criteria.  Greatly impaired vision, produced quickly, with
 pupil still clear, and not much contracted may be restored. If sight
 should  have been totally lost, before the pupil  has closed; or if that
 opening be much  contracted, and  vision gone, there is  no hope.  The
 loss of vision is not altogether discouraging in itself, but it is  a bad sign
 when connected with considerable change in the  iris and  pupil, and
 great external redness.
   The prospect is more  favourable when the complaint owes its origin
 to obvious external agencies, such  as excessive and imprudent exertion
 of the organ, than when it  is referable to constitutional causes; also, in
 persons of good constitution and health, than in those naturally delicate,
 or whose health is already  impaired.
   The treatment is the same as in iritis; it must be antiphlogistic in the
 first instance, unless reduced constitutional power should forbid direct
 depletion;  and  this must be followed up by the  use of mercury, com-
 bined with the local employment of belladonna.
   It might be  expected that antiphlogistic  measures alone would an-
 swer the purpose; but this is not the case; they check the disease, they
diminish the external redness,  the  pain  and  headach, and  relieve the
patient altogether,  but they  do not improve the sight much; they do not
control  that excited state of the capillary circulation,  which threatens
such dangerous  results  to  vision.   Mercury is equally powerful  in 
INTERNAL OPHTHALMIA.
457
checking this, when  it occurs in the retina, as in the  iris, and the ob-
ject cannot be accomplished without this  remedy, nor, in many cases,
without its decided action on the system.  The beneficial results  from
the combined action  of the antiphlogistic and mercurial plans are  often
truly surprising.   It has so often happened to me to see depletion,  even
when carried to the largest extent, fail, and  vision immediately bene-
fited, and soon restored by the employment  of mercury, that on this
point I speak with the greatest confidence.
        INTERNAL INFLAMMATION OF THE EYE CONSEQUENT ON FEVER.

   In the fourteenth  volume  of the  medico-chirurgical transactions,
 page 286, there is "Jin essay on a peculiar inflammatory disease of the
 eye, and on its mode  of treatment," by Mr.  Wallace, of  Dublin, in
 which he describes what  he calls a most obstinate and dangerous form
 of inflammation of the eye, frequently observed among those who  had
 laboured under fever.  He observes that "the complaint in question strong-
 ly resembles venereal  iritis, not only in the  appearance of the diseased
 organ, but also in the  character of the patient's countenance.  The eye-
 lids are  half closed, reddish, and swoln; the vascularity of the sclerotic
 and conjunctiva being greatly increased, with a peculiar dark brick red
 colour.   The iris is altered in colour, generally greenish, and incapable
 of motion ;  the pupil  contracted, with its edge thickened and irregular.
 The cornea  is  dim, with an appearance like that  of glass which  has
 been breathed upon.   There is often a turbidness of the aqueous humour;
 and a pearly appearance  of the  parts behind the iris may be observed
 by looking through the pupil.   There is great intolerance of light, and
 a copious, hot, lachrymal discharge.   The vision will be found for the
 most part, so extremely imperfect, that the patient can merely distinguish
 light from darkness, and he is often tormented by flashes of light which
 shoot across his eye, and  these occur more particularly in dark places;
 or he is troubled by brilliant spectra, or  by the constant presence of
 muscae  volitantes.  There is very considerable pain, which  returns in
 paroxysms,  and these are almost always more severe at night.   The
 pain is  sometimes referred to  the ball of the eye, sometimes to one of
 the lids,  sometimes to the  temple, or  the circumference of the orbit.  It
 is, one while, compared to the action of a saw on the  bones, and on
 other occasions, to  the darting of a  sword through the eye-ball.  This
 disease occurs as frequently in the male as in the female.  The youngest
 patient,  of whose case I have a note, was ten years of age, and the oldest
 thirty-six years.  It seldom attacks both eyes, and the right eye suffers
more frequently than the left.  Of forty cases which I have noted, there
were onlv four  who had the disease in the left eye, and only two who
had it in both.   The general health  seldom  appears  to be  much de-
ranged.   The tongue  is for the most part slightly white.   There is often
considerable thirst, and the pulse is somewhat accelerated.   The bow-
els are  frequently confined, and there  is  occasionally a  disposition to
nausea.   The disease has occurred more generally in those who  have
been the subjects of relapse, but the period at which it takes place after
the first  attack  of fever is extremely uncertain.  In some it has ap-
      58 
458
INTERNAL OPHTHALMIA.
peared immediately, in others not for months.   Sometimes  a state of
apparently full health  has  intervened between the attack of fever and
the commencement of the inflammatory disease of the eye; on other
occasions, the general health has seemed imperfect from the  time of the
fever, until the occurrence of the ophthalmic affection."
  Mr. Wallace proceeds to observe that the disease presents two dis-
tinct stages, in the first of  which there are amaurotic symptoms alone,
to which, in the  second, those of inflammation  are  superadded.   The
period at which  the  former commence  after fever, and the length of
time that they exist before external redness comes on, are very uncer-
tain.   Sometimes dimness of vision  and muscas volitantes  have been
experienced at or before the time of convalescence from fever; yet the
inflammatory stage has not supervened for weeks or months; while on
other occasions, the dimness has not commenced for weeks  or  months
after the febrile attack, and has  then been immediately followed by the
symptoms of inflammation.  The inflammatory also precede the amau-
rotic symptoms in the time of disappearance.
  Mr. Wallace  had  found  the treatment by  depletion and mercury
insufficient,  and even  injurious, when  he accidentally witnessed the
rapid recovery of a case, in which the patient took bark on  account of
an intermittent under which  he  laboured at  the same time.  This led
him to employ the same  remedy in other  cases, which he  did with
striking, and apparently constant success.   At first he did not venture
to employ it when the inflammatory symptoms were severe,  without
previous bleeding and purging.   " But latterly," he adds, " whenever a
case has presented itself, 1 have  prescribed the  bark alone, or  simply
with such medicines as were suited to the regulation of the bowels, and
with the most decidedly good effects.  Indeed, I have thought  that the
abstraction of blood has, on  some occasions, considerably retarded'the
cure; yet cases  may occur in which bleeding and purging may be neces-
sary."  Mr. Wallace gave the  bark in powder, half a dram or a dram
three or four times in  the twenty-four hours; or the sulphate of quinine
in two grain doses.  He  relates several instances in which this treat-
ment had been  employed,  both where mercury had been used  in vain,
and where it had not been resorted to.  He employed it equally during
the amaurotic stage, and  after the inflammatory symptoms had com-
menced.
  At page 187, I have quoted from Professor Walther a case of oph-
thalmia occurring after fever; apparently  similar to the  affection de-
scribed by Mr. Wallace:  it was successfully treated by loss of blood.
  Mr. Hewson* has related five " cases of ophthalmia succeeding  to
typhus fever," in which the  symptoms were exactly the same as those
described  by Mr. Wallace. They  all  yielded readily to  mercurial
treatment.
  The observations of Mr. Wallace, respecting the efficacy of bark  in
this affection, are confirmed by the testimony of Dr. Reid in  the follow-
ing passage. " On my first noticing this  affection  of the eye. as a
sequela of fever, I was informed by Mr. Wallace of this city, that  in
some cases  of a  similar nature, which came under  his treatment, he

  *  Observations on the history and treatment of the Ophthalmia accompanying the second-
try forms of the hues Venerea, p. 109—114. 
INTERNAL OPHTHALMIA.
459
had found small doses of Peruvian bark  the  most efficacious remedy.
I therefore immediately adopted his suggestions, and with ultimate suc-
cess, in all  the  cases which  came  under  my care.  There were two
patients with this form of disease, to whom  I gave preparations of bark:
after a few days the ophthalmia certainly  disappeared, but  they had a
relapse of fever  in an aggravated form."*
   This species of internal ophthalmia has been  described by Dr. Jacob,
of Dublin, in the work last quoted.f   This gentleman and Mr. Wallace
agree very nearly in  what they say respecting  the  history  and symp-
toms of the  disease; but on the subject of treatment, particularly in
reference to the  powers of bark and  mercury, their evidence  is com-
pletely contradictory.
   Dr. Jacob  had met with seventy or eighty cases of the disease within
the year.  He had not seen it at a later age  than forty-five; and of thirty
cases in which the ages were noted, three only were above twenty-five.
It is more frequent among the poor than  the  rich, and among  females
than males.   Children are not exempt; cases have been seen at three,
five, and seven  years of age.  It came  on generally within six weeks
or two months after recovery from  fever; sometimes earlier,sometimes
at the end of four, five, or even eight months.  It affects only one eye.
Dr. J. does  not remember  seeing  any case in  which both  suffered.
Symptoms of retinal  affection occur first, and  the inflammation super-
venes in six, eight, or ten days: the interval is  sometimes longer, even
to two months.   " In  this inflammation the transparent parts are ren-
dered more  or  less  clouded  or  opaque;  the  cornea especially has its
margin or circumference almost always of a whitish  or grey  appear-
ance, presenting an opaque  circle resembling the arcus senilis.   The
anterior chamber of the eye appears clouded, independent of the opa-
city of the cornea, arising probably from thickening of the membrane
of the aqueous humour; this cloudiness is sometimes general, sometimes
it presents a  muddy  patch behind the cornea  as in syphilitic  iritis.  In
the worst form of the disease the lens itself becomes partially opaque,
reflecting light falling obliquely upon  it, and presenting an opaline am-
ber colour; indeed it  is in this way I have observed vision to be destroyed
when the disease has been fatal to the organ."   The iris is always
altered in colour, and loses its brilliancy; but Dr. Jacob has not seen it
assume the decided yellowish green, observed in some other inflamma-
tions; nor has he observed the formation  of  abscesses or tubercles of
lymph.  Hypopyon  sometimes  occurs, but  not  as  a consequence of
more intense inflammation; on the  contrary, it is seen in  very mild
cases, even when the pupil contracts on  exposure to light.   The pupil
is slightly irregular, but does not contract adhesions, or become closed :
often the iris moves actively.   A stinging or  aching pain darting to the
temple or nose is generally present, often there  is little or no suffering.
There is intolerance  of light, with lachrymation and severe pain on
exposure to  strong light.  "Vision is in all cases much impaired; some
cannot read print of moderate size, others cannot distinguish large capi-

  * Clinical Observations made during the Epidemic  Fever of 1826; in the Transactions
of the Association of Fellows and hicentiates of the King and Queen's College of Physi-
cians, vol. v. p. 294.
  t On internal Inflammation of the Eye following  Typhus Fever, p. 468—478.  This
paper read in January, 1828, wae published in the same year.  Mr. Wallace's essay was
read in December, 1827, and published in 1828. 
460                    INTERNAL OPHTHALMIA.
tal letters, others are unable to see a key, or other large object, held at
a short  distance from the eye, while others can  only distinguish light
from darkness.  I have not observed that the degree of injury to vision
was proportioned to the extent of the inflammation; the cases of mildest
appearance being sometimes attended by the most defective sight. The
patient can seldom  distinguish all  the prismatic colours, deep blue and
green generally appearing  black."
  " The treatment of this inflammation of  the eye is not attended with
much difficulty.  Bleeding, locally, or generally, in proportion  to  the
urgency of the symptoms; blistering, where there is much pain or  in-
tolerance of light;  purgatives, antimonial medicines, and opiate stupes,
are obvious  means of  relief."  Dr. Jacob strongly  advises  the  use of
belladonna, and adds, " I do not, however, by any means recommend
that the surgeon should  depend on  these remedies alone; on the con-
trary, I believe that they will prove ineffectual in  the majority of cases,
and therefore we must have recourse to mercury, which has been found
so valuable a  resource  in  other  cases.  In my own practice I have
found the relief from the use of mercury so certain  and decisive, that I
have trusted to it  almost  exclusively, with the assistance of  the bella-
donna.  I have generally found that two grains of calomel with a quar-
ter of a grain of opium, three  times  a-day, answered every purpose;
and in the majority of cases I produced  the necessary mercurial action,
as marked  by tenderness of the gums, in eight or ten days, by the use
of three, four, or five grains of the blue pill  alone, three times a-day;
and if the pain should be severe, combining hyoscyamus or belladonna
with the dose taken at  bed-time.   I have  heard that  the  sulphate of
quina has been administered with  advantage in these cases;  but  as my
experience of  its efficacy is not considerable, I cannot speak of it with
any certainty.  In two cases which I saw  after the inflammation had
subsided, and in which vision was as much impaired as  if no remedies
had been adopted, bark in powder had  been administered for ten days.
I gave trial to the sulphate of quinine myself in four well marked cases
for eight days, but  finding  no relief, had recourse  to mercury, which
effected a cure in the usual time."
           ARTHRITIC INFLAMMATION OF THE INTERNAL TUNICS.

   In arthritic iritis, which has been already described, the disorder be-
gins in, and is chiefly confined to, the iris.   But in the gouty, or in per-
sons whose constitution and general  health  are impaired in a similar
manner, a  more extensive inflammation is frequently developed, affect-
ing the internal parts of the globe generally, that is, the choroid, iris,
retina, vitreous humour, lens and its capsule, and involving the sclero-
tica and cornea secondarily.  It ends in  loss of sight, with a dilated
pupil, and opaque lens.   Sometimes  the latter change does not occur,
but there is deep-seated green discolouration of the pupil, that  is, the
appearance called glaucoma: the  disease might then be named  acute
glaucoma, in contra-distinction to the slowly occurring change of simi-
lar character, which will be afterwards described.   Beer* has  given
                      * Lehre, vol. i. § 567—572. 
                        INTERNAL OPHTHALMIA.                    4G1

an account of this affection under the name of arthritic iritis, thus lead-
ing to the erroneous notion of its being confined to the iris, although his
own description of its progress and destructive influence on vision, as
well as of the changes of structure produced in various parts of the globe,
shows it to  be much more extensive.  This disease almost  invariably
destroys sight; while the eye  will recover completely from repeated
attacks of arthritic iritis.  Benedict* and RosasI have given it the appro-
priate name of ophthalmitis  arthritica, because it attacks  gouty per-
sons, and involves the whole globe.
  A severe burning or tearing pain is felt deep in the globe, with a sen-
sation as if the eye were too large for the orbit.   At the same  time, a
dull and rather livid redness is  developed in the sclerotica,  increasing
in intensity to the edge of the cornea,  from which, however, it is  sepa-
rated by the narrow white ring mentioned in the description of arthritic
iritis.  Soon the vessels of the conjunctiva become distended, and  the
cornea loses  its brightness.  In  the  beginning there is  increased sensi-
bility to light and lachrymation.  The pain of the eye becomes severe
and  almost  intolerable, and extends to the orbit, face, and side of the
head; it entirely prevents rest, and sometimes is hardly lessened by the
the most active treatment.   The  iris  is  rendered  darker and dull, the
pupillary margin being turned backwards, and the  opening itself dilated
and  fixed, sometimes having an oblong figure in the transverse direction.
A dull green discolouration is observed deep in the eye, and  considered
to indicate  loss  of  transparency in the  vitreous  humour, or organic
change in the retina.  The posterior parts of the globe swell, and push
forwards the lens into the  dilated pupil, wedging  it into the aperture,
and  squeezing it  against the  cornea.   Under such  circumstances, or
without being thus displaced, the lens  loses  its transparency, turns of a
dull  green, yellowish green, or dull white, forming a green or glaucoma-
tous cataract.  This vascular congestion, and the consequent swelling
of the internal parts, distend the sclerotica, and  give to the globe a
stony hardness.  The disturbance in  the vessels of the  sclerotica ex-
tends to the  cornea, ofien causing considerable haziness; this change,
and  those in  the iris and pupil, destroy all the brilliance and  expression
of the organ, making it look almost  like  a dead eye.  Sight is  greatly
impaired, often entirely lost, from  the  very beginning : this  loss of
sight may be sudden, taking place  in the course  of a  ni^ht.  Yet the
patient often perceives flashes  and various luminous appearances, al-
though unable to distinguish light from darkness ; and  from time to
time a glare of light is seen, which leads to  the falacious hope that sight
may be recovered.
  The pain  and  redness lessen, and the affection  subsides, leaving an
iris of dull leaden hue, a fixed and dilated pupil, either  of a  dull green
colour, or occupied by a glaucomatous cataract, with total and irrepa-
rable loss of vision.   The external trunks lying on  the sclerotica are en-
larged, knotted, and varicous, {varicositas  oculi,^  cirsophthatmia, vari-
cous ophthalmia.)  Sometimes there is a distention with partial absorption
of the sclerotica,  giving it a dull leaden or bluish appearance, especially
in the situation of the ciliary body, causing small  projections, supposed

  * Handbuch, vol. ii. p. 263.  t Ibid, vol. ii. § 814—828.  t Beeh, hehre, vol. ii. p. 247. 
4G2
INTERNAL OPHTHALMIA.
to arise  from various enlargement of the choroid  veins, or the larger
bulgings, which constitute  staphyloma  scleroticae, and  alter the form
of the globe.   These appearances in the sclerotica must be ascribed to a
morbid condition of the choroid and other internal parts.   Mr. Macken-
zie says, that in a preparation belonging to Beer he saw varices of an
inflamed choroid as large as  small peas.   (Practical Treatise,  p. 460.)
It has been found in some cases that effusion of fluid has occurred be-
tween the choroid and retina.
   The disorder generally affects the two eyes in succession; but both
may be attacked at once. The course of the affection varies in  rapidity
and severity of symptoms.  Sometimes sight is more slowly extinguished,
pain is  less, and  even inconsiderable, the change in the  iris is not so
remarkable;  the varicous  enlargement of the external vessels is  not
seen.
   The pathology is imperfect from  the  want of dissections.   We do
not know where the disease begins; what structure is  its primary and
essential seat.  The early  diminution  or entire loss of  sight shows  us
that  the  retina is disordered in the  very outset, and that it undergoes
serious disorganization;  if, therefore, the complaint  were  to be named
from the structure, in which  it first breaks out, we  should call it retini-
tis.  Mr. Wardrop informs  me that in two cases of acute glaucoma,
where blindness occurred in the very beginning of the attack, he found
after death opacity and thickening of the retina, in a space about equal
to the nail of  the little finger.  The  changes in the pupil indicate alte-
ration in the transparent media; while the tension of the globe and the
bulgings  of the sclerotica imply congestion and  swelling of the cho-
roid.
   The chief cause of the affection is an unhealthy state  of constitution;
it takes place in gouty subjects, and  in such as have had other forms of
gout.  We see it in elderly persons, always  after the middle period of
life; in those of full habit, of corpulent make, with the bloated, red, pur-
ple,  and  veined faces, that denote habits of indulgence.
   It is important to distinguish this affection from cataract; from amau-
rosis, properly so called ; and from com'mon internal ophthalmia.
   The prognosis is entirely unfavourable.  Where vision  is  lost in such
a case, it is  never restored;  nay, if the characteristic symptoms  are
present,  we may be tolerably certain that the disease will'go on to the
extinction of sight; and  we cannot prevent it.  The disorder indeed is
so unmanageable, that treatment has very little effect upon it:  the pain
in the eye and head continues in spite of our treatment,  and vision is
neither restored nor improved.  In the beginning we resort to depletion,
perhaps  to loss of blood, according  to the degree of local and general
disturbance; subsequently a mild mercurial course, with aperients, regu-
lated diet, and blistering may be necessary.
   This disease is  sometimes  seen in  the  chronic  form, the symptoms
and  progress  being essentially the same  as in the  acute affection, but
much milder  and  slower.   Vision is  impaired  in  the  beginning, with
scintillations or  other luminous appearances, and  perhaps pain in the
eye  or brow.  There is  dull or livid redness of the  sclerotica,  with en-
largement of its vessels; the  iris undergoes change of colour, and loses 
GLAUCOMA.
463
its mobility; a dull or brighter greenish appearance is seen deep in the
pupil, no longer observable when we  look  at the eye  sideways, and
varying its apparent position according to the direction  in which  light
falls on the organ.   The pupil is often dilated transversely, so as to as-
sume  an oblong  form.   Ultimately, glaucomatous cataract occurs,
perhaps with staphylomatous bulging of the sclerotica, varicous enlarge-
ment of the subconjunctival vessels, and complete extinction of sight.
  As weeks or months may elapse without the complaint making much
progress, an opportunity is afforded for trying the effects of treatment,
which hardly occurs in the acute disease.  We may remove the affec-
tion in an early stage, and arrest its progress at  a  more advanced pe-
riod.
  The subjects of the complaint are generally individuals, at or beyond
the middle  period  of life,  of unsound constitution or impaired  health.
Depletion, or  any treatment calculated to lessen constitutional power
must therefore be resorted to cautiously.  Local abstraction of blood
may be required, and the mild employment of mercury, if the  system
will bear its influence, is of great service.
  The protection of the organ from excitement, or other injurious influ-
ence, the removal  of all  causes, whether  bodily or mental, capable of
lowering the  energy of the nervous system, residence in pure air, and
tonic or restorative medicine under particular circumstances, are im-
portant, or rather essential auxiliaries.
                             GLAUCOMA.

   The name of glaucoma, which wras formerly given to cataract, is now
used to denote  an affection of the eye  attended  with  alteration in the
colour of the pupil.   It is an important disease, because the discoloura-
tion of  the pupil may be confounded with  cataract, and because it  is
either originally attended with impaired vision, or leads in its progress
to diminution or loss of sight.
   Symptoms.—The first symptom is pain in  the head, usually situated
over the brow,  and frequently the patient describes it as extending quite
across the forehead.  This pain in many cases is severe, but in others
not so strongly marked, or even absent.  At the same time, the patient
begins to complain of dimness or weakness of sight; and, if we examine
the eye, we find that instead of exhibiting its natural black  colour, the
pupil is sea green, clear green, muddy green, or yellowish green. There
is a discolouration,  which,  if we look at it in a strong light, appears like
a yellowish metallic reflection, and sometimes concave: it looks almost
as if there was  a portion of metal at  the bottom of the eye.  The  pupil
at the same time is  rather dilated, and  the iris sluggish.  The stale  of
vision  is different  in different instances;  in  some,  the alteration  of
the pupil is distinctly produced, and yet vision remains  tolerably per-
fect.   In other cases vision  is entirely lost,  though  the  change  of
colour in the pupil is inconsiderable.  Sometimes vision is impaired  in
one eye and not in  the other, though the pupil may be  equally disco-
loured  in both.
   In the progress of the  disease, vision gradually grows worse; the 
464
GLAUCOMA.
 discolouration of the pupil, or rather of the fundus of the globe behind the
 pupil, is more considerable; the iris is more sluggish, until it becomes at
 last motionless,  and  vision  is entirely lost.   The  affection does not
 always stop at this point, but sometimes attacks the lens, and renders it
 opaque, so that it is no uncommon  thing for cataract  to occur subse-
 quently in an eye  which was originally attacked by glaucoma.   The
 cataract thus produced is greenish, yellowish or dirty white, {cataracta
 viridis or glaucomalosa.*)
   Sometimes the lens and iris are pushed forwards, so that the latter is
 convex;  it may  even be in contact with the cornea.  The external
 vessels of  the globe are sometimes enlarged and varicous; but  all the
 characteristic appearances of glaucoma may occur with loss of sight,
 without any change in the  state of these blood-vessels.
   Causes.—We  can point  out  nothing peculiar  as  contributing to its
 occurrence.   It takes place at or after the middle period of life, in those
 whose constitutions have been impaired  by free living, especially by
 drinking.   It  appears  to  me  to be the  most chronic form  of  the same
 affection which I have described, as arthritic inflammation affecting the
 internal tunics; the changes which occur in the retina, vitreous humour,
 and lens, as the consequences of that inflammation,  are rapid and  sud-
 den, whilst in the present case the disease has a slower progress.  It cer-
 tainly occurs more frequently in such persons as  are liable to  gout than
 in others.  "Glaucoma and green cataract,"  says Beer,! "considered
 as  consequences of inflammation, belong  to arthritic inflammation of
 the globe; and the same  forms of disease, when  occurring without in-
 flammation, are only seen in the gouty.''
   Seat of disease.—The situation of the  discolouration has  naturally
 led to  the supposition that it arose from change of structure in the vitre-
 ous humour, and it  has accordingly been assumed, without direct  evi-
 dence, that inflammation  of this structure produces  the phenomena of
 glaucoma.  From the immediate  contiguity and close connexion of the
 retina we might expect that it would  often suffer in  conjunction with
 the vitreous  humour originally;  or  that inflammatory affection com-
 mencing in the latter, would soon extend to the former.  Thus we might
 explain how sight  is  seriously impaired, from  the  beginning, in some
cases; while  in  others, amaurosis  appears secondarily, and  proceeds
slowly.  Mr.  Mackenzie  has recently  shown, by pathological exami-
nations, that the commonly received notions on this subject  are incor-
rect.   He found the following changes to have occurred in eyes which
had been affected by glaucoma :—" 1. The choroid coat, and especially
 the portion of it  in contact  with the retina, of  a light brown colour,

  * Weli.er has  delineated, in several figures, the appearance of the eye in  the  various
stages and forms of glaucoma.  See his Iconrs ophthalmologics, fascic. i. plate 1, 2.
  Von Ammon has given numerous representations of eyes affected with glaucoma illus-
trating the changes caused by the disease in the iris and pupil, in the crystalline, the scle-
rotica, and the external vessels of  the globe. Klinische Darsteliungen, pt. i. tab. 10, fie.
 14—24 ; tab. 15, fig. 1.
  Two excellent representations of the disease will be found in Beer's hehre ; vol. i. tab.
2, fig. 6; and vol. ii. tab. 3, fig. 5.
  A figure of glaucoma is also given by  iYIr. Tvrrell, vol. ii. pi. 5, fig. 1;  and by Mr.
 Morgan, tab. 11,  fig. 3.
  t  hehre, vol. ii. p. 255. 
GLAUCOMA.
465
 without any appearance of pigmentum nigrum.  2. The vitreous humour
 in a fluid state; perfectly pellucid ;  colourless, or slightly yellow.  No
 trace of hyaloid membrane.  3. The lens of a yellow or amber colour,
 especially towards its centre; its consistence firm; and its transparency
 perfect, or  nearly so.   4. In the retina, no trace  of limbus  luteus or
 foramen  centrale."  (Glasgow Medical Journal, vol. iii. p.  259.)   Mr.
 Mackenzie considers that the glaucomatous discolouration of the pupil
 is owing to the change in the lens.
   Professor Walther  (Abhandlungen, p. 40—42,) examined the eyes
 of a man, who had lost his sight a year before death, with violent pain
 of the  head.   Besides the discolouration of the pupil, which was not
 considerable in proportion to the loss of sight, the aperture was rather
 dilated, the iris convex anteriorly, the sclerotica bluish over the corpus
 ciliare, and vision completely extinct, although light was offensive.
 Several varicous vessels were observed in the conjunctiva and sclerotica.
 The lens  and  vitreous  humour were in the normal state, and perfectly
 transparent: no change in the  choroid.  In the retina of both eyes were
 numerous black, and partly reddish spots, roundish, and of various size:
 they were more numerous towards the dentated margin, and not dis-
 turbed in their situation by gentle pressure.
   Two  glaucomatous eyes were dissected by Eble.  (Ammon's Zeit-
 schrift, vol. i.  p. 310, 311.)  One was from a woman of sixty, who had
 suffered much from gout, and  had had glaucoma completely developed
 in one eye for a year before death.  The covering of the uvea was
 reddish brown, instead of the usual dark  pigment.  The vessels of the
 choroid were  varicous in several places, particularly  in the ciliary pro-
 cesses ; the pigment was  much lighter than natural, and had disappeared
 in many parts.  The retina  was  of  extraordinary  softness;  it was
 almost fluid.   The capsule was partially opaque; the lens small, firm,
 and  of amber colour.   The whole vitreous humour had a yellowish
 tint; and there were scattered through it twenty or  thirty points of  a
 grey, brownish green, or sea-green colour.
  The other patient was seventy years old, had frequently experienced
 arthritic  inflammation of the  eyes, and  had  become  glaucomatous
 shortly  before   death.   The vitreous humour was partially thickened,
 and firmer to  the touch.   The retina was more seriously affected than
 in the  former  instance, the vessels  exhibiting some varicous enlarge-,
 ments, and the colour being dark grey.
  " The pathological changes," says Professor  Rosas, " exhibited by
 glaucomatous   eyes are  various.    The  vitreous tunic is  commonly
 thickened, covered with  lymph, ossified;  the vitreous  humour  degene-
 rated;  the retina thickened, and  marked with  red spots;  the  choroid
 varicous.  In  a case, which I examined, the vitreous humour contained
a reddish  grey fluid, with brownish particles intermixed; the retina was
thickened, the  choroid varicous, and the lens converted into a yellow-
ish, red, cheesy mass.  In another instance the vitreous humour formed
a true fungous growth, {schivammgewdchs,) from which, when cut into,
blood flowed;  the retina  was  leathery and white, the  choroid thin and
atrophic, and the lens converted into a purulent fluid.   In a fourth case
I found the vitreous humour, together with the lens which had become
confounded with it, ossified, the retina cartilaginous, and the  choroid
       59 
466
GLAUCOMA.
atrophic.   All these preparations are preserved in the pathological col-
lection of  the  ophthalmic department  in  the  university of Vienna."
(Handbuch, vol. ii. § 1203.)
  From  the  preceding pathological facts, we  may conclude that  the
vitreous humour is  not originally and essentially the seat of glaucoma:
we may perhaps draw the  further inference, that  affections  in  some
respect different  are included  under that  term.   When we  consider
the numerous gradations between the acute internal arthritic ophthalmia,
which destroys sight at once; and  the imperfection of vision, which
comes on so slowly in glaucoma, properly so called ; also that difference
of morbid changes may be expected according to the stage of the  com-
plaint, we shall not be surprised at finding that the  results of examina-
tion are not always alike.
  The cases  examined by Professor Rosas  must have  been  arthritic
inflammation of the internal tunics, and chiefly in their chronic stage;
some of the  disorganizations, which he met with, are such  as occur
only after long continuance of disease.
  The phenomena of glaucoma, according to these  dissections, must be
referred to disease of the choroid and retina; and the reflection of light
from the surfaces thus morbidly altered, especially if  the lens should
have begun to exhibit that change to amber colour which takes  place
in advancing age, will sufficiently explain the change of colour behind
the pupil.
  Diagnosis.—The discolouration of the pupil arising from glaucoma,
and that from cataract, may be distinguished by the tint of colour.  In
glaucoma  it  is green or yellowish green,  and  if we look at the eye
laterally, we see no discolouration, whilst in cataract the pupil is  grey,
or greyish white, and it has the same appearance in whatever direction
it is viewed.  The loss of vision in glaucoma is  not in direct proportion
to the change of colour in the pupil; with  an inconsiderable  change,
vision may be entirely destroyed or seriously impaired; but in cataract
there is a direct proportion between the degree of opacity and the injury
to sight.   In cataract, vision is best in a moderate  or  weak light; but
in glaucoma it is most perfect in  a strong light, because in glaucoma,
as the retina is less sensible, more light  is required to make an impres-
sion on it.
  Prognosis.—The prognosis in glaucoma is unfavourable; we have no
means of changing that condition of the internal parts, on which the
loss of transparency depends;  we cannot bring back again the natural
appearance of the pupil; we cannot restore the vision which has  been
lost; and all we can expect  to do, is to  preserve the little sight which
remains.
  Treatment—Beer says (Lehre, vol. ii. p. 254—256,) that no treat-
ment will  be  of any effect in preventing complete amaurosis.  As  he
speaks of glaucoma with green cataract, his observations probably  refer
rather to the state in which the eye is found after acute  arthritic inflam-
mation of  the internal  tunics, than to the disease  which I have  been
describing, in which sight is affected in conjunction with a peculiar
discolouration behind the pupil, the lens retaining its transparency, and
without previous  apparent inflammation.  I  have found by repeated
experience that many of these cases admit of considerable relief;  but I 
GLAUCOMA.
467
  quite agree with him  in  regarding the combination of glaucoma with
  green cataract as incurable.
    There is sometimes congestion in the head, the removal of which is
  attended with  considerable benefit.  The treatment must in such cases
  be antiphlogistic; we must take  blood by cupping; give  active purga-
  tives, and administer mercury; the patient must be put upon a regulaled
  plan of diet, and  avoid all strain or fatigue of the eye.   If this treat-
  ment be followed up, we shall  at least prevent  the disease from ad-
  vancing.
    In the first place when there is active congestion with pain, the patient
  is relieved from  uneasy sensations.  The  continued prosecution of the
  plan will not only prevent the progress of disease, but  even improve
  sight when  it is begun  at an  early period of  the affection.   After
  taking blood by cupping, which may be repeated according to circum-
  stances,  it  may be necessary to persevere for weeks or  months in the
  mild use of mercury,  not carrying it to the extent  of  salivation, care-
  fully regulating the diet,  and attending in other respects to the health,
  and  the  state  of constitutional power.  In this way I have  seen the
 swoln  and pimpled countenance of a drinker surprisingly altered for the
 better, with corresponding improvement in the complaint; and in some
 instances, where glaucomatous discolouration of the pupil has been at-
 tended with slow  inflammation of the  iris, evidenced by adhesion of its
 margin,  and with protrusion of it against the  cornea, the  disease  has
 been kept in check, and good  vision has been preserved for years.
    [Glaucoma cannot, strictly speaking, be considered  as a disease; the term
 being applied to a group of symptoms which result from several and very dis-
 tinct pathological conditions.  The existing imperfect state of our knowledge,
 however, relative to these conditions, and our inability to distinguish them in
 many cases  during life, are  perhaps valid  reasons  for treating of them under
 one head.
   The appearances presented by glaucoma are usually considered as resulting
 from some change  in the vitreous humour  or hyaloid membrane, the retina or
 choroid.  Dr. Mackenzie's  investigations led him to  believe that  these ap-
 pearances much more frequently result from a change in the crystalline  lens.
 He is inclined  to  think that there  is never any very distinct glaucomatous
 appearance (ihat is to say, cloudiness of a greenish hue,) except what is caused
 by the amber or reddish-brown colour of the central and posterior  lamina? of
 the lens.  " In lenticular glaucoma, the lens," he says, " has become, in a cer-
 tain sense, dichromatic,  being of a deep amber when  allowed  to transmit the
 light, but  appearing green by reflected light; the green hue being probably the
 result of the absorption of the extreme prismatic rays of the light entering the
 eye, while the middle prismatic rays are but little affected.
   "The reddish-brown colour,"  he  adds, "upon which lenticular glaucoma
 depends, affects  only the internal and posterior laminae, and fades away into
 an amber  hue  towards the  surfaces, and especially the anterior surface and
 circumference of the lens.   These, so long as the disease is one of simple len-
 ticular glaucoma, have lost comparatively little of their natural transparency, but
 the reddish-brown part often presents, on making a section of the extracted lens,
 a peculiar  dryness of substance, as well as a considerable degree of opacity.
   44 After lenticular glaucoma has existed for a time, the surfaces of the lens
may become coagulated and opaque, so as to constitute a complication of glau-
coma with cataract.  This sometimes occurs very suddenly."
  The eatoptrical signs of the three stages of lenticular glaucoma are the follow-
ing:— 
468               affections of the vitreous humour.

  1st. In the first degree or incipient stage, both the deep erect image, and
the inverted  one, are distinct, (Mackenzie.)  While the outline of  the  deep
erect image remains pretty sharp, its size is rather larger and brighter than in
the healthy eye: it is also somewhat of a yellowish hue; and with the increase
of glaucoma the inverted image becomes larger, and more of a yellowish colour;
its outline becomes sooner diffused than that of the deep red  image.  (Sta-
beroh.)
  2d. In the second degree of glaucoma, the inverted image is pretty distinct
when formed near the circumferential part  of the crystalline;  but as  the can-
dle is moved across the eye, the inverted image becomes less and less distinct,
and in some cases is altogether extinguished; but when the candle passes to
the opposite side, the image reappears. (Mackenzie.)  Both images of the can-
dle are represented by yellowish spots, or  blazes, of a pretty bright appear-
ance, following the motions of the candle in their respective directions.  (Sta-
beroh.)
  3d. In complete lenticular glaucoma the inverted image is no longer visible
even at  the edge  of the lens.
  4th. The deep erect image, according to Dr. Mackenzie, " is better seen
in the second and third degrees of glaucoma  than in  the healthy eye.   It is
large and evident, but its outline is not  sharp, so that it appears like a diffused
blaze.   It is best seen when  the eye is looked at downwards and from one
side.  The fact of its being more distinct than in the healthy eye is to be attri-
buted to the reddish-brown part of the  lens serving  as a foil to the image."
{London Med. Gaz. April, 1838,  and Am.  Jour. Med. Sc. May, 1839.)
  We shall  relate in the  chapter on cataract a case which presented the  glau-
comatous discolouration  of the pupil,  in  which we had  an  opportunity of
making a post mortem  examination; and  notice more fully the diagnosis of
these two conditions.]
           SECTION IV.--AFFECTIONS OF THE VITREOUS HUMOUR.

  Hypertrophy  or vitreous dropsy.—I have  seen hypertrophy of this
structure, that is,  enlargement of the globe apparently dropsical, where
the contents were transparent, but too thick to escape through a small
puncture of the  coats at the middle of the  globe.
  Ecchymosis.—Mr. Travers mentions effusion of blood into the vitre-
ous cells, as occurring after the operation  of  extraction, or from exter-
nal violence.  {Synopsis, p. 200.)
  The vitreous  humour has been found  after  death reddened through-
out, and permeated by numerous red vessels in the purulent ophthalmia
of infants, and in  other ophthalmias; yellow, with numerous red vessels
in an icteric patient; green, and of increased consistence in an  amau-
rotic eye ; in cases of old disease affecting the internal parts, sometimes
shrunk and atrophic, sometimes of firm consistence and opaque.*
  Synchisis oculi.—A change occurs in the vitreous  humour, the nature
and causes of which are obscure;  it is the conversion of it into a fluid
state, and is called synchisis, a Greek word, which means melting.   It
may be the result  of  chronic internal ophthalmia, or a  gradual change
in the consistence of the vitreous humour, unconnected with inflamma-
tion.  The fluid  is sometimes of brownish colour.  The  iris  is little

  * The several  changes mentioned in, the text are exhibited by Von  Ammon, lib. cit.
tab.  1C. 
AFFECTIONS OF THE VITREOUS HUMOUR.
469
affected in its appearance or figure; but instead of the natural changes
of the pupil, or rather instead of the gradual contraction and relaxation
of the iris, there is  a peculiar tremulous or oscillatory motion  of the
part.   (See the remarks on tremulous iris in Chapter XVII.)
   The globe loses its tension  and feels flaccid.  The lens often loses its
transparency in these cases, and cataract is added to the other affection ;
the capsule of the lens has been found converted into a cretaceous sub-
stance, which could be distinguished by its peculiar yellowish white
colour.
   Beer* says that, as  the result of inflammation he has seen synchisis
only after venereal ophthalmia, and that a careful consideration of such
cases had led him to the conclusion, that it was owing  to the abuse of
mercurial  medicines, particularly calomel.  I have  met with no facts
capable of supporting such an opinion, which seems to  rest merely on
the antiquated notions  which ascribe to mercury a resolvent power.
Having used this remedy freely, both in syphilitic iritis and other forms
of ophthalmic disease, I should  have had ample opportunities of ob-
serving the fact, if Beer's supposition had  been  correct: such a result
has never come under my observation.
   I have seen synchisis produced by internal inflammation consequent
on penetrating wounds of the globe.   I have also seen it with flaccidity
of the globe and impaired vision in a boy of eighteen,  in whom  there
was no apparent cause for it.   Discolouration of the iris with tremulous
motion, cretaceous cataract, and adherent pupil, are  sometimes met
with, though the globe may not be flaccid : it is doubtful, in these cases,
whether the vitreous humour is  fluid or not. I have, however, seen it
flow out of the eye, as a brownish watery liquid, when extraction of
the cataract has been performed in such a case.
   Sir  W.  Adams says on this subject, " In three  cases which I have
seen, it was in one of a pea-green colour; in another of  a yellowish hue
resembling amber; and, in the third, of a dark brown colour like por-
ter.  In all, the vitreous humour was as fluid as water."f
   Usually, this state of the vitreous humour indicates a  diseased condi-
tion of the internal parts of the  eye; and we find accordingly that the
retina has  lost its sensibility.  Such a  state of the humour cannot be
remedied ;  and if a cataract should be present, its removal  will not im-
prove vision.
   Change  of structure and  consistence.—Mr. Travers has seen the
vitreous humour converted into an opaque substance resembling curd;
in one case it was like boiled rice.  The appearances in the early state
are like those of incipient medullary disease.   The lens subsequently
becomes opaque, and is pushed forwards with the iris against the cor-
nea, giving to the  globe a conoidal figure.   Mr. T. found this disease
of the humour in the eye of a fine infant, eight months old, which he extir-
pated under the belief that it was a case of malignant fungus.  The child
grew to be a healthy  boy, without any reappearance of disease.!;

  * hehre, vol. ii. §216.              t Treatise on Artificial Pupil, SfC p. 116, note.
                      X Synopsis, p. 202, pi. 3, fig. 7. 
470
AFFECTIONS OF THE LENS AND CAPSULE.
            SECTION V.--AFFECTIONS OF THE LENS AND CAPSULE.

   An opaque change in the capsule, incidental to advancing years, and
 analogous to the arcus senilis of the cornea, has been alluded to in the
 account of the latter.  See Chapter XIV. § 4.   Injuries of these struc-
 tures have been described in Chapter III. § 1.
   The subject of cataract generally will be considered in Chapter XXI.
   Inflammation of the  capsule, either in its anterior or posterior portion,
 has been described.  It has been represented that the vessels are  en-
 larged, so as to contain red blood, and to be visible with a magnifying
 power;  and the appearances under such examination have  been deli-
 neated.*  The  opacities, the thickening and induration of the capsule,
 so frequently met with, as well  as  the irregularities of surface caused
 by the deposition and  organization of fibrine, are closely analogous to
 the changes produced by inflammation in other membranous structures.!
 But the  previous inflammatory disturbance  leading to these effects
 escapes our observation; at least, I have not recognised it as a distinct
 affection.
   If the lens is  susceptible of inflammation commencing in and confined
 to itself, the  symptoms, excepting the opaque change  in the part, are
 hardly distinguishable.   I have not seen tbem, although cases of cataract
 occur occasionally, in which the development of the disease is attended
 with muscae, luminous  appearances, and other evidences of congestion
 in the internal  tunics.  This point  is  adverted to in  the  chapter  on
 cataract.
   If the presence of capsulitis  or lentitis were recognised, the treat-
 ment directed for internal ophthalmia  would be proper.
   Inflammation commencing in  the iris, or other internal structures, is
 readily propagated to the crystalline body; hence capsular or capsulo-
 lenticular cataract is among the effects of internal  ophthalmia.  Even
 purulent ophthalmia sometimes leaves behind, particularly in the infant,
 a small, circumscribed, central,  dense opacity.
   The cataracts caused by internal inflammation are complicated with
 effusion of fibrine, with adhesions and irregularity of the pupil, or its
 closure by adventitious membrane;  with various changes  in  the state
 of the iris, and  sometimes with deposites  of pigment  on the surface of
 the capsule.J
  Where inflammation has been so  serious as to have produced these
effects, it will be found  to have extended to the retina, disorganizing it,
 and thus causing amaurosis.  Such results of inflammatory disease  are
 irremediable.   Lymph  may be removed  from the pupil and from  the

  *  Capsulitis,  hentitis, also Hynlitis,  are described  by Mr. Mackenzie, Juengken, and
 Rosas.
  Inflammation of the lens and capsule  is dwelt on at considerable length by Walther,
 in an Essay on "The Diseases of the Crystaline Lens, and the formation of Cataract" in
his Abhandlungen aus dem Gebiete der praktischen Medicin; Land.shut, 1810, with figures.
  See also Mackenzie's Treatise, ed. 3, chap. xii. § 27.
  1 Von Ammon has delineated an eye, in which  the anterior portion of tie capsule is
 thickened and  opaque from interstitial deposition.  Enlarged vessels carrying red blood
are seen ramifying upon it.  Klinische Darsteliungen, pt. i. tab. 11, fig. 9.
  I Such changes are delineated by Von  Ammon, tab. 10, fig. 1—4. 
AFFECTIONS OF THE LENS AND CAPSULE.
471
 affected tunics of the eye, while the effusion is recent, but  not when it
 has become organized.   Hence the  condition of the lens and capsule
 cannot be altered by internal treatment; and the state of the retina in
 most instances precludes all expectation of benefit from an operation.
   Glaucomatous cataract is a result of inflammatory disturbance, more
 or less active, in the internal structures of the eye; the peculiar appear-
 ance of the opacity being referable  to  the peculiarity of the preceding
 inflammation.*
   Calcareous and bony change of the capsule and lens.—The capsule
 may be converted into  a thin  brittle shell of earthy  or  bony composi-
 tion! {cataracta gypsea.)   Its dead white or yellowish colour, and solid
 aspect, denote clearly the nature of the alteration.   When thus changed
 it may separate from its surrounding connexions, so  as  to constitute a
 floating cataract.  Mr. Gibson found partial ossification of the capsule
 in a case, on which he  was operating;  " it felt gritty to  the couching-
 needle, and produced a noise, as  if the instrument  passed over a piece
 of dry parchment."  (Practical Observations, &c. p. 121.)  Mr. Ward-
 rop has seen several examples of complete  ossification  of the capsule,
 which has sometimes retained its natural form, and contained an opaque
 lens, while in other cases it  has been  shrivelled, and the lens partially
 or completely absorbed.  The ossified capsule  has  sometimes been thin
 and brittle; in other instances thicker and firmer.  He has "met with
 it in eyes where there was  ossification of  the choroid  coat; in eyes
 where the hyaloid membrane was converted into bone;  in  some cases
 of fungus haematodes and in staphyloma."!;
   The lens has  been  found ossified  more rarely.   Mr. Wardrop met
 with an instance in an eye so shrunk and disorganized that little of the
 natural structure remained.   (Essays,  vol. ii.  pi. 14.)  In  another in-
 stance, of an eye long preserved in spirits, the central  portion of the
 lens was  found converted into hard bone,  the external laminae  being
 soft.   (Ibid, p. 96, pi. 11, fig. 5.)   Mr.  Tyrrell found an ossified  lens
 in a lad of fifteen who had received  a blow on the eye some years  pre-
 viously; deep-seated inflammation, amaurosis, and cataract had  been
 the result.  Subsequently the cataract had passed partly through the pupil
 into the anterior chamber, keeping up by its pressure inflammation of the
 iris with much suffering.   Mr. T. extracted  the offending body, which
 consisted of an opaque thick  capsule, containing a mass  about equal to
 one-third of  the  original lens, hard  and brittle, so that it broke on at-
 tempting to separate it  from the capsule.   (Practical  Work, vol. ii.
 p. 343.)
   Mr. Alexander showed me  an ossified lens.  It was of the natural
 size, hard as  bone, perfectly opaque, and  scabrous  on the surface.  In
 an eye rendered amaurotic by disease of old date,  this lens had passed
 into the anterior chamber, where it  excited so much  irritation, that its
removal was necessary.

  * The various appearances of such cataracts are represented by Von Ammon in the last
eight figures of tab. 10.
  t  Mr. Wardrop's Essays, vol. ii. pi. 11, fig. 6.  Von Ammon's  Klinische Darsteliungen,
pt. i. tab. 9, fig. 22.
  X Lib. cit. p. 114—117, pi. 11, fig. 6, pi. 14, fig.  1 and 2. 
472
AFFECTIONS OF THE LENS AND CAPSULE.
   Mr. Middlemore says that he has removed the ossified lens and cap-
 sule, by a surgical operation, on ten occasions. {Treatise, vol. ii. p. 52.)
   The changes now described are met with in eyes which have  been
 affected with severe and long continued internal inflammation, either
 from injury, or, more frequently, from internal causes, and which  have
 thus become  completely  amaurotic.   If this kind of cataract, having
 become loose and displaced, should be a source of irritation, it must be
 removed through an opening of the cornea.   In two instances Mr. Tyr-
 rell depressed cataracts of this kind, at the request of the patients, to
 get rid of the deformity caused by the presence of the opaque body in
 the pupil.  (Lib. cit. p. 344.)
   Spontaneous passage of the crystalline into the anterior chamber.—
 A few instances are recorded, in which the  lens, either in an opaque, or
 in its naturally transparent state, has come through the pupil into the an-
 terior chamber without any apparent cause.   In one instance, observed
 by Professor Himly,* the vitreous  humour was in a fluid  state; in the
 others, the eye was more or less diseased.  The previous changes in the
 organ, and the mode in  which the displacement occurs, are not how-
 ever as yet clearly  understood.  The presence of the lens in  the ante-
 rior chamber, as in the instances in which  it becomes thus displaced
 from external injury, sometimes causes so much inflammation and  pain
 as to render its removal by incision of the cornea expedient.
   From the two following  cases, related  by Professor Chelius,! of
 Heidelberg, it would seem that this spontaneous prolapsus may occur
 in eyes previously healthy.  " A robust man, about thirty years of age,
 felt suddenly a violent pain in the left eye; at his admission, a few days
 afterwards, great intolerance of light  and lachrymation were present;
 the conjunctiva and sclerotica were injected.   The iris was not changed
 in colour, but its upper margin was pushed forwards.   Part of the  lens
 protruded into the anterior chamber, transparent, though of a greyish
 yellow  hue.   Under suitable  treatment, the inflammatory  symptoms
 subsided: the lens remained in its position, and after a few weeks gra-
 dually became opaque, so that sight was completely lost.  The patient
 would not consent to the performance of extraction.   A middle-aged
 woman, who had formerly been subject to  rheumatism, was affected
 with rheumatic ophthalmia and spontaneous prolapsus of the lens, ac-
 companied by the  same  symptoms as in  the  preceding case.  The
 inflammation having been subdued, extraction was performed, with par-
 tial recovery of sight.
  In a case related  by Professor Ammon,}: a  serious injury of the eye,
 had occurred in  early life, followed by " a prolapsus of the choroid
 coat, which drew the pupil outwards, and increased to such a size by
 accumulation of fluid within, that  its removal became necessary,  and
was successfully performed by Dr.  Schmaltz, of Pirna.  The patient
could use her eye after the  operation, although  she felt weakness in it,
which  did not trouble her  much."   Many years after, (April, 1830,)
having had occasion to exert herself considerably, she  felt pain in the

              * Loder's Journal, vol. i. p. 127.
              t Heidelberger klinische Analen, B. iv. St. iv. p. 521.
              X Zeitschrift fiir die Ophthalmologic, Band I. p. 260. 
AFFECTIONS OF THE LENS AND CAPSULE.
473
eye: the sight became very dim, and her husband saw what he thought
a bladder in the anterior chamber.   Various means were used without
relieving her pain, which was considerable, and she consulted Professor
Ammon in August.  The eye was now inflamed, painful, and watering,
the anterior chamber being completely filled by an opaque lens.  The
pains were relieved, but returned with great violence, and several remis-
sions and exacerbations occurred till the month of October, from which,
until the time of writing the history, in December, the patient  had been
easy.  On each alleviation of the inflammation and pain, the lens under-
went visible diminution, and  it was thus reduced to  one-third of its
natural size, lying obliquely in the  anterior chamber, and leaving the
pupil free.   Vision was lost.*
  Mr. Middlemore! saw a patient in whom the lens, retaining its trans-
parency  had passed spontaneously into the anterior chamber.   He had
previously lost the sight of the right eye: some years  after confusion of
vision came  on  in the left, without any assignable cause.  The lens,
preserving its figure, size, and transparency, was found in the anterior
or  posterior chamber, according to the position of  the head.   There
was no useful sight.  As the eye thus appeared amaurotic, and was free
from irritation, it was not thought proper  to extract the lens.
  The opaque lens may become detached from its surrounding connex-
ions, and pass into the anterior chamber.  A lady had cataract, which
had formed with pains in the head, redness and uneasiness in the organ.
She experienced a violent attack of headach, with pain  in the eye so
severe that  she  felt as if the organ had been traversed  by some foreign
body.   An  opaque lens was  found in the anterior chamber, but still
partly engaged in the pupik   It was extracted with favourable results.!.
  Another patient, thirty-one years of  age, had  cataract since the age
of  six.  The opaque body sunk behind the iris at the time of  puberty.
At  nineteen, in consequence of exertion in military duty, the opaque lens
came into the anterior chamber, and caused so much pain that he left
the service.  Demours dropped a  solution of belladonna into the eye,
and directed the patient to lay on his back for twenty-four hours.  The
lens went back  behind the pupil, and continued  there for  eight years
and a-half, when it again passed forwards.  By varying the position of
the head, he could place the cataract either in the anterior or posterior
chamber.§  Another instance is mentioned by Demours of a palient who
had lost the sight of one eye from cataract for fourteen years.   He ex-
perienced a violent disturbance with convulsive  movements and  fever
during the night, and  found  in the morning that he had regained  his
sight.  The cataract had sunk behind the iris, leaving the pupil quite
clear.  There was slight tremulous motion of the iris.||
  Dr.  Ullmann,TI of Marburg, extracted  the  lens  from  the  anterior
chamber of a patient, thirty-seven years old, in whom cataract had taken
place before  the age of twenty.  This  female, in whom menstruation

  * In Ammon's Klinische Darsteliungen, pi.  i. tab. 9, fig. 11, an eye is represented with the
transparent lens lying in the anterior chamber.  A similar view is given in Langenbeck's
neue Bibl. vol. iv. tab. l.fig. 3.  He merely says that it was the case of a young man, and
that he removed the lens through an incision of the cornea.
  t Treatise vol. ii. p. 49.    J Demours, Traite des Maladies des Ycux, torn. iii. Obs. 449.
  §  Ibid, Obs. 450.    || Ibid, p. 395.   f Zeitschrift fur die Ophthalmologic, vol, ii. p. 129,
       60 
474
amaurosis.
had begun late, and been  very irregular, and who had suffered  much
from catarrhal and rheumatic affections, pains  in the head, erysipelas
of the face, and disordered digestive organs, represented that the lens
had  been in the  anterior chamber  nine  months,  having  previously
passed occasionally through the pupil, and returned on  lying down.
Since the lens had been permanently in its unnatural situation, there
had been great pain in the eye and head, with frequent inflammation of
the former, and muscas volitantes on  the opposite side.   The  anterior
chamber was filled with a brownish grey cataract, squeezed against the
cornea, which Dr. U. found it necessary to remove.   It was a capsulo-
lenticular cataract; the capsule formed a thick cretaceous shell, in the
cavity of which there  was a  small nucleus of the  lens.  The  pains
ceased after the operation, and the  health was much improved.  At
the end of some months the pupil was clear, and there was considerable
vision.
CHAPTER  XX.
AMAUROSIS, AND OTHER DEFECTS OF SIGHT.
           SECTION I.--GENERAL OBSERVATIONS ON AMAUROSIS.

  The imperfection or loss of sight, which results from affection of the
nervous apparatus belonging to the eye, whether that affection be seated
in the retina, the optic nerve, or the sensorium ; whether it be idiopathic
or primary, sympathetic  or secondary; whether it consist in vascular
congestion, inflammation, or  organic  change, or simply in  functional
disturbance, is called Amaurosis.  This word which is Greek {ctf*.*vpt»<nr
from ccfixvpuo, obscuro, to darken,) considered etymologically means dim
or darkened sight; it  is a general term, embracing  affections of the
nervous visual apparatus in  all their forms and degrees.  Amblyopia
{ctp.pxv&>7rict, hebetudo visus,  from avfixv?,  hebes,  obtuse, dull, and W"*">
sight,) to which  the epithet  amaurotica is sometimes attached, denotes
the less  considerable degree of the disease, in which objects, even of the
smaller  size, can be recognised, but are seen imperfectly.  The expres-
sion, Gutta Serena, employed by the writers of the middle ages, is often
used as synonymous with Amaurosis : it is more properly applied to
that full development of the nervous affection, in which complete blind-
ness has been produced ; the patient can no longer discern objects how-
ever large; he can perhaps distinguish light  from darkness, or he may
be unable to make that distinction.  This term seems to have been derived
from the pathological notions formerly prevalent respecting the cause
of blindness.   It was supposed to result from the effusion of a humour
or fluid  at or behind the pupil; as the latter opening retained its natural 
amaurosis.
475
  blackness in amaurosis, the effused drop was said to be clear.  In the
  following passage of his address to light, Milton translates literally this
  technical expression of Gutta Serena—

                ......." But thou
                Revisit'st not these eyes, that roll in vain
                To feel thy piercing ray, and find no dawn ;
                So thick a drop serene hath quenched their orbs,
                Or dim suffusion veiled."

    Suffusion* is also a  technical term, employed by Celsus and other
  medical writers of antiquity, to denote generally imperfection or loss of
  sight, whether arising from cataract or from  affection of the  nervous
  structure.  The  latter has sometimes been called sufifusio  nigra, or
  calaracta nigra,-\ because the pupil generally retains its natural black-
  ness.
    Since amaurosis may arise  from affections of the sensorium, of the
 optic nerve, or of the retina,  we can understand how it happens that it
 sometimes appears in  both eyes at once; that it may be confined to one
 eye, or that,  having  taken  place in  one, it  may attack the  other also
 after a longer or shorter interval.
    Amaurosis may be induced by causes  acting immediately on the ner-
 vous apparatus of the eye, such as excessive exertion of the organ, or a
 stroke  of lightning; it may arise, secondarily,  from sympathy between
 the nervous structure of the  eye,  and some other  previously affected
 organ, as from irritation of the  stomach, or of the nerve of the fifth
 pair, or it may be a symptom of affection of the sensorium more or  less
 general.   Hence the distinction of the complaint into idiopathic, sym-
 pathetic, and  symptomatic.  According to  differences in degree and
 duration, it is called incipient or recent, inveterate or confirmed, partial
 or imperfect {amblyopia,) and complete {amaurosis strictly so called, or
 gutta serena.)
   It has been  divided into organic, and functional or dynamic; the lat-
 ter  being supposed, at least  in many cases, to be sympathetic.   The
 distinction would be important, if it could be clearly established during
 the patient's life; unfortunately, we  cannot accomplish this.   The  re-
 tina is withdrawn, by  its situation,  from direct  observation and investi-
 gation ;  its disease produce no  visible changes in the exterior of  the
 globe, from which we can determine the exact nature of the affection ;
 and, as they do not terminate fatally, we are  deprived of the light, which
 pathological inquiries after death might  throw on the subject.  Hence
 it is a mere matter of conjecture, in many instances, whether the ner-
 vous structure of the eye is affected organically or only functionally.  In-
 deed if we could see the parts it might not be so easy as the familiar
 employment of these terms implies, to establish the distinction in ques-

  * In Greek, t/Tsva.w* or vro^ua-K, which as employed by the earlier Greek writers, include
 amaurosis and cataract; for the cases were not then distinguished. Subsequently, the latter
 was called ■yxa.ux.cejuct.
  t The Germans apply the same substantive staar, to cataract and amaurosis, distin-
guishing them by the epithets grey and black.  Thus cataract is graue staar, and amauro-
sis, schwarze staar. The German staar is the name of the starling. The Greek **T*f*x/r»j,
from which catarait is derived, is not only applied to a waterfall, but also to a bird of the
cormorant kind, perhaps the pelecanus bassanus. 
476
AMAUROSIS.
tion;  for medical inquiries have not yet determined the exact limits of
the changes  which  they call  organic.   We apply  the  epithet func-
tional to those diseases which produce no  changes in a part recogniza-
ble after death.  But we cannot infer in  these cases that no alteration
had existed during life.   The state of an organ necessary to the correct
execution of its function  is a living not a dead condition; it requires,
not merely a certain organization as we find it after death, but a supply
of healthy blood in a certain quantity, a  natural  state of nervous in-
fluence and sympathy, and perhaps other  circumstances not clearly un-
derstood.   If all these conditions are combined, can we consider it pos-
sible that  the function should be disordered or interrupted 1  If one or
more should be altered  or wanting, can the disease be properly regard-
ed as simply functional?  Vascular congestion is an obvious deviation
from the normal state of a part.   If the  retina, or any other organ, be
said to be functionally disordered, when its vessels appear twice as nu-
merous and  large as in the  normal  condition, the expression must be
employed too loosely to convey any clear information.   Some  restrict
the term organic to alterations in the essential structure of an organ,
thus excluding changes in the state  of circulation, even  although they
should be visible after  death.  Since, then, the epithets  organic  and
functional are  indefinite, being employed  in different senses by different
persons;  since they do  not denote, generally, well ascertained  and
clearly understood conditions of parts; and since the situation of the ner-
vous apparatus of sight renders  it impossible for us  to know its exact
 state in most instances, I consider this distinction of amaurosis to be of
 little practical utility, but, from its vagueness, rather  calculated to mis-
 lead.   We may, however, employ the terms conveniently to denote the
 general character of disease, remembering that they are not used strictly,
 and that, from the completely concealed  position of the retina, the  pro-
 priety of their application is often doubtful.
   Amaurosis has been divided into  the continued and  the intermittent,
 the latter being either periodical or  irregular.   It has been further dis-
 tinguished into the purely local or nervous, and the complicated.  In the
 former the affection is  confined to the nervous structure; while, in the
 latter, there is at the same time disease of other textures in the eye, or
 of other organs.  Cataract and strabismus are complications of amau-
 rosis  situated in  the visual  apparatus; the combinations with diseases
 of other  parts, or with morbid constitutional dispositions may be very
 various.
   Choroiditis, inflammation of the internal tunics, glaucoma, dropsy, and
 atrophy of the globe, and some  other affections, are  occasionally de-
 scribed as amaurosis complicated with other disorders.   I think it bet-
 ter to confine  the name of amaurosis to the instances in which the dis-
 ease has commenced in, and being  originally confined to, the  nervous
 structure.   In course of time other changes, such as cataract, may be
 superadded to the nervous affection.
    The diseases of the  nervous apparatus are less understood than  those
 which affect other parts of the eye.  They do not come under our im-
 mediate  observation during the  active state of  disorder;  and we very
 seldom have the opportunity of exploring, after death, the pathological
 condition of the  affected parts, especially in the instances of most fre- 
AMAUROSIS.
477
quent occurrence, where the disease is seated in the retina.  Hence the
attention of medical observers has been directed to the impaired vision,
the various modifications of defective sight, the pain in the eye or head,
rather than to those changes in  the  nervous structure, constituting the
real disease, of which these circumstances are merely symptoms. Amau-
rosis and amblyopia, then, like dyspnoea, indigestion, and jaundice, are
merely names of symptoms, with which we are obliged to be contented,
in our ignorance of the morbid conditions producing them.  Our notions
of the nature and treatment of these nervous affections must remain im-
perfect, until  they can be founded on a more correct pathological know-
ledge of the  diseased parts.  How should we  be able to treat dis-
eases of the  lungs or stomach, if we  knew nothing more of the  mat-
ter than the  simple fact,  that respiration and  digestion were  disor-
dered  and  imperfect?   Could we  expect any beneficial result, if we
should follow in these cases the same course which has been often pur-
sued, and is still recommended in treating weakened sight, that is, to ad-
minister a variety of stimulating and tonic remedies.in order to remove
the imaginary debility  or torpor, on which the impaired function has
been supposed to  depend?
   As the true nature of amaurotic affections is not yet understood, we
cannot be surprised at  finding that the divisions of the subject, even in
modern works, are objectionable.   It has been  divided into organic and
functional, although we are without data sufficient to mark the distinc-
tion.   Of the latter, the following subdivisions have been adopted: viz.,
increased sensibility, diminished sensibility, and paralyzed condition of
the structure.  As these are merely degrees of impaired  function, and
may all exist successively in one and the same case, they  can afford no
proper grounds for nosological  distinction.  Again, species have  been
established on very questionable, if not obviously erroneous grounds.
Thus, in the  epileptic, convulsive, and paralytic amauroses of Beer and
others, the impaired vision  and the concomitant symptoms, from which
the specific names are  derived, instead of standing to each other in the
relation of cause and effect, are merely joint results of common causes.
Although Beer has a chapter devoted to the amaurosis caused by cer-
tain vegetable bitters, and narcotics, and  by  lead, it is  at least  very
doubtful whether  either of these can  produce the affection in any de-
gree.  We can admit  that the nervous structure  of the eye may be dis-
eased in the rheumatic and gouty, as  well as in  other persons;  but it
will require clearer evidence than we possess  at present, to show that
there are distinct gouty and rheumatic amauroses.
  To avoid all ground of dispute, we  may consider the subject  under
three divisions, according as the disease proceeds from affection of the
sensorium, or of the optic nerve, or of the retina.  I must however, ob-
serve beforehand, that we  cannot  always make the distinction  quite
satisfactorily.  The evidence during life leaves us sometimes in  doubt
whether the case ought to be referred to one or another of these heads.
   Perhaps there might be  reason for  establishing a  fourth division of
amaurosis arising from affection of the ciliary nerves.  These, and the
retina, although not actually connected in the eye, are  so intimately
united  in function, that they exert a powerful  mutual influence.  The
pathology of this  subject, on which I have made a few remarks in the 
478
AMAUROSIS.
subsequent division of  this chapter on  symptomatic  and  sympathetic
amaurosis, requires further elucidation.
         SECTION II.--AMAUROSIS FROM AFFECTIONS OF THE BRAIN.

   Temporary or permanent blindness may result from compression or
severe concussion of the brain.
   I have related two cases at pages 108 and 109, in one of which com-
plete blindness, and  in the other, imperfect vision in one eye, followed
concussion, and were the only permanent consequences of the injuries.
   In another instance of concussion the left eye remained totally blind.
The injury was not  particularly severe, nor attended with danger; and
the sensorial functions were not impaired  in  any other respect.   The
eye and the surrounding region suffered no direct injury, and the occur-
rence of blindness was not noticed till the patient began to recover from
the accident.  The, insensibility to light was  complete;  the pupil  was
partially dilated; the independent motion of the iris was lost, but  it
moved  in harmony with that of  the other eye.  There was no other
visible change in the organ.  The patient remained under observation
and treatment for some weeks; but no improvement of vision was ef-
fected.
   While these sheets are passing  through  the press, I have  seen a pa-
tient who was stunned  by falling  down a  flight of  steps in  the night.
There was no  external wound; but the right temple had come to the
ground.  He found himself blind  with the right eye, but had no other
symptom of injury  of the  head.   When I saw him, on  the fourth day
after the accident, no active measures had been adopted. Both pupils
were about the middle size; the iris  moved very slightly in  each  eye,
perhaps less in the right than in the left.   He  could  not see the persons
who stood round  him in  the room; but, in looking  straight  forwards,
he faintly discerned an individual placed on his right side.
   In the third volume of the  Glasgow Medical Journal, at page 201,
Dr. Auchincloss has reported a  case of injury to the head, accom-
panied  with complete  amaurosis, in which   the  iris  retained its  mo-
bility.
  "James Armour, aged twenty-seven, a quarrier, admitted 8th of May.  The acci-
dent had happened  a week previously, and was occasioned by a quantity of earth fall-
ing upon him.  He remained insensible for two hours, during which,  considerable
hemorrhage is said to have taken place  from the right ear.  On recovering, he felt
acute pain on the right  side of the head, for which he was twice bled with marked
relief.   On admission, he had little or no uneasiness, and complained chiefly of giddi-
ness when he attempted to raise his head from the pillow.  He was perfectly blind of
the left eye, the pupil of which, however, contracted freely on exposure to light.  The
sense of hearing in the riffht ear was much impaired.   His mouth was slightly drawn
to the left side, which deformity increased greatly when he spoke."  The other symp-
toms were nearly removed in the course of a month, but the siaht was not recovered.
   Amaurosis occurs as a symptom of cerebral disease, either when the
latter is general, and therefore includes with the rest that portion of
the sensorium, with which  the optic nerves are connected, or when it
is partial, and so  situated as to affect  that part.  That  the  amaurosis
owed its origin  to sensorial affection, was proved by dissection in the 
AMAUROSIS.
479
 last of  the  four following  cases;  the point is not so clear in  the first,
 though the circumstances lead obviously to that conclusion.
   Case I.—Imperfect amaurosis remaining after violent disorder  of the head.—In
 August,  1826, I saw a lady, forty-two years  of age, who was still menstruating.
 Twelve or fourteen months previously she had been reduced to so dangerous a state
 by violent disorder of the head, that her medical attendant had discontinued his visits,
 Btating that further efforts were useless, and death  inevitable.  The gentleman who
 came with her to my house, and who had been called in on this occasion, found  the
 patient comatous, and discharging her  urine and feces unconsciously.  By leeches to
 the head and  other antiphlogistic treatment,  her  state was improved, and she  ulti-
 mately recovered, but with loss  of sight in both eyes.  I  found  the  pupils of middle
 size, with scarcely any sensible  change on variations  in the quantity of light.   The
 right was a little altered in figure, and slightly dull in colour.  She could make out,
 one after the other, capital letters  of the  second size in  the title page  of an octavo
 book.  Her health was excellent.  Before  the illness, she had suffered much for years
 from  headach; since  her recovery she  had been thrown from a gig, and freely bled
 and evacuated.  This depletion had completely removed the pain in the head.
   Case II.—Complete amaurosis, with perfect motion of the irides occurring with
 violent pains of the head.—A girl of eighteen was brought to me by her mother totally
 blind.  The sight had been gradually lost, with violent pains in the head, three years
 previously, when she  had not begun to  menstruate.  She had been treated at the time
 by cupping and  other corresponding measures.  The pupils were rather dilated, but
 the appearance of the eyes was in other respects perfectly healthy; and the irides
 acted well.  She menstruated regularly, but had still pains in the head.  The latter
 were removed by a course of the  hydrargyrus cum creta with  aperients; but vision
 was not improved.
   Case III.—Complete amaurosis produced suddenly by sensorial congestion.—A
 patient in St-  Bartholomew's Hospital, about thirty years of  age, with enlargement of
 the testicle, had been directed to rub a  little mercurial liniment on the part, daily, and
 had done this  four or five  times, when salivation  occurred.  He felt  indisposed in
 the evening of Saturday, but went to bed without making any complaint.   He awoke
 in the middle  of the  night with great pain in the head, and feeling very  ill.  He
 got  up, and  thought that the  candle, usually kept burning during the night,  had
 gone out, for he could not  see it; in fact,  his sight which had been  perfect when  he
 went to bed, was lost.  The house surgeon found him with a full, strong, and frequent
 pulse, and bled him.  He afterwards administered an emetic, which  was acting when
 I saw him at twelve o'clock, Sunday.  The pulse was still  full and strong, and there
 was great pain in the head.  The pupils were about the middle state, the irides nearly
 but not quite  motionless, and  vision  so completely extinct, that   when a lighted
 candle was held near the eyes, the patient was not sensible of its presence.  I ordered
 repetition of bleeding, and the application of a large blister at the nape.  These means
 were again repeated.   In a week vision was restored, and in a  fortnight the patient
 left the hospital  quite well.
   Case IV.—Sudden complete amaurosis from violent inflammatory attack of the
 brain and membranes.—A patient,  thirty-seven years of age, came under my care at
 St. Bartholomew's Hospital on the 2nd  of March, 1832, on account of inflammation of
 the basilic  vein, consequent on venesection : the affection had begun on the 29th of
 February.  The symptoms, which were serious and alarming, subsided  under active
 treatment;  the phlebitis had completely disappeared by the  16th of March, when  the
 circulation  was tranquil, the rest sound, the tongue  clean, and the appetite good.  A
 mutton chop was ordered daily,  at the  urgent request of the patient, who felt very
 hungry, and a  draught of infusion of cascanlla, with infusion of rhubarb,  three times
a day.  He took the chop, and three draughts on the 17th, slept  well, and  had  the
bowels opened on the  18th, when he arose and dressed himself, and was found by the
dresser sitting by the fire.   He said  he felt so well, that he could not remain in bed;
he complained of being very hungry, and requested that he might have wine or beer at
dinner: this was immediately refused.  In the course of the morning his friends came
to see him, and it was strongly suspected  that they had brought him wine or spirits.
He could not eat the  chop  at dinner; but he made no  complaint at that time.  At six
p.m. he was suddenly seized with faintness, loss of sight, and slight  pain in the head.
He went to bed immediately, and had some calomel and James's powder, followed by 
180
AMAUROSIS.
an ounce of castor oil in four hours.  19th. Restless and delirious durin? the whole
night; the retina? are totally insensible, so that he cannot distinguish light from dark-
ness.  The pupils are slightly dilated, but contract when a candle is held before the
eyes, although he is not aware of its presence.  The head is hot and painful.  He  is
sensible, and answers questions rationally.  The pulse small and quick, tongue white
and rather dry; there is great thirst.   (The head to be shaved and covered with cold
lotion; cupping on the nape to 14oz., a blister between the shoulders; a saline draught
with antimonial wine every four hours.)  20th. Vision the same.   (Twenty-four
leeches to the  temples; a dose of castor oil; two grains of calomel, with two of anti-
monial powder every four hours.)  21st.  A little sleep towards the morning; vision
improved, so that he can see fingers  held before him, and tell the number.   In the
middle of the day the former symptoms returned in an aggravated degree; delirium
came on with continual muttering, and the 6tools were passed unconsciously.  (Blis-
ters to the calves.)   Death took place on the 23rd.  Sero-purulent effusion was found
in the pericardium, and purulent infiltration to a considerable extent had taken place
in the muscular substance  of the heart. Unequivocal evidences of vascular excitement
were found throughout the encephalon ;  the medullary substance was partially soft-
ened in several situations. The arachnoid membrane was thickened at the basis of
the brain, and yellow, apparently  from purulent infiltration.  These changes were
particularly conspicuous about the infundibulum, and the union of the optic nerves.
   Impaired vision, in  a  greater or less degree, is  a symptom occur-
ring generally, if not invariably, in hydrocephalus both acute and chro-
nic.  The  state of the  retina  in  the former varies according to the
stage of the  affection.  During the period  of excitement, their  is in-
creased sensibility to  light; strong  lights  are  avoided, the eyes  being
opened only in the dusk; if the lids are separated the cornea turns up
behind the upper.   When effusion occurs, dulness  succeeds to the in-
creased  sensibility; the  natural direction  and  harmony of the  optic
axes are lost; the patients squint  and  look downwards, the pupils are
dilated,  or  exhibit oscillatory  movements,  without being  sensible to
light.   In the last or paralytic  stage, when convulsions  come on, suc-
ceeded  by palsy,  the  sight is lost, the pupil highly dilated, sometimes
contracted but motionless.   There is generally squinting, with fixed di-
rection of the hoop downwards.   Sometimes loss of sight is an early
symptom of hydrocephalus.
   Amaurosis may exist in the chronic form of hydrocephalus, as  a per-
manent consequence of the distention of the ventricles.  Mr. Langstaff's
museum contains  some  interesting pathological specimens, illustrating
the mode in which the blindness is produced in these cases.   The third
ventricle is  enlarged by the accumulated fluid,  and its parietes bulge in
front, so as to press on the united portion of the optic nerves.
   I examined the head of a female, who died at the age of eighteen,
after suffering from hydrocephalus internus for eight or nine years. The
symptoms came on and increased very gradually.   They first consisted
of change in manners and character, inability to learn, or to attend to
any subject.  There were occasional attacks of pain requiring depletion.
The intellectual faculties  then gradually declined.   She was confined
to the house for the last three or four years, and to bed for about  two
years totally blind.  Severe  paroxysms of active affection took place
occasionally.   The pia mater was loaded with serous fluid to an  extra-
ordinary degree, forming a loose  spongy mass, under which the cere-
bral convolutions could not be  discerned.   There were about eight or
 nine ounces of fluid in the ventricles.   The  anterior part of the third 
AMAUROSIS.
481
 ventricle was greatly enlarged, so as to cause pressure on the union of
 the optic nerves.
   The eyes exhibit no other change than a motionless state of the iris,
 with dilated pupil of its natural clear black.  In a boy, six or eight years
 old, in whom the head far exceeded its natural dimensions, and in whom
 all uneasiness and every symptom  of active disorder had been removed,
 and an excellent state of health produced, by long perseverance in occa-
 sional mild antiphlogistic measures, with the use of mercury, total insen-
 sibility to  light remained, with partially dilated pupils; but the irides
 acted naturally on exposure to light.
   Partial  amaurosis, with  strabismus  and double  vision, occasionally
 precedes an apoplectic attack.  It is frequently attended with  vertigo
 and headach, as well as with derangement of other parts.   In a gen-
 tleman of full habit and short neck, who had  many years previously ex-
 perienced  a severe apoplectic seizure, the return of vascular excitement
 in the head, which had been vaguely indicated for some time by head-
 ach, sense of heaviness, lassitude,  and  various uneasy feelings, was at
 last accompanied  with so much confusion of vision and giddiness, that
 he could not keep his eyes open.
   There can be little  doubt that the amaurosis, in  the following case,
 arose from cerebral hemorrhage :
   A  coal-weigher, fifty-five years of age,  lost the use of his right eye suddenly:
 "Whilst attending  to his business, he  was  suddenly seized  with  giddiness  and
 slight pain in the head, with the  feeling of a  snap, as if something had given
 way.  From the  immediate effects of  this he  recovered in  a  few  minutes,  but
 found  that he  was unable to elevate the upper eye-lid; and that when  he  had
 done so with his ffngers, he  saw only the half of objects, and that very indistinctly.
 He was assisted home, where he  remained quiet for two days.  On looking at him,
 the first thing that attracted my attention, was the upper eye-lid hanging down over
 the eye-ball  so as completely to conceal it.  He had nn power whatever over  it.  Ort
 examining the eye-ball it appeared perfectly sound.   The pupil was very much con-
 tracted and immoveable, being as small as a pin's head  ; did not dilate with belladonna.
 Stated that three years previously he had a slight paralytic shock, of which be re-
 covered; and that he had been subject to hemorrhoids, and strongly suspects this attack
 to have been brought on by their getting better.  Bowels were also confined."*
   Amaurosis is one of the symptoms attendant on various organic dis-
 eases of the head; such as induration, softening, suppuration, tubercles,
 hydatids, fungus haematodes of the brain, enlargement of the pituitary
 gland, aneurism of the internal  carotid  artery,  tumours in the mem-
 branes of  the brain, exostosis, caries, or various  sarcomatous growths
 of the bones,  especially when these diseases are so situated as to inter-
 fere with the optic nerves behind their junction, or with that part of the
 sensorium with which they  are immediately in relation.  These affec-
 tions are accompanied with other important  symptoms,' which show
 that the malady is  not  confined to the nervous apparatus of vision.
 Among these may be enumerated vertigo, pain in the head, often of the
most racking kind, either preceding or accompanying the affection, or
coming on at a later period; an impaired state of other senses, or of the
intellectual faculties ;  delirium, or  sleepiness, and coma ; convulsions,
impaired speech, hemiplegia, or other  paralytic  affections.   One eye
only or both may be affected, according to the situation of the internal

            * Mr. Knox, in Glasgow Medical Journal, vol. iii. p. 348, 349.
       61 
482
AMAUROSIS.
disease.  Dark  appearances are seen {scolomata,) and objects appear
confused or distorted {metamorphopsia.)  There is often increased sen-
sibility to light, with luminous  sparks  or flashes before the eye.  Ac-
cording to  the period and character of  the complaint, the pupil may be
either contracted or dilated.   Squinting occurs occasionally, sometimes
with  convulsive movements  of the globe or eye-lids.
       SECTION III.--AMAUROSIS FROM DISEASE OF THE OPTIC NERVE.

  Fractures of the skull at the anterior part of its basis may cause pres-
sure in one or both optic  nerves, or on  their  union, or may otherwise
injure them.   They may  be variously affected by diseases of the bone,
or of its membranous  coverings in the  same situation, or in the orbit.
Such disease may have a venereal origin, which may be indicated by
the simultaneous  existence  of other  symptoms referable to the same
cause.
  A  remarkable example of the latter kind is related  by Mr. Wilson,
in the third volume of  the  Transactions of a  society for the improve-
ment of medical and chirurgical knowledge.   (Art. xii. p. 115.)
  In the spring of 1803, the patient had  been attacked with very severe deep-seated
pain in the orbit of the left eye, for which antiphlogistic means, nervous medicines,
change of air, and various other remedies, were tried without any advantage.  The
complaint, on the contrary, became worse;" the sense of hearing in the left ear was now
totally lost.  The levator palpebral muscle of the left side  became  paralyzed, and  a
great  degree of strabismus was produced by the rectus  externus  having also lost its
power.  The pupil of the left eye became  much and constantly dilated, and the sight of
that eye was lost.  The right angle of his mouth was permanently drawn to the right
Bide.  An  extreme hoarseness took  place, and his articulation became so indistinct,
that he could not be understood even by his friends.  He lost the power of swallowing
solids, and swallowed fluids with great difficulty, as the attempt brought on a distressing
Bense  of suffocation."
  When Mr. Wilson saw the patient in  1806, there was hemiplegia of the right side.
Violent pain continued in the  left orbit:  there were severe pains in the cervical ver-
tebra, and at the top of the shoulder.  He could not raise  his head from the pillow;
he  could scarcely sleep at  all, and had no respite from excruciating pain;  in  short,
dissolution was hourly expected.   Mr. Wilson also learned that he had had chancres
and buboes two or three  times before his present illness commenced, and had used
mercury until they had disappeared.  He further discovered enlargement of the tibia
and of the cervical vertebrae, swelling of the acromion and spine of the scapula, of the os
brachii near the insertion of the deltoid, and of the clavicle,  which was three times its
U6ual thickness. Deeming the disease to be venereal, Mr. Wilson immediately  began
the use of mercury by frictions, and placed a seton in the  back  of the neck.   The
mouth became affected in four days, and the influence was continued for eleven weeks,
with rapid disappearance of the symptoms, and proportional recovery of strength and
health.  The enlargements of the bones  were reduced, and the pains removed; the
muscles of deglutition and those of the paralyzed  limbs recovered their power.   The
pupil of the left eye remained somewhat dilated, and the upper eye-lid could not be
completely elevated.  Objects and colours could  be distinguished with the left eye,
and even small objects when  green  spectacles were used, and the left eye  only was
open.  When both eyes were used, double vision  with some confusion was produced.
   Amaurosis may be caused by injury of the optic nerve in penetrating
wounds of  the  orbit, or  in fractures with displacement  of the orbital
 parietes; by pressure from orbital  tumours, from exostosis, or  other
 disease of the socket; or by stretching  of the nerve in consequence  of
 protrusion of the globe  {exophthalmia) from  accident or  disease.   If
 the protrusion is recent, the amaurosis incomplete, and the replacement 
AMAUROSIS.
483
 of  the eye can be satisfactorily effected, vision may be completely re-
 stored.   (See the case related in Chapter XXIV. § 1.)
   Atrophy of the nerve, either in the orbit, or throughout its course,
 has often been found after death in  cases of  complete  and  incurable
 amaurosis.   It is also found  in  other instances, where the  eyes have
 been seriously disorganized for a long time before death ;* hence, when
 it occurs in conjunction  with amaurosis, it may probably  be the effect,
 and not the cause of that disease.
   Among  the  invaluable  pathological  treasures  of Mr.  Langstaff's
 museum,  there is a specimen  in  spirit,  consisting of the eyes, optic
 nerves, and part of the basis of the brain of a man who had been amau-
 rotic for twenty-eight years before his death.   The sclerotica and cor-
 nea, iris and  pupil, choroid and  retina  are perfectly healthy, so far  as
 an  opinion can be formed  of the state of  such  parts after long immer-
 sion in alcohol.   The optic nerves, in their whole extent, from the globes
 backwards, are shrunk into white cords, not larger than a small crow-
 quill.  At  the  point of union they merely lie  together  without being
joined, and each  proceeds to  its own side of  the brain.   Where  they
 sweep round the  crura cerebri  they are  gradually confused and  lost.
 Mr. Langstaff has  favoured me with the following history of the case.
  Thomas Maddey died in June, 1821, at the age of sixty-tour, in Cripplegate work-
 house, of which he had been an inmate from December, 1806. He had been subject
 for  many years  to severe attacks of gout in the feet, knees, hands, and wrists, by which
 he  at last had become completely crippled.  All the fingers and  toes were deformed
 by  depositions of what are called chalk stones;  and both knees were greatly enlarged
 by  effusion into the joints, the swellings being firm and elastic.  He had been blind
 twenty years when Mr. Langstaff first saw him.  Previous to losing his sight, and
 almost ever since, he had suffered violent pain in the front of the head.   He had been
 under the care  of an oculist, who had bled him  copiously, and produced  salivation.
 The irides were dark, and completely insensible to light; the pupils greatly dilated.
 In other respects the organs were healthy.  He continued subject in the workhouse
 to severe inflammatory attacks, having the character of acute rheumatism rather than
 of gout, particularly in the knees, and he sunk under one of these,  which was attended
 with high fever and delirium. The examination of the head presented obvious marks
of recent and considerable inflammatory disturbance in  the brain and its membranes,
and, besides, thickening of the dura mater, with partial cartilaginous induration and
ossification of the membrane, which adhered to the skull with unusual firmness, and
cartilaginous and osseous thickening of the arteries at the basis of the brain.  The eyes
presented a perfectly normal structure.  The aorta was converted into a cartilaginous
and bony tube.  The liver was small,  indurated, and granulated.  The synovial mem-
branes, articular cartilages, and ligaments of the affected joints, were extensively dis-
organized ; but the bones were healthy.
  Professor Rostan has detailed the  fatal illness and examination  after
death of a woman seventy-five years old,  admitted on account of blind-
ness, into  the Salpetriere, where she had lived several years.   The state
of  her eyes is not described.  She died from  softening  of the brain.
" The optic nerves were flattened, diminished  in calibre, in a  state of
atrophy, of reddish  appearance like a small arterial tube, and without
any resemblance  to  the  whitish  cord  which they ordinarily represent."!
  Dr. Monteath, of Glasgow, who translated  Weller's Manual of the

  *  Three examples are figured by Vo.v Ammon in his Klinische Darsteliungen, pt. i. tab.
6, fig. 1, tab. 7, fig. 8, and tab. 18, fig. 1.  They  were cases of staphyloma sclerotica and
atrophy of the globe.
  t  Recherches sur le Ramollissement du Cerveau.  Seconde edition, obs. ii. p. 28—31. 
484
AMAUROSIS.
Diseases of the Human Eye, has mentioned in a note a somewhat simi-
lar case.
  " Mrs.----, aged eighty-three, had been completely blind from amaurosis for thirty
years before her decease in 1817.  She had also been subject to irregular gout, which
assumed a variety of forms, and seven months before her death she was attacked with
palsy of one side.  On opening the head, aqueous effusion was found below the tunica
arachnoidea, and in both ventricles.   One part of the cerebrum was observed to be of
a pulpy texture; but these appearances were most probably connected with the recent
paralytic attack, and not at all with the amaurotic.  All the nerves, with the exception
of the optic, had the usual appearance.   On examining the membranous sheaths of
these nerves, it was ascertained that their medullary matter .had been completely re-
moved, and this change had taken place even nearer to the brain than where the nerves
cross each other." (Vol. ii. p. 79, 80, note.)
   Demours mentions two cases of amaurosis caused by disease of the
optic nerve, in both of which the iris retained its power of motion.  The
first w:as a man forty years old, who had  lost the sight of his left eye
six months  before  death.   The  affection,  which had  come on slowly,
had been  attended  with severe pains in the head, ascribed to his occu-
pation, that of a porter.  The eye appeared  healthy, and the iris re-
tained its  complete mobility.   He died of fever in  the Hotel Dieu.
The eye was sound, the optic nerve partially softened.   The state of the
latter is thus described :—" On slitting the  sheath of the nerve, I found
it, in nearly half its extent, as it were in  a  state of suppuration, and re-
duced into a liquid of dirty white colour."
  The other patient, thirty-six years old, had lost  his  sight gradually,
without pain, for two months before death, which took place from chro-
nic peripneumony.  The eye-ball was perfectly sound.  In the middle
of the optic nerve  was found a small hard tubercle, of  greyish colour,
about the size of a hempseed.   (Trait e des Maladies des Yeux, torn. i.
p. 74—76.)
  Von Ammon has delineated the following morbid changes in the optic
nerve; thickening  of  the neurilema, effusion of fibrine  between it and
the substance of the nerve, ecchymosis  in  the situation of the arteria
centralis, induration of the medullary texture.   (Klinische Darsteliun-
gen, pt. i. tab. 20, fig. 12—17.)
  In speaking of amaurosis which arises from disease of the optic nerve,
Beer says, that "it is  developed slowly, commonly in one eye only,
seldom in both.   A black cloud appears before the eye, and  becomes
gradually thicker, while the patient experiences  an annoying distortion
of objects, without  the smallest  uneasy sensation in the eye or head;  he
only feels a  slight sensation of pressure in  the back of the orbit, as if
the globe were pushed out of the socket,  of which, however, there is no
appearance.   In the very beginning of the affection, the pupil is consi-
derably dilated, and  the  pupillary margin of the perfectly motionless
iris is angular at various  points, so that the pupil often presents an irre-
gular pentagon or hexagon.   Gradually, but very slowly, a glaucoma-
tous degeneration of the vitreous humour, and even of the lens occurs,
forming the only kind of glaucoma that  I have hitherto seen without
any varicous affection of  the blood-vessels of the  globe.   At last the
eye is visibly lessened, but complete atrophy does not take place." He
proceeds to observe, that the affection  is caused by morbid  change  of
the nervous structure, that  he cannot explain its origin, and therefore 
AMAUROSIS.
485
merely details what  he has met  with on  dissection.   " The  diseased
alterations which I have hitherto met with, have consisted of true indu-
ration of the optic nerve, and adhesion of it to the sheath.   Within the
cranium, the grey and completely shrunk optic nerves, as far as to their
connexion with the brain,  have been without a trace of medullary mat-
ter; the thalami nervorum opticorum have had their natural appearance;
the  neurilema has been destitute  of medulla, tough, not easily torn,
and has  consisted of  a simple vascular  membrane.   On one occa-
sion, though both eyes were perfectly blind, and had  been so for the
same length of time, the nerve of  the left eye only and its neurilema
were in this state of  atrophy as far as the sella Turcica, while that of
the right eye was indurated and closely adherent to its sheath, without
being in the least shrunk.   Between the union of the two  nerves and the
brain,they were in a perfectly normal state.  The left corpus striatum was
so hard, that it required a  strong and sharp scalpel to divide it, but its
colour  and form were natural.  The plexus choroideus was  wanting
on this side.  In three amaurotic persons of this kind, I  found hydatids
in the sheath of the optic nerve, the medullary substance  being appa-
rently pushed aside;  and on the most careful examination, I could  not
discover the lenticular (?) ganglion, (Augennervenknoten.")  Lehre, vol.
ii. pp. 578,  580, and  581.
         SECTION IV.--AMAUROSIS FROM AFFECTION OF THE RETINA.*

   The retina may be affected originally and exclusively, or secondarily
 and  in  conjunction with other parts of the globe.  Under the name
 amaurosis cases of the first  description are generally understood ; and
 in order to prevent confusion, it would be well to  confine the term to
 them.  In the affections, wmich either originally or subsequently involve
 the nervous together with other structures, such as general inflamma-
 tion of the globe {ophthalmitis,) inflammation of the internal tunics {oph-
 thalmitis interna,) whether idiopathic, syphilitic, or arthritic; in glau-
 coma, in atrophy, and dropsy of the eye, in  fungus haematodes, cancer
 and melanosis, blindness is ultimately produced;  and, inasmuch as the
 retina is disorganized, the  eye may be said at last to be  amaurotic,
 though the diseases are properly named from other more prominent cha-
 racters.
  The effect of laceration and  concussion of the retina, in producing
 blindness or injury to vision, has been  already considered in  speaking
 of wounds of the globe.  (See page 163, and page 172 to 175.)   The
 cases there detailed show that amaurosis, more or less complete, which
 sometimes admits of cure, sometimes  not, may result from  such acci-

  * In compliance with general usage, I apply to the affections considered in the present
 division, the name amaurosis, without any epithet to denote the particular seat of the affec-
tion.  This name should be confined to the cases in which either the optic nerve or the
retina is the seat of disease.  In the other instances, the disease is in  the brain, or in its
immediate neighbourhood, and impaired sight is only one out of many  symptoms.
  As the characteristic symptoms are not sufficiently known for us to establish clearly and
satisfactorily, in every instance, the diagnosis between that amaurosis which has its source
in the retina, and other forms of the affection, the following observations, are principally,
but not exclusively, applicable to the former. 
480
AMAUROSIS.
dents.   Mr. Knox mentions the following instances of partial injury to
vision from external violence.   " A central, black cloud appeared in
the eye from a blow with  a chip of stone, beyond  which  vision was
perfectly distinct.   There was  no other apparent cause for the affec-
tion.  Mydriasis, in another case, was produced from a blow on the eye
with a snow-ball; blood was also mixed with the humours.   In a third
instance, diplopia, and  confusion of vision, particularly when looking at
distant objects, were occasioned by a fall, which at the time caused in-
sensibility.   Strabismus and visus  dimidiatus, in a fourth  case, were
produced by a blow with a stone on the lower eye-lid;  and in a fifth
case, the pupil became perpendicularly oval and dilated, and  vision very
much impaired, in consequence of a blow on the eye-ball with a  blunt
arrow."*
   Mr. Knox observes further,  that  " a considerable period sometimes
elapses between the receipt of  the  injury and the  occurrence of  the
amaurotic symptoms.   In many cases those symptoms do not evince
themselves until weeks or months  after the  receipt of the  blow."  In
some cases, the sound eye becomes affected, sooner  or  later after  the
accident, with amaurosis, which may be called  secondary or sympa-
thetic.   An example is mentioned at page  173.   Mr. Knox mentions
the case of a girl, who received  a blow from a potato on the outer can-
thus.  Vision, though injured, was  not destroyed till four weeks  after
the accident, when complete amaurosis occurred, and the globe after-
wards became  soft.   About five months  afterwards, the sight of  the
other eye failed, and was ultimately completely lost.!
   Amaurosis has been sometimes ascribed to the direct pressure of a
hard lens on the retina, when the operation of depression has been un-
skilfully executed.  Beer mentions a remarkable illustration of this point.
" A patient had become perfectly amaurotic immediately after the  de-
pression of a hard cataract in each eye, probably from the lens having
been incautiously carried down too far, and thus having pressed on the re-
tina.   The cataracts rose again into their places, in consequence of the
patient, when in a state of intoxication, having fallen on  the head from
a high bed.  I extracted them, and thus restored sight, after eight years
of blindness."J
   That small simple punctures  of the retina, and  slight  transient pres-
sure from the displaced lens, lead to no consequences injurious to vision,
is proved by the experiments of Magendie, mentioned at p. 85.  In  the
operation of depression the  retina is punctured without any bad effect.
  The amaurosis having its origin  in the  eye itself, which is the  most
frequent and important form of the disease, arises, in many cases, from
inflammation of the nervous structure, and the usual result of such dis-
turbance, namely, organic change, which, if not  removed at an  early
period, becomes so established as to render the part permanently  inca-
pable of executing  its  function.   Under the term  inflammation may be
included all degrees of increased vascular activity, whether  designated
as fulness or turgescence of vessels, determination of blood, congestion,
or as inflammation  in  its more  limited sense.  From the structure of

  * Glasgow Medical Journal, vol. iii. p. 344.         t Ibid, vol. iii. p. 345.
                         % hehre, vol. ii. p. 448, 459. 
AMAUROSIS.
487
the retina, we might expect that it would be liable to such affections.
The minute ramifications of  the arteria and vena centralis retinas are
connected together so as to form a membrane of extreme thinness, but
appearing, after successful  injection, to consist almost entirely of ves-
sels: in this vascular  network the nervous pulp is expanded, like  a thin
layer of soft jelly.   This delicate organization not only participates  in
those causes of vascular disturbance which affect the head generally,
but  is exposed  by the nature  of its  office  to  numerous, powerful, re-
peated, and long-continued  impressions.   Thus it may be compared  to
the brain, in its structure, and  in the  morbid influences which  it expe-
riences.   When the disturbance of its capillary circulation has  reached
a certain height, interstitial deposition and change of structure may  be
expected.   Von Ammon has found effusion of fibrine on the retina, with
adhesion between  it and the choroid.*   He has also  given representa-
tions of the membrane under various morbid changes, such as increased
vascularity, ecchymosis, thickening and  induration, and  the  formation
in its texture of numerous minute black spots.!   The retina of an  amau-
rotic eye, dissected by Langenbeck,J exhibited  increased firmness  of
texture, with  numerous blood-vessels and  yellow spots.  It has been
found, in other  cases, thickened,^ opaque, spotted, buff-coloured,  tough,
and sometimes even  ossified.||   It  may be probable, as  LangenbeckTI
suggests  that the  change   of colour occasionally seen in the pupils  of
amaurotic eyes, arises from alteration in the condition of  the retina con-


  * Klinische Darsteliungen, pt. i. tab. 20, fig. 1—4.
  t Ibid, tab. 19, fig. 4, 5,  7—11.  In tab. 20, fig. 7 and 8, it  is seen separated from  the
choroid, and thrown into folds.
  X Neue Bibliothek, vol. i. p. 56.
  § In an eye, dissected by Magendie, the retina was converted into a white fibrous mem-
brane, very firm, and like an aponeurosis. On its outside, and adhering closely to it, was
an osseous stratum, varying in thickness from one-fourth to three-fourths of a line.  The
choroid adhered to the  external surface of this  bony layer.—Demours, Traite des  Mai. des
Yeux, torn. i. p. 73, 74.
  || In an account of the  Ophthalmic School of Vienna, by Dr. Juengken of  Berlin, he
mentions that it contains a collection of anatomical and pathological preparations of  the
eye, unique in its kind, as he supposes.  Among them is a series of amaurotic and atro-
phic eyes, in which the retina and ciliary body are ossified.  The change begins in  the
retina from the foramen centrale; a bony ring is formed round it at first, in the middle of
which the foramen remains open, and larger than in the natural state.  In some  eyes no-
thing is seen but this  ring; while in others, the  ossification  of the retina, which is  col-
lapsed and in folds, extends towards the circumference, and there gradually ends. In the
most diseased eyes, ossification is seen in the ciliary body, as well as in the  retina, the
change being most considerable in  the middle of each organ, and less strongly marked
where they approach each  other.—Graefe und Walther's Journal, vol. i. p. 514.
  IT " What,"  says he, " can afford a stronger argument that the retina undergoes a mate-
rial change, than the pale  dull colour of the fundus oculi so often observed in the amau-
rotic?  If the substance of the retina becomes changed by an inflammatory process, the
fine pulpy texture must be  lost, it must become incapable of receiving luminous impres-
sions, and sink to the level of organs destined to fulfil less important offices.  If  we  look
back to causes, we find in many cases that  amaurosis obviously  proceeds from various
morbid states of constitution {dyscrasien,) of which the first effect is inflammation. During
the prevalence of the humoral pathology, several cases of amaurosis were supposed to re-
sult from the deposition of morbific matter.  Why do not we proceed in investigating the
causes of amaurosis as we do in arranging inflammations of the eye ?  As there are oph-
thalmiee from dyscrasia or metastasis, so there may be inflammations of the retina of  like
nature.  In very vascular  organs  inflammations are always more acute than in  less vascu-
lar and more nervous structures : hence inflammation of the retina has a chronic rather
than acute course."—Reflexionen uber die  Natur, Ursachen und Heilung des  schwarzen
Staares; in the Neue chir. Bibliothek,  vol. i. p. 56,  57. 
488
AMAUROSIS.
 sequent on inflammation; but this point is not  as yet proved by dissec-
 tion.
   In  representing that increased activity of circulation is the most fre-
 quent cause of amaurosis, I do not mean to assert that every alteration
 in the function of the  membrane,  displayed in amaurotic affections is
 attended with visible changes of structure: there  may be a temporary
 impression, leaving no traces after  death.  On  the whole, however,
 impaired vision bears  the same relation to the retina and optic nerve,
 as other symptoms do to the various organs from  whose disorders and
 diseases they proceed.
   The prevailing notions respecting amaurosis have been not only dif-
 ferent, but almost opposite.   It has  been supposed to  arise generally
 from  debility.   Patients commonly speak  of  their sight being weak,
 and fancy that  it requires to be strengthened.   The vague opinions thus
 expressed seem  to be  the  only foundation for the views which  long
 prevailed respecting the pathology and treatment of amaurosis.  Be-
 lieving that the  complaint arose from  atony or debility of the  optic
 nerve, medical  men have endeavoured to combat this state by strength-
 ening treatment, by tonics and stimulants of all kinds, both  local and
 general.   As this view of the disease is  totally erroneous, the treatment
 founded on it must be not only improper, but injurious.   Let us apply,
 for a  moment,  the same notions and treatment to  other cases.  What.
 would be the result if  we should view diseases of the brain, lungs, or
 stomach, in the same light;  if we should see nothing but the impaired
 function, and proceed immediately, without considering the state of the
 organs, to adopt a course of direct stimulation, in  order to remove the
 weakness of the mind, of breathing, or digestion 1  The pathology of
 amaurosis must be founded on the  same principles as that of the affec-
 tions  just alluded to;  and the only successful treatment will  consist,
 with  the exceptions to  be noticed hereafter, in the variously modified
 antiphlogistic measures deduced from those principles.
  It must be understood at the same time, that amaurosis often occurs
 in conjunction with depressed  constitutional power; and that, in certain
 cases, it  is  the direct  offspring of debility, arising from a weakened
 state  of circulation, and consequent deficient supply of blood  to the ner-
 vous  structure.   Hence the important division  of sthenic  and asthenic
 amaurosis.  Again, the affection of the  retina is, in many  cases, purely
 functional, and  excited sympathetically  by disorder in other  quarters.
  Inflammation of the retina, or at least active  disturbance of its capil-
 lary circulation, sometimes comes on suddenly, and proceeds  rapidly
 to loss of vision.  Although the affected texture  is out  of  sight, the
 symptoms demonstrate clearly the  seat  and nature of the  disease, and
 we do not hesitate in calling it retinitis: it might be termed acute amau-
 rosis.   (See Chapter XIX.  § 2.  It is equally obvious that  inflamma-
 tion of the retina exists in the  disease described in  the third section of
 the  same  chapter.)  In the great majority of instances, the  disease
 arises gradually, and proceeds slowly, observing altogether a chronic
 type.  The  following account is a description  of this affection, which
 might be named, in order to  distinguish it from  the other,—chronic
retinitis or chronic amaurosis.  There is no boundary between the two
forms of disease, which pass gradually into  each other.  A similar 
AMAUROSIS.
489
insensible transition connects simple retinitis, whether acute or chronic,
with inflammation of the internal tunics* either  idiopathic  or arthritic.
Indeed the latter cases differ from the former only in the extent of dis-
ease.
                       SYMPTOMS OF AMAUROSIS.1

    Impaired  and altered sight.—The leading symptoms of amaurosis
  consist in the variously altered state of the function.  We find sight im-
  paired in all  possible ways.   The most  various imaginary objects and
  colours appear before the eyes.  In different instances there are all kinds
  and degrees  of defective perception in respect to the form, colour, and
  proportions of objects, and their relations to each other; augmented and
  diminished sensibility to light; impediments to vision most diversified in
  degree and kind.
    In the beginning of the affection patients complain of the sight being
  weak or dim;  the imaginary objects called muscas are seen;  objects
  are perceived but imperfectly; they appear more or less  obscured  by
  cloud or haziness; the letters of a book run into each other and become
  confused; the eye is soon tired, and waters or becomes bloodshot if ex-
  ertion  is  continued.  Sometimes near objects are not clearly recognised,
  when those more distant are seen perfectly.  This  incipient stage, in
  which vision is partially  impaired, is amblyopia, or weakness of sio-ht:
  it is sometimes seen as a permanent condition.
   They who divide amaurosis into two kinds, that with increased, and
  that with diminished sensibility of the retina, enumerate, as symptoms
  of the former, various kinds of impaired vision, some of which rather
  denote the period of excitement in disease of the retina, than the more
 advanced stage, ordinarily designated as amaurosis.  Some of the symp-
 toms now alluded to are merely the offspring of sympathetic disturbance
 caused by primary disorder in other quarters.
   Beer observes that in some rare cases of incomplete amaurosis, the
 sensibility of the retina to light is so much increased, that the patient avoids
 all places where there is strong light, particularly where strong reflected
 light falls on  the eye, and seeks comparative darkness; protecting the
 eyes, when he goes abroad, with a green shade or with green spectacles.
 This state passes under the name of intolerance of light, or photophobia.
 Under  such circumstances, the patient  sometimes discerns for a short
 time, that is, for a few moments, or more rarely for a  longer period,
 even the smallest objects  in  an extremely weak light, as clearly as the
 best eye can see them in  the light  of day; while, at other times, he can-
 not distinguish even larger things in the same light*  This state, which
 is called oxyopia ,that is,  acuteness of sight, (from «fi/«-, sharp, and «^ir,
 vision,) deserves the  particular attention of  the  practical  surgeon."
 (Lehre, vol. ii. p< 426.)
   This  increased sensibility  of the retina may become so considerable,
 that  the presence of light  cannot be borne; at least it causes severe pain
 in the eye and brow, with discharge of tears and  confusion of all ob-
jects.  The patient, therefore, remains in a darkened chamber, and may
be said to  suffer under  a kind of day blindness, or nyctalopia.  I saw a
       02 
490
AMAUROSIS.
patient, in whom, although amaurosis  had existed for some time, and
advanced considerably, the smallest light could not be borne ;  and he
remained constantly in a room with the  very crevices of the shutters
carefully stopped up.  More commonly the retina is in an opposite state.
Its increasing insensibility, and the  consequent necessity of  a powerful
impression to produce any effect, lead the patient to get as much light
as he  can.   He seeks clear  and bright lights; and  in attempting to
read, places his back towards the window, that the light may fall on the
book.
  When the amblyopia, with increased sensibility, proceeds a little further,
a shining glare appears before the eye, sometimes with rainbow colours,
sometimes tremulous, surrounding and confusing objects.  A light cloud
may pass before the eye;  or luminous and fiery points, flashes, or  streaks,
may appear.  Blue or yellow flashes, or globes of fire,  are seen in the
dark, or when the lids are closed.  This glare of light, and these va-
rious luminous  appearances, often continue when  the sensibility of the
retina  has been  completely extinguished, and lead the patient to  indulge
in hopes that his vision may be restored {vicus lucidits; photopsia, from
d)»f, light, and o^cr, sight; Marmaryge of Hippocrates, that is, ftM^x^vyn,
flashing or dazzling light.)
  Objects are sometimes perceived with prismatic colours, haloes or
rays round them;  sometimes they appear completely altered in colour,
for example, as if  seen through  a yellow  glass {visus  coloratus;
chrupsia*
  The preceding, and various other defects of sight {vitia visus,) which
have sometimes been enumerated, as if they were peculiar affections,
or even distinct diseases, are merely forms of the impaired function,
symptoms of amaurosis,  that is, of  disease seated in the nervous struc-
ture of the eye.  One of the most  frequent of these symptomatic  phe-
nomena is broken or interrupted vision  {visus interruptus.)  The eye
misses parts  of  objects;  letters or words are  lost  in  reading, and the
patient  moves the whole head  to  search  them  out.   Sometimes the
upper or lower half, sometimes the  right or left half, is  not  seen {visus
dimidiatus;  hemiopsia:)  sometimes a  small  part only of the retina
retains its sensibility, and such things only are seen as  are placed in a
particular direction with  respect to  the eye.   Slight movements of the
head or eye put the latter out of its proper position for  vision, and it is
not easily brought back  again to the right place.  Things sometimes
appear deformed or distorted  {visus  defiguratus; metamorphosia;) some-
times as if enveloped in a mist or cloud, which  may be light, dark, or
changeable, or apparently composed of minute objects coalescing {visus
nebulosus.)   This  cloud  becomes thicker and more extensive, until the
perception of objects is destroyed.
  A common symptom of incipient  amaurosis is the  appearance of
floating or moving bodies before the eye, {visus muscarum;  myode-
sopsia.)  Dark,  grey, or semi-transparent threads, spots, streaks, insects,
rings, chains, globules, indeed minute substances of every description,
seem to float before the eye, moving rapidly upwards and then falling,

  * This word, employed by Beer, {Lehrc,  vol. ii. p. 428,) seems to  be compounded of
fcgw, or X£octi colour, and o^t;, sight. 
AMAUROSIS.
491
 more conspicuous and more troublesome  in impeding vision in a clear
 light, or in looking at a white or light object.   A single black speck is
 called scotoma; the  more numerous moving bodies are called muscce
 volitantes.   It is  not uncommon for the patient to see before the eye a
 black disk, which increases in size as the  affection proceeds, becoming
 larger and larger until at last it covers  the  field  of vision.   As the
 moving bodies increase in number, they become more completely opaque,
 and unite so  as to form a net or thick veil, more or less  completely
 enveloping whatever the patient looks at,  {visus reticulatus.)   This net
 appears dark in a clear place, or against a white ground; while in the
 dark it is shining, and whitish or yellowish.
   Double vision {diplopia, visus duplicatus) is a common circumstance
 in  incipient  amaurosis.   The  affected  eye deviates from  its proper
 direction, or  squints, so that the optic axes do not correspond.  Hence
 objects are seen double; the two images sometimes  being equally clear,
 though the second is  generally fainter.  The two  may be close  toge-
 ther, or at some distance; and the second may be above, below, or at
 one side of the first.   When either eye is  closed, vision with the other
 is single.  The movements of the two eyes coincide  in certain  direc-
 tions, so that the  double sight is only partial.
   Squinting and  double vision may be caused by sensorial affections,
 without amaurosis.  The  symptom  in this form  sometimes precedes
 apoplexy.
   The very rare occurrence of double vision with one eye must be re-
 ferred to affection of the retina.  Beer calls it diplopia nervosa.
   In some instances the commencement of amaurosis is attended with
 near-sightedness  {myopia}) or far-sightedness {presbyopia.)  The latter
 is the  most common.
   In some instances vision is enjoyed during a part only of the twenty-
 four hours, and the patient is blind during  the other part.  He may see
 well in the day, and be blind at night  {cascitas nocturna or hemeralopia;)
 or vision may  be imperfect in the  day,  and  better  at night {cascitas
 diurna or nyctalopia.)
   Although the various kinds of imperfect vision, now enumerated and
 described, are designated by appropriate  names, they are not distinct
 diseases, but  mere variations in the state of the function  originating in
 a common cause, namely, disease, or disorder of the retina.  The pa-
 thological conditions of this texture, especially in the early and active
 periods of disease, are almost entirely unknown  to us; and we are
 therefore unable to point out the  particular circumstances in the affec-
 tion which give rise to each of these modifications.
   The central portion of the expansion, which is the usual seat of im-
pression, loses its sensibility first; the circumference, which does not
undergo  the same degree of habitual exertion, retains its powers longer.
Hence patients  can frequently  see objects  placed laterally, particularly
on the temporal side, after the power of distinguishing them in the direct
line of vision is totally lost.
  Progress of the disease.—The origin and progress of amaurosis are
very various.   It may be  produced suddenly, and reach its full develop-
ment in a few hours.   This is exemplified in the cases related at page
479^ as well as in that of the patient struck with lightning, at page 453. 
492
AMAUROSIS.
I have seen a few instances, in which persons having gone to bed with
perfect  sight have  been totally blind  the  next morning.   Sometimes
blindness is produced  in a few days, weeks  or months, while in other
instances years elapse  before vision is altogether lost.  In  some cases
the imperfection  of vision reaches  a certain point, and the  disease is
then stationary.
  I was consulted by a gentleman,  twenty-six years of age, who, three
years previously, had  gone  out  shooting  at night, the  ground being
covered with snow.  The next day his  sight was dull:  within  a few
days  it had become very  imperfect, and had  continued  in the same
state to the time  of my seeing him, in spite  of various  treatment.  In
the large print of a title page, he could just slowly make out the letters
one by one.  The pupils were about the middle size, and the irides pos-
sessed but little power  of motion.
  More commonly, and especially under  neglect,  with  continued  ex-
posure to  the causes which have induced  the  affection, or injudicious
treatment,  it ultimately ends in total blindness.  In this stage there is a
peculiar vacant  stare,  very characteristic of  the  affection.   On enter-
ing a room, instead of looking at persons  or surrounding objects,  the
eyes are directed forwards with the lids  wide open, and are fixed in a
kind of gaze on vacancy.  There is a want  of movement  in the eye-
balls and the head, and a  quiescence  of all  the  external  parts whose
motions ordinarily harmonize with those  of the direct visual apparatus,
which immediately betray the state  of the case even to an inexperienced
observer.   This  vacant stare at nothing does  not occur in cataract.
Although the patient may be  unable to discern objects, he  looks about,
as if conscious that vision  still exists.  In short, the state of the eyes,
eye-lids, and surrounding parts, with the  mode of carrying  and moving
the head, are expressive of blindness in  the  one case, of  sight in  the
other.
  The surface of the  organ, in some rare instances, is more  or less
bloodshot  in  amaurosis; though, in the  great majority of cases,  the
only visible changes are those in the size  and  form of the pupil, and  the
motions of the iris, with the  fixed state and peculiar expression of  the
eye.
  Slate of the pupil and iris.—The pupil and the iris of amaurotic  pa-
tients exhibit various changes, some of which are so conspicuous as to
attract the notice even of careless  observers.  The  former is  dilated,
often considerably, even  in the strongest light: sometimes it is equally
contracted, and  that permanently.   The opening often  deviates from
its normal  form, being  oval, oblong, or angular at different points of its
circumference.   It  may deviate from its central situation  in the iris,
being most frequently displaced upwards and inwards: in  such cases
the margin generally presents angular irregularities.
  In many cases, the  clear blackness which characterizes the normal
state of the opening is  lost, and the  pupil  has, instead, a dull, smoky, or
cloudy discolouration of greenish, greyish, or leaden cast; sometimes
it is of a yellowish green, much like that of  glaucoma.  The  healthy
retina is transparent, and  the  dark  choroid seen  through  it gives  the
pupil its black colour.  If the texture  of this nervous expansion be
changed by disease, corresponding  alteration in the appearance of  the 
AMAUROSIS.
493
pupil may be expected.  It is difficult to account for  the  symptom in
question, except on this supposition.   Beer says that " the blackness of
the pupil in amaurotic  patients is seldom so clear as in the healthy eye
of a young person.   Sometimes the opening is slightly smoky, or cloudy,
and we cannot  always distinguish at what distance from the uvea this
inconsiderable discolouration  is situated, or determine whether it pro-
ceeds from change in  the  transparent media, in  the retina, or choroid.
When the pupil is dark grey, or rather greenish grey,  we can discover,
by looking  at the eye  sideways, that the change must be either in  the
vitreous humour or  behind it."  (Lehre, vol. ii. p. 436, 437.)  If this
symptom be caused by alteration in the state of the retina, the latter is
not  irremediable; and consequently, the former is not of itself a suf-
ficient ground for unfavourable prognosis.
   Beer proceeds to  state, that the pupil may be  reddish, or  really red,
or yellowish white, in  amaurosis; and that, in  all  such cases, the dis-
colouration is obviously in  the fundus of the eye and concave.  I  think
that  such  appearances would denote organic  disease of  the eye-ball,
rather than amaurosis, in the strict sense of the word.  I once, however,
observed  a red appearance in the pupil  of an amaurotic eye.
  Case.—A student at one of the universities, of sanguine complexion, light hair,  and
full habit, about twenty years of age, who had been reading, but not very hard,  was
not aware of any other cause for the complaint on which he consulted me, namely,
loss of sight in the right eye.  Dimness had come on two months previously, and  had
increased gradually, so that  he could merely discern large objects with the right eye,  and
he saw them  best when they were placed quite to the right of the  eye.  The iris acted
equally on both sides.  I thought that I caught a glimpse of something red behind  the
iris, in some movements  of the  eye, and therefore, dilated  the pupil by means  of  the
extractum belladonna?.   A  portion of blood was then distinctly seen behind the lower
part of the iris. It was of  arterial  colour, and moved a little up and down, when  the
globe was moved.  The dilatation of the pupil produced no alteration  in the state of
vision. I did not see this gentleman again.
   In the following passage Richter states his experience respecting  the
change of colour in the pupil of amaurotic patients.  " Colorem pupillae
oculi gutta  serena affecti nigrum, sanum, omnisque vitii expertem esse,
plerique uno ore affirmant.  Hoc autem assertum magis  adhuc quam
prius erroneum esse, iterum iterumque expertus sum.  Plerumque sane
splendido illo puroque nigrore orba est pupilla oculi, qui amaurosi  labo-
rat;  languorem in illo hebetudinemque, loco nitoris illius, quo gaudet
sanus integerque  oculus, quilibet in illo  animadvertet.  Aliquofies tarn
insignem pallorem pone pupillam percepi, ut, quod ingenue fateor, dubius
aliquando hasserim, cataractane  incipiente an amaurosi aeger laboret.
Facilis sane in hoc  casu  error  est, imprimis si  perfecta nondum  est
amaurosis,  motuque adhuc pupilla, luminisque  quodam  sensu retina
gaudet.  Plures sane, quod affirmare possum, ad me pervenerunt  segri,
et medicorum suasu,  qui cataracta illos laborare credebant, operationem
petierunt."  {Obs. chirurg. fascic. ii. p. 65, 66.)
  A motionless  state of the iris, together with dilated pupil, has usually
been  enumerated  among the  symptoms of  amaurosis, as if it were a
constant attendant on the complaint.  There are, however, many excep-
tions  in respect to both circumstances.  The various impressions on  the
retina bv light in its several gradations are the cause of the motions ex-
hibited by the iris in the natural state of  the eye. Hence  we should
expect what we usually see, namely, that the iris moves imperfectly in 
494
AMAUROSIS.
proportion as the sensibility of the retina is impaired, being at first slug-
gish, and then  ceasing to move when blindness  is complete.   In the
early stage of the  affection, the iris  and pupil will not deviate much
from their normal condition, the fixed and dilated state of the latter not
occurring  till the  amaurosis is complete.   In some individuals,  whose
sight is perfect the iris possesses but little mobility ; and, occasionally, it
is  even motionless  with unimpaired vision',  on the  other hand, the full
power of motion sometimes exists in  complete amaurosis.   Janin* has
mentioned two instances in which he noticed this  circumstance.  One
was a boy, nine years old, who had been blind six months; the other,a
female of thirty-two, who  had lost her sight three years before.   Both
were  totally blind, although the eyes were  to all appearance perfectly
healthy, and  the irides had the full natural degree of motion.  The same
combination  came  twice under the observation of Schmucker,! and had
been  seen still more frequently by Richter : " Vidi  enim non  raro,"
says the  latter, " perfectissima amaurosi  occascatos,  quorum pupilla
mobilis erat, et  ad minimum  lucis attacturn valde vivideque  se con-
stringebat."J
   I have mentioned, at page 480, the case of a boy totally blind from
hydrocephalus, in whom the motions  of the iris were unimpaired.
  Case.—Amaurosis of one eye with perfect motion of the iris.—A lady of fifty-six,
of spare habit,  healthy appearance, temperate, and always enjoying good health, had
lost the sight of the right eye fifteen months before I saw her, without pain, headach,
or any obvious  cause.  She had never used her eyes imprudently in reading, needle-
work, or any injurious occupation.  The  two eyes  were so  completely alike, that I
could not discern which was amaurotic.  With the right she could merely distinguish
liorht from darkness.  The independent as well as the associated action of the iris was
perfect, and both pupils were of the same size under similar circumstances of light.
   When the affection is confined to one eye, the other remaining sound,
we shall  not, in many cases,  observe the  slightest defect  in the  amau-
rotic  eye, so long as both  are open.   But as soon  as the sound  eye  is
closed, the pupil of the other  is dilated and fixed, and its margin per-
haps becomes angular.  In other words, the iris of the  amaurotic eye
moves in harmony with the other after its independent action is destroyed.
In complete  amaurosis of old  date, accompanied with change of colour
in the iris, I have sometimes seen the associated action perfect, when the
strongest light directed on the affected eye with  the other closed, has
caused no sensation nor change in the state of the pupil.
   Other symptoms,—Cases of amaurosis differ considerably in the ac-
companying pain, whether of the eye or head.  Sometimes the disease
arises insensibly,  and is  developed  very  slowly, without any pain.
Sometimes there is an uneasy  feeling  in the eye and neighbouring parts
without  pain; a sensation of fulness and an unusual weight in the globe.
Sometimes the patient feels as if dust or sand were under the lids. Fre-
quently, the  impaired vision  is preceded or accompanied by headach,
giddiness, dizziness.   Sometimes  there are  pains in the  forehead, over
the eye-brow, and  in one  side of the head  : these are occasionally se-
vere.  There may be heaviness about the eye, aggravated  by motion or
employment of the  organ.   The pain may begin with the amaurotic

  * Dissertation sur la Mobilite  de Vlris dans des Yeux affectes de la plus grande cecile;
in Memoires et Observations Anatomiques, etc. sur VCEil, p. 425.
  + Vermischte chir. Schriften, p. 13.                    \ Obs. chir. fascic. ii. p. 63. 
AMAUROSIS.
495
affection, or precede  it by  some considerable time.   If it comes on
after vision has been lost in one eye, or in both, we may conclude that
the  pain and the amaurosis are  both caused by some other disease.
This observation holds good of  many cases of painful amaurosis; the
pain not being caused by the latter affection.  Racking pain in the brow,
temple, or head, not relieved by  treatment, or,  if alleviated, quickly re-
turning, and accompanied by similar pain in the eye, either constant or
brought on by slight exertion, indicates the existence of disease in the
orbit, skull or brain.
  The state of  the  circulation,  and  of the digestive organs,  is very
various in amaurosis: the former may  be excited, with fulness and
strength of pulse; it may be natural; or the pulse may be small and fee-
ble ;  that is, the retinal affection  may be  sthenic or asthenic.   Some-
times the latter are in an unhealthy state, and the disturbance of this
important system is a leading feature in the affection, contributing, with
other circumstances, to its origin and  continuance;  on other occasions
there is no marked derangement of their functions.
   Causes of amaurosis.  Age; the disease sometimes congenital.—The
disease may occur at all ages, and is sometimes even congenital.  A
fine  and healthy infant, which I saw at the age of six months, was quite
blind.   The eyes, on cursory inspection, would have been pronounced
free  from defect.  They were blue, like those of the mother and father.
The pupil, which was of middle size and clear, was  not observed to
vary in its dimensions.   The iris was in contact with the cornea.  The
mother had brought forth seven  children, three of wThom had been born
blind in this way.  I have seen other instances of congenital amaurosis,
where the eyes appeared perfect.  In a family of children belonging to
a  healthy father and mother, one of  whom had blue, the other dark
eyes, some were light and the others dark-eyed.  The latter had all of
them become successively amaurotic  in their  early years, without ap-
parent cause.
  " Five or  six years ago,"  says Mr.  Gibson, " I recollect to have seen
five  or six  children, the families of  two sisters, who  were all totally
blind, and in an idiotic state, with cataracts accompanied by amauro-
sis."  {Edinburgh Med. and  Surg. Journal, vol. vii. p. 398.)
  Dr. Monteath saw  a family at  Paisley, the  three eldest of whom
were born amaurotic.   He gives the following account of one, who at
the time of his examination  was an interesting girl of eighteen.   "Her
eyes and their appendages are well shaped; the iris is of a blue colour;
the pupils are of  natural size, form, and colour.  The size, however,
does not perceptibly vary from the action of different degrees of light,
at least I could not discover any motion of the iris.   Her eyes have not
the inanimate appearance so characteristic of amaurosis, and they have
less of the irregular  involuntary motions usually observed in blind peo-
ple."   The  father and  mother, and  their  relations, have good eyes.
{Manual of the Diseases of the Human Eye, vol. ii. p. 82, note.)
  Although  the disease spares no age,  it  is  most frequent at, or after,
the middle period of life, especially about the cessation  of menstruation
in females, and the corresponding age in the male.
  Hereditary disposition.—The influence of peculiar hereditary forma-
tion in predisposing to amaurosis is unequivocal.  I had under my care, 
496
AMAUROSIS.
at the London Ophthalmic Infirmary, twin sisters, whose habit of body,
features, complexion, and state of health, were exactly alike, as well as
the colour of the hair and eyes.  They were both amaurotic at the same
time, and with exactly the same symptoms.
   " Amaurosis," says Beer, " is much oftener hereditary than cataract;
thus we see many members of a family for more than one generation,
becoming blind from this cause at a certain period of life.  I know more
than one family, in which this is the case; and the circumstances in one
instance are curious.  The  females, even in  the  third generation, be-
come completely  and  incurably amaurotic,  as soon as  menstruation
ceases; but they who have borne children escape.   The males of this
unfortunate family, who as well  as the females have very dark  brown
eyes, show a disposition to amaurotic amblyopia, though none have be-
come actually blind." {Lehre, vol. ii. p. 442.)
   I  have quoted,  at page 484, from Dr. Monteath, the  case of an
amaurotic old lady, in whom the optic nerves were found atrophic.  Dr.
M. adds, that " the twin sister of this lady died in the eighty-first  year
of her age, and for eight or ten years before her death she also had  been
completely amaurotic.   Though her general health was  more entire
than is usual at such an advanced age, she had lost completely not only
her sight, but also  her senses of  taste, of  smell, and of hearing.  She
could not distinguish animal from vegetable  food, or one sort of  fluid
from  another.  No opportunity  was obtained of inspecting the head.
The only daughter of Mrs.----- (the  lady mentioned at p. 484) is at
present  alive, and  has been  totally blind  from amaurosis  for several
years; she is at present in her fifty-sixth year.  I have been consulted
by the son  and grandson of Mrs.----, who have both weak eyes.  The
grandson, in particular, has  a  very distressing degree of congenital am-
blyopia*  Any exertion  of his eyes  induces  temporary blindness, and
though he can sometimes  see a minute  object, at others he will walk
directly against a chair or table." (Lib. cit. p. 81, 82.)
   General causes;  plethora.—The causes,  which contribute  more
directly to the occurrence of amaurosis, are analogous in their nature
and operation to those, which produce disease in other textures of the eye
and in other parts of the body.  Excitement of the circulation by errors
in diet, particularly by intemperance in drinking, and the determination
of blood to the head more immediately produced by such indulgences,
are circumstances  of frequent and powerful operation in causing disor-
der and disease of the retina, as  well as of other parts of the eye, and
of the brain.   A sedentary mode of life, and residence in bad air, se-
riously aggravate the injurious effects of these disturbances.  The con-
tinuance of such habits through a course of years impairs  the functions
of the assimilative  organs and nervous system, and thus induces an un-
healthy  state of constitution,  in which amaurosis occurs more frequently
than in  the direct  plethora  caused  by excess in an individual whose
general  powers are unbroken.
  Excessive exertion of the organ.—In a great number of instances the
immediate or exciting cause  is excessive exertion of the organ, particu-
larly its employment on minute or shining objects.   In many cases the
affection can be clearly traced to  inordinate use of the eye, which brings
on the disease without any observable influence from the remote or pre- 
AMAUROSIS.
497
 disposing circumstances just alluded to.  Hence it is frequent in those
 who follow the various occupations requiring close attention and  con-
 stant exertion of the organ, as in tailors, shoe-makers, mantua-makers,
 milliners, sempstresses, law-writers, compositors,  engravers, painters,
 especially in miniature, jewellers, watch-makers, and the various workers
 in metal.  When we consider, that in these, and  many other  similar
 cases, the eye is incessantly exerted for several  hours daily, and reflect
 on the delicate texture of the retina, we shall only  be surprised that it
 should retain its powers so long unimpaired.
   Limited  or temporary exposure to strong light may produce  amau-
 rosis suddenly, as in a stroke of lightning, coup de soleil, or microscopic
 observations.  But  it  is more frequently seen as  the consequence of
 habitual exposure to less powerful lights, as in cooks, workers in metal,
 and in glass-houses, in soldiers or sailors when living in tropical coun-
 tries, in  those who pursue their employments under strong gas-light.
   Indirect  causes of general plethora, or of determination to the head.
 —All circumstances favouring the production of  general plethora, or
 determination to the head, render the occurrence of amaurosis  more
 probable; such  are  the sudden suppression of accustomed discharges,
 the cessation of menstruation at its usual period, its interruption  at an
 earlier age, and  its non-occurrence at  the time when it ought to  com-
 mence.   In enumerating the causes of the complaint, many writers lay
 great stress on the suppression of bleeding from the hemorrhoidal vessels,
 on that of  epistaxis, perspiration, or the secretion of milk, on the rapid
 healing of  itch,  or other cutaneous eruptions, or of large  ulcers of the
 lower extremities.   Without denying the agency of these causes, which
 in some instances is unquestionable, I  consider that it has been  greatly
 exaggerated, both  in frequency and degree.  I  have  never seen any
 disease, internal  or external, caused by the cure of itch, although I often
 see the complaint in its worst form, and see it rapidly disappear under
 proper treatment.   I never traced  an amaurotic affection to the repul-
 sion or cure of a cutaneous disease.   Some of  the causes above-men-
 tioned, by producing unnatural fulness and excitement of the circulation,
 may  render the occurrence  of amaurosis more probable  in those pre-
 disposed to  the disease.   Thus amaurosis  is  one out of many effects that
 may  proceed from  such causes, the influence of which is not. exerted
 directly on  the retina, but is of a more general kind.  The retinal affec-
 tion,  therefore, is not specific, but similar in its nature to that proceed-
 ing from  other causes,  and requiring analogous treatment.   Proceeding
 on these views, I cannot but think that to establish, as Beer* has done,
 specific distinctions of  amaurosis founded on the supposed cause, is er-
 roneous in principle, and calculated to produce confusion and indecision
 in practice.
   Sympathetic influences.—Disordered states of the abdominal  viscera
 often  have  a share in producing amaurosis.   Sudden  or violent irrita-

  * He has devoted separate chapters to the following forms of the complaint; namely,
 that from irregularity or suppression of the acute exanthemata, as scarlatin i, measles, and
 small-pox.— hehre, vol. ii. p. 522; from the suppression  of coryza without apparent collec-
 tion of mucus  in the frontal sinuses.—Ibid, p. 530; from the disappearance of impetiginous
eruptions, and  the healing of old ulcers.—Ibid, p. 556; from the suppression of coryza with
accumulation of mucus and pus in the frontal sinusew.—Ibid, p. 566; from the suppression
of milk in suckling women.—Ibid, p. 572.
       63 
498
AMAUROSIS.
tion, as by acrid ingesta, or by worms, may cause temporary blindness.
Here the retinal affection is sympathetic.   More frequently, disorder of
the stomach and alimentary canal is one circumstance, and an import-
ant one, in the chain of events leading to that unhealthy state of consti-
tution, in which amaurosis  most frequently occurs.   If the hypochon-
driac or gastric disorder should be strongly marked, the retinal affection
will probably be ascribed to it, though I believe that there are few cases,
if any, in which amaurosis can be traced to the direct and simple action
of such a cause.
  Syphilis.—Syphilis has sometimes been enumerated among the causes
of amaurosis;  according to my experience, without sufficient reason.
There is no syphilitic inflammation of the  retina, like that  of the iris.
In the  latter disorder, the inflammation which  begins in the iris, often
spreads to the internal tunics generally, and the  eye is sooner or later
amaurotic.  Thus, in describing syphilitic  amblyopia and  amaurosis,
Juengken* enumerates the symptoms of syphilitic  iritis, or, more pro-
perly speaking, of syphilitic inflammation of the internal tunics, including
change of colour in the iris, effusion of lymph, adhesions and disfigura-
tion of the pupil, and vascular zone round the cornea.   But that chronic
affection beginning in, and  confined to, the nervous  tunic of the eye,
which we generally understand by the term amaurosis, has  never been
produced  by syphilis, in the way that iritis is, within my observation.
The optic nerve may suffer by contiguity in consequence of syphilitic
disease in the bones of the head.   Something of this kind seems to have
occurred in the case quoted at p. 482.
   Gout and rheumatism.—Amaurosis may occur in the gouty and rheu-
matic ; but the local affection receives no peculiar character from the
constitutional disposition, nor does it require peculiar treatment.
  Beer! and JuengkenJ have given the name of  arthritic amaurosis to
an internal inflammation of the globe occurring in gouty persons, gene-
rally very slow in its progress and development, accompanied by change
of colour in the iris and pupil, enlargement of the sclerotic vessels  and
dulness of the cornea, and ending in glaucomatous cataract, varicosity
of the external vessels, and  staphylomatous bulgings  of  the sclerotica.
In these cases  the  retina undoubtedly suffers in common with other
parts,  and thus impaired sight is one of the first symptoms, while blind-
ness often occurs at an early period of the affection.   This disease may
appear either in an acute or a chronic form ; the first  is described in
Chapter XVIII. § 3, under the name of arthritic inflammation of the in-
ternal  tunics; the second in Chapter XXII. under that of glaucoma.
  At page 483 I have related the history of an amaurotic affection in a
gouty individual.   The narrative is the more interesting as it contains
a description of the changes in the affected organ and in other parts dis-
covered on examination after death.
  I subjoin the  following case to show that when amaurosis, in the more
strict and proper sense, occurs in an  arthritic subject, the appearances
in the organ present no characteristic peculiarity.
  Case.—Amaurosis in an arthritic subject; trial of mercury without benefit.—In
the year 1828, I saw a gentleman, about thirty, affected with nearly complete amau-

  *  Die hehre von den Augenkrankheiten, p. 803.      t hehre, vol. ii. p. 544—555.
 X Die hehre von den Augenkrankheiten, p. 801—803. 
                                  AMAUROSIS.                              499

 roais of the right eye.  He had been laid up with a severe attack of rheumatic gout in
 the right instep, in the spring of 1820,  when at college, after three months of the
 closest application to study previous to an examination for his degree.   This was pre-
 ceded by a copious running, which he supposed to be gonorrhoea, though  it did not
 yield to cubebs, which quickly stop true  gonorrhoea with him.  The eyes were not
 affected.   In the autumn  of next year,  being then at Venice, he had what seemed
 gonorrhoea, though he could not account for it.  The discharge stopped by the use of
 cubebs, and the eyes became affected, so that he could not bear the light; he was laid
 up for ten days.  There was no affection of the joints.  He says, "I set this down at
 the time for gonorrhoea and nothing else,  and it seemed to yield to the cubebs, which I
 took in quantities on the road  from Venice  to Rome.   I think now, however, that the
 remedy only changed the seat of the disorder from the  urethra to the eyes.  This was
 a short attack,  but the only one  in which the eyes  were affected.  In the following
 four years I had three or four attacks, all  preceded by running,  similar to that of gonor-
 rhoea, though in some instances, I stoutly maintained that there was no gonorrhoea in
 the case, but in vain.  Every one of these  attacks was in the  joints, generally in the
 feet or in the knees, sometimes for a time flying about  the chest.   From 1825 to  1828
 I was entirely free, though I once or twice  had gonorrhoea, which always stopped in a
 short time by  rest, low diet, and the use  of cubebs.  In 1828 I was seized with rheu-
 matic gout in the left foot, which came on in one night, so that having gone to bed
 well, I rose quite lame.  For about three weeks previously the bowels had been disor-
 dered, and flying pains had been felt in  the joints.  Both feet suffered, but the left
 principally; the knees were also affected.  This attack lasted one month, at the end
 of which I discontinued medicine, and  went into the country, still weak  in the limbs."
 Colchicum was freely given, with magnesia, and afterwards sulphate of quinine.   Soon
 after this, the right eye began to  be affected.  The attack in the limbs commenced on
 the 9th of August; the patient left Dublin  on the 6th  of September, still continuing
 the 6ulphate of quinine, under which the pains of the limbs  had ceased.  The eye
 began to be affected on the llth of September.   There was slight inflammation of the
 Ud, and for two or three days slight pain in the eye-ball on turning the head.   He
 began to perceive that sight was impaired about the 14th.   He could distinguish ob-
 jects only  in the lower portion  of the field of vision, and this portion  gradually les-
 sened, so that by the 28th nothing could be  seen.  He  returned to  Dublin on the 4th
 of October, when his sight was gone.  Eight ounces  of blood were taken from the
 temple by  cupping;  a blue pill was given  every night.  Afterwards, electricity and
 sulphate of quinine were  employed.   When I saw this gentleman  on the 24th of
 October, 1828,  there was no useful vision with the right eye, although he could distin-
 guish light from darkness.   He saw nothing straightforwards; but he could sometimes
 distinguish an object, such as the  hand, when held towards his  right side.  The  asso-
 ciated action of the iris was perfect;  but  when the left eye was closed,  the right
 pupil dilated, and continued in  that state.  There was no pain ; and the left eye was
 unaffected.  A  mild mercurial  course was recommended in  consultation on  this  case.
 Five  grains of blue pill were taken twice, thrice, and sometimes four times daily,
 until the mouth was slightly affected.  Calomel with opium was then  administered,
 so as to increase the mercurial influence;  the bowels became disturbed, and the patient
 thought the eye worse.  On the 24th of December the  sight remained as at  first; the
 health was improved.  He was ordered to leave off the blue  pill gradually.
   Narcotic  poisons and  various  other  substances.—The  German
 writers, particularly Beer and Benedict,  consider that amaurosis may
 be caused by  various   articles of food, and  by many of the substances
employed in medicine.  They enumerate the vegetables, which have
 the property of dilating the  pupil;  viz.,belladonna, hyoscyamus, stra-
 monium,  and  cherry  laurel;  also opium, succory-coffee, bitter beers,
 bitter almonds ;  gentian, quassia, simaruba, centaureum, cynoglossum ;
atnmoniacum and galbanum ; and  the various preparations of lead.*

  * Beer, hehre, vol. ii. p. 445.   He has also  an express  chapter " On the Amaurosis pro-
duced by the abuse of bitter substances, and such as contain carbon, in food and medicine,
and by the narcotic, metal, lead."  Ibid, p. 499—505.  Benedict, Handbuch, vol.  v. p.  95—
100. 
•
500                         AMAUROSIS.

  In describing the influence, which  the  four  vegetables  first named
exert over  the iris and  pupil, at  page 363 I have mentioned the
confusion or  interruption  of sight  which  occur when the  dilatation
of the pupil is carried to its full extent.  This temporary diminution of
eight which seems to  depend, not on  any immediate  influence exerted
by the vegetables in question over the retina, but on the previous dilata-
tion  of the pupil, goes  off in proportion as that opening recovers its na-
tural size; and no permanent injury to sight has been produced within
my experience.
  In two soldiers, who had eaten the young shoots of the hyoscyamus
niger dressed with olive oil, giddiness and stupidity came on, with loss
of speech and sensibility, difficult breathing, small and intermittent pulse.
The pupils were excessively dilated, and the eyes so insensible that the
eye-lids  did not wink when the cornea was touched.  Vomiting  was
soon excited in one, when he recovered in a short time.  Both were fit
for  duty in two  days.*  The loss  of sight  after poisoning by bella-
donna, which is sometimes so complete, that the brightest light cannot
be  perceived,  together  with extreme dilatation of  the  pupils,  may
last  for two or three days; and these symptoms, in a less degree may
continue  for  two or  three weeks;  they disappear spontaneously, but
6lowly.
  According  to Dr. Christison, opium, when taken in large quantities
for the purpose of self-destruction, generally causes contraction of the
pupil, which is sometimes  excessive.!   The facts observed  and collect-
ed by this judicious and indefatigable  inquirer, show clearly that no
injury to vision is  produced by this  powerful drug, either  in  small or
large  doses,  or when habitually taken in  large quantity by opium
eaters.
  The roots of the wild  succory {cichorinm intybus,)  roasted, have
been long employed as a substitute for coffee; and when the latter was
rendered extremely scarce and  dear by the  prohibitory regulations of
Napoleon, the practice became general, particularly in Germany. BeerJ
says that he was more than once consulted on account of weakness of
sight depending entirely on the free  use of this  substance, and that the
complaint disappeared simply by avoiding the exciting cause.
  Benedict^ states  that this practice  had afforded no clearly marked
instance of the affection.   The wild  succory has been so extensively
used in diet and medicine, that if it possessed  the  noxious properties
ascribed to  it by Beer, the fact must have  been long ago well known.
The continued employment of the plant sufficiently proves the negative.
The same observation is  applicable to beer, bitter  almonds, and the
vegetable bitters and gums above enumerated.
  According to Beer, amaurosis may be brought on by the continued
and  incautious handling  of colours  and other preparations  containing

  * Dr. Christison, Treatise on Poisons, 2nd  ed. p. 648.
  t Ibid, p. 620, 621.  " The pupils are always, at least sluggish in their contractions,
often quite insensible; sometimes they are dilated, but much more commonly contracted,
occasionally to an extreme  degree." In the case last noticed they were no bigger than
a pin's head.  The insensibility of the iris may probably be explained by the state of tha
sensorium.
  X Uhre, vol. ii. p. 445.                            § Handbuch, vol. v. p. 97. 
AMAUROSIS.
501
 lead; by the application to the face and breast of colouring matters pre-
 pared from lead;  and by any preparation of lead swallowed in large
 quantity.   He says, that he  had  often seen amaurosis from this cause,
 and treated it successfully.*  The information on the effects of lead,
 collected  by  Dr. Christison,!  affords  no confirmation  of this opi-
 nion.
   Beer considers that a diminution of  the  dark pigment covering the
 choroid and uvea may explain the imperfection of sight incidental to
 elderly persons {amblyopia  senilis.)  It would be difficult to verify this
 opinion.   The pupil often becomes grey or green as  persons advance
 in years, and there can be no doubt that this  change arises from dimi-
 nution in  the quantity of the pigment.   Yet sight  is perfect in such
 cases.
   I shall speak subsequently of debility as a  cause  of amaurosis, and
 particularly of the impaired  vision induced by protracted suckling; also
 of the disease as caused by affection of the nerve of the fifth  pair.
   Diagnosis.—The distinction between amaurosis and cataract will be
 considered in the chapter on the latter disease.
  [The most certain means of distinguishing amaurosis from cataract is af-
 forded by a catoptric examination.  In perfectly uncomplicated amaurosis, the
 three images of a candle can always be seen; whilst in cataract the second up-
 right, and the inverted images are one or both absent, or changed in size, bril-
 liancy or distinctness, as will be pointed out in the chapter on this disease.]
   The retina is affected in  glaucoma, as well as in  amaurosis; but in
 the former other textures are also involved, and the presence of symp-
 toms arising from  this source, in addition to impaired vision,  will afford
 the distinguishing marks of glaucoma.   These symptoms are the deeply
 seated green discolouration of the  pupil, and  the altered colour of the
 iris.  If, as it sometimes happens,  the pupil should be  also dilated and
 fixed in the commencement of the affection, the distinction will be  still
 more easy.  The colour of the iris is not always changed in  glaucoma;
 green discolouration of the  pupil is sometimes seen in amaurosis, while
 a sluggish or motionless state of  the iris and dilated pupil are common
 to  both.   Hence the distinction  is difficult in some cases.   It is more
 important in reference  to prognosis than in treatment; for the same
 means are applicable to both affections, though the chance of benefit
 is much less in glaucoma than in amaurosis.
  The distinction between internal ophthalmia and amaurosis does not
 involve the nature of the disease, but its precise seat  and extent.  By
 the former we designate inflammation affecting the internal tunics gene-
 rally, and therefore including the retina; when the latter alone  is affected,
 the disease is called amaurosis.   The presence  or absence of the alte-
 rations caused by inflammation, whether acute or chronic, in the iris or
 pupil, will  form a  sufficient ground of distinction.  When the source of
disease is in the retina, the affection, in the greater number of instances, is
 inflammation of that structure, more or less violent. When the affection
is active, its pathology is clear, and we name the disease retinitis. This
active inflammation may extend to the internal tunics  generally, and
thus produce ophthalmitis interna.  Under other circumstances, the na-
ture of the affection is not so obvious, and instead of calling the disease
* Handbuch, vol. v. p. 501.
t Lib. cit. p. 489—494. 
502
AMAUROSIS.
 chronic relinitis, after the organ affected, as we probably should do if
 its pathology were well understood, we name it from a symptom; and
 we must continue to  employ the term, although it conveys no informa-
 tion of  the seat or nature of the disease, until the morbid changes, of
 which the retina is susceptible, shall have been more  accurately investi-
 gated.
   Since the principles of treatment are the same in both instances, it is
 of no importance practically to draw an accurate line of distinction be-
 tween the cases, in which inflammation,  whether  acute or chronic, is
 confined to the nervous structure, and those in which the internal tunics
 generally are involved in the inflammatory affection.
   Prognosis.—This turns principally on two points; viz., the degree in
 which vision is impaired, and the length of time the disease has existed.
 It is more favourable in  proportion as the injury to vision is less, and
 the attack more recent.  If the affection be partial, and the case seen
 early, a complete  cure may be  expected.   We  think favourably of
 the  event when amaurosis is evidently caused  by active congestion in
 the head; for  that  cause  can be  removed by suitable treatment.   We
 take a similar  view of the subject when the disease approaches more or
 less nearly to chronic  internal inflammation. Our prognosis is doubtful in
 the earliest cases if the insensibility of the nervous structure be complete;
 it is equally so  in imperfect amaurosis of long standing. Violent vascular
 disturbance may at  once produce so serious a change in the retina as to
 render it incapable of vision, and a less degree of congestion will have
 the same effect, if it be long continued.  The prognosis is bad when the
 complaint has  been preceded and accompanied by severe pains in the
 brow, temple,  and head; by pains either not relieved by treatment, or, if
 relieved, quickly returning; also when attended with  similar pain of the
eye, whether constant or brought on by  slight exertion of the organ.
 The same observation applies to the cases  attended with epileptic symp-
 toms, paralytic  affections, or  great change in the pupil.  Under such
circumstances we  may reasonably suspect the existence of organic
changes in the retina, optic nerve,  orbit, skull, or brain.
   We Cannot trace an accurate line of demarcation  between  what  is
 called internal ophthalmia and amaurosis: in the former the inflamma-
tion is more active and affects more parts; in the latter it is a slower
 affection, and confined to  the  retina.   The bolder and more strongly
 marked inflammation is more easily arrested  than  the more chronic
form.  The  prognosis is doubtful, and rather unfavourable than other-
wise, as to the complete recovery of vision, if the affection, even in its
 most  recent  state, should have produced  complete insensibility of the
retina.  We should speak  doubtfully of the result in the case of com-
plete insensibility to strong light, even if it had only lasted twenty-four
hours.  I  have,  however, already detailed cases in  which  vision was
completely restored after such insensibility of several days duration, (see
pages 453 and 454,) and I shall subsequently bring forward other ana-
logous instances. It is difficult to say in what number of days or weeks
 we should give up all  hope of recovery.  In the supposed case of total
insensibility, or  even  of a near approximation to it, there would be
more ground for apprehension than hope  at the end of a week, though
sight is sometimes restored under these circumstances; but the lapse of 
AMAUROSIS.
503
 a few weeks without improvement, makes the case hopeless.   In a case
 of amaurosis related at p. 454, sight was completely restored, although
 the complaint had last several weeks, and had nearly attained the degree
 of complete insensibility to light.  When we succeed in the earlier cases
 of these serious affections, the restoration of sight is often only partial,
 the patient remaining in a state of amblyopia or weakness of sight.
   The amaurosis  attendant  on confirmed hydrocephalus is hopeless;
 congenital  cases  are completely so.   The subject of amaurosis conse-
 quent on direct mechanical injuries, has been already considered.   See
 p. 172 to 175.
   It is important to know what is likely to happen in the opposite  eye,
 when amaurosis has occurred in one only.   The causes of this affection
 are not merely  local, or  confined  within the affected organ; they will
 generally, if unchecked, bring on disease in both eyes.  The close sympa-
 thy between the two organs  must also be considered ; they both suffer in
 most cases, even in forms of disease that cannot be traced to causes of
 general influence.  Interesting evidence on this point is afforded by those
 cases of wounds  in which the sight of one eye is lost:  in many such
 instances  internal inflammation,  change of structure,  and  blindness
 occur subsequently in the other  eye.   See p. 173—175.  Hence our
 prognosis must be directed to the sound as well as to the diseased eye;
 hence, also, without expecting to benefit the diseased organ, we institute
 active treatment, and follow  it up steadily in many cases, for the pur-
 pose  of preventing the occurrence of disease in the sound eye.
   Treatment.  Antiphlogistic measures.—The object is to put a stop to
 vascular excitement, to prevent the permanent injury of altered struc-
 ture  and impaired function  in a part, the peculiar delicacy of which
 particularly exposes  it to  such danger.   We must,  therefore,  em-
 ploy  antiphlogistic treatment, following  it  up with  a  decision  and
 steadiness  commensurate with the importance of the affected organ.
 Under this head must be included  general and  local bloodletting, more
 particularly the latter, as by cupping from the back of the neck or the
 temples, or by the application of leeches, the evacuation of the bowels
 by purgatives, and a  restricted  diet.   Repose  of  the  organ should be
 observed, more or  less complete, according to the nature of the case,
   [The following case shows the efficacy of these measures in simple conges-
 tive amaurosis.
  Margaret McQuid, setat. 19, a robust Irish girl, a servant in a family in West
 Philadelphia, applied to me February 18th, 1839.   She  stated that she had
 lost the sight of  her left eye suddenly, two days previously whilst washing
 clothes; she  had  at  that time  intense headach which still  continues.   Her
 bowels are open; menstruates  regularly; eyes  natural in appearance—three
 images of a flame visible in the pupil.   Irides  light blue, moderately active;
 pupil mean size.  Vision with right eye perfect, with  left she cannot distin-
 guish  any object, not even a lighted candle, though she has  a  faint perception
 of the light from  it.   She is of full habit; pulse active.  I ordered her to be
 bled to the extent of sixteen or eighteen ounces and to take the following pills,
 R. calomel pp. gr. viij;  pulv. rhei gr. x.; G. aloes gr. ij. M. Ft. pilul. No. iv.
 Strict  antiphlogistic diet.
  20th. The patient had neglected to attend to these prescriptions until last
evening.  The headach had been  promptly relieved by the bleeding.  Pills
have not operated; there is a slight improvement in vision.   Ordered magnes.
sulph.  3j- 
504
AMAUROSIS.
  22d. Medicine has operated freely.   Can see now pretty well the smallest
objects, though they all appear as through a thin mist.   Ordered a blister be-
hind right ear, and senna and manna tea.
  27th. Vision quite restored.  Intends returning to her place.
  I met this patient in the street ten or twelve days subsequently, and learned
from her that her sight was as perfect as ever.]
  Use of mercury.—This  remedy  is as beneficial in many  cases  of
amaurosis, as in iritis, or general internal inflammation.  The remark
which I made respecting its employment in those affections, applies also
to the  present case, namely, that its good  effect mainly depends upon
the promptitude with which it is administered.   The  alterative form is
insufficient; we give it with the view of arresting inflammation in the
structure, which is the  very seat  of  vision; that structure  is easily
changed by the inflammatory process; our only chance of success is  to
push the mercury  in a decided  manner, and if we do so, we shall put a
stop to the  affection.  In the more.acute cases, the remedy must be em-
ployed freely; it must sometimes be carried to the extent of producing
ptyalism; and its use must be continued for  several weeks, in  order to
ensure all the benefit that it is capable of conferring.  I have treated
numerous instances of amaurosis on this plan with the most favourable
results; with such  benefit as I have not seen produced under any other
mode of proceeding.
  This mode of treating certain  cases of  amaurosis, that is,  those in
which the disease consists of active vascular disturbance in the retina,
whether, simply congestive or  inflammatory, which is now generally
adopted, and supposed to be of recent origin, is found to be the revival
of an old practice.  That it was thoroughly understood and clearly de-
scribed  by Mead, has been shown by Mr. Middlemore, {Treatise, vol.
ii. p.  276,) who adduces the  following quotations from  the  medical
works, {London, 1762, p.  536,)  of our celebrated countryman, thus add-
ing  to modern practice the weight of comparatively ancient authority.
" First of all blood is to be drawn both from the arm  and  the  jugular,
and to be repeated according to the degree of the disease.  Then it will
be necessary to give cathartics, especially such as purge gross humours;
it will then be very proper to join calomel to other cathartics; or rather
to take it by itself, and a few hours afterwards some  gentle purgative.
And this method often succeeds when the disease is beginning or recent;
but  if it be of some standing,  it  requires  a  more powerful treatment,
that is, a plentiful salivation,  raised by mercurials taken inwardly in
small quantities, and at short intervals."  "I made the first trial of this
course on  poor  patients  in  the hospital, when  I was a young practi-
tioner, and  afterwards on others, who thereby recovered their sight, for
which I was complimented  by the physicians, who till  then had looked
on the disease as incurable."
  Some  readers  may be  surprised  at  seeing this remedy mentioned
again; at finding a plan of treatment proposed for amaurosis so nearly
similar to what has been advised in other widely different  affections.
The free use  of mercury has been already recommended in iritis  and
other internal inflammations, and in inflammation of the cornea, when
proceeding to change  of structure.  Is it then a  panacea ?   How does
it happen that the same remedy should have  the power of counteract- 
AMAUROSIS.
505
       ing disease in textures so different from each other ?  This intended ob-
       jection seems to me to constitute the strongest ground for confidence in
       the remedy.   Although inflammatory diseases  differ  in  their pheno-
       mena, symptoms, and results, and although these differences are often
       very striking in different textures, the essential nature of the diseased
       process is every where the same: it is unnatural exertion of the capil-
       lary  vessels; and if we should have a remedy capable  of checking that
       excitement in one part, there is  every reason to suppose that it would
       be equally effectual in other instances.  Thus  we resort  to abstraction
       of blood  in the affections of organs most different from each other in
       structure.  In the same way, if we are correct in ascribing to mercury
       the power of controlling certain forms and effects of inflammation, its
       use will be co-extensive with those forms and effects; consequently, each
       new  example of its efficacy, instead of being inconsistent with our for-
       mer evidence  of its powers, affords fresh  confirmation of its general
       influence.
         Counter-irritation is  a valuable auxiliary in the treatment of amau-
       rosis ; and blistering is generally the most convenient mode of carrying
       it into  effect.  The nape, behind the  ear, the temporal and frontal re-
       gions are the most eligible situations, and may be blistered successively;
       a fresh application being  made every five, six, or  seven  days.   The
       blister  should be  of moderate size, particularly when applied on  the
       temple or forehead.
         When  the means now recommended have failed, we shall not effect
       much by other measures.   We must  enjoin the mode of living most
       conducive to general health, and take the chance of such local amend-
       ment, as  the affected organ may slowly experience under gradual gene-
       ral improvement.   Residence in pure air, frequent exercise in the open
       air, a plain and mild but nutritious diet, the regular  use of mild ape-
       rients, and repose of the affected organ, form  a combination of mea-
       sures best calculated to invigorate the system  generally, and thus to
       arrest local disease.  It would be quite consistent with this plan to try
       the effect of mercury in minute doses continued for a long time.  Coun-
       ter-irritation may  be employed at the  same time.   Blisters may be ap-
       plied behind the ears, and at the  side or  back of the neck, and a  dis-
       charge may be kept up by the savine  cerate.  But I prefer a succession
       of blisters, applying a new one  to a  fresh surface every five, six, or
       seven days.   Some persons make blistering a principal part of the treat-
       ment, using thirty, forty, or more blisters in a single case.   A seton in
       the back  of  the neck is another mode of accomplishing the same  ob-
       ject.
         Dr. Prichard has strongly recommended an incision through the scalp
       in the whole length of the sagittal suture, and converting it into an issue
       by filling  it with peas.
         The treatment I have described must be graduated,  according to the
       violence of the attack, the constitution, age, and strength of the indi-
       vidual, and numerous other circumstances.  No one mode of treatment
       is proper  in all cases.   It must not be supposed that all amaurotic  pa-
'       tients require bleeding and salivation.  When we meet with the affec-
       tion in the form of active inflammation of the retina, more especially in
       a young and vigorous individual of full habit, where there are obvious
             64 
506
AMAUROSIS.
marks of local vascular congestion and constitutional excitement, we
must  adopt active treatment, and  follow  it up  steadily.   A  similar
course of proceeding is  necessary in the slower  inflammation that is
confined to the retina, when it occurs in robust and plethoric individuals,
though it should not be attended with constitutional excitement; indeed,
the indication for loss of blood, whether general or local, is not  to be
drawn entirely from the state of the circulation, but partly from that of
the organ.  The condition of the retina, as indicated by the degree of
vision and other  local circumstances, is the principal guide.   General
fulness of the vascular system, or  determination to  the head  without
general  plethora, constitute additional reasons for abstracting blood,
and for taking it freely from the  system.   If the affection be chronic,
and unattended either with general plethora or congestion in the head,
mercury may be administered in a milder  way;  and it may be neces-
sary to pursue the treatment longer.
   Amaurosis often comes on slowly and insidiously  in persons of en-
feebled constitution.   The organ suffers from habitual excessive exertion,
at the same time that the general powers are depressed by residence in
confined dwellings, and bad air, by sedentary occupations, unwholesome
diet, costiveness, and the other injurious influences of such causes. In
a pallid and feeble woman, who had destroyed her health by close con-
finement to needlework, and whose eyes were beginning to fail, the same
active measures would by no means be admissible as in  the former
case.   To think of bleeding and  salivating  such a patient would be per-
fect madness; we should,  in such a  case, obviate  costiveness, take  a
little  blood locally, if at all, by cupping, or by leeches behind the  ears,
and then use mercury in the alterative manner, together with mild ape-
rients.   A  few grains of  Plummer's  pill, or of the  hydrarg. c.  creta,
might be given every night, or every second night, and the bowels might
be kept open by electuary, castor oil, rhubarb  and magnesia  in  some
 warm vehicle,  or the compound decoction of  aloes with tincture of
rhubarb or senna taken occasionally.  The blue pill may be taken in
combination with aloes, or the compound extract of colocynth.  If the
 retinal affection is serious,  it might be necessary to  persevere with mer-
 cury, slowly increasing the dose  until  a slight influence is visible in the
 mouth.  A nutritious diet, with  or without stimuli, good air and  exer-
 cise, and repose, or sparing and regulated exercise of  the affected organ,
 are important auxiliaries; a succession of moderate-sized blisters might
 be advantageously combined with  these means.  Thus while the same
 principles regulate our treatment, it is modified in degree  according  to
 the violence  of the symptoms and  the patient's strength.   In the latter
 description  of cases, after  mild  antiphlogistic  means and  clearing the
 alimentary canal, it may be expedient to administer tonic and strength-
 ening medicines, such as  sarsaparilla, quinine, cusparia, calumba, cas-
 carilla; and to allow a nutritious diet with porter or  wine.
    I subjoin a few cases, in order to illustrate practically the principles
 of treatment just explained.
   Case  L—Complete amaurosis, with congestion  in the head,  in a plethoric subject;
 perfect recovery.—A young woman, twenty years  of age, came to the London Oph-
 thalmic Infirmary, then in Charter-house Square, labouring under active  congestion
  in the head ; her countenance  was peculiarly florid; all the veins were obviously tur-
 gid, and she had considerable pain.  Before I saw her, she had experienced  severe 
AMAUROSIS.
507
external inflammation of one eye, which had produced a large leucomatous opacity of
the cornea: the latter was in the state of incipient staphyloma. These serious changes,
and  the consequent loss of an eye in a young female of considerable beauty, were the
obvious results of inactive treatment.   She still suffered occasional relapses of inflam-
mation  in the eye; and at these times she experienced so much sympathetic affection
of the opposite eye, that she could not use it without pain.  Hence she readily sub-
mitted to the removal of the staphylomatous projection, which quickly and effectually
relieved the sound eye.  Within a month she came again, saying that she had lost the
sight of the  other eye.   On examining it, I found that she had an attack of almost
complete amaurosis ; although it had existed  only two or three days, she could hardly
distinguish the situation of the window.  She had a dilated  pupil, and the iris  was
nearly motionless; there was no external redness, hut she had, in addition to her usual
florid colour, a flushed countenance, considerable pain  in the head, and some febrile
disturbance of the system.  Knowing from experience how prone she was to inflam-
matory  attacks in the eye, I had her bled largely, and cupped on the back of the neck,
placed her upon low diet and gave purgative medicines; but although this plan of treat-
ment was followed up vigorously, no improvement of vision ensued; the retina indeed
became quite insensible.  Mercury was now used actively; as soon as it caused sali-
vation, the affection began  to give way, and she recovered her sight perfectly.   She
was still liable to returns of congestion about the head, and repeatedly lost blood by
Venesection and cuppin? ;  she continued to employ mercury and aperients, and  ulti-
mately  had a seton in the back of the neck.  In spite of such  means, continued and
repeated for more than a year, during which time she was often bled and cupped, and
took an immense quantity of mercury and purgatives, she still retained her beautiful
colour and the florid red of a person from the country.   She attended the infirmary
nearly a year and a half, undergoing the treatment above described, more or less active-
ly, during the whole time.  I saw her two years afterwards, the  eye remaining per-
fectly well; but, although she had still much colour, the characters of youth and beauty
were in a great measure lost.
   Case II.—Imperfect  amaurosis with plethora, before  menstruation had begun.—
Another young woman came to the Infirmary with  impaired vision; her countenance
was red and flushed, and she complained of considerable pain in the  head; there was
evident congestion in this part.  She was about fifteen  years of  age;  menstruation
had  not commenced, and the consequence was  a plethoric condition of the system.
She was bled two or three times, purged actively, and continued this plan of treatment
for two or three weeks before the retina was relieved, when the menses appeared and
she completely recovered.
   Case III.—Imperfect amaurosis with congestion in the head;  antiphlogistic and
mercurial treatment; recovery.—I  was consulted  in  January, 1829,  by Mr.  M., a
linen and woollen draper, of florid complexion, with much colour in the face.  He was
rather lusty,  but stated  that he  had been originally spare.  He  was accustomed to
much exercise in the open air, and said that he  did not live freely.   On more minute
inquiry, I found that he  ate heartily  of animal food, and drank  daily a quart of table
ale, and a glass or two of spirit and  water.   Two years previously he had experienced
a severe attack in the head, attended  with slight paralytic symptoms.   He was then
twice bled, and cupped: he underwent other treatment, and  waylaid up for five months;
but the  sight  was not then  affected.  On the 25th of December,  1828, he felt heavi-
ness and dulness in the  head, and was altogether unwell; but he took no medicine,
and  followed his usual  occupations.  On the 1st of January, 1829, the sight became
dim, and the eyes would not bear employment.   When he came to me on the 2nd, the
appearance of the organs was natural; the iris acted on both sides, not very briskly,
but as well as in many persons with  healthy eyes.   There was no pain  in the eyes,
nor in the head.   With  the left eye he could not see even  large print; with the right
he could distinguish small print; but if he used them for a minute or two, as in read-
ing, writing, or examining patterns, the  sight became confused, and be could not go
on; words and lines ran  together, the  stripes of a pattern became broken and mixed.
The appetite was good,  the tongue clean, the bowels regular, the pulse of moderate
Btrength and not accelerated. (To lose twenty ounces of blood by venesection; a dose of
calomel and jalap immediately, and a purgative draught the next  morning ; to discon-
tinue fermented liquors and solid animal food.)  3rd. Cupping  in the nape to twenty
ounces;  afterwards, two grains of calomel and one-fburth of a grain of opium every six 
508
AMAUROSIS.
 hours.  5th. Not worse, nor sensibly better.  7th. The head had been  very uncom-
 fortable yesterday, when the purgative draught was  repeated with complete relief.
 To-day, the mouth  is  considerably affected, and the  sight much improved;  he can
 read ordinary print with the left eye, and he can employ the eyes without experiencing
 confusion of vision.   9th. Mouth very sore ;  breath fetid.   Sight perfect.   The irides
 act natorally, and he sees equally well with both eyes.   (To continue the mercury.)
 13. He has taken two  pills daily, for the last three days, and is freely salivated.  He
 went on a little longer with one pill daily;  and in about three weeks the mercurial
 effect had gone off.
   CasE IV.—Amaurosis nearly complete ; antiphlogistic and mercurial treatment;
 recovery.—Sarah Raymond, seven years old, with florid colour and blue eyes, was
 brought to  the London  Ophthalmic Infirmary, in December, 1825.  On first view she
 appeared healthy; but, after closer inspection, »he might have been considered rather
 too fleshy;  the colour of the countenance was beyond that of health.  She had become
 blind of the right eye, without any marked  pain or  complaint, and  without obvious
 cause of any kind.   The right eye  was almost completely amaurotic; the left unaf-
 fected.  1st Dec. Four leeches  to  each temple; a dose of calomel and jalap every
 second day.  8th. Five grains of hydrarg. c. creta night and  morning; a dose of rhu-
 barb occasionally.  15th. Vision completely restored; medicines continued.  22d. The
 powder to be taken every night,  and the aperient every second day.  As she continued
 perfectly well, on her next attendance, after a few  days, §he  was discharged,  with in-
 structions  to her friends respecting the mode of living.
   Case V.—Amaurosis of both eyes, complete in one, imperfect in the other; anti-
 phlogistic and mercurial treatment; recovery.—About the same time another instance ,
 of amaurosis occurred at the infirmary, in a girl about fourteen.  Sight had been lost
 in the right eye, and it was beginning to  fail1 in the left.   The duration of the affec-
 tion on the right side  was not  known; the blindness had not been noticed until the
 sight became impaired in the left eye.  There had been no pain of the eyes or head;
 and 1 could ascertain no other circumstance calculated to throw light on the origin and
 nature of the affection, than that the appetite had been good, and animal food had been
 taken freely.   There was an  appearance  of fulnessr with some flushing of the face,
 and a dull,  heavy look.  The parent, who accompanied  this girl, applied on account
 of the left eye, considering the condition of the  right  hopeless.   The treatment con-
 sisted in the abstraction of blood by cupping and leeches, aperients, the administration
 of mercury, (hydrargyrus cum creta,) and abstinence from animal food and fermented
 liquors.  In about a month vision was completely restored in both eyes.
   Case VI.—Amaurosis, with visus dimidiatus in the first instance; use of mercury
 toptyalism; complete recovery.—A gentleman,  thirty-eight  years of age, of middle
 stature, moderate in his way of  living, and constantly enjoying good health, came to
 me  on the 14th of August, 1826, on account of  impaired  vision in the left eye.   He
 had usually been employed from nine to twelve hours daily in his profession, that of an en-
 graver ; and he had been working very hard for several weeks on an important plate.  He
 said that he chiefly used his right eye. The vision of the left had been imperfect for a few
 days.   He could see the upper part of an object perfectly, with sharp outlines, as usual,
 but  the lower part was confused. In looking at  the title page of  a book, or a word in
 capital letters, the lower half of the leaf or of the word was  not seen with  clearness.
 He could not read an ordinary print with the left eye, and could only make out small
 capitals one by one, and with difficulty.  He had experienced  some uneasiness; a kind
 of throbbing over the brow, and a weight of the upper lid, as if he could not elevate it
 so easily as the lower.   There had  been no general headach.   There was no percep-
 tible difference between the two eyes, nor any change in the  pupil, the iris, or its mo-
 tions.  By the advice of his usual medical attendant, he had been cupped and taken ape-
 rient medicine the day before.  (To lose sixteen ounces of blood by cupping on the nape;
 aperient pills daily ; to abstain from  fermented liquors, and take animal food  sparingly,
 and  not to employ the eye.)   This patient did  not visit me again  till the 21st, when
 the pain was removed, but the sight had become worse.   He now saw the entire object
 imperfectly, and could not distinguish the capital letters in a title page.  (Ten ounces
 of blood from the left temple by  cupping;  two grains of calomel, with one-third  of a
 grain of opium, every six hours.)  31st.  Mouth not affected, sight rather worse.  (To
 rub in ung. hydr. fort. 3j. every night, and  to continue the calomel and opium.) 24th.
 Sept.  The  mouth has been sore for three weeks, and is now severely affected, with
great irritation of the bowels and constitutional  disturbance.   Vision  is greatly im- 
AMAUROSIS.
509
  proved.  (To keep  up the mercurial influence by means of blue pill.)  10th Oct.
  The mercurial  effect has been maintained in a slighter, but still deckled degree.
  Health is recovered.  Vision is perfect, but exercise of the eye brings on uneasiness.
  24th. He can read the smallest print, but the eyes do  not yet bear exercise.  (To
  leave off mercury; to goto the country, for change of air; and to return slowly to the
  use  of the eye.)  In a few weeks this gentleman had completely recovered.  In 1829,
  I learned from his brother that there had been no relapse; that vision continued perfect,
  and  that the patient followed his occupation of engraving regularly as he had done be-
  fore.  In the present year (1840) I have heard that  no return of disease has beea expe-
  rienced in  this case.
    In the preceding case, the  patient saw only the upper half of objects with the af-
  fected eye.  In another instance, which came nnder my observation in the autumn of
  1830, where there was incipient amaurosis of one  eye, the  patient saw only the left
  half of objects; thus in the word Clinique  he saw only the first three letters.
    Case VIL—Imperfect amaurosis of four weeks' duration; treatment by depletion
  and  mercury;  recovery.—In  the summer of 1830, I saw the captain of a merchant
  vessel, between  fifty and sixty years of age, who had lived freely.  He bad enjoyed
  but little sight with the right eye since he  had the small-pox ; but the cornea, iris, and
  pupil were natural.  In coming home from the Mediterranean, the sight of the left
  eye  failed.  When I  saw him, four weeks after the attack, he could not  distinguish
  even capital letters.   The pupil was in the middle states  the iris acted equally well
  in both eyes.   He had been bled and  purged.  I ordered  mercury.  The mouth be-
  came sore, but was  not considerably affected; it remained so for five weeks, when  I
  saw  him again.  He could now read ordinary print.  I recommended that the mercu-
  rial influence should be carried further, and kept up for some weeks.
    Case VIII.—Imperfect amaurosis, with partial double vision ; antiphlogistic and
  mercurial treatment; recovery.—James Bailey, fifty-five years of age, a tall muscu-
  lar man, with light complexion and eyes, applied at the London Ophthalmic Infirmary
  in 1826, with  imperfect amanrosis of both eyes: he saw double in some directions.
  He could make out capital letters, a third of an inch in height; but he could not read
  even a large ordinary print.   Severe headach had preceded and accompanied the fail-
  ure of vision.   The motion of  the irides was hardly impaired.  The pulse natural.
  Jan.  5th. (Venesection to twenty ounces:  a dose of calomel and jalap immediately,
 and afterwards five grains of blue pill three times a day.   Toabstain from animal food
 and  fermented liquors.)   7th.  Vision improved.   (Cupping on the nape  to sixteen
 ounces; the pills continued.)  10th. The mouth is sore;  the dooble vision and  head-
 ach are gone;  he can  read middle-sized print.   (The pills continued.)  17th. Sight
 quite recovered.   (Five grains of blue pill every night, and an occasional aperient.)
 28th. Quite well; recommended to continue the remedies for a fortnight.
   Case IX.—Amaurosis nearly complete; mercurial treatment; recovery.—Mrs. G.
 forty-four years of age, of fair complexion and blue  eyes, who had ceased to menstru-
 ate two years, consulted me for an affection of the eyes, on the 27th of July, 1831.
 Her  eyes  had been  bad eight years  before, while  she was suckling.    The disease
 began a month after delivery:  there was some external  redness, and the sight was so
 bad, that she could not see to read or work for some  months.   This gradually went off,
 and sight was  completely restored.  She  had been confined to the house for three
 weeks before I saw her with an attack of influenza,  in which the bronchial  membrane
 had been principally affected.  The illness had not  been  considerable.   Leeches had
 been  once applied to the chest; she had felt weak, and the tongue had been foul.   She
 had felt some  imperfection of sight, but had been  able to  read.  On the 24th vision
 had become rapidly worse.  Six leeches had been applied to the temple, on the 26th,
 without any benefit.   When I saw Mrs. G. on  the  morning of the 27th, the appear-
 ance of the eyes was nearly natural; the  irides  were rather sluggish, and the pupils
 slightly dilated.   With the right eye she could distinguish nothing; with the left she
 could difficultly discern  a large object, such as a  person,  but without being able to
 determine what it was.  There was  no pain in  the eyes,  and  she said that she felt
 none in the head; but it appeared, on close  examination, that there was some unusual
 sensation about the right temple.  She felt weak; the pulse was a little accelerated,
 but not full nor strong.  The tongue is foul.   (Cupping on the nape to fourteen ounces;
an aperient draught;  then two  grains of calomel with one-third of a grain of opium
every six hours.)  llth August.  The  calomel  and opium have been continued to
this time, without affecting the mouth further than to produce an unpleasant taste in 
510
AMAUROSIS.
 the morning.  The bowels have not been disturbed;  indeed they have required  the
 occasional use of aperients.   The  tongue has become cleaner; the health and spirits
 are improved.  There  has been a regularly progressive amendment of vision;  and
 Mrs. G. was this day able to read  the  print of an ordinary octavo.  The  eyes, how-
 ever, are fatigued  even by  a  short trial, and  light is rather offensive.  16th. The
 bowels  had  been  irregular  and  rather confined,  and an  attack  of  purging, with
 considerable pain, took  place on  the 14th.   Chalk mixture with tinct. opii was  or-
 dered by  Mrs.  G.'s usual medical attendant.  She felt very ill, and  the  sight was
 much worse on the 15th, the nervous structure of the  eye  probably partaking of  the
 depression under which the  system  generally was labouring.  Last night  6he slept
 well, and she is much better to-day ; the sight not only having recovered, but improved.
 She can now read a small print.   (To omit the pills for twenty-four hours;  then to
 take five grains of hydrarg. c. creta three times a day.)  20th. A return of pain in  the
 lower part of the abdomen took place,  with  purging:  there was a sensation as if  the
 bowels were imperfectly relieved, and there was still something to come away.  Pur-
 gatives were ineffectual.  On  examining the rectum, it was  found  blocked up with
 hardened faeces,  which it was necessary to remove with the finger and instruments.
 Very copious evacuations then ensued, with complete relief of the intestinal symptoms.
 Mrs. G. continued the hydrarg. c. creta for ten days or  a fortnight, the power of vision
 having been previously completely restored.  The eyes, however, remained unnatu-
 rally sensitive to light, so that the protection of a shade or coloured glasses was neces-
 sary when she went out; and employment of them in reading, writing, or needlework,
 could not be borne for more than a few minutes without bringing on confusion of vision
 and pain.   Mrs. G. now went into the  country to recruit her health.   The power of
 continued exertion has returned but slowly; and Mrs. G. cannot now (December, 1832)
 exert the eyes for more than two hours at a time.  She can discern the minutest ob-
 jects as well as ever.  Subsequently the powers of the retina were completely re-
 stored; this lady's eyes became, and  continue, (1840,) as strong and useful as ever.
   Case X.—Impaired vision with presbyopia; mild  antiphlogistic and mercurial
 treatment;  recovery.—Late in  the spring of 1827, a young  lady had severe inflamma-
 tion of the fauces, attended with loss of voice, for which she was confined to bed nearly
 a fortnight, and employed depletion to the extent of  weakening her  considerably.
 "During this illness," she says, "the light was very distressing to my eyes;  but when
 a little recovered, they appeared quite uninjured, and I  was able to read, &c. as usual:
 till one day, my strength being  a little restored, I was induced to walk a few paces  in
 the open air, but quickly returned into the house, being sensible of pain from  the glare
 of sunshine, and also finding my eyes  water from  the influence, as I supposed, of a
 keen east wind.   Whether the  light or the wind had any thing to do with the disorder
 that ensued, I do not pretend  to determine, only stating the fact, that the suffusion  of
 water in the eyes continued for two  or three days, during which time I  gradually ex-
 perienced more and more  difficulty in reading, &c.   For a  time I could read a good
 print at the distance  of eighteen or twenty inches; afterwards at the  distance of a
 yard ; whilst, on holding the book nearer, the letters were quite confused; but in a few
 days I lost even this power, and could no longer clearly discern small objects  in any
 part of the room : a  white thread would appear double, and one fly on the  ceiling would
 seem to be two.  The indistinctness of objects to my sight  resembled that which we expe-
 rience when looking through  a  lens at a wrong focus, with this difference, that whilst
 perpendicular and curved lines were  indistinct, horizontal ones were distinguished  as
 clearly as before.  Though I had not then completed my twenty-third year, I had all the
 symptoms of that decay of sight which accompanies old age, and found the defect sup-
 plied by convex glasses; but as the  use of these was followed by unpleasant sensations,
 and as 1 had  occasionally some pain above the eye-brow, with a weakness which made
 it difficult to fix the eye steadily on any object, it was judged expedient  that some re-
 medies should be  tried  in preference to having recourse to the use of artificial aids  to
 the sight.  Bleeding with  leeches under the eyes, and  some other means, were tried
 ineffectually."
  When I saw this lady on  the 1st of June, I found, that after the inflammation  of
 the throat had been  removed, she  had begun to live more freely, in order to restore
 her strength; but yet had proceeded cautiously.  Soon after, slight uneasiness was felt
 about the forehead, and some imperfection of sight was noticed.   In consequence  of
 the menstrual discharge  having  failed, steel was given,  with some benefit, in respect
to the intended object; but the sight became rather worse.  At this time there was a
little pain across the lower part of the forehead, only mentioned on close questioning ; 
AMAUROSIS.
511
a little flushing of countenance.   The left iris is rather sluggish.  A luminous circle
appears before this eye, on using it.   There is general debility.  It appeared  to me
that the impaired vision depended, in this case, on an affection of the retina of inflam-
matory character, caused in a debilitated individual by slight stimuli, which would not
have affected one of ordinary health and strength.   The treatment recommended was,
leeches to the temples, mild aperients, five grains  of the hydrarg. c.  creta twice or
thrice daily, simple and unirritating, but not low diet, gentle exercise, and taking the
air in an open carriage.  19th.  The mercury soon produced gentle salivation, and has
agreed well: the symptoms are decidedly improved.  26th. The gums continue sore;
objects can now be seen at various distances nearly  as well as ever; but the eye is soon
fatigued.  In the following statement, dated January, 1828, the intelligent patient
describes the progress of her recovery.
  "Some improvement was observed as  soon as the soreness of the gums came on;
but it was not till the means had been persevered in for several  days, that any further
benefit was perceptible.  The power of distinguishing objects at various distances  re-
turned by degrees, together with  the increase of distinctness in their outline.   I  was
greatly surprised one day, on taking up a book, to find, that, instead of the perpendicu-
lar lines being doubled, as I had before uniformly observed to be the case, it was the
horizontal which then exhibited this curious variation;  but  very soon after  this, the
power of distinct vision was restored, and I once more beheld  every  object, whether
near or distant, clearly.  It was thought best to continue the use of the mercury for
some time longer; and even after discontinuing  the medicine, I was advised to abstain
for some months from  every employment which  required much exertion of sight;  in-
deed the weakness  of my eyes  rendered  this  caution necessary, as well as  that of
avoiding the glare  of sunshine and  lamp-light, both of which gave me pain.  Six
months have now elapsed, and I am thankful to state, that  I have been able to  per-
ceive a slow, but steady increase of the power of sight, which has kept pace  with the
restoration  of my general health and strength."
   Although the preceding cases exhibit, in a striking point of view, the
power of mercury in controlling that disturbance  of  the retinal circula-
tion, which  causes amaurosis, it must not be inferred that  all cases will
yield to the  remedy.   The  prognosis  seems  to me  particularly unfa-
vourable,  when the pupils are contracted, as will be  apparent from the
following instances.
   Case.—Amaurosis with contracted pupil; mercury employed without benefit.—In
the summer of 1826, I saw a patient who had lost the sight of his left eye in the East
Indies two years before.  No effectual treatment had been adopted.  When he reached
England, he consulted a surgeon, who made light  of the complaint, and said  that it
would do well, and advised him to  live as usual, and  take four  or six  glasses of wine
daily.   When I saw this gentleman  in May, the sight of the left eye was gone ;  the
right was still perfect. Both pupils were rather contracted, and equally so, not quite
circular, but of natural colour.   The irides moved but very slightly.   He had not ex-
perienced much pain in  the eyes or head.  The countenance was rather flushed, the
tongue foul, and the breath offensive. It appeared, on close examination, that although
sight was etill perfect with the  right eye, the use of it brought on pain.  I recommended
cupping, mercurial alteratives  and aperients, and regulated diet, which were adopted
with some advantage.  After a consultation held on the case with Dr. Farre, a mer-
curial course was tried without any benefit.  Indeed, at the  end of it, there was more
pain in both eyes, especially after using the right;  the sclerotic vessels were distended
in both.  When these symptoms had been removed by cupping and  blistering, I re-
commended removal to a pure  air,  exercise in the open air,  quiet and regular living,
mild and simple diet,  with regulation of the bowels.
   Case.—Amaurosis with contracted pupils; not benefited by mercury.—A gentleman
about  thirty,  rather tall and  thin, who had been occupied for many years in the
counting house, and  had  lived  freely, gradually  lost, first  one, and then the other
eye.  I saw him a few times at  distant periods, but he did  not follow any plan regu-
larly.   When he was nearly blind with the second eye, he thought more seriously of
the  matter, and consulted Dr.  Farre  with  myself.  Both  eyes were amaurotic;
the  pupils contracted and  motionless.  Mercury was tried for  twelve weeks without
any benefit.
   Local applications.—These have been  frequently employed in amau- 
512
AMAUROSIS.
 rotic  cases;  but what good  can we  expect from such means in the
 affections of a part so deeply seated as the retina?  They have gene-
 rally been of a stimulating kind, and have been used on the erroneous
 notion of the affection depending on weakness, of its originating in a de-
 bilitated state of the optic nerve.   Spirits of wine and ether have been
 applied round the orbit and on the forehead; and when there is conges-
 tion and increased heat,  the evaporation may have produced some be-
 nefit.   Luckily these applications  cannot  accomplish the purpose for
 which  they have been generally recommended, that is, stimulating the
 optic  nerve.  It is  necessary sometimes to  employ local measures to
 s-atisfy patients, who often feel, or fancy that they feel, better after them.
 We may prescribe, as an embrocation  for the forehead, rose water,
 with some rectified  spirits  or spirit of rosemary; Hungary water, or
 Eau de Cologne.  Ammoniacal vapours have been applied to the eye
 itself; and the stimulus to the conjunctiva might possibly relieve the re-
 tina.   It has been  recommended to wash the head every morning with
 cold water;  this  is  often  attended with  pleasurable feelings to the
 patient, and it is a  practice which cannot  do  harm under proper dis-
 crimination.
    In the foregoing remarks, I have represented that form of amaurosis,
 which has its origin in the  retina, as a symptom,  in the majority of in-
 stances, of inflammatory affection,  or, at least, of  disturbed circulation
 in the nervous structure ; and, consequently, requiring treatment analo-
 gous  to that pursued in the management of other inflammations.  Whe-
 ther the correctness of  the pathological view be  admitted  or not, the
 practical deduction will, I am sure, be justified  by experience.  The
 treatment now  recommended  is nearly  opposite  to  what  has  been
 heretofore advised and  relied on.   I must  therefore advert shortly to
 some of the ordinary modes of proceeding.
    Emetics.—Schmucker,* RicHTER,f and Scarpa have placed great con-
 fidence in medicines of this class, followed by what they call resolvent
 remedies; using them, not merely where decided symptoms of disordered
 stomach might lead to the conclusion that the amaurotic affection was
 caused  sympathetically by disturbance in the alimentary canal, but very
 generally in cases of imperfect amaurosis.   Scarpa says that "by an
 attentive examination of the nature  and causes of the imperfect amau-

   * In his Chirurgische Wahrnehmungen, first part, Schmucker states that he had often
 seen soldiers become suddenly  blind on forced marches, particularly in hot  weather, and
 when they had much to carry.  A venesection immediately, and ihe day after three grains
 of the tartrite of antimony, generally restored the sight.  If recovery did not take place,
 the jugular vein was opened, the antimony repeated on the following day, and a blister
 applied: these means were usually successful.  The commencement of the second volume
 of his Vermischte Chirurgische Schriften is devoted to amaurosis, ia certain cases of which
 he recommends the tartrite of antimony, given in such doses as to excite nausea, but not
 vomiting.  He had often experienced the best effects from his pills, which are mentioned
 further on.
  t In the fourth volume  of the Commentarii Soc'Reg. Scient.  Goctting. Richter says,
 that in a patient who had become blind after being in a violent  passion, he restored sight
 by an emetic, administered on  the following day.  In his Anfangsgrunde der Wundarz-
 neykunst, he recommends emetics and purgatives, with other resolvent  medicines, in the
 cases where there is reason to suspect the existence of acrimonious matters in the primee
 via?; vol. iii. § 448.  He also advises this mode of proceeding, on merely empirical orounds,
 when the cause of the affection is not discovered ; and we are consequently unable to pur.
sue a rational plan of treatment.  Ibid, § 454, 
AMAUROSIS.
513
rosis which admits of a cure, it is found, from the careful observations
of Schmucker and Richter, that this disease is most frequently derived
from a morbid excitement or irritation in  the digestive organs, from
sordes, or from worms, especially in children, either alone or accom-
panied with  general nervous debility, in  which  the eyes  participate
sympathetically.  Agreeably to these principles, in the greater number
of cases of recent imperfect amaurosis, the principal indication of cure
which the surgeon ought to fulfil in the treatment of this disease, is that
of unloading  the stomach and primae  viae of the  crudities, worms, or
morbific stimuli;  and afterwards, of strengthening the gastric system,
facilitating the digestion, and at the same time exciting the whole nervous
system, and particularly that of the eyes, which are affected and rendered
torpid by a sympathetic connexion."   (Treatise, &c. p. 458.)
  " With respect to the first part of the treatment of the imperfect amau-
rosis, the intention is perfectly answered by emetics and internal resol-
vents {antiphlogistic purgatives.)  In  the  class of emetics, experience
has  taught that the  antimonium tartarizatum is preferable  to  every
other, and that when given afterwards, in small and divided doses, it
answers the purpose  of a resolvent medicine, the action of which may
be increased  by conjoining  it with gummy or saponaceous substances.
In the treatment  of  the imperfect amaurosis, therefore, which is most
frequently sympathetic, and depending on  acrid matters in the  prima)
viae, it will be proper at first, in  the greater number of cases, to dissolve,
for an adult, three grains of tartarized antimony in four ounces of water,
of which two table-spoonsful may be taken every half-hour, until it pro-
duces nausea, and afterwards  abundant vomiting.  On the following
day he should be  ordered to take the  resolvent powders, composed of
one ounce of the crystals of tartar, and one grain of the tartarized anti-
mony, ilivided into six equal parts, of which the patient should take one
in the morning, another four hours  afterwards, and the  third in  the
evening, during eight or ten successive days.  This medicine will pro-
duce a slight  nausea, and some  evacuations of the bowels  more than
usual, and perhaps, after some days, even  vomiting.  But if, during the
use of this opening powder, the  patient make ineffectual efforts to vomit,
and complain of a bitter taste and want of  appetite, without any amend-
ment of the sight, the emetic  should be repeated, and even  a third  and
fourth time, if the presence of the morbific stimuli in the stomach, bitter
taste, tension of the hypochondria, acrid  eructations, and tendency to
vomit, require it.   For it not unfrequently happens, that the patient, on
the first action of the remedy, throws up only water, with a little mucus;
but, on repeating  the emetic, after the  nauseating powder has been used
for some days, a  considerable quantity of yellowish green  matter  will
be thrown up, which will greatly relieve the stomach, head, and eyes."
(Treatise, &c. p.  459, 460.)  When the disease is  caused  in children
by worms, Scarpa recommends the  coralline of Corsica,  {mousse de
Corse, fucus  helminthocorton;)  or, when  that cannot  be  procured, the
semen santonici  (qusere, artemisia sanlonicum?—Ibid, p.  460, 461.)
When the stomach has been cleared, he advises the pills of Schmucker,
or those of Richter, of which the following are the formulae.  For the
former; R. gum. saga pen. galbani, saponis veneti, aa. 3j.; rhei. opt. 3jfi.;
antimon. tart. gr. xvj.;  succi  liquirit. 3j. m.   The mass should be
       65 
514
AMAUROSIS.
divided into pills of one grain, and fifteen should be taken morning and
evening for four  or  six weeks.   For the latter;  R. gum. ammoniaci,
asafcetidae, saponis veneti, radicis valerianaa, summitatum armcac, aa.
31J;  antimon. tart. gr. xviij.  misce.  To be  divided  into pills of  two
grains each: fifteen  to be  taken  three  times a day for  some weeks.
(Ibid, p. 461, 462.)
  "The  phenomena," says Scarpa, "which are  usually observed to
happen  in consequence of this treatment, are the following:—the pa-
tient, after having vomited  copiously, feels  more easy and comfortable
than before.   Sometimes, on the  same day on which he has taken the
emetic, he begins to distinguish the surrounding objects;  at other times
this advantage is not obtained till the fifth, the  seventh, or the tenth
day; and in some cases  not till some weeks after the administration of
the emetic, and the uninterrupted use of the opening powders and pills.
As soon as the patient begins to recover his sight, the pupil is found less
dilated than before,  and  also contracts more when exposed to the vivid
light of a candle; and in proportion as the power of vision augments,
this contraction and mobility of  the pupil  increase.  Upon  the  whole,
the cure is seldom  completed in  less than a month, during which time
the use of local remedies calculated to  excite the torpid action  of the
nerves  of the eye should  not  be neglected." (Treatise, &c. p. 462.)
For the latter purpose,  Scarpa recommends the vapour  of the liquor
ammoniae.   The eye may be exposed for half an hour at a  time, three
 or four times  in the day, to the penetrating vapour arising from this
 fluid in a  small vessel, as  near to the  organ as  can be borne  conve-
niently.
   When the stomach has been cleared, and  the patient  has in a great
 measure  regained his sight, Scarpa endeavours to strengthen the sto-
 mach, and invigorate the nervous system :  An ounce of powdered cin-
 chona, and half an  ounce of valerian  root  should  be divided into six
 powders, of which one may be taken night and morning  for at least five
weeks.   During this time, exercise in a good air, and tender juicy food,
with a moderate quantity of wine, are recommended. (Ibid,  p. 463.)
   The respect justly due to  the names of Richter  and  Scarpa would
naturally lead us to  try a mode of treatment which they have so strongly
recommended.  I have  accordingly employed their plan in some in-
stances  which appeared favourable, but entirely without success.  I
have seen no case of amaurosis cured, nor even relieved, by such mea-
sures.  On the contrary, after the ineffectual trial  of emetics and  nau-
seants, I have removed the disease by  the abstraction of blood and the
other treatment already described.   I have therefore entirely abandoned
the use of emetics in amaurosis.   I should not  consider them  safe  if
general plethora, determination to the head, or active disturbance of the
retinal circulation were present.  As the full trial of the plan would re-
quire several wreeks, we must also consider the  loss of time  that  it
involves.  If the disease does not yield to our treatment; it will advance;
and, from being imperfect and curable, it may become in a few weeks,
complete and incapable of cure.
   [Our own experience is  in entire  accordance with that of Mr. Lawrence re-
specting the value of emetics in the  treatment of amaurosis.]
   Electricity has been frequently  employed  in amaurosis, as well as  in 
AMAUROSIS.
515
 most other nervous affections.   Mr. Hey,*  of  Leeds, published  some
 cases of amaurosis which he considered to have  been much benefited
 by electricity; and the late Mr. Ware! seems to have relied on it almost
 entirely.   Indeed this  influence, in all the varieties of its application, as
 well as various other stimulants, has been tried  over and over again in
 this affection, with so  little decided benefit, that its efficacy is altogether
 doubted by the profession.  This doubtful  remedy is objectionable in
 the early stage of the  complaint, because it  supersedes other means, of
 which the  superior efficacy is well established.  Nor can I deem it safe
 at  that  period, inasmuch  as  a powerful stimulus  is  not  likely to tran-
 quillize  an over-excited organ.   For this reason I should consider it dan-
 gerous  whenever congestion  exists in the head, or active  disturbance in
 the eye.  The indiscriminate use of electricity, therefore, for which the
 authority of Mr. Hey and Mr. Ware  might be quoted, seems to me
 both  ineligible and unsafe.  If, however, the rational means, which a
 full consideration of the  case points out, should have been judiciously
 tried  without effect, the patient may take the chance of this  empirical
 remedy.
   [We have related at p. Ill some cases in which galvanism was used  by us
 with advantage.]
   Sternutatories.—Mr. Ware  has strongly recommended the use of a
 snuff consisting of ten grains of turbeth mineral  (not in the London
 Pharmacopoeia ; it  is the hydrargyri oxydum sulphuricum of the Dublin)
 and one dram of ihe pulvis asari composilus (Dublin Pharmacopoeia : it
 was formerly called pulvis  slernutatorius.)   " A small  pinch  of this
 snuff taken up the nose is  found to stimulate it very considerably; some-
 times exciting  sneezing, but  in  genera] producing a large discharge of
 mucus."  (Ibid, p. 405.)   Mr. Ware afterwards  says, that " in order
 to be more exact in the use of this remedy, I have  lately accustomed
 myself to prescribe one grain of the turbeth mineral to be  mixed with
 twenty  grains of the  powder of liquorice, of snuff, or  of sugar; and
 one-fourth, or one-third of this powder to be snuffed up the nose two or
 three times in the course of the day.  And in  those cases, where the
 nose has been particularly dry, I have rendered the powder more effect-
 ual by directing the patient to inhale the steam of warm water through
 the nose previous to the use of the snuff."  (Ibid, p. 417.)
  Stimuli and tonics.—The generally prevalent notion, that amaurosis
 depends on  nervous debility or atony, has led at all times to  the  free
 employment of various means supposed to possess  the power of rousing
 the energy  of the  retina or of  the  nervous system  generally.   Such
 means, or at least some of them, have been called antiamaurotic; and
 they have not unfrequently been  used  empirically, one after the other,
 where the  practitioner has not perceived  any obvious indications of
 treatment.   A  glance  over the  list  that follows will  show how much
 physic must have been wasted in practice conducted on such principles.
If I were to enumerate all the remedies of this description, which  have
been recommended and actually used, the catalogue would comprehend

  *  Medical Observations and Inquiries, vol. v.
  t Memoirs of the Medical Society of hondon, vol. iii.  Also, UA Description of fifteen
 Cases of the Gutta Serena, with  Incidental Remarks,''1 in Observations  on the Cataract,
Gutta Serena, SfC  Third Edition, 1812. 
516
AMAUROSIS.
every thing that comes under the head  of tonic and stimulant, of ner-
vous, antispasmodic, and antiparalytic.  The  greatest favourites, how-
ever, have been the various  bitters  and  tonics, the  arnica  montana,
Pulsatilla, valerian, bark, black hellebore, calamus aromaticus, camphor,
opium,  hyoscyamus,  musk, asafnetida,  castoreum, phosphorus, ether,
ammonia, flores  zinci, steel, and  naphtha; even  millepedes have been
strongly recommended.  If the treatment already advised be capable of
doing any good; if the pathological views on which that treatment is
founded approach in any degree to correctness, all this farrago of ner-
vous medicines and stimulating substances must not only be inefficacious,
but absolutely injurious; and indeed, on referring to many of the articles
in this list, we cannot suppose that they  could be put into the stomach
without disordering the health generally.   If these substances  are capa-
ble of doing any good in this  affection, then the antiphlogistic  and mer-
curial treatment must  be completely wrong.  I am, however, firmly
convinced that the  tonic and stimulating  plan is entirely erroneous; that
it is  founded on mistaken  notions, or rather on  complete ignorance of
the pathology of the affection.  Unfortunately this error is not an indif-
ferent one, for if we treat a case of amaurosis on wrong principles, we
are not  only losing time, which is of the greatest value, but contributing
to the progress  of  the  disease.  I have seen too many cases where the
disorder has  been decidedly aggravated by the very means used for the
purpose of removing it.
  A  striking example  was afforded by the case of a boy at school, about fifteen years
of age.   He came home to dine  with his family not having felt ill, nor made any com-
plaint.  In helping himself to wine, he poured it  not into the glass, but by the side. It
was found by examination, that the sight of one eye was very imperfect. A gentleman,
who was consulted, directed a few leeches to the temple on account  of slight pain in
the head, and opening  medicine; measures of proper kind, but not sufficiently active.
At the end of two or three days, the symptoms not being removed,  the  parents were
informed  that the imperfection of sight arose from want of tone in  the nerve, which
must be remedied by generous diet  and  tonic modieine: the pilula ferri cum myrrha
was prescribed.  Under this plan, in ten days, the eye first affected, had become totally
amaurotic, and  dimness of sight occurred in the other.  I  saw the patient at  this
period,  and could only succeed in  preserving imperfect vision  in the eye last af-
fected.
  In the  summer of 1831, I saw a lady, thirty years of age, with light hair and grey
eyes, of spare habit, married, and menstruating regularly, but without children.   She
had been  accustomed to read much, particularly at night.  In  the  preceding winter
she had experienced headach, to which she had not been previously subject, and  she
still suffered much from it.   Five months before  I saw her, the sight of  the right eye
had become dim, and the affection had gradually increased.   Within a  few days she
had been  alarmed by imperfection of vision in the left eye.   She had been told, some
time previously, that the affections of the eye was nervous, and that  she  ought to take
strengthening medicine and to live well.  In pursuance of this advice, she drank  por-
ter, and brandy  and water.  I found  her with a strong and full  pulse, hot skin, headach,
and foul  tongue.  With the right eye of which  the pupil was in or about the middle
6tate and motionless, she could see  nothing straightforwards: there was still a little
sight of objects placed towards her right.  The pupil of the left eye was rather smaller
lhan that of the right, and sluggish. Light was very offensi ve, causing  a dazzling, which
prevented sight almost entirely.   With this eye  she could see the smallest print; but
she could not read ten lines.  Abstraction of blood from ihe temple, which  was accom-
plished twice by cupping and once  by leeches, discontinuance of the dietetic stimuli,
and the administration of mercury for six or seven weeks, removed the general ex-
citement  and the headach, made the  tongue clean, and improved the health  con-
siderably.  The sight of the right eye, however, was not restored; nor were the incon-
veniences produced by strong light on the left entirely removed. 
AMAUROSIS.
517
   The belief  that amaurosis depends on impaired energy of  the nerve
 has been strengthened by the circumstance  occasionally noticed, that
 patients  feel and see better after the excitement of wine or of a full meal.
 The failing powers of the retina may experience a momentary increase
 by the temporary  acceleration  of the  circulation  consequent on the
 stimulus; as ideas are produced more rapidly, and  thoughts  and lan-
 guage become more powerful and brilliant, when  the blood circulates
 more quickly  in the brain, and as the enfeebled stomach of the drunkard
 is  roused by a dram.  What should we expect from a regular course
 of drams, or from permanent excitement of the brain?
   Tonics and stimuli, medicinal and dietetic, occasionally find place in
 the treatment  of  amaurosis.  The disease, in some cases, depends on
 weakness of the nerve, or is connected with general  debility.   In other
 instances the patient  is  reduced by our treatment, and  perhaps by the
 distress of mind, often amounting to  despondency, consequent on the
 dreadful calamity of  blindness.  Sometimes, when there is no longer
 any reasonable prospect of  restoring sight, nothing is left for us but to
 enable the sufferer to bear up  under his  privation, by upholding the
 general powers, and restoring the tone of the nervous system.   In these
 several cases  there are sufficient reasons for employing medicines of the
 class now under consideration.   My objection is to their indiscriminate
 use, to their bein^; ranked as primary and principal means in  all cases
 of amaurosis, merely because the  nerve is said to be weakened, and to
 the blind empiricism  which often  administers  them in  succession, be-
 cause they have been called antiamaurotic.
   Use of strychnia.—As this remedy both in its external and internal ad-
 ministration, has been found  a powerful stimulant of the nervous system,
 in  various  cases of  paralytic  affections and impaired  sensibility, its
 powers have been tried  in  amaurosis.  It  may be considered particu-
 larly applicable to  the  instances  in which  simple want of power, or
 atony of the nervous structure without vascular excitement, is the cause
 of the symptoms. Mr. Mibdlemore, who has  tried the remedy in many
 cases, says, "If a person be  suffering  from loss or diminution of the
 power of vision from  an atonic state of  the retina, or other part of the
 nervous apparatus of  the eye, or of the system generally, the local use
 of strychnia will be, in my opinion, the most likely means of removing
 the defect, more especially if it be of recent  occurrence."
  On another  occasion Mr.  M. describes more particularly the cases in
 which benefit  may be expected from strychnia. " If a patient has over-
 worked the  eye by long continued  action, confined to the inspection .of
 objects of the  same colour  and  description, an enfeebled condition of
 retina  (just as  we produce an exhausted  state of muscle by over exer-
 tion,) will take place.   If a  man subject his eye to unnatural stimulus,
 by looking for many hours daily at  bright  substances of the  same or
 nearly the same colour,  or to sudden transitions from an artificial glare
 to comparative darkness (as miners;) or to  a diminished stimulus, as by
 working  in dark rooms, or places imperfectly supplied with light;  or to
 any cause allowing the visual textures of the eye to  remain, for a long
period, in a  state of inactivity, as takes place where large opacities of
the cornea, and fully formed cataract exists, ihe power of the retina will
be partially destroyed, its susceptibility to the stimulus of light diminished;
but in none of these cases will there be found any  structural change in 
518
AMAUROSIS.
 the retina or the optic  nerve, any congestion of vessels, or any disco-
 verable alteration from a  healthy and natural  condition;  nor will the
 system, in all probability,  be found affected; no altered state of health,
 sufficient to account for the dimness of vision, will be found to exist."—
 " Loss or diminution of the power of vision  sometimes comes on from
 certain causes which diminish  the vigour of the system generally, as,
 for instance, after profuse salivation, long continued  suckling, menor-
 rhagia, &c.   In all these cases, I believe, the strychnia is calculated to
 produce great and permanent advantage, in combination, of course, with
 other remedies  suited to the particular exigencies of the case: for ex-
 ample, if the  retina be weakened in consequence of diminished vigour of
 the system, remedies adapted  to strengthen the system, and a removal
 of the cause  enfeebling  it, might be joined to  the local application of the
 remedy in question.   But the power of the retina will not always return
 with the returning strength of the system ; in such cases the strychnine
 is  singularly  valuable, producing with wonderful rapidity, the restora-
 tion of the organ of vision.  Strychnine, given internally, does not pro-
 duce the  same  beneficial  effect upon the retina, as when applied ex-
 ternally."
    The mode of employment is to  place a blister over the eye-brow, to
 remove the cuticle, and  then dust the  remedy over the denuded surface,
 beginning  with the sixth of a  grain  on  each  side, and gradually  in-
 creasing the  quantity until  one grain is used on each side, or until the
 head becomes  affected.  Mr. M.  considers  that greater effect is pro-
 duced when the substance  is applied over the supraorbitary nerve.  He
 gives the following general directions :—" Place a narrow blister over
 each eye-brow, which must not extend beyond  a  line  drawn upwards
 from the external  canthus; when it has  arisen sufficiently, cut  away
 the cuticle, and apply, for  half an hour, a piece of  linen to absorb the
 serum, which is apt to be discharged  in large quantities for a short time
 after the removal of a blister; then dust the remedy chiefly in the situa-
 tion of the supraorbitary nerve, but not so thickly as to prevent the ab-
 sorption of the whole layer of the powder, at the time  of the second
 dressing, which should be  twenty-four hours afterwards ; this is a pro-
 per interval between  the dressings; cover the blistered surface with a
 piece of linen thinly spread with  ung. cetacei."  " Increase the dose of
 strychnia very gradually until the state of vision is improved, or symp-
 toms indicative  of the injurious  agency of the remedy  occur.   If
 there be  much local  pain, excited by the application  of the strych-
 nia, dilute  it  with flour, or  mix  it with opium ; and  if that do' not
 succeed,  suspend its employment,  until the  stomach   and  bowels be
•improved, by  a plan of treatment instituted  expressly for their benefit,
 and then resume its use.   If severe pain in the head, convulsive muscu-
 lar twitchings, great general nervous excitement, or other symptoms,
 denoting the injurious agency of the  strychnia  upon the constitution,
 supervene, and the condition of  vision be  not improved, it must be dis-
 continued altogether."*

  *  Report of the  Birmingham  Eye Infirmary, in the Midland Medical  and Surgical Re-
porter, May, 1830, vol.ii. p. 158, 159; also, On the Utility of Strychnin in certain forms of
Amaurosis, ibid, p. 481—4t5.  The remarks arc repubhahed  in the hondon Mcd'icul Ga-
zette, vol. viii. p 434—437.
  In another  short notice contained in the  same periodical, Mr. Middlemoke mentions, 
AMAUROSIS.
519
   This remedy has been employed  by Mr. Liston,* in the Edinburgh
Royal Infirmary.   He  applied  ihe blisters on the temples, and began
with a  quarter of a grain of the  strychnia  on each side, gradually in-
creasing the quantity to one grain and a half, which brought on head-
ach, vertigo, debility, nausea, and muscular tremors.  As other means
were employed at the same time the evidence respecting the powers of
strychnia is the less clear.
   In  his  Treatise  on Diseases of the Eye, (vol ii. p. 290, 291,) pub-
lished since the observations previously quoted, Mr.  Middlemore states
that his favourable opinion of strychnia has been strengthened by sub-
sequent experience.
   Mr. Tyrrell says that he has frequently tried the remedy in the cases
which appeared to him  most appropriate, but that he had not seen one
single instance of benefit from its employment, although  he had per-
severed until alarming muscular contractions were produced.  He con-
siders further that serious mischief has resulted from its indiscriminate
use.  (Vol. ii. p.  316.)
   My own experience coincides with that of Mr. Tyrrell, in reference,
not only to strychnia, but also to veratria, which he has found  equally
inefficacious.
   The latter remedy is employed  in the form of ointment, in which from
ten to twenty grains of the veratria are incorporated in an ounce of lard
or spermaceti cerate.   The size of a large pea, or a horsebean is to  be
rubbed on the temples and forehead  for a few minutes, once or twice in
twenty-four hours.  The application causes redness, heat, and tingling;
sometimes with more considerable irritation; and  the friction should  be
continued until these effects are  produced.   In  this mode of employ-
ment the veratria may  be of some service as a mild counter-irritant.   I*
have seen  it used many times, but it has never produced essential and
unequivocal benefit in a decided case of amaurosis within my observa-
tion.   Sometimes, in females, it has  irritated excessively, causing ner-
vous  symptoms,  which  have  excited alarm; and patients  have even
stated  that it has injured sight.
  [The results of our experience with strychnine in amaurosis, are much more
favourable to the value of this remedy,  than those of Mr. Lawrence and Mr.
Tyrrell. It has certainly proved inefficacious in not a few cases which seemed
favourable for its employment, but in others, it has been productive of the best
effects.  We have found  it far more effectual, however,  when applied to  the
eye, in the form of collyrium, or given internally, than when applied to a blis-
tered surface; indeed we do not remember a single cure effected by the latter
method of using it.   The cases in which it shows its best effects are those
attended with  dilatation of the pupil; for this article has almost as decided an
effect  in producing contraction, as belladonna has of causing dilatation of the
pupil.
  The following case is one of the  most striking we have met with of  the

that in two or three instances it has produced so much  headach and spasm, that its em-
ployment could not be continued; whilst two or three patients who were much  benefited
by it experienced so much local pain, that they would not persevere  in the use of the  re-
medy.   In three cases where it was serviceable, its  continued use was necessary to
preserve vision,  which was invariably  lost, when the strychnia was discontinued—Ibidt
p. 240.
  * hondon Medical Gazette, vol. v. p. 541 and 575. 
520
AMAUROSIS.
efficacy of the  remedy:—Harriet Taylor, aged 12, was admitted into Wills
Hospital, November 10th, 1838, with amaurosis of right eye; vision in left eye
good.  Her mother stated that she had first noticed her daughter's defect of sight
about three years ago, since which period it had been growing gradually worse.
For four months the right eye, to use the patient's own expression, had been
"quite dark."   She cannot distinguish a candle with it, though  she has a
faint perception of the light.   The patient has  light hair;  complexion  fair;
irides grey, contracting on exposure to light;  pupil of right eye rather more
dilated than that of left; is sometimes  troubled with headach.  We could not
learn any thing from the history of the case, as given by her mother, calcu-
lated to throw any light on the cause of the loss of sight.
   There was evidently no congestion of the cerebral  organs, or inflammatory
excitement in the system, and we therefore ordered a  dose of sulphate  of mag-
nesia at bed-time, and the next morning a few drops of the  following to be ap-
plied to her right eye.   R. Strychnin, gr.  ij; acid, acet ^j. aq. purae ^j.  M.
   November 11//*. Noon.   Medicine has purged her actively.   The nurse
had applied the solution to the eye early in the morning, and the patient find-
ing her vision  much improved, afterwards, in the absence of the nurse, had
twice used  it  herself.   Says  she can now see  pretty well with her  right
eye.  Upon trial found she could read with that eye, the other being carefully
closed with my fingers, a newspaper which happened to  be at hand. Says
there is some cloudiness  of right eye.   Continue collyrium.
   \2th.  Sight improved.  She read with either eye almost  equally well, the
other being closed, a proof sheet of this Journal, which we had taken for the
purpose  of trial.  Cloud before right  eye diminished but not entirely gone.
Continue collyrium.
   13//*.  Cloudiness of right eye entirely gone; sees perfectly well  with it; 13
not sensible of any difference in the power of vision of her two  eyes.   She
was discharged November 17th, and went to  hei mother who resides a  few
aniles in the country.
   The rapidity of the  cure in this case led us at  first to suspect deception; on
inquiry we could  not  discover any ground for such suspicion.  The fiiend
who had recommended the patient to our care informed us that her mother
was a respectable, industrious  widow,  who supported  by  her labour several
children  of which the patient was the oldest; that the daughter was intelligent,
active and obliging, and her aid was of so much importance  to her mother,  that
he had interested himself to have her relieved from her infirmity, which much
lessened her usefulness.   As to the excellence  of her sight, when she  was
discharged from the hospital, we  verified this  in  a way that admitted of no
deception.
   In June, 1839, we had the  gratification to  learn from the friend who  sent
this patient to  us, that the cure  had been so far permanent.  He informed us
that he had seen Harriet frequently, and  that a short time before he  had in-
quired particularly of her respecting her sight, and was assured  that it was
perfect.]
          SECTION V. — PARTICULAR KINDS OF NERVOUS AFFECTION.

   To the general principles of treatment, which I have now explained,
together with the modifications required under certain circumstances,
there are some exceptions, which will be  noticed in the following re-
marks on particular kinds of nervous affection.
   Affection of the  retina from excessive employment; commonly 
AMAUROSIS.
521
called weakness of sight.  The retina may lose the power of continued
exertion from habitual or excessive use of the eyes, as in  reading or
writing, particularly by  candle  light,  in drawing or painting  minute
objects, in microscopic or telescopic observations,  or in  any other
way in which  they are closely and  intently occupied.   I  have seen
this affection principally if  not solely in young  persons, especially
in university students, and in  females who have been employed through
several successive hours of  the day, as  well as by candle-light, in
drawing, music, needle-work, reading and  writing.  The power of
vision is not impaired;  the minutest objects  are  seen clearly as in the
natural state of the eye.  But when it has been exerted for  some time,
the organ becomes tired;  objects appear  dull, confused,  or distorted,
and can no longer be  recognised; a sense of weariness comes on in
the part, occasionally with redness and lachrymal suffusion.   The eye-
lid drops, and a painful pressure is felt in  the brow.   The  uneasiness
goes off by rest, the powers of the retina are restored,  and the eye
may be  employed again;  but, if exertion  be  imprudently pursued,
the organ becomes sooner tired.   The time, in which this occurs, varies
in different instances, from an hour and a  half or two hours to a  few
minutes.   I have seen many instances, in which  the  patient could not
read more than five minutes at a time.  No pain  is experienced in pas-
sive vision, or  in  looking at distant objects out of doors;  nor is even
strong light offensive.   The patient is often annoyed by the appearance
before the eye in various forms, of the imaginary object called muscce
volit antes.
  Patients naturally enough  call this state weakness of sight. We can-
not propose any technical name, because the  pathology of the affection
is unknown; the  mode in which  the retina suffers has  not yet been1
ascertained; nor  do we know whether the primary seat of  mischief is
in the retina or the choroid.  The term amblyopia, designating the early
stage of amaurosis, in which, although smaller objects can be discerned,
they are seen under some imperfection, is not applicable to this affec-
tion, in which  the power of vision is unimpaired.
  This disease  is  very obstinate and tedious, often lasting one, two, or
more years, in spite of all our  efforts, and appearing at least to cease
spontaneously, rather than to yield to medical or  surgical treatment.  It
is not benefited by strong measures, such as cupping, blistering, purging,
&c.   The  state of the organ, or  of the circulation  in the head, may
render moderate depletion by cupping or leeches advisable  occasionally;
and in the same way blistering  may sometimes be required.  A princi-
pal  circumstance  is moderate  use of the weakened organ : the eyes
must not be employed so as to bring on fatigue and pain.  The diet and
state of the bowels must be attended to ; the patient should live regularly.
He should reside in a pure air, and take exercise freely both on horse-
back and walking.  Washing the head every morning with  cold water:
the cold and shower  baths will often be  advantageous.  In short, the
mode  of living should be  such  as  is most favourable to health and
strength, most likely to brace the nervous system.  Gentle stimuli to the
surface of the eye and the lids have  sometimes  appeared  to do good.
The vapour of ammonia or  ether, the vinum opii, and a stimulant lini-
ment to the edges of the lids, may be employed for this purpose.
       66 
522
AMAUROSIS.
   In a gentleman, about thirty, whom I saw with this affection, the eyes
 became tired and painful in about half an hour.   There was some unu-
 sual vascularity, and he appeared rather of full habit.   Scarification of
 the lids afforded temporary benefit.  He regulated his diet, and attended
 carefully to the stomach and bowels.  In four months he was less ple-
 thoric, and the eyes were  quite natural: he could read for an hour, and
 sometimes from one to two hours.  He washed the head with cold water,
 paid great attention to diet,  and occupied himself  considerably with
 travelling.  The affection gradually declined, and might be said to be at
 an end in about a year and a  half from its commencement.
   In the following  case,  there may, perhaps, have been a natural dis-
 position to the  complaint.
   I saw, in 1827, a gentleman from Norway, thirty-one years of age, stout and healthy,
 with fair complexion and blue eyes.  His left eye, which  had always been imperfect,
 appeared healthy : the pupil was  of middle size, and  the iris moved as usual.  He
 could see the first and second sizes of print in the title-page of an octavo.  Five years
 before, the right eye began to  be weak, and had continued in nearly the same state.
 He could see the minutest  objects perfectly, and could read the smallest print, but
 employment either in reading or writing soon fatigued the eye.  A brown smoke or
 mist, and sometimes  a bright glare  came before it, and in an hour, or an hour and a
 half, he was obliged  to desist.  Heat, strong light, and the reflexion from snow in
 sunshine, were painful: coloured glasses gave relief.  The less he used the eye, the
 better he felt  it.   Leeches on  the temple, with alterative  and aperient medicines,
 were of some service. He had been under my care in London two years before, and
 had derived benefit from similar measures.   Since that time he married, having pre-
 viously led a chaste life, and he thought himself better for the change.  No unusual
 appearance could  be discerned in the right eye.  The father and mother of this gen-
 tleman had always enjoyed excellent sight; also the grandfather and grandmother, of
 whom the former  could read without spectacles at the age of eighty-seven.  He had
 two brothers; one about twenty, who had laboured for a year and a half under a simi-
 lar affection of both eyes.  The other, rather older,  had experienced some degree of
 the same inconvenience.  He had one sister, whose  eyes were weak.
   Symptomatic and sympathetic amaurosis.—When the function of
 the retina is disturbed, as it frequently is more or less seriously, not from
 primary disease of the nervous  structure, but from affection of some other
 part, the state of the organ  primarily diseased must  be  the object of
 treatment;  and no good can be expected from measures calculated to
 acton the eye.   Increased sensibility of the retina, and impaired vision
 in various degrees, sometimes  with squinting and double sight, may be
 symptoms of disease existing in or affecting the  sensorium or its  mem-
 branes ; the questions will be, whether  we can  ascertain the  nature
 and seat of such disease,  and whether we  may be able  to arrest and
 remove it.
   The retina may be affected  in  consequence of inflammatory disease
 originating in and confined to  other tunics of the eye, as the cornea,
 sclerotica, and  even the conjunctiva.   The cause and nature of the
 affection are here too obvious to be mistaken.
   The retina often sympathizes with remote organs, especially with the
 uterus and the  alimentary canal.  To  this  head must  be referred the
 intolerance of light {photophobia,) whether of scrofulous children, or of
 hysteric females, muscae volitantes, with  or  without dimness or heavi-
 ness of the eyes, various modifications of altered vision, in which ob-
jects are confused or distorted, seen irregularly or imperfectly, and im-
 paired sight in various degrees even to complete amaurosis, in children 
AMAUROSIS.
523
 more especially, whose stomach and bowels are disordered, or in young
 women in whom menstruation either has not occurred, or is interrupted,
 irregular,  deficient, or painful.   A careful  investigation of the mode in
 which the affection of vision has begun, and of all the attendant circum-
 stances, with an inquiry  into the past  and present  state of  health, will
 not fail to point out the origin of the  disease, and the quarter to which
 our treatment must be directed.
   The  effect of the  eye of an  irritating cause in the  stomach is  ex-
 emplified in  a case related in the Medical and Physical Journal, for
 December, 1816.
   A child seven years old was affected with severe and almost intolerable  pain of the
 left eye,  in occasional paroxysms of some minutes, recurring at uncertain intervals,
 and extending to the eye-lids.  There was no visible change in the organ.  The food
 was rejected unaltered.   The affection had lasted three weeks.  An emetic was given
 in the evening, and a purgative of calomel and jalap the next day.  With the motions
 produced by the  latter, a coral bead  came away: the little patient immediately re-
 covered.
   In the following interesting  case, recorded  by Mr. Wishart, com-
 plete amaurosis of some  months duration was caused  by a loaded state
 of the bowels, and cured by clearing the alimentary canal.
   A boy nine years of age was brought to Mr.  W. with complete blindness of the left
 eye, which was insensible even to bright sunshine:  the pupil was of natural  size, and
 the iris moved readily.   The right eye was unaffected.   Pain was occasionally felt
 over the left eye.  He was  pale and languid; and the  tongue was  slightly loaded.
 He had been always subject to disorder of the  stomach from any irregularity of diet,
 apparently from his nurse having been in the habit of giving him whisky to quiet him
 at  night.  The  loss of sight, which had lasted  about four months, was said to have
 occurred in consequence of his grandmother's death having been incautiously com-
 municated to him.  An  emetic of ipecacuanha  was  first administered, and was fol-
 lowed by two pills, night and morning, consisting of the compound extract of colocynth,
 with  one grain of calomel, and the same quantity of James's  powder.  The emetic
 and the pills operated freely; the latter were continued for twelve days.   The vapour
 of the liquor ammonia? was applied to the eye three or four times a day; and at the
 end of a week, a small blister was placed over the mastoid process, and  subsequently
 dressed with savine ointment.  Under a suspicion that he might have worms, a dose
 of oil of turpentine and castor oil was administered, but  no worms came away.  On
 the evening  of the twelfth day, when  the reading lamp was brought into the  room, he
 said that he  could see the light of it; but on trial he could not distinguish the finger,
 or any object held up before him.   The next day a dose of senna tea was given instead
 of the pills; it operated three times, but less abundantly:  he said that he could see his
 fingers.  On the  following morning, he  awoke with  a  smart attack of fever; with
 quick pulse,  dry hot skin, thirst and  headach.   A copious evacuation of  the bowels
 soon took place in greater quantity than any preceding one, and very consistent, with
 numerous lumps of indurated  feces.   About mid-day sight was perfectly restored; he
 saw every object even as minute as the seconds' hand of a watch.  The recovery of
 vision was permanent, and the patient soon  left  Edinburgh quite well.   (Edinburgh
 Medical and Surgical Journal; vol. xxiv. p. 64—66.)
  Case.—Amaurosis from worms.—In the last winter (1839—40,) I saw a boy, seven
 or eight years of age, whose sight had recently become so defective, that he could not
 distinguish even the capital letters of print.  The irides were sluggish, and the pupils
 large, the eyes in all other respects  being quite healthy. The  general health was
 undisturbed.   I ordered some alterative and aperient  medicine, and two leeches be-
 hind the ears.  After I had seen him three or four times, during which no change had
 occurred  in the state of the complaint, it was mentioned  that he had ascarides.  The
oil of  turpentine was now twice  administered  in the form of injection, and  brought
 away a considerable number of worms, none of which were seen afterwards.  Vision
 was now  restored rapidly and  completely.
  In  the case just related, the  irides were  nearly motionless, and the
pupils dilated^ while in  Mr. Wishart's  patient the iris moved freelv, 
524
AMAUROSIS.
and the pupil was natural.  Disorder of the alimentary canal may affect
vision by acting on the retina, or through the medium of the ciliary sys-
tem of nerves; the ophthalmic ganglion being the upper extremity of the
ganglionic system.  These affections may be quite distinct, although gene-
rally if the retina be seriously disordered, the ciliary system suffers, as
we see from the condition of the iris  and pupil.  Disorder of the ciliary
system, which is not an unfrequent effect of abdominal irritation, does not
so commonly extend to the retina.   The dilated state of the pupil, how-
ever, impairs vision so considerably,  that the retina may be supposed to
be diseased where the case is simply  mydriasis, and where vision would
be found to be  perfect if the patient  were to make the trial of looking
through a small hole in a card.   In  a doubtful case the state of vision
should be  carefully examined, especially in young subjects, before we
pronounce a decided opinion on the nature  of the affection.  If  the
retina retains its sensibility to light, the prognosis is more favourable
than under the opposite state.
   [A case of complete amaurosis in a child, which instantly ceased, on a worm
being puked up, is recorded by Mr. Welsh, in the  medical communications
of the Massachusetts Med. Soc. vol. i.  p. 87.]
   Amaurosis from  debility.—Persons who are ignorant of physiology
and pathology  may naturally suppose that imperfection of sight depends
on weakness of the optic nerve, and that the  remedy must  be found in
means capable of strengthening the weakened structure.   We should
not have expected that they who understand the structure of the body,
the nature and action of the causes  which produce disease, and the in-
fluences which remove it,  should borrow this  opinion, and refer amau-
rotic affections to debility or atony of the nervous structure, or to weak-
ness of the frame  generally.  The  following statement  by Beer will
show  how extensively the notion prevails, and  how firmly it is  be-
lieved.
   " The cause  of amaurosis very often consists in direct local or gene-
ral weakness,  which  may be produced by moral influences capable of
agitating  the nerves  generally, or by real physical commotion of the
nerves of the head, more particularly of those belonging to the forehead
and  eyebrow, by concussion of the spinal cord, by a jump from a con-
siderable  height with  the whole weight of the body coming on the heels,
by concussion of the globe, even by violent and continued sneezing, and
still more by contusions  of the eye with blunt  instruments.   One of the
causes to which the greatest influence must be ascribed in the produc-
tion of amaurosis, is  the  serious direct weakness induced  by loss  of
fluids, as  in  cholera, continued diarrhoea, in  salivation, not  forgetting
the copious spitting of the tobacco smokers, who in modern times pur-
sue their  unmannerly practice in  all places, in hemorrhages, in  para-
centesis abdominis  when incautiously performed, in the loss of seminal
fluid  from excessive venery, nocturnal pollutions or onanism, and  in
the abuse of issues.  General debility, capable of exercising a very pre-
judicial influence on the nervous structure of  the eye, may be induced
by other directly weakening causes; for instance, long and bitter afflic-
tion, continued vexation, incessant weeping, with constant anxiety about
the means of subsistence, particularly if the diet be unwholesome, long
fasting and watching, sudden and violent fright, inconsiderate washing 
AMAUROSIS.
525
and bathing the eyes with very cold water, particularly when they are
already weak and irritable, long residence in dark dwellings, especially
in the exercise of occupations which strain the eyes, a case very com-
mon in Vienna.  The amaurosis occasionally seen at the end of typhus,
without headach, or any signs of excitement in the eyes, and occurring,
according to my experience, only  after the pure and not the contagious
nervous fever, must be regarded merely as a symptom of the general
weakness: and this view is supported by the method of treatment, which
consists simply in directing a suitable plan of diet."  (Lehre, vol. ii.
p. 449, 450.)
   It is not necessary to comment on  the heterogeneous nature of the
influences, which are thus incongruously assembled under the common
head of causes weakening the retina ;  to show that direct injury of that
structure by laceration and concussion, as well as  execessive exertion
of the eye on minute objects, produce a kind of disorder which cannot
be  called nervous weakness without  a  total perversion of terms; to
observe, that if amaurosis should follow general  concussion of the body
or typhus fever, the  effect must probably  be  produced through the
medium of the sensorium; or to  express the  doubts which will imme-
diately occur to  every intelligent reader, whether  amaurosis has ever
been produced by many of the causes here assigned, such as washing
the eyes with cold water, the discharge of issues, and the spitting inci-
dental to the modern accomplishment of tobacco smoking.   The latter
point may be recommended, for attentive consideration, to the amateurs
of the pipe and the cigar.
   Dimness, confusion of sight, and  blindness, previous to fainting, are
well known temporary effects referable to  the suspension or diminution
of the circulation in the  retina and sensorium, when the heart's action
is enfeebled or stopped by loss of blood or other causes.  Two interest-
ing illustrations of this  subject occur in Dr. Gooch's Essay on The
symptoms in  children erroneously attributed to congestion of the brain.
He mentions the case of  a young and  delicate child, who  had  been
brought into  a state of dangerous and ultimately fatal exhaustion, by
the injudicious application  of leeches.  " The child,"  he says, " was
deadly pale, it had scarcely any pulse, its skin was cold, the pupils were
dilated and  motionless when light was allowed to  fall on  them, and
when a watch was held to its eyes, it  seemed not to see; there was no
squinting.  Did this state of  vision  depend on the pressure  of a fluid,
effused into the brain since the bleeding and during this exhausted and
feeble state of circulation, or  did it  depend on  the circulation of the
brain being too languid to  support the sensibility of the retina ?   It is
well known that large losses of blood  enfeeble vision.   I saw a striking
instance of this in a lady who flooded to  death.  When I entered the
chamber she had no pulse, and she was tossing about in that restless
state, which is  so  fatal a sign in these terrific cases.  She could still
speak, asked whether I was come, (she knew I had  been sent for,) and
said, 'Am  I in any danger?—How dark the room  is!—I  can't  see.'
The shutters were open, the  blind up, and the light  from  the  window
facing the bed fell strong on  her face.  I had  the  curiosity to lift the
lid, and observe the state of the eye;  the pupil was  completely dilated,
and perfectly motionless, though the light fell strong upon it.  Who can 
52G
AMAUROSIS.
doubt that here the insensibility of the retina depended on the deficiency
of its circulation V  Dr. Gooch adds, that  the child died at the end of
a week,extremely emaciated and exhausted; that she sometimes revived
a little,'so as to induce an expectation of recovery; and that she clearly
regained her sight, for if a watch was held up to her, she would follow
it with her eves.   (An account of some of the most important Diseases
peculiar to Women,  p. 359—361.)
  This transitory effect of diminished  circulation  on the functions of
the retina or sensorium must however be distinguished from permanent
amaurotic affection,  which has not occurred, under my observation, as
an effect of the extreme debility consequent on want  and  starvation, on
fevers, and  severe bowel complaints, or of that connected with profuse
suppurations and  repeated hemorrhages, although I  have seen some
instances  of slightly  impaired  vision referable to  the latter cause, and
easily remedied by strengthening measures.  I have never witnessed an
amaurosis under the influence of  mercury, that  could be  ascribed to
the quantity of fluid discharged from the mouth.  In the case related at
page 479, the  sudden loss of sight was obviously caused by the excite-
ment consequent on the use of mercury, and not by the ptyalism, which
had hardly  become established.
  It is well  known that the energy of the nervous system may be se-
riously impaired by excessive venery and by onanism : it seems not im-
probable that the nervous structure of the eye might  suffer in the same
way by those  enervating  causes;  but  examples of this  kind  are not
common.   I am convinced that nocturnal seminal discharges, simply
considered,  do not injure sight.
  1 shall not, however, deny that the powers of the retina or optic nerve
may be impaired by causes, of which  the exact operation is not yet
understood,  and which may be denominated  weakening, until we are
able to  appreciate more exactly their mode of action.   And it is an
unquestionable practical truth that  strengthening treatment, including
tonics and stimulants, is employed with advantage in many cases  and
states of amaurotic disease.  One of the clearest cases of this kind is the
amaurosis brought on by protracted suckling; the local affection being
accompanied by unequivocal evidences of general debility caused by the
unusual drain on the  system.   This  occurs particularly among the poor,
who keep their children a long time at the breast to prevent the recur-
rence of pregnancy,  being obliged at the same time to work hard, and
•often with insufficient  and unwholesome food.  Such women  become
thin, pale, and weak ; they are subject to palpitation, hurry of the cir-
culation, and profuse perspirations.   Without any apparent change  in
the organ, they complain of dimness, confusion of sight and giddiness,
and see imaginary appearances before  the  eye.  It is a matter of pri-
mary and urgent importance in these cases to wean  the  child, and  to
avoid all  fatiguing exertion.   A good  diet with moderate  use of fer-
mented liquors, will be advantageous.   The combination  of tonic  and
nervous medicines, such as bark and valerian, or the sulphate of quinine,
and mild aperients, if the bowels require them, for example, rhubarb and
magnesia, or castor oil, constitute the essential features of  treatment.  If
the affection should not give way to such measures, which it  usually 
AMAUROSIS.
527
 does,  blistering may be resorted to, or a  trial  may be made of elec-
 tricity.
   Case.—Complete amaurosis from debility caused by suckling.—E. N., twenty-five
 years of age, of slender make, fair  skin, and red hair, who bad  been married a year
 and a half, brought forth her first child four months before I  saw her, which was in
 the middle  of June, 1830.  She suckled the child, which was  strong and took the
 breast very frequently : her milk  was abundant.   Lately she had begun to feel very
 weak ; she could not lift a weight, and she cried frequently without having any reason
 for uneasinpss or complaint.  Being totally blind, she was led to my house by a friend.
 She was pallid and had a small feeble pulse.  The pupils were  in the middle state,and
 the irides moved slightly.  The retinae were completely insensible ; she could  not dis-
 cern the situation of the window, nor see a lighted candle held close to her.  I directed
 her to wean the child, to drink porter, and take the sulphate of quinine.  In a few days,
 as sight did not improve, I ordered a blister to the nape, and afterwards friction of the
 tartar emetic ointment in the same situation.   When the latter began to produce its
 effedt, the sight mended.  On the 2nd of July she could see nearly all objects, but was
 unable to read : the motions of the iris and the pupil were  natural.   (To leave off the
 quinine; four grains of Plummer's pill every night; a draught  of infusion of rhubarb,
 with compound decoction of aloes daily.)  16th July.—The pills have been increased
 to two daily; the health and strength are good : the irides act well, and the pupils are
 natural.  Sight is improved : she can see the large  letters over doors, but is unable to
 distinguish even the capitals of print.  As this patient found herself improving, she did
 not  return to me for some time, but continued her  medicines.  When I saw her in
 November, she had long left off all treatment, and had resumed her usual active occu-
 pations.  Her health  and strength were good ; the sight was completely restored, and
 she read to me the smallest print with facility.
   The following case of amaurotic  affection from  suckling is related
 by Mr. Ware.
   A lady, thirty years of age, found her strength fail after suckling for six weeks, and
 she soon became incapable even of moving about the house without experiencing pain-
 ful languor.   About the same time  her sight also was affected;  first  only in a small
 degree, but afterwards so considerably that the full glare of the mid-day sun appeared
 to her no stronger than the light of the moon.  She began  to feel a violent pain in the
 neck, running upwards  to the side of the head ; and four ounces of blood  were taken
 from the  part by cupping.   After this, ihe sight was worse  than before, and soon
 the use of both eyes was entirely lost.  The pupils were much dilated, and remained
 so in the strongest light.  The means directed for her were, to wean the child imme-
 diately, to apply the vapour of ether frequently to the  eyes and forehead,  a  bark
 draught three times a day, and opening medicine on account of costiveness, which had
 existed  since her delivery.   On the fourth day, the strength and spirits were improved,
 and faint glimmerings of light could  be perceived, though the pupils remained  dilated
 and  fixed as before.  The  former means  were continued, and electricity was em-
 ployed in addition.  The first application of the latter was almost immediately followed
 by amendment, so that the patient, to whom  all objects had before been confused, could
 now tell how many windows there were in the room, though  she was unable to  dis-
 tinguish the  frames.  On the third day the menstrual discharge  came on, and  the
 treatment was left off until it had ceased.   At the end of  a week she could perceive
 large objects, and in a short time her sight was so much recovered, that she c(,uld read
 even the smallest print.   Her strength did not return so quickly;  but it was soon re-
 stored  by change of air,  and a  mild nutritious diet.  (Observation  on the Cataract,
 Gutta Serena, &c. 3rd edition, p. 385—389.)
   [Dr. Ashwellin an interesting paper, in Guy's Hospital  Reports, April 1840,
 " on the morbid consequences of undue  lactation" remarks, a Functual Amau-
 rosis, accompanied by  congestion of the conjunctiva, is  a  frequent result  of
 excessive lactation;  and seldom feils, from its interference with the sight, at
 once to arouse the patient's fears  lest vision should be entirely and permanent-
ly lost.  These apprehensions may with truth be allayed; as doubtless, in the
greater number of cases, prompt weaning will alone remove the affection: still,
it may be necessary repeatedly to apply small blisters near  the  eye, and abso- 
528
AMAUROSIS.
lutely to forbid its employment.   Improved diet, country and sea air, exercise
out of doors, iron and quinine, are important remedial auxiliaries.  Nor is it
unimportant that quickly-recurring pregnancy should if possible be avoided. I
have known several instances where, during a pregnancy immediately succeed-
ing the exhaustion of over-nursing, the eye has been almost constantly in a
state of " blood shot" or congestion, and the sight excessively imperfect.
Months, and even years, sometimes elapse, where able treatment has done its best
before distinct and strong vision is re-acquired.  Specks, and slight ulcerations
of the cornea, are occasionally connected with the exhaustion  and irritability
of nursing.  In all these cases, provided there be no serious organic change,
the sufferer may be encouraged certainly to expect the restoration of this most
invaluable faculty.]
   If amaurosis should occur in an individual who  has been weakened
by any of the causes just alluded to, or by others of analogous operation,
and if well  marked  symptoms of debility should be present,  strengthen-
ing means, both dietetic and medical, must be resorted to, as in the fol-
lowing  example.
  Case.—Imperfection of vision from debility consequent on miscarriage.—I saw a
female in 1826, nearly  forty years of age, who had experienced a severe miscarriage
six weeks previously.   She was pallid and feeble; the palpebral conjunctiva was quite
white; the motions of the iris and the pupil natural in both eyes.  She experienced
dizziness with dimness of sight,  and saw black specks before  the  eyes.   I de-
sired her to drink porter, to take a dose of powdered bark three times a day, and ten
grains of rhubarb occasionally.   In three  days she was nearly well.
   The effect of suckling on the eyes is not always clearly explicable on
the supposition of  debility.  Ordinary inflammatory affections of the
organ are more severe and obstinate  during this state, so that it  may
probably exert some general influence of which we  do not  understand
the exact  nature.
   We must take care  not to confound the complaint just described with
other modifications  of amaurosis, to which women are liable during
pregnancy and suckling.  In the  general fulness, which exists during
utero-gestation, and particularly in its latter period, when the pressure
of the enlarged uterus impedes the  evacuation of the bowels, determina-
tion of  blood to the head  with  impaired vision may occur.   Venesec-
tion, purging, and regulation of diet would be  necessary in such a case.
Amaurosis may occur during suckling from plethora  induced  by diet
too abundant and stimulating, and  particularly by that free use of por-
ter and  other strong liquors which  are erroneously considered necessary
to support the strength of females during this process. The local symp-
toms are here attended with a full pulse, heat of skin, flushed  face, head-
ach, and white tongue;  an assemblage of circumstances very different
from those which attend debility from protracted suckling, and requiring
depletion with change of diet.
   Beer states that amblyopia or amaurosis, accompanied with nausea or
with vomiting which cannot be  quieted, sometimes occurs early in preg-
nancy, and  ceases after parturition.   He saw a young Jewess,  who, in
her first three pregnancies, which  followed  in quick  succession, began
to grow blind in the early period,  and Became  quite amaurotic in the
third or fourth month.  On the first two occasions she continued blind
until after parturition; and sight never returned the third time   f Lehre
vol. ii. p. 444.)                                                 v
   He has also  devoted a chapter to what he calls amaurosis from sup- 
AMAUROSIS.
529
  pressed secretion of milk  in  suckling women.   (Ibid, 572—575.)  In
  this, which he describes as a very rare affection, he says  that all the
  blood-vessels of  the eye are  turgid, the  pupil slightly dilated, the iris
  changed in colour and swelled, and the transparent media turbid ; that
  there is amaurotic blindness with intolerance of light and luminous ap-
  pearances before the eye, and racking  pain of the  eyebrow and fore-
  head.   The complaint is obviously not amaurosis, strictly so called, but
  acute inflammation of the  internal tunics.  In the constitutional excite-
  ment attending so violent a local disorder, we may expect that the se-
  cretion of the mammary glands would be diminished or suspended.  It
  would require very strong  evidence  to  convince us that the latter cir-
  cumstance and the amaurotic affection stand to each other in the rela-
  tion of cause and effect.  Beer says that the prognosis is most unfavour-
  able ; and I doubt not that this remark would  be fully justified by the
  event, if the affection were treated in  the manner he proposes.   Instead
  of the active antiphlogistic measures  so  urgently required in a disease
  of this violent arid dangerous character invading the very seat of vision,
  he is contented with endeavouring to restore the  mammary secretion,
  by poultices with chamomile flowers, hemlock, and other herbs, by aro-
  matic herbs with camphor, by rubbing the breast with  flannels strewed
  with frankincense and mastic: if  these means  do not  succeed, arnica,
  calomel, and camphor are  recommended, with issues.
   In persons of bad constitution and impaired health who use their eyes
  excessively, or even in those  otherwise  healthy, who exert the organs
  imprudently, their strength  being impaired by confinement and unwhole-
  some diet, an affection of sight may supervene, characterized by muscEe
  volitantes, dimness, and want of power to sustain continued exertion.
  The symptoms may here be referred to  atony of the nervous structure;
  at least  they are kept up and aggravated by the depressed condition of
  constitutional power.   The necessity of tonic and* restorative measures
 in medicine, diet,  arid general management, with discontinuance of the
 exciting cause, is obvious  under such  circumstances.  Subsequently,
 counter-irritation, the cautious use of mercury, or both may be required,
 if the imperfection of vision should continue arid indicate disease of the
 retina.
   [There is a form of amaurosis to which allusion may be  made here;  it is
 that which occurs in hysterical persons, and to which attention has been re-
 cently more particularly drawn by Mr. Hocken.  It is well  known that hys-
 teria simulates a great many diseases, among which number is amaurosis,
 not Only in its mildest grades and of brief continuance, but sometimes amount-
 ing to complete blindness and of protracted duration.  The treatment must
 be first directed to the correction of the derangement of the particular function
 which has called the constitutional  disorder into activity, usually some distur-
 bance of the digestive or uterine organs, and next to allay the irritability of the
 nervous system.]
   Amaurosis from affection of the nervus trigeminus.—I have already
quoted the papers in which Mr. Megendie has shown that injury or dis-
ease of  this nerve within  the cranium will  cause inflammation of the
eye, with destructive  ulceration of the cornea, and that ultimately,
evacuation of the globe and collapse of the tunics ensue.   (See p. 85.)
   These  changes are sometimes preceded and accompanied by insen-
       67 
530
AMAUROSIS.
sibility of the parts supplied by the trigeminus, including the surface of
the  eye.   The latter may become insensible without  passing into  the
state of inflammation and ulceration.
   A striking illustration of this subject is afforded by an interesting case
recorded  in the  first volume,  (page  531,) of the  London  Medical
Gazette, by my colleague, Mr. Stanley.
  In a lady, forty years of age, inflammation of the brain came on immediately after
her confinement: she subsequently suffered severe and almost constant pain in the head.
She was confined again about three months before her death.   When nearly recovered,
she was attacked with pain in the head more  acute than usual, and delirium, which
subsided, and were followed by hemiplegia of the left side. During the last two months
of her existence, sensation and motion were completely lost on the  left side of the face,
but the former remained in the arm and leg.  Frequent attacks of erysipelas occurred
on the left side of the face; from  the interior of the left nostril, which was deep  red,
blood was frequently discharged.  Hearing was lost on the left side, and sensation on
the same side of the tongue;  but motion remained in the latter.  Great vascular  dis-
tention took place in  the left eye and was followed by opacity and ulceration of the cor-
nea, and escape of the aqueous humour.  The pons Varolii was enlarged on its left side,
so as to compress the trigeminal, auditory, and facial nerves of that side, against  the
basis of the skull.  This enlargement arose from a tumour about the size of a  walnut,
formed in the pons, of which it occupied the whole leftside, and extending into the left
erus cerebelli.  In the eye, which is preserved in the Museum of St. Bartholomew's
Hospital, the  central portion of the cornea  is destroyed by ulceration.   The edge of
the pupil is everted, and the opening filled by a dark substance.   The iris ciliary  lig-
ament, and choroid  appear natural.   The state of the interior parts  has not been
ascertained.
   Injury, or other irritation of the  branches  of the  trigeminus, may
bring on impaired vision or amaurosis.   This  point has been already
illustrated, in reference to wounds of the supraorbital nerve.  (See  pp.
108—113.)  The sympathy between the trigeminus and the immediate
nervous apparatus of  vision  affords  the only explanation of some ap-
parantly obscure  cases, in which amaurosis seems to have depended on
a carious  tooth, or on some other local affection seated in  the head.
  Case.—Amaurosis caused by a carious tooth.—F. P., thirty years of age, posses-
sing  a good constitution, and enjoying good health, with the exception of pains in  the
head and limbs, which never lasted long, suddenly experienced, in the autumn of 1825,
a violent pam shooting from the left temple  to the eye and the side of the face:  he
ascribed it to cold.   This pain lasted several days, then lessened, and re-appeared
from time to time without being sufficiently severe to induce the patient to seek medi-
cal aid.  In about two months it suddenly increased in intensity, occupying the eye,
particularly, with a feeling as if it would pass out of the orbit.  F. P. now'discovered
that  he was blind with that  eye, and applied to  a neighbouring  physician, whose
treatment, continued for two months, did no good.   The pain, however, was no longer
continual: it assumed a somewhat periodical character, leaving the patient easy for
some hours in the day.  At the end of the  following six months  the pain increased,
the cheek swelled, some spoonsful  of bloody  matter were discharged by a spontaneous
opening in the lower eye-lid, after which the swelling subsided, and the pains nearly
disappeared, although the blindness remained complete.   The discharge was renewed
from time to time, during the following six months, and there was no great suffering.
But in the autumn and winter (1826) the pain, particularly in the eye, became so  vio-
lent, that F, P. came to Wilna in the beginning of 1827, determined to have  the or-
gan extirpated, if no other remedy could be found.  Professor Galenzowski found
the left eye totally insensible to light, with the pupil dilated, and no other visible alte-
ration.  The pain not then so severe, consisted in violent  occasional prickino- or dart-
ing sensations m the left temple, and parts round the eye.  There was discharge from
the lower eye-lid.  The first molar tooth of the  left side was carious; it had not caused
much uneasiness; and the toothach, when it existed, had  not coincided with the pains
in the temple and eye. The professor determined on removing this tooth, and  having
done so, was surprised to see a foreign body at the extremity of the  fang.   When 
AMAUROSIS.
531
 drawn out, it proved to be a 6mall splinter of wood, about three lines in length, which
 had traversed the centre of the tooth, and had probably been introduced in picking the
 teeth.   A probe passed from the socket into the antrum, from which a few drops of thin
 purulent fluid escaped.  The pain ceased almost entirely, and, on the same evening,
 the eye began to be sensible to light.  Vision gradually improved, so that, on the ninth
 day, the patient could see as well with the left eye as with the rijrht, after a blindness
 of thirteen months: on the eleventh day he left Wilna to return to his family.  (Archives
 generales de Medecine, t. xxiii. p. 261—264.
   I had the   pleasure  of becoming acquainted with Professor Galen-
 zowsky, when he visited England subsequently  to  this  occurrence.   He
 showed me the  tooth and splinter of wood.  He  pointed out two cir-
 cumstances in the case as particularly worthy  of  hotice:—1st, that the
 entrance of the foreign body into the tooth had not  been noticed at the
 time;  and 2ndly, that a local irritation, hardly  perceived in  the seat of
 injury, should have  affected the ramifications of the nervus trigeminus
 so violently as to produce amaurosis.
   [A number  of similar cases in which amaurosis resulted from irritation of the
 nervus trigeminus might be adduced from various writers.  We extract the fol-
 lowing from our MS. work on the diseases of the eye.
   Mr. Traver's has seen an incipient amaurosis distinctly arrested by the ex-
 traction of a diseased tooth, when the delay of a similar operation had occa-
 sioned gutta serena on the opposite side,  two years before, (Synopsis of the
 Diseases of the Eye,  p. 305, 3rd Ed.;) and Richter relates a case of a lady who
 had been blind for years, and who experienced a short recovery of her sight on
 having a tooth extracted.  (Aufangsgr.)  Mr. Caffe quotes the case  of a per-
 son  who  had  an  upper molar tooth excavated by caries, and who, whenever
 a portion of food entered its cavity became  immediately  amaurotic in the eye
 of the corresponding side.   The amaurosis ceased as soon as the cavity of the
 tooth was cleared. (La Lancette Frangaise, 22, Aug.,  1839.)  Dr. Watson
 states  that  the son of a physician of his acquaintance,  in  London, became
 blind in one eye  on two or three occasions, without obvious cause, and with
 no visible change in  the organ,  and the blindness on each  occasion, went
 off, apparently, in consequence of the extraction of some teeth which had grown
 irregularly, (Lectures  in London Med. Gaz.  5 Feb.,  1841.) and Dr. Ashburner
 says that such cases are common, (Ibid, p. 712.)
  Dr. James Hunter relates the following case of temporary amaurosis  in one
 eye, following the extraction of a tooth.
  In July, 1838, a lad, aged 17, applied at the Dispensary  on account of a dim-
 ness of sight in the left eye,  which  had come  on rather suddenly and under pe-
 culiar circumstances.  He stated that the sight of both eyes had been very good
 till four days previously, when, suffering from toothach,  he went in the evening
 to a druggist to have a carious tooth extracted from the left  side of the upper
jaw.   The operation was easily and dexterously performed, and the pain was
 not particularly excruciating.  At the moment the tooth was loosened from the
 socket, he perceived a brilliant flash of fire before the left eye, which was  fol-
 lowed for some minutes by several fainter ones at short intervals.  On going to
 bed an hour or two after, the flashes of fire reappeared, and continued for about
 an hour, when they gradually ceased.   Next day he found the sight of the left
 eye very much impaired, and all  objects seen with it appeared enveloped in a
thick mist.   He also observed a sort of luminous coloured  ring, whirling round,
as it  were, in the interior of the eye.  This state of matters continued much the
same for the next two days, and, on  the  fourth day, he thought there was a
decided improvement.
  " On examining the left eye, its pupil  appeared a very little more contracted
than that of the right eye, but its  shape was perfectly regular, and  the motions
of the iris unimpaired.  In every  other respect, too,  the organ presented a per- 
532
AMAUROSIS.
fectly natural appearance.  The general health of the lad, who was of a some-
what sanguineo-nervous temperament, was good.   He had no pain in the eye,
or in the brow, and no symptoms of cerebral congestion, or of derangement of
the digestive organs.   When  he closed the right eye, the sight of which was
sufficiently acute, and looked with the left one at the page of a book, printed in
a type  which I have since ascertained can be  easily read by a good eye at the
distance of 48 inches, I found he could not make it out at a greater distance,
than about 15 inches, and even then with  difficulty, and at any nearer distance,
though  the letters appeared  larger, they still  seemed to run into each other.
When  I tried him with type about one half the size of the first, he was unable
to read a single word of it at any distance."  "Neither convex nor concave
spectacles improved  his sight.   His  perception of colours appeared somewhat
impaired, but I had not the means at hand of examining  carefully the condition
of the  eye in this respect.  The tooth which had been extracted was the first
great molar on the left side of the upper jaw.   On making  firm pressure with
the points of my fingers in its socket, there was no unusual tenderness nor any
shooting nervous pain produced, and I could not discover any remaining portion
of the tooth, nor any splintering of the alveolar process."
   Dr. Hunter left the case to nature, and at the end of a fortnight he could dis-
tinguish all but very minute objects.  He did not return afterwards, so that his
recovery was probably complete.—(American Journal, Med. Sc. Oct., 1841.)
   A case of amaurosis following a lesion of the fifth pair of nerves, occurred also
in the  service of Mr. Pasquier, at the Hotel des Invalids.   The subject of it was
a lieutenant, convalescent from lumbago, who had had the first large molar of
the right side of the  upper jaw extracted, in  consequence of its being carious,
and giving him  much pain.   In the operation the alveolus was broken and the
gum torn, which caused inflammation and suppuration in the alveolus, and the
discharge of some small portions of necrosed bone.   The day after the operation,
the  patient suffered from pain, extending to the right temple, without swelling,
redness, or heat; this pain was lancinating, exacerbating  at frequent and irregu-
lar intervals, most frequent in  the evening, and was increased by pressure.  The
pain extended in the direction of the temporal nerves of the seventh pair as far as
the parotid plexus; and also towards the forehead in the direction of the super-
ciliary  branch of the ophthalmic division  of the fifth pair.   The pain afterwards
concentrated in the  last mentioned branch, the superciliary.  At this time, five
days after the  operation, the  right eye became almost perfectly amaurotic, the
pupil was dilated, and the patient experienced a constant convulsive action of
the eye-ball, as  if the eye was  leaping from its socket.   The  eye-lids of that
eye were slightly tumefied, and almost constantly contracting.  The secretion
of tears rather diminished than increased. At this time there appeared an abun-
dant thick puriform, greenish foetid discharge from the right nostril.
   A blister  was applied to the temporal region, and  the raw  surface  pow-
 dered  morning and  evening with half a grain of acetate of morphium.  The
pain was promptly abated by this treatment, and by the tenth day vision was
restored.  By the seventh day the discharge from the nostrils diminished and
 lost its fcetor, and  on the 22d day the pain entirely ceased.  Until this last date
the local application was continued.  La Lancelte Franpaise, 22, August, 1839.]
   The eye-brows  and eye-lid's are involved, often very seriously, in the
 neuralgic affections incidental to the external branches of  the ophthal-
 mic and superior  maxillary divisions of the  nervus  trigeminus.   The
 treatment  of such  cases, as well as that of similar pains in the eye-ball,
 which sometimes occur, comes under the general therapeutic principles
 applicable to neuralgia.
   Amaurotic caVs-eye.—This is the name given by Beer to an  amau- 
AMAUROTIC CAT'S-EYE.
533
rotic affection, accompanied with a remarkable change of colour in the
pupil, which presents, apparently in the fundus of the eye, a lighter tint,
yellowish  or brownish yellow, instead  of its natural  clear  black.  He
"says that  " a pale grey, or whitish yellow  opacity, sometimes with a
reddish cast in  certain lights,  is developed in the bottom of the globe,
far from the pupil.   The sight is not  merely weak, but in the strictest
sense confused;  for all objects, particularly those of smaller size, seem
to run together, when  the patient  attempts  to  survey any  thing  atten-
tively.  As the disease proceeds, the bottom  of the eye becomes clearer
and more visible, and   the  colour of  the  iris paler,  the latter change
being particularly obvious in dark  eyes.  When sight is completely ex-
tinguished, we may discern, on close inspection of the pupil, a fine vas-
cular network over the opacity, being  apparently the ordinary ramifi-
cation of the arteria and vena centralis rendered visible on the shining
opal-like  fundus of the globe.  Such an eye, when  seen in particular
directions, has a yellowish or reddish luminous appearance in twilight,
resembling, in some degree, that of the cat, whence I have derived the
name."  (Lehre, vol. ii. p. 495—498.)
   The  following  cases of  this affection, which is uncommon,  came
under my  observation at St. Bartholomew's Hospital.
  Case.—Robert Mason, twenty-three years of age, a spare youth, of delicate appear-
ance, was admitted into St. Bartholomew's Hospital  under my care in the summer of
1828, on account of impaired sight in both eyes.  He said that  he had enjoyed good
health; that the sight of the left eye began to fail eight years ago, and is now very
imperfect; that the right has become dim in the last  nine months;  and that the com-
plaint has not  been attended with any pain.   The  anterior chamber was unusually
small; the iris dark brown, and sluggish; the pupil about the middle size, and of a dull
grey, instead of the natural black colour.  When the pupils had been  dilated by the
belladonna, an apparently concave opacity, of a grey or dull yellow colour, with small
blood-vessels ramifying on it, was seen far behind the iris, in the very back of the  left
eye.  A similar appearance was found in the right eye; but the opacity was less ex-
tensive, and no vessels were visible.  With the left eye, the patient could merely  dis-
tinguish light from darkness, while, with  the right, he could read large print.   He
left the hospital at the end of a month, the  means  employed having been of no ser-
vice.
  Case.—Ann Milling, twenty-five years of age, of spare habit, dark complexion and
hair, and brown irides,  has usually enjoyed good health, living  in service, and not
using her eyes in any occupation likely to be  injurious.  Seventeen months ago  she
began to observe a mist or cloud floating before the  left eye: in  twelve months the
sight was entirely gone.  She has experienced no pain.  The iris is darker  than in
the opposite eye:  it moves in harmony with the other, but has lost its independent
action, excepting a slight oscillatory movement.  The pupil, which is of natural size,
presents a deeply-seated  brownish yellow discolouration, which  occupies uniformly
the whole fundus of the globe,  whether observed in the dilated or contracted state of
the aperture.  Vision  is totally extinct.   The general health is good.
   At the London Ophthalmic Infirmary I saw two boys with this affec-
tion: one was  fourteen the other eight years old.   In the latter both
eyes were diseased; vision was entirely lost  in one with a pale and dull
yellowish discolouration of the whole fundus of the globe.   In the other
eye the discolouration  was partial; its boundary could be seen when  the
pupil was  dilated,  and imperfect vision still remained.
   Mr. Tyrrell considers that this disease  is more common than has
been generally supposed ; but that it escapes observation unless the organ
be very carefully examined.   Until within the  last two or three years
he had considered it to be extremely rare; but he had found latterly that
the metallic appearance exists in some degree in many cases of amau- 
534
musc^: volitantes.
rosis.  It is most easily seen when a moderate light falls on the eye, and
the observer is a few feet off.   In a boy ten years of age brought to the
London Ophthalmic Infirmary for loss of sight, no change could be de-
tected in the pupil by close examination.   The nature of the case was
not detected until the patient had attended several times.  At last, when
he was standing a few feet off in a part of the room shaded from direct
light, Mr. Tyrrell observed a brilliant metallic reflection from the eyes,
which was no longer discerned when the eyes were exposed to a strong
bright light.
  The appearances in the pupil leave no doubt that blindness is caused
in these cases by organic changes in the retina and choroid  coat;  but
hitherto the nature of the alterations has not been elucidated by dissec-
tion.*
  We know nothing  about the  causes of the disease, which has always
proceeded, within my observation, to complete  loss of sight.   Beer,
however, says that  it seldom reaches this  full development, but usually
remains stationary after causing a more or less considerable degree of
amblyopia.  I suspect that the latter observation arises from his classing
under this name cases which probably belong to  other affections.  He
says, for  example, that the affection called amblyopia senilis is probably
of this nature ; although with  a pale grey discolouration of the  pupil,
there is often  but little diminution of  sight.  He  states that it is more
common in the old  than in the young, which does not correspond with
my experience.  And he also represents that it follows  violent injuries of
the  globe.   A bright yellow discolouration of the pupil, with inequality
of surface, sometimes remains, in the latter cases, after violent internal
inflammation, and the globe becomes atrophic.  This effusion of lymph,
consequent on  high inflammation, is a case quite distinct from the dis-
ease just described.
  The early stage of fungus haematodes may be  confounded with  the
amaurotic cat's eye.   The  distinguishing  circumstances may be col-
lected from the  description of the latter affection.
  Musccb volitantes.—The imaginary objects occasionally seen moving
before the eyes, and called in common language motes, are technically
termed muscce volitantes, by which name their apparent motion is desig-
nated. I have  already mentioned them as an early symptom of amau-
rosis, and consequently as precursors of impaired  vision.   (See  page
490.)  They frequently, however, occur from some affection of the eye,
which produces no  other  unpleasant effect, and  consequently they do
not, then, forebode any injurious consequences to vision.
  Their appearances  are infinitely varied.   Sometimes they are  spots
of various shape and  size, black or  lighter coloured; sometimes  dark,
with a luminous edge. They may be streaks or lines, straight, waved,
angular, twisted, or united in  various ways.  Sometimes they appear
as transparent bladders, or luminous chains, which are generally undu-
lating.  They may  have a metallic appearance, like globules of quick-
silver ; or may seem transparent, like water or glass.   Often there is the
likeness of an insect, as  a spider, worm, or  that  of a spider's web, or
portion of net.  In figure, number, size, and colour, they present end-

tinn Ji°MA£r° ■ ^ r\Uemf,'ed t0 delineate the appearances which characterize this affec
tion in his Klinische Darsteliungen, part i. tab. 15, figs. 10 and 11. 
MUSdE VOLITANTES.
535
less varieties.  Frequently there is a single dark spot, moving with the
eye and presenting before any object that is  looked at: there may be
many such, described as resembling the blacks floating in the atmos-
phere of London.  When they are numerous, they interfere with vision,
and annoy the patient greatly.   They move with the eye, and  appear to
descend when the eye is  turned upwards, and vice  versa.  Often they
are luminous  and  various  coloured, or like sparks.  They are most
distinctly seen in a strong light, as when the person is looking towards
the sky.   They present themselves particularly when the organ is ex-
erted, becoming more inconvenient as the exercise of vision is continued,
and compelling  the patient to desist.  Often  one eye only is  affected.
Sometimes they  are seen even when the lids are closed.
  In some cases this complaint is obviously connected with  increased
determination of blood to the head.   The first appearance of the muscss
is generally traced to circumstances directly affecting  the eye, such as
unusual and continued exertion of the organ.  They will  be more likely
to occur when the stomach and bowels are disordered, and when the
energy of the  nervous  system  is impaired by pressure of  business, by
anxiety and distress, by severe and continued affliction, or overwhelming
grief.  Often  the  complaint seems simply referable to  causes  of the
latter description ;  and it aggravates the mental  disturbance by creating
apprehensions for loss of sight.
  These imaginary objects, depending  on occasional  causes in many
instances, have  only a temporary existence.   Sometimes  persons are
troubled  with them for  many years,  the  sight  remaining  perfect  in
all other  respects;  and it is difficult,  or even  impossible to remove
them.
  The important point is to distinguish  whether these muscas volitantes
are a symptom of incipient amaurosis or cataract; or whether they arise
from  some affection of the  eye, which  causes  no  other mischief.   If
they should be attended with a cloudiness of vision, objects being seen
as if a mist or fog  surrounded them, the case may be incipient cataract,
and careful examination of the eye under artificial dilatation  of the pu-
pil may be advisable.  If other symptoms indicating  amaurotic affec-
tion should be present, such as  a sluggish or motionless state of the iris,
alteration of vision in any of the ways  just described  as indicating af-
fection of the  nervous structure, change in the  colour of the pupil, pain
in the head and eye, we must  regard the muscse volitantes as a symp-
tom of approaching amaurosis.  In these respects  the shining or fiery
objects, such as  luminous stars, sparks, and flashes, are  the most unfa-
vourable.
  If the motions of the iris be perfect, if the pupil  possess  its natural
colour, and if  the patient can distinguish minute objects as well as be-
fore, the musca?  volitantes need not excite alarm : vision is in no danger.
  [We must add a few words as to the importance of a correct diagnosis, where
muscae volitantes present themselves; for we have met with instances in which
from a mistake in  this, patients have been unnecessarily thrown into the greatest
alarm, and subjected to severe treatment.
  Some years since, we were  consulted with our friend, Dr. S. Jackson, by a
young gentleman  of the legal profession, from the south, affected with muscse,
which his  medical adviser supposed  to be premonitory of amaurosis.  The
patient had been greatly reduced by profuse depletion, low diet, blistering, &e. 
536
MUSCiE VOLITANTES.
  by which he had been rendered exceedingly nervous, and his affection aggra-
  vated.  After  a careful examination, we assured him that he need have no ap-
  prehension of loss of vision; that if he would dismiss his fears of this, and by
  improved diet, with  country air, regain his strength, he would soon be accus-
  tomed to the appearance of his muscse, and they would then scarcely be noticed
  by him.   We  advised him to visit Saratoga, and travel for a month or two, to
  re-establish his health.
    On his return south he called on us, with his health much improved, and with
  better spirits : and he then informed us that the apprehension of becoming blind,
  of thus being a useless member of society—all his youthful ambitious aspirations
  blasted—had been too much for him, and that he had determined, if we had
  confirmed the prognosis of his physician  at home, to put  an end to his existence.
  On taking  his  leave, he expressed his  hopes that  the encouragement we had
  given him might be well founded, and remarked in  a significant tone, " you shall
  hear of me one way or another."  We have heard of him, and not as a wretched
  suicide, but as one of the most prominent and influential men in his State.]
    The immediate cause of this symptom has not yet been  satisfactorily
 explained.  The  notions of  partial  pressure  on the nervous structure,.
 by distention  of vessels in the retina or in the choroid, or  by  inequality
 in the surface of  the latter membrane, are plausible  but merely conjec-
 tural.  Luminous  appearances and imaginary objects of various kinds
 with  temporary dazzling  are  produced  by holding down  the head, in
 healthy persons.  The vessels of the choroid and  retina must be filled
 in such  an attitude.   The explanation, derived  from  minute particles
 supposed to be floating in the aqueous humour, seems to me to have no
 foundation; at least I have never seen them:  and  ihese  muscse, which
 are seen in eyes  apparently perfect, do  not occur  when a fragment of
 lens or capsule is in the anterior chamber, or when opaque specks exist
 in the cornea.
   [Dr. Mackenzie believes it to be probable " that both the semi-transparent and
 the dark muscse are generally owing to a dilated, or varicose state of the branches
 of the arteria centralis retina, or corresponding vein, ramifying on the concave
 surface of the retina.  It is possible, however," he adds, " that in some instances,
 muscse are the  effects of certain portions of the retina having become insensible
 to light, either from the pressure of some irregular  projecting point or points of
 the choroid, or from some other cause.   We can conceive the nervous layer of
 the retina to be in one, or in  many exceedingly minute  portions of its extent,
 so  altered by disease, or so pressed upon by the neighbouring parts, in a mor-
 bid state as to be no  longer capable of being  stimulated by light at the parts
 affected, each of which will necessarily give rise to  the sensation of a muscse
 volitantes.   Blood effused, either by the vessels of  the retina, or those  of the
 choroid, is a likely cause of partial insensibility of the retina, and,  consequently,
 of muscse volitantes."   (Practical Treatise, p. 812.)
   Mr.  Clay Wallace conceives, with  some plausibility, that the nervous appear-
 ances of muscse may be accounted for, by the structure of the retina, which, it
 should be remembered, is composed of four layers, a vascular, a fibrous, a globu-
 lar, and a serous. " I have occasionally,"  he observes, " when entering an ordi-
 narily lighted room, after a full meal, and exposure to a bright light, witnessed
 glimmerings like a network, which, from its resemblance to the vascular coat, left
 no doubt in my mind, that the blood-vessels of the retina were visible: at other
 times, in the same circumstances, there was a twisted tube, or a chain of beads,
 as if there had been an error loci of one of the curved fibres of the retina; or there
 was a cloud of  globules sometimes packed together, but more frequently sepa-
rated, and floating in all directions.  Each globule was visible for a considerable 
MUSCLE VOLITANTES.
537
 time, and reoccupied the same space.  When  clustered  together,  they had a
 great resemblance to the globules of the retina.
   " From the similarity of the drawing of the floating network, in Case No.  1,
 to the vascular coat of the retina, I am persuaded that any person who has seen
 both, will have no hesitation in locating the disease; and if the network, curved
 filaments, and globules, appear to  others as they do to  me, the various  muscce
 will be ascribed to affections of the structure which they resemble."     *  *  *
   " If, when the eye is directed forward at a distance, we move a lighted candle
 up and down on one side of the line of vision, a representation of the vessels of
 the vascular  membrane shortly appears, as  if displayed upon  a screen.  The
 vessels are greatly magnified,  on account of the  portion  of the retina which they
 occupy, compared with that of an ordinary image.  We may hence infer, that
 a very minute congestion, may cause a large musca.
   " It is stated by Demours, that the diameter of muscse appears to  increase in
 proportion as we  recede from  the  plain in which they are examined.   Such  a
 filament as appears one-sixth of a line in diameter, and one inch long, when seen
 on a leaf of very white paper, at the usual focal distance, appears two lines in
 diameter, and more than a foot long, when we examine  it by looking at a white
 wall, at the distance of twenty or thirty feet; and in the only case in which he
 mentions the  subject, Mr. Ware  says, that the magnitude of the moats, de-
 pended much on the distance  at which they were observed, being larger when
 seen far  off, and  smaller when near the eyes.   Can the diminution arise from
 the less degree of pressure as  the lens approaches the cornea, when adjusted to
 near objects'!
   " As the papillse of other nerves become erected when excited, it would seem
 that the fifth, which is  a compound nerve, enables the expanded fibres of the
 optic nerve to be placed in a proper condition for conveying a distinct impres-
 sion to the sensorium.   Should there be any unusual turgescence of the vascu-
 lar membrane, or any  error loci of the globules, or  of the sentient fibres, or
 diminished supply of motive power to the latter, or should there be effusion of
 lymph or varicosity of the choroid, the fibres will not be free  to the action of
 light, but will  convey false  impressions, and there will be  an  appearance of
 motion, when during their erection or tension,  the fibres come in contact with
 diseased vessels, filaments, or globules.
   " It is  difficult  to keep the eye on one object for a long time, but when it is
 accomplished, the retina soon becomes fatigued, the fibres lose their tone or
 tension, and the  object disappears.  As soon  as they  have rested, the object
 comes again into view, and there is an alternate disappearance and reappearance
 of the object as long as the experiment can be continued.   If, when the light is
 very obscure, we look intently at a feebly illuminated object, the fibres, in en-
 deavouring to adapt themselves to the degree of light,  soon become  painfully
 affected, and the object is no longer visible." A Treatise on the Eye, p. 80—85.
 New York 1839.]
   Treatment.—If muscse volitantes be  caused by vascular disturbance
 of  the retina, it is not of a nature to require loss of  blood.   Without
 asserting that this cannot be necessary in any case, we may safely say,
 that in the majority of instances it is neither advisable nor admissible.
 Should the stomach and bowels  be disordered, a  dose of calomel  and
 an  aperient   may be  proper.    We should then  improve the general
 health by mild alteratives and  aperients, attention to  diet, and regular
 mode of living.   If the nervous system  is weakened, and if the patient
is  in  bad  health, and  feeble, from  confinement, sedentary occupation,
unwholesome residence, and other debilitating influences, tonic and ner-
vous medicines, such as bark,  the vegetable bitters, valerian, ammonia,
       08 
 •~>^s                        IIEMERALOriA.

 camphor, ether, with which conium or hyoscyamus may be combined;
 and moderate  stimuli, whether medical  or dietetic, with removal into
 pure air, will be of service.  Where mental causes have been concerned
 in inducing the  disease, change  of occupation, as well as  of air, and
 scene, may be advantageous in combination with some of  the former
 means.
   Mr. Ware* has recommended local  measures, such as fomentation
 of the eyes two or three times a  day with warm water, or a warm in-
 fusion of chamomile flowers,  or  of the herb eyebright, and afterwards
 embrocation of the forehead, temples, and outside of the eye-lids, with
 camphorated  spirits, eau de Cologne, Hungary water, or some similar
 application.
   When the health  is improved, the muscse volitantes  become fainter
 and less troublesome.  They do  not interfere with sight, and are only
 noticed under particular circumstances, or when attention is expressly
 directed to them.  They do not usually disappear altogether.   In three
 cases related by  Mr. Ware, in the paper just  quoted, the symptom of
 muscse volitantes  had existed to a troublesome extent, and had been
 relieved by suitable  treatment.   The patients were  seen again at the
 end  of ten, twelve, and twenty-five  years, when the  objects were still
 perceived, though only in strong light, or when the attention was directed
 to the subject.  Vision had continued perfect.

                    hemeralopia and nyctalopia.

  The two states of vision, in one of which persons see imperfectly or
 are blind by night, and in the other, by day, might be properly  denoted
 by the plain English  words night-blindness and day-blindness, though
 they are more  generally called by names derived from the Greek, viz.
 hemeralopia and nyctalopia.   A great confusion has arisen in the appli-
 cation  of these learned terms, each  word  being  nearly as often used to
 express one affection as the other.  Hippocrates uses  the term hemera-
 lopia to denote night-blindness, and  we may as well follow his example.
  Night-blindness, or hemeralopia,  {caligo tenebrarum; dysopia tene-
 brarum.)—Hemeralopia is that state of vision  in which a patient sees
 well during the day, but imperfectly as twilight comes  on;  and, when
 the affection is fully formed, he loses his  sight entirely at the approach
 of night, not being able to see a lighted candle brought close  to the eye.
 In the commencement of the affection the  person can see by moonlight,
 or when the room is lighted by a  candle,  but as it proceeds, he can dis-
 cern nothing after sun-set: in the morning vision returns.  There is no
 unnatural appearance in the eye:  indeed, if a person  can see perfectly
 during the  day, the  organ can have undergone no important  change.
 There is a little increased irritability in the commencement, but as the
 affection proceeds, the pupil  becomes rather dilated.   It is said, that as
 the complaint  goes on, the retina becomes at length  completely insen-
 sible.
  The duration of the disease varies from one night to six or twelve

  * On the Musrw Volitantes of nnvous persons; in the M'dico-cJiirurgical  Transactions,
foL v. p. '-'73. 
HEMERALOriA.
539
 months, or even  longer.   More generally it lasts  from two weeks  to
 three or six months, when left to itself.   Relapses are frequent, so long
 as persons remain exposed to the exciting cause.
   The cause of this affection seems to be the exhaustion of the power
 of  the retina by exposure to strong light during the day;  hence night-
 blindness is only found in those places and climates where there is strong
 light, and is seldom seen except between  the  tropics.   In these regions
 the full glare of a vertical sun in an unclouded  sky, and the powerful
 reflection of the solar rays from the  sea, or from a sandy soil, produce
 an excitement of  the retina  to which we are wholly unaccustomed  in
 our latitudes, although in  some parts of Europe analogous influences
 exist in a sufficient degree to cause the affection.   After the retina has
 been so strongly excited in  the day,  the  feeble light of night and twi-
 light does not impress it sufficiently for perfect vision.   Europeans often
 suffer from this cause in the West Indies, and more particularly  those
 much exposed, as  soldiers and sailors.  The cases are especially nu-
 merous among the  latter, and great numbers  of a ship's crew  often
 suffer.
   [Hemeralopia, is  of rare occurrence in the United  States, except in the
 extreme northern  and southern portions; and  according to  Dr. Forry, it
 " is nearly eleven times more prevalent in the  latter than in  the former.  In
 Florida, however," he  adds " it may be regarded as endemic."  (Am. Journal
 Med. Sc. Ap. 1842, p. 318.)
   This affection is more prevalent, than is generally supposed we have reason
 to believe in very high latitudes where the sun during a portion of the year
 scarcely sets, and the light from this  luminary is  reflected from the snow and
 ice.   Sailors who have been much exposed on  watch, in these latitudes, are
 frequently affected.   The peasants  in the  interior of  Russia are also very
 subject to it; and  this disease, Dr. Mathew  Guthrie  states, is there  called
 Kuritsha Slepota, or hen blindness.  It most  usually occurs during the harvest
 (in June and July,)  at which period the sun dips but a very little below the ho-
 rizon, and that for a short time.  And he states that some hundreds of a Russian
 detachment, during the war in Finland were  affected with this disease.   {Me-
 dical Commentaries, vol. xix. p. 284.)
  Hemeralopia also sometimes occurs as a sympathetic affection, an interesting
 example of which  is recorded by Dr. Alancon, in  the Journ. des  Connaiss.
 Med. Chirurg. for Sept. 1835.  The subject of it was a boy whose  health in
 all respects appeared perfectly good, and no  cause for the affection  could be
 traced.  During the day he saw as well as usual, but as evening set in, his  vision
 declined, and at night he became blind.   Learning that he had been subject to
 worms, Dr. A. administered a large dose of oil, which  brought away a number
 of these animals, after which his sight immediately improved, and in ten or twelve
 days was perfectly restored.]
  The  prognosis of the affection is  quite favourable; it may exist for
 weeks or months, yet the organ will  recover perfectly, even if left  to
itself.   There is a good description of this night-blindness  in the fifth
volume of the Medico-Chirurgical Transactions,  by  Mr. Bampfield,*
who  states that he observed  about  three  hundred  cases within  a
very short time, and in  all of them the  complaint  ended without any
permanent injury to vision.
  In saying that hemeralopia is a complaint  of hot climates, I did not

  *  A Practical Essay on Hemeralopia or Night-blindness, commonly called Nyctalopia. 
510
HEMERALOPIA.
 mean to assert that it never occurs in other situations.  Under some
 peculiar circumstances, it happens in countries  situated beyond the tro-
 pics.  There is an account in one of the periodical works, of its having
 prevailed extensively among some French troops stationed in Belleisle,*
 under a  combination of local peculiarities, calculated to act powerfully
 on the retina, and at a season of the year favourable to their influence.
 A similar epidemic  occurred among  some Prussian soldiers  stationed
 on the Rhine, in the summer of 1834.f  In all the cases which 1 have
 seen, the affection has commenced in the East or West Indies, and been
 brought  to England.
   If the complaint will run  its course, and come to  an end without
 injuring  the organ, it cannot be necessary to  adopt any powerful treat-
 ment.  Mr. Bampfield had an  opportunity of trying various proceed-
 ings, and he says, in his essay, that what  he  ultimately found the most
 advantageous, was, in addition  to thouse of aperient medicine, the  ap-
 plication of blisters to the temples: they very much abridged the dura-
 tion of the complaint.  In the few  instances whieh I have met with, I
 have adopted the same practice; with the addition in one  or two in-
 stances,  of previously taking some  blood by  cupping, from the temples
 or nape  of the neck.  With such treatment  the complaint has readily
 given way.
  [Dr. W. L. Wharton of the U. S. Army, relates in the American Journal of the
 Medical Sciences, several cases which were cured simply by exclusion of light.
 One of these was of three months  duration.   The cure was effected, in from
 24 to 60 hours.]
   Congenital and hereditary hemeralopia.—In  some rare instances
 night-blindness has been seen as a congenital affection.
   H. C.  E. Richter has related three cases of congenital hemeralopia,
 which occurred in a family of nine, the other six  children and the pa-
 rents being free from all defect  of sight.  The  circumstance was  first
 observed when the children began to go alone ; they moved about very
 well in the day, but were quite unable to find their way as twilight came
 on.   When the account was drawn  up, they had reached the age of
 from twenty to thirty without any alteration in the state of sight-  The
 eyes presented their normal appearance; and  there was nothing unusual
 in the movements of the iris or state of the pupils, except that the latter
 were rather dilated  at night.  These persons saw well in the daytime,
 but  very imperfectly at night, though  they were  not  absolutely blind.
 They saw in  strong moonlight or  candlelight, but not well.  One of
 them had never seen any  stars, another only seven; but the sight of the
 third was rather better.J"
  Dr. Cunier, of Ghent, has lately recorded a unique and very remark-
 able example, in which this disease, probably congenital in  the first in-
 stance,  has been  transmitted by hereditary descent  through six ge-

  * R. de  Hautesierk, Recueil  d'Obs. de Mtdecine des  Hopitaux Militares, torn. ii. and
 iii.  He represents that the  complaint  is common in Belleisle, a dry and  hot situation
 Bleeding, vomiting, and purging, followed by  blisters, constituted the most successful lr«at!
 went.
  t Dublin Journal of Mtdical and Chemical Science, vol. viii.
  \ Diss, inaug.  exhibens tres Hemeralopia s. Ccecitatisnocturna, casus; Jena;rl828;  in
Radius, Script. Ophthalm. Minor, vol. iii. 
NYCTALOPIA.
541
nerations.  At the hospital St. Eloy,  Montpellier, Dr. Cunier, saw a
young conscript, who claimed exemption  from military service on the
ground that he could not see at night.   It had been supposed  that the
complaint was feigned;  but Dr. C. found on careful  examination, that
this was  not the case.   The iris was  motionless, even in the strongest
light; and the pupil, when examined with a magnifying  power, was
hexagonal.  The pupil was smaller in the evening, and there  was an
appreciable motion of the iris when a  light was brought into the room.
This young man represented that he belonged to a family in which many
individuals were hemeralopic;  and Dr. Cunier repaired to the  com-
mune of Vendemian, near Montpellier, to inquire into the circumstances.
According to  received  tradition,  the affection began with a certain
Nougaret, surnamed the Provencal, from whom it  was propagated, by
means of his  descendants, not only in Vendemian, but in neighbouring
places where it had never been  seen except in  individuals of this race.
Dr. Cunier was accompanied by a gentleman skilled  in antiquarian re-
searches, who drew up  a genealogical table of Nougaret and his de-
scendants.
  From  this table, which is nearly seven feet long, and appended to the
pamphlet of Dr. Cunier, we learn the following particulars.   In  the first
generation, consisting  of three persons, a daughter and  two sons of
Nougaret, all were hemeralopic.   The se'cond generation included 16
individuals, of whom 10 were hemeralopic ;  in the third  generation,
there were 14 out  of 81 ; in the fourth-, 23 in 208; in the fifth, not yet
completed, 24  in  218; in the  sixth, including  103  persons, there
are 11.
  Among more than 60O individuals  who have descended during the
last two  centuries from  Jean Nougaret, of whom from \ to \ have been
hemeralopic,  there is not a  single example of the  affection  in the chil-
dren of parents who were themselves free from it.
   The hemeralopia  has Been  transmitted in this  family more by the
women than by the men.  Of 41 descendants from Elizabeth Gineste,
24 were  affected, though in the fourth, fifth, and sixth generations, to
whom these belonged, the general proportion was not more than •£.
  Dr. Cunier observed  nothing very remarkable in the eyes of those
whom he examined.  The  pupil was  regular, but very large,  and did
not contract even on exposure to the ardent mid^day sun of Languedoc.
Those affected with it see at night  by the help of lights, and sometimes
under very brilliant moonlight.  The light  then produces a  winking, the
pupil contracts, and objects are gradually seen better.   Sight, however,
is still confused.  If they go into a cellar by day they lose their  sight.
The pupil contracts a little at night, and a motion of the iris can then be
seen on sudden exposure of the organ  to strong light.*
  Day-blindness;  nyctalopia.—The opposite  state to the former, or
blindness during the  day, is called nyctalopia.   There are many states
of the organ in which vision is imperfect, even to blindness, in the strong
light of day, and much better sight is enjoyed in twilight and the dusk :
but I have not seen this as an amaurotic affection, or a condition of sight

  * Historic d'une Hemcralopie htrtdituire dcpuis deux sieclts dans une famille  de la com.
mune de Vendemian, pres Montpellier, par F. Cunier M.D., in the Annates de ta Societe de
M^decine de Gand, lfc>40.^ 
542
NYCTALOPIA.
opposite to the preceding, dependent on disease of the  retina or optic
nerve.
   In central  leucoma of the cornea, in central lenticular cataract, in
incipient opacity of the lens, in central opacity of the capsule, in con-
tractions of the pupil from prolapsus irides or adhesion of the pupillary
margin, connected with either of the former circumstances, the patient
will see best in a weak light, and find vision very imperfect in a strong
glare.  The enlargement of the pupil in the former, and  its contraction
in the latter state, sufficiently account for this difference.   On the  same
ground sight is much improved in some of these circumstances by  the
use of belladonna.
   In strumus ophthalmia the intolerance of light often amounts to blind-
ness during the day; while the  symptoms remit in the evening, when  the
eyes are opened, and the patient sees.well.  Unnatural sensibility to light,
and consequent photophobia is the form which sympathetic affection of
the retina sometimes  assumes.   Persons thus affected may be able to
see well in dull lights.
   The  Albinoes are nyctalopic; the absence of pigmentum nigrum ren-
ders  them  acutely  and almost morbidly sensible  to light;  they are
hardly  able to open their eyes in a strong sunshine; they contract their
brows,  and keep  the palpebrae almost closed during the day, and when
twilight comes they are able to see distinctly.
   Such are the only forms of nyctalopia which I have  seen.   I never
saw a case in which it existed, as an amaurotic symptom, to the degree
of vision being perfect in the night or even twilight, and  lost during the
day, as we see the converse in hemeralopia.
  [" Among the few original observations," Mr. Mackenzie remarks, (Practical
Treatise pp. 821-2,) "tending to  establish the fact of there being such  a dis-
ease as  a periodic amaurosis, which makes its attack through  the day, and
departs at night, may be quoted the following from Ramazzini.
  ' I have repeatedly observed,' says he, * among our country people, and espe-
cially in boys, a thing sufficiently strange.  In March, about the  equinox, boys
about ten years of age were affected with a great degree of weakness of  sight,
so that through the whole  day they saw little or nothing, and wandered about
the fields like blind people; but when night came they saw again  distinctly.
This affection ceased without  any remedy, and by the middle of April, the pa-
tients were completely restored to sight.  I frequently observed the eyes of these
boys, and found the pupils much enlarged.'"  (De Morbis Artificum, cap. xxxviii;
Opera, p. 363 ; Londini,  1718.)
  A gentleman related to Dr. Guthrie that he had witnessed the following example
of day-blindness.   Whilst in garrison in Landau, in Alsace, in the summer of
1772, two hundred men of the regiment of Picardie, were seized with a species
of blindness during the meridian splendour of the sun, and could not see their
way when it was not overcast,  insomuch that when they had strolled out into
the fields during a cloudy day, if the sun suddenly shone out, they were  abso-
lutely obliged to be led  by their companions till a cloud once more obscured
the solar light, and enabled them to pursue their course.  (Duncan's Medical
Commentaries, vol. xix. p. 290; Edinburgh, 1795.)
  " These instances look like an endemic or epidemic day-blindness; but are
evidently too vague to furnish  grounds for any general conclusions.
  " Baron Larrey has recorded a remarkable case of sporadic day-blindness, oc-
curring in an old man, one of the galley-slaves at Brest who had for thirty-three 
1IEMI0PIA.
543
 years  been shut up in  a subterraneous  dungeon.  His  long residence in
 darkness had had such an effect on the organs of vision, that he could see only
 under  the  shade of night, and was completely blind during the day.  (Me-
 moires de Chirurgie Militarie, Tome i. p. 6; Paris, 1812.)
    " Another case, connected with a venereal taint, and cured by mercurial fric-
 tions, is related by Mr. Isbell.  (Edinburgh Medical and Surgical Journal, vol.
 ix. p. 269; Edinburgh, 1813.)
    [Hemiopia, from nfMtrv? half and «i/-<s- vision, or that form of partial blindness,
 in which the patient is able to see only the half of objects, may affect one or both
 eyes.   Sometimes it is the right, and at others the left half of objects which can
 only be seen; again it may happen, Dr. Mackenzie observes, " that the upper or
 the lower half of the field of vision may appear dark, or that the patient, looking
 directly forwards, may see tolerably well  within a certain angle, but nothing to
 either side.   These latter  varieties of hemiopia are less common than that in
 which the right or the left half of each retina appears to be insensible to light,
 but are not  less worthy of attention."   (Practical Treatise, p. 822.)
    Hemiopia is apt to be sudden in its attacks and  to recur at considerable in-
 tervals of time.
    Dr. Wollaston attracted considerable attention to this affection, by the publi-
 cation of an account of two attacks of it which he  himself experienced, and of
 some cases  of it which he met with in others.  {On the semi-decussalion of the
 optic nerves.   Philos. Trans, for 1824.)
    " It is now more than twenty years," says he, " since I was first attacked with
 the peculiar state of vision to which I  allude, in consequence of violent exercise
 I had taken for two  or three  hours before.  I suddenly found that I  could see
 but half the face of a man whom I met; and it  was the same with  respect to
 every object  I  looked  at.  In attempting to read  the name Johnson, over a
 door, I saw only     son ; the commencement of the name being wholly oblite-
 rated to my view.   In  this instance the loss of sight was toward my left, and
 was the same whether  I looked with the right eye or the left.   This blindness
 was not so  complete as to amount to absolute blackness, but was a shaded dark-
 ness  without definite outline.  The complaint was of short duration, and  in
 about a quarter of an hour might  be  said to be wholly gone, having receded
 with  a gradual motion from  the  centre of vision obliquely upwards towards
 the left.
   " Since this defect arose from over-fatigue, a cause  common to many other
 nervous affections, I saw no reasons to apprehend any return of it, and it passed
 away without any need of remedy, without any farther explanation, and without
 my drawing any useful  inference from it.
   " It is now about 15 months since a similar affection occurred again to my-
 self, without my being  able to assign any cause  whatever, or  to connect  it
 with any previous or subsequent indisposition.   The  blindness was  first ob-
 served, as before, in looking at the face of a person I met, whose left eye was to
 my sight obliterated.  My blindness was in this instance the reverse of the for-
 mer, being to my right  (instead of the left) of the spot to which my eyes were
 directed; so that I have no reason to suppose it in any manner connected with
 the former affection.
   " The new punctum caecum was situated alike in  both eyes, and at an angle
 of about three degrees from the centre ;  for when  any object was viewed  at
 the distance  of about five yards, the point not seen was about ten inches distant
from the point actually looked at.
  " On this occasion the affection, after having lasted with  little alteration for
about 20 minutes, was  removed  suddenly and entirely by the excitement of 
544
HEMIOPIA.
agreeable news respecting  the safe  arrival of a  friend from a very hazardous
enterprise."
   In consequence of reflecting on these attacks of hemiopia, Dr. Wollaston was
led to adopt  the following hypothesis regarding the arrangement of the optic
nerve, the hypothesis, in fact of Sir Isaac Newton.
   " Since the corresponding points of the two eyes," says he, " sympathize in
disease, their sympathy is evidently from structure, not from mere habit of feel-
ing together, as might be inferred, if reference were had to the reception of ordi-
nary impressions alone.  Any two corresponding points must be supplied with
a pair  of filaments from the same nerve, and the seat of a  disease in which
similar parts of both eyes are affected, must be considered as situated at a dis-
tance from the eyes at some place in the course of the nerves where these fila-
ments are still united, and probably in one or the  other thalamus nervorum op-
ticorum.
   " It is plain that the  cord, which comes finally to either eye under the name
of optic nerve, must be regarded as consisting of two portions, one half from the
right thalamus, and the other from the left thalamus nervorum opticorum.
   " According to this supposition, decussation will take place only between the
adjacent halves of the two nerves.   That portion of nerve which proceeds from
the right thalamus to the  right side of the  right eye, passes to its destination
without interference; and in a similar manner the left thalamus will supply the
left side of the left eye  with one part of its fibres while the remaining halves of
both nerves in passing over to the eyes of the opposite sides must intersect each
other, either with or without intermixture of their fibres.
   " Now, if we consider rightly the facts discovered by comparative anatomy in
fishes, we shall find that the crossing of the entire nerves in them to the opposite
eyes, is in perfect conformity to this view of the arrangement of the human nerves.
The relative position of the eyes to each other in the sturgeon, is so exactly back
to back, on opposite sides of the head, that they can hardly see the same object,
they can have no points which generally receive the same impressions as in us;
there are no corresponding points of vision requiring to be supplied with fibres
from the same nerve.   The eye which sees to the left has its retina solely upon
its right side;  and this is supplied with an optic nerve arising wholly from the
right thalamus;  while the left thalamus sends its fibres  entirely to the left side
of the right eye for the perception of objects situated on the right.   In this ani-
mal an injury to the left thalamus might be expected to occasion entire blindness
of the right eye alone, and want of perception of objects placed on that side.   In
ourselves, a similar injury to the left thalamus would occasion blindness (as be-
fore) to all objects situated to our right, owing of  insensibility to the left half of
the retina of both eyes."
  Having thus explained his hypothesis, Dr. Wollaston  goes  on to relate the
following additional instance of hemiopia.
  "A disorder" says he, "that has occurred within my own knowledge in the case
of a friend, seems fully to confirm this reasoning, as far as a single instance can
be depended  upon.  After he had suffered severe pain in his head for some
days, about the left temple, and toward the back  of the  left eye, his vision  be-
came considerably impaired, attended with other  symptoms indicating a slight
compression on the brain.
   " It was not till after the lapse of three or four weeks that I saw him, and found
that, in addition to other affections which need not here be enumerated, he  la-
boured under a defect of sight similar to those which had happened to myself but
more extensive, and it has unfortunately been far more permanent.  In this case
the blindness was at that time and still is entire, with reference to all objects situated
to the right of his centre of view.  Fortunately, the field of his vision is sufficient 
HEMIOPIA.
545
for writing perfectly.  He sees what he writes, and the pen with which he writes,
but not the hand that moves the pen.  This affection is, as far as can be observed,
the same in  both eyes, and  consists in an insensibility  of the retina on the left
side of each eye.   It seems most probable that some effusion took place at the
time of the  original pain on that side of the head, and has left a permanent
compression on the left thalamus.   This  partial  blindness  has  now  lasted
so  long  without  sensible amendment,  as  to make  it very doubtful  when
my friend may recover  the  complete  perception of  objects on that side of
him."
  Dr. Wollaston gives in the same paper the following  account of another case
of this disease.
  " One of my friends " says he, " has been habitually  subject to it for sixteen
or seventeen years, whenever his  stomach is in  any considerable degree de-
ranged.  In him the blindness has been invariably to his right of the centre of
vision,  and from want of due consideration, had been considered as tempo-
rary insensibility of the right eye;  but he is now satisfied that this is not really
the case,  but that  both  eyes have been similarly affected with half-blindness.
This symptom of his indigestion usually lasts about a quarter of an hour or 20
minutes,  and then subsides, without  leaving any permanent imperfection of
sight."
  Dr. Wollaston died, about four years after the  publication of the paper, from
which  these extracts are taken.   In  the account  which has been published
of the appearances observed on inspecting his body, it  is stated, that  the optic
thalamus of the right side was of an unusually large size, and that on making
a section of it, little or  no vestige of  its natural substance  was perceptible,
with the  exception of a layer of medullary substance on  its upper  part.  It
had been converted into a tumour, as  large as a middle-sized hen's egg, towards
the circumference of a greyish colour, and  harder than the brain itself, some-
what of a caseous consistence, but in  the centre  of a brown colour, soft, and in
a half-dissolved state.  This diseased structure was not confined to the thala-
mus, but extended to the neighbouring portion of the  corpus striatum.   The
right optic nerve, where it  passes on the out side of  the thalamus, was  of a
brown colour, more expanded, and softer than natural.   (London Medical Gaz.
vol. iii. p. 293.)
  " The reader will readily perceive,"  "  Dr. Mackenzie  observes," that between
this state of the brain, and  the previous symptoms of  hemiopia, there may or
may not have been a connexion; for there were two distinct attacks of the dis-
ease, at the interval of twenty years, each attack subsiding entirely after fifteen
or twenty minutes, in the first attack objects to the left appearing dark, and in
the second, those to the right.  We know that morbid alterations in the substance
of the brain often produce periodic diseases, and that certain additional causes
of excitement operating upon an unsound brain, one or the other of  the func-
tions of that organ are for a time impeded, till the new  cause ceases to operate,
when the individual immediately returns to his former state of apparent health.
(Practical Treatise, p.  826-7.)
  An interesting case of hemiopia, in  a  person affected with slight hemiphlegia
of the left side is related by Dr. Crawford.  The  patient regained the use of her
limbs, but from the time of her seizure till her death, about five years afterwards,
when she looked at an  object, she could see distinctly only the one  half of it
which was towards her  right hand the other being very obscure.  This  was
equally the case, whether she looked with both eyes, or only with the right one,
but when she looked with her left only, the obscurity was greater.  When four
fingers were held before her, she could see two of them  distinctly,  the third
she could distinguish, but could not see  plainly;  and the fourth she could not
see at all.  When  she looked at three fingers, she could see two of them pretty
       69 
510
HEMIOPIA.
plainly—the first, however, plainer than the second, the third, she could not dis-
tinguish at all.  When she looked  at  two fingers, she could see only one  dis-
tinctly.
  After she had recovered so as to  be able to get out of bed, it was discovered
that, although she could see only half of an object plainly, when held directly be-
fore her, )'et if it was moved towards her right hand, and she continued to look
straight forward,  she could see the whole of it distinctly.  On the contrary if it
was moved, toward  her left hand, keeping her eyes  fixed as before, she could
not perceive any  part of the object.
  It should be remarked, that it was the motion of the left side of the body that
was impaired, yet it was the right half of each retina which was insensible.
(London, Med. and Phys. Journal, liii. 48.)
  Another case of hemiopia is related by Mr. Lawrence.   See p. 508-9, of this
work.
  In reflecting on Dr. Wollaston's paper—the following remarks Dr. Mackenzie
states have occurred to him.
   1. " The notion of a semi-decussation of the optic nerves had not merely been
entertained by several distinguished authors,* before Dr. Wollaston, but had in
some measure been demonstrated by dissection.1  Even the idea that the two
portions, of which each optic nerve may be regarded as consisting, remain  dis-
tinct, after they form the retina, appears to belong to Sir Isaac Newton.  It is
supported, however,  by Dr. Wollaston, by an argument which is new, and pro-
bably without foundation; namely, that any two corresponding points of the
two retinae  must be supplied with  filaments either from the right or from the
left optic nerve, and that upon this depends their correspondence.  Dr. Wol-
laston appears to have overlooked the fact, that as the optic nerves pass through
the sclerotica and choroid considerably nearer the middle line of the body than
the centre of the globe of each eye, the two optic axes, which if any points
deserve to be considered as  such, are surely corresponding  points, will not be
formed by filaments from the  same nerve, but from opposite nerves.  It has
always occurred  to me as more probable, that the two portions, of which  each
optic nerve consists, mingle their fibres, and then expand into the retina, so that
the membrane in  each eye should be regarded as a plexus, every point of which
contains fibres derived from each side of the brain.
   2. " It is not, however, by mere reasoning upon a subject like this, that we can
arrive at any sound  conclusion.  By far the greater  part of the mass of facts, in
pathological  and  in  what may be  called experimental anatomy touching this
question, go to  prove, that injuries and diseases affecting one side of the brain,
instead  of hemiopia in both eyes, produce amaurosis only in the opposite eye.|
The fact, also, which has been already mentioned in the beginning of this sec-
tion, that we meet with a horizontal  as well as a perpendicular hemiopia, appears
scarcely reconcileable  to the hypothesis of Dr. Wollaston.   Not so, however,
that other variety of the disease, in which objects to each  hand  appear dark,
and those only which are placed in  front are seen distinctly; for where any tu-
mour or excrescence to press on the anterior edge  of the chiasma of the optic
nerves, the effect would be according to the hypothesis of semi-decussation, to
paralyze the inner half only of each  retina.   I had under my care a patient with
amaurosis of the inner half of each retina, attended with  total loss of the sense
of smell, and an imperfect sense of taste.   He presented no other signs of cere-
bral disease, and I thought it probable that the imperfection in taste was owing

  * Newton, Vater, Ackermann, Vicq-d'Azyr, Caldani, Cuvier, &c.
  t JosephusetCarolus Wenzel dePenitiore Structura Cerebri, pp. 109, 333. Tab. vi. fie. 1.
labingee, 1812.
  t Serrcs, Anatomie Coinparce du Cerveau, Tom. i. p. 331.  Paris, 1827. 
HEMIOTIA.
547
  to the loss of the power of smell and that this along, with the hemiopia, was
  owing to some pressure on the optic nerves, immediately anterior to their union,
  and on the olfactory nerves."  Practical Treatise, p. 826-7.
    The treatment of hemiopia, must be conducted in reference to the cause by
  which it is produced.  If resulting from cerebral congestion, general or local de-
  traction of blood, with revulsives &c, may be demanded. A frequent cause is
  disorder  of  the digestive organs, and  of course,  remedies appropriate for
  the correction of the particular derangement must be employed.]
    Want of power to distinguish colours.—Some individuals are natu-
  rally unable to distinguish colours, and to judge of their relations.   In
  rare cases this defect embraces all colours, so that a coloured drawing
  or painting seems all of one tint; the objects are clearly seen, the light
  and shadow are understood, but the  differences of colour are not per-
  ceived.   Some persons can only distinguish certain colours, and refer
  the others to one  or other of these.   Thus  a person could perceive
  only red, yellow, and purple in the rainbow.  Some are unable to  dis-
  tinguish one or two colours; red and green,for example, are commonly
  confounded  in these cases.  The eye has its natural appearance,  and
  vision is perfect in all other respects.
   This  incapacity of distinguishing colours, which is an original defect,
  frequently exists in several members of the same family.
   In a person named Harris, the defect was first observed at four years
  of age: he could not distinguish the fruit from the leaves of a cherry-tree
  by their colour; nor could he understand why a stocking was called red;
  though he saw objects as well and at as great a distance  as others, when
  the distinction did not depend on colour.   The gentleman, who gives an
  account of this individual  in the Philosophical Transactions, vol. lxvii.
  art. 14,  says, " I believe he could never do more than  guess the  name
 of any colour; yet he could distinguish white from black, or black from
 any light or bright colour.  Dove or straw colour he called  white, and
 different  colours he frequently called by the same name;  yet  he  could
 discern a difference between them when  placed together.  In general,
 colours of an equal degree of brightness, however they might otherwise
 differ, he frequently confounded  together.   Yet a striped ribbon he  could
 distinguish from a plain one, but he could not tell what the colours were
 with any tolerable exactness.   Dark colours in general he often mistook
 for black, but never imagined white to be a dark colour, nor a dark to be
 a white colour."  He had two brothers, whose perception of colours was
 imperfect like his own, and two other brothers and sisters, who, as well
 as their parents, were free from this defect; one of the  first-mentioned
 brothers pronounced an orange  ribbon to be the colour of grass, green.
 When asked  whether the various colours were mere differences of light
 and  shade, various degrees  between  white and  black,  he replied no,
 but with  some hesitation.
  In an instance recorded in the subsequent  volume of  the   Transac-
 tions, art. 27, the defect was not so general.  The  relater, describing
 his own infirmity, says, " I do not know any green in the world ; a pink
 colour and a pale blue are alike; I do not know one from the other.  A
 full red and a full green the  same;  I have often thought them a  good
match:  but yellows (light, dark, and  middle,) and all degrees of  blue,
except those very pale, commonly called  sky, I  know  perfectly  well, 
548
HEMIOPIA.
and can discern a deficiency in  any of those  colours, to a  particular
nicety.  A full purple and a deep blue sometimes baffle me."  He adds,
" It is a family failing: my father has exactly the same impediment; my
mother  and one  of  my sisters were perfect, in all colours;  my other
sister and myself alike imperfect; but she has  a  daughter who is very
perfect. I have a son and daughter, who both know all colours without
exception ; and so did their mother.   My mother's own brother had the
like impediment with me, though my mother, as mentioned above, knew
all colours very well."
  In the seventh volume  of the Medico-Chirurgical Transactions, Dr.
Nicholl  has related  the  case of a boy, eleven years old, who has this
defect.  " He does not call any colour green. Dark bottle green he calls
brown.   Light  yellows he calls  yellow; but darker yellows and  light
browns he confounds with red.   Dark brown he confounds with black.
Pale green he calls light red ; common green he terms red.   Light red
and pink he calls light blue; red he calls by its proper name.   On look-
ing through a prism,  he said that he  could discover no  colours but red,
yellow, and purple.   I showed him paper stained with red radish root;
this he said was blue: I dipped this paper in diluted nitrous acid, which
converted the pale red colour into scarlet; he then called it  red.  I
placed this scarlet colour by the side of paper stained with litmus; he
said that both colours were the  same, but that  the litmus paper was a
lighter shade than the other.  I then placed the  scarlet  paper on the
grass, and afterwards on  green  baize;  he  said that the grass and the
baize were the same colour as the paper, but that they were a  shade
lighter.   I made him put on a pair of green spectacles, which he called
red glasses; he said that every body and everything in the room had a
reddish cast when seen through them."  (Page  477, 478.)  This boy
has four sisters, who, with his mother and her  sister, are free from the
defect, which however exists in his  maternal grandfather.  The latter
gentleman, being in the navy, purchased a blue coat and waistcoat with
red breeches to match the blue.   He, as well as his grandson, seems to
have no perception of green.  He had two brothers and three sisters:
the defect existed in one brother, the other and  the  sisters  being free
from it.   His  brother has mistaken a  cucumber for  a  lobster, and a
green leaf for a stick of red sealing wax.
  A gentleman,  who has detailed the circumstances of his own case in
the Glasgow Medical Journal, vol. ii. art. 2, seems to be most deficient
in the  distinction of reds and greens.  He can distinguish dark  green
and dark purple; but pale green, pink, and pale blue, all appear to him
the same  colour.  He says, " I  cannot perceive a bit of red sealing-
wax, if thrown down upon the grass, nor a piece of scarlet cloth hung
upon a  hedge, till I am almost  near enough the  latter to touch it; al-
though in one instance, which I particularly remember, this was so con-
spicuous to ten or twelve other persons as to be distinctly visible to them
a mile  off.   I once gathered some lichen, as a great curiosity, from the
roof of a fishing house, situated on the estate of  a friend.  This lichen
appearing  to  me of a  bright scarlet, from the circumstance of its
seeming to be of the  same colour as the roof of  the house, which was
composed of fanciful shaped tiles; in reality the lichen was of a bright
green, and the tiles of an unusually  brilliant red. 
HEMIOPIA.
549
  The communication to the Glasgow Journal, by Dr. Colquhoun, in
which the preceding account is found, contains a minute history of ano-
ther instance, in which the defect is particularly observed in regard to
red and green,  more especially the latter.
  This peculiarity which is an original defect, and not a pathological con-
dition, depends, according  to the opinion of Drs. Gall and Spurzheim,
on the sensorium.   They conceive that the function of the eye is limited
to the receiving certain impressions, but that  the judging of these im-
pressions, the power of understanding the relations which colours bear
to each other, is the function of the sensorium : and they assign this fa-
culty to a particular part of the brain.  It is certain  that an eye may be
excellent for the general purpose of vision, and capable of distinguishing
the minutest objects, and yet  the individual may not be able to judge
of colours.   The  latter power with the accurate perception of the har-
mony of colours, and their various relations to each other, is a higher
endowment; indeed, only a few persons possess it  eminently.  Some
can draw correctly, can take  a portrait very well, although, if they at-
tempt to colour, they fail entirely.  We even find that  among the great
painters, only a few have attained the reputation of thoroughly under-
standing the subject of colour, and have been able to reduce that know-
ledge to practice  in their art.
  In  the case of an original defect, and  one probably seated in the or-
ganization of the  brain, we can afford no remedy: indeed the matter is
only mentioned now, in order to show the difference between this natu-
ral peculiarity and pathological states of the eye.
  [Inability to distinguish colours, hitherto supposed  to be always an original
defect, we have  observed  to occur, also, as a pathological condition.  A case
of this kind, was reported by us  in the American  Journal of the  Medical
Sciences, for August, 1840.   We shall here  relate this case with  some infer-
ences, relative to the laws which govern this defect, to which we have been led
by a comparison of the  various cases of it  which have  been recorded.
  Mary Bishop 20 years of age, unmarried, a segar maker, was admitted into
Will's Hospital, Feb. 9th 1839.  She stated that she  had  suffered, previous to
admission into hospital, two attacks of cerebral disease,  one in the spring of
1837, the other in the winter of 1837-38.  After recovery from the first attack,
objects for a time appeared to her double.  The second attack left her entirely
blind, in which condition she continued for four months.   After this her sight
began to return, and at the period of her admission into the hospital she could
read large print, as  the heading of a newspaper.  She was of a short, robust
stature, full habit, very dark complexion, black hair and hazel irides, flushed face,
colour of her cheeks at times almost of a purplish hue; catamenia suppressed.
When she first came under my notice, which was  in  May, 1839, she had been
largely depleted and had taken remedies  for the restoration of the menstrual
discharge, under the direction of my friend and colleague Dr. Fox, under which
treatment her sight  had improved.
  Whilst examining her at this time to  ascertain the degree  of  vision she
possessed, her reply to one of our questions led us to  suspect that she was un-
able to distinguish colours.  When asked whether  she could see the figure in
her dress, which  was a calico one with red spots, she replied " Yes, I see the
brown spots."  Our attention thus  directed to the  subject, we soon ascer-
tained that while she could distinguish forms, even of small size, with accuracy,
her perception of colours was exceedingly imperfect.  Repeated and careful in- 
550
IIEMIOriA.
 vestigations during this and  on several subsequent occasions, satisfied us that
 the only colours which she knew with certainty were yellow and blue.   Nearly
 all other colours she termed brown, or hesitated to name, designating, however,
 their shades or intensity of colour accurately.  Thus a deep  red  she  called a
 dark brown, a bright green a  light  brown, and a very pale pink a very light
 shade of brown.
   We exhibited to her both by day and by candle light, a number of colours and
 have them now in our possession with the names she bestowed on them.  With
 the exception of yellow and blue all the other colours  were named with much
 hesitation, and some only after our insisting on her doing so, and she then mani-
 festly named them by guess.  We abstain from giving the details because we are
 satisfied they lead to no further useful  results than to prove that she could not dis-
 tinguish other colours than  the  two just mentioned.  On one  occasion our
 friend, Professor A. D. Bache, visited  the patient with us, and with a  view  of
 comparing her defect of vision with that of Mr. Dalton of  Manchester, ex-
 hibited to her a number of fabrics of various colours, which he  had received
 from that distinguished chemist, with  their names,  as they appear  to him,
 attached.  Nothing new or  worth recording was elicited by this experiment,
 unless the following  circumstance, which for a moment greatly perplexed us,
 be considered as such; and  it  is so perhaps in one point of view, as showing
 how careful it is necessary to be in similar investigations to avoid being deceived.
 After manifesting her inability to  distinguish correctly any except two  colours,
 she  surprised us by naming accurately the colour of some red silk, and which
 she  had previously misnamed.  A bunch of red cotton, however, shown her im-
 mediately afterwards, she termed brown.   On inquiring why she termed the
 first red, she said that she had " discovered some days before that red produced
 sparkles before her eyes."   Suspecting from this that she had been somehow led
 to connect glossiness with red, I called her attention to some bright, glossy green
 silk, which she promptly called red.  When these same articles were shown her
 in such a light  that she could not perceive their gloss, she miscalled them  as
 usual.   How the patient came to connect glossiness with a colour we could not
 discover, but as her  defect was at this time known through the house it is pro-
 bable that some one had shown her a glossy red and given her its name.
   The patient was not at all sensible,  when we commenced the investigation of
 her case, that she laboured under any particular defect in distinguishing colours.
 She had noticed, she said, however, that grass and roses did not appear as they
 formerly did to her ; the latter especially, did not seem of their natural  colour;
 but as her sight was  imperfect she considered this as a1 natural consequence.
 She remembered when questioned, that  as her sight began to return, the first
 colour she perceived was yellow.   This  fact is of  much interest, and she stated
 it  with a degree of confidence, and  mentioned  some particulars which lead
 us to believe  it to have been  the case.  She  asserted most positively also
 that she  had formerly been as well able to  distinguish colours as any other
 person.
   With a view to a revulsive action  on the  brain, and also to re-establish the
 catamenial flow, the patient  was  ordered pills   of blue  mass,  rhubarb and
 aloes, every alternate  night, in  a dose to  purge  actively; mustard  pediluvia
 at bed-time, and  a  blister to the sacrum.   Two days before her  regular
 period I ordered, in addition,  mustard  cataplasms to be applied nightly to the
 inside of her thighs, and the  same diluted with an equal  part of flour to her
mammae.
   On the 29th of May, her catamenia  appeared and flowed copiously, but con-
tinued only for  a single day.  It was  followed, however, by very marked im-
 provement in vision.  She  stated to me at my visit on the 31st of May, with 
HEMIOPIA.
551
much satisfaction, that the roses now appeared to her of their natural colour,
and that she could distinguish the difference between the colour of the rose and
of the leaves of the bush, which she had not previously been able to do.  Roses of
different colours being presented to her she named them all correctly; she could
also distinguish quite small letters distinctly, but not more than three at one time
—her field of vision seemed limited.
   On the first of June Dr. Fox took charge of the hospital, and from this period
until the commencement  of my regular term of service in October following, I
saw the patient only at considerable intervals.  During this time her sight  im-
proved and  with it her ability to distinguish colours.   By the middle of June
she was able she said to  see the eye of a needle  and the end of a thread,  but
could not thread a needle from inability to see both at the same time.  At  this
period Mr. Bache again  visited Mary with me and exhibited to  her the pris-
matic spectrum.  She distinguished pretty accurately the yellow, blue,  green
and red.   The orange she  hesitated about, and the violet she could not name.
The colours were shown her together and separately: under  the two circum-
stances she said they appeared somewhat  different.   Her retina on this,  as on
former occasions, seemed soon to become weakened by use.   She would gaze
at a colour for some time before naming it, and, when looking from one colour
to another, the impression of the first seemed to remain on the retina and for a
time to confuse her perception of the second. To avoid fatiguing the eye by too
much exercise and to insure the accuracy of our observations, it was necessary
on all occasions to conduct the experiments slowly and at  intervals, and with
great care and caution.
   On the first of October, when the patient  again came under my care, her
vision was in the state just described, but her  catamenise were still suppressed,
and she was subject  to occasional attacks  of fulness of the head, during  which
her sight somewhat diminished.  She also suffered  during the early part of this
month from attacks of dyspnoea, which came on every morning before  dawn
and continued for an hour or two.
   October 18///. For the last  three days she  has suffered much from fulness
of the head.   Face flushed; pulse active.   Ordered v. s. ^xvj. and to be purged
with senna  and salts.  These remedies entirely relieved her head, and on the
22d of October  she  was free from all uneasiness,  and could distinguish  the
different  colours  in  a dress  readily, and also  small letters.  She was now
ordered mustard  cataplasms to inside of her thighs, to sacrum and mamma?,
and mustard  pediluvium at  bed-time, with a view  to a  restoration of  her
catamenia.
  25th. Fulness of head; has had a return of dyspnoea; costive;  sight  not
so good.   Ordered cups to sacrum; to be purged  briskly; mustard pedilu-
via.  These relieved the head, but the period passed off without any catamenial
flow.
  30//*. Feels quite well.  Sight good;  can read readily the small print of a
newspaper.  Distinguishes all the primitive colours readily and names most of the
secondary ones as correctly as could be  expected  from one of her moderate
intelligence,  with the exception of violet: this last she seems always at a loss to
name.
  She  would now have been discharged but for her earnest request to be al-
lowed to remain in the hospital one month more, that another  effort might be
made for the restoration of her catamenia.  It  would be uninteresting to  detail
the treatment to which she was subjected during this month  and which  failed in
producing the desired effect.
  November 30th.  Discharged this day, with  her vision restored, and in good
health, the catamenia, however, still suppressed. 
552
HEMIOPIA.
   This is, we believe, the first example hitherto recorded of this inability having
resulted from disease, or being  coexistent only with it.*  As a natural defect,
the power of distinguishing forms being perfect, it is not rare.   Several instances
of this have come under our own observation, and not a few others have been
mentioned by writers.   Such of these last as have been recorded  with sufficient
details to furnish data  for comparison, viewed in connexion with the  case we
have recorded, lead to conclusions which it may not be uninteresting to notice.
   1. As a natural defect, inability to  distinguish colours may exist in different
degrees.
   2. In the worst degree, the individual is able merely to distinguish shades,—
the perception of colour is entirely absent.  Examples of this are afforded in
the two Harris's, who could distinguish a striped riband from a  plain  one, but
could not perceive the difference  between any one colour and another, except
as darker or lighter,! and in Dr. Elliottson's second case.f
   3. In the  next degree the individual can distinguish  only a single colour, and
that colour is always yellow.  Thus Dr. Butter states that Robert Tucker knew
to a certainty yellow only ;§ and it appears that the boy whose case is recorded
by Dr. Nicholl|| was in  the same  condition.1T   Now it  may be called  to mind
that Mary Bishop states when her  sight improved the first colour she recognised
was yellow.
   It may be mentioned  here as connected with this  subject, that we noticed a
similar phenomenon in the case of a lady whom we attended for amaurosis in the
winter of 1837-8.  This patient, who was  quite  blind, began to recover her
sight, and among the  early evidences of improvement she mentioned,  was her
ability to distinguish shades of colour, as the stripes in a Venitian carpet; she
could not perceive, however, a single colour.   When further improvement took
place she stated that she could  recognise the yellow colour of a large  looking-
glass  frame.  A relapse then took place,  from  which she has not since re-
covered.
   4. We may consider as the next degree of this defect where  the individual
can recognise two colours only ; and these seem to be always yellow and blue.
This is the most common grade  of this defect.   Examples of it are afforded in
Scott,** Dalton and his brother,ff in the case recorded by Dr. Nicholl in the Med.
Chirurg. Trans, ix. 359;  in that of J. B. related in the Transactions of the Philoso-

  * A case related by Mr. Mayo, of retinitis caused by a stroke of lightning, is  quoted at
page 453-4, in which it is  stated that  the patient lost the power of distinguishing colours.
But the details of the case  in regard to this particular are, so  few and imperfect, that Mr.
Lawrence has entirely overlooked this feature of it, as it was also by ourselves at the
time we drew up the above account.   Mr. Mayo does not seem to have inquired whether
the defect was actually the  consequence of the disease or had previously existed.
  t Huddard, in Philosophical Transactions for 1777, p. 260 and 263.
  t Am. Journ., vol. xxiii.,  p. 446.  The narrator states that  this patient was deficient in
discerning two primitive colours.  It is manifest from the account, however, that this de-
feet extended to all, and that the gentleman could merely distinguish shades.  The rain-
bow, it is said, appeared to him " as a band of a lighter colour than the other part of the sky,
but a  little darker at one side than the other, and gradually shaded off' between the two
sides."
  § Transactions of the Phrenological Society, p. 209.
  || Medico-Chirurgical Transactions, vol. vii., p. 472.
  1 It would seem, indeed, that it was only the lighter yellows that this boy recognised
accurately; he confounded  the darker  with red.  This last  colour he is said  to name cor-
rectly, but the whole account proves that he could not distinguish this colour.  Thus he
called green,  red; light red and pink, blue;  paper stained with  red radish  root he termed
blue; green spectacles he called red glasses, &c.
  ** Philosophical Trans, for 1778, p.  612.
   Tt Memoirs of the Literary and Philosophical Society of Manchester, vol. v. p. 28. 
INABILITY TO DISTINGUISH COLOURS.
553
phical Society of Edinburgh, vol. x. p.  253 ;  James Milne,* Mr. C..f and Mr.
Troughton,]:  Dr.  Elliottson's first  case,§ and  Sir David Brewster's  case.||
Mr. Scott, J. B.1T and Mr. C. were  imperfect  in  their recognition of blue;  in
the other cases the perception of yellow and blue seems to have been complete.
   It is remarkable that, whilst all the individuals who belong to this class of cases
are able to discern yellow and blue, they cannot distinguish these colours when
presented in a state of mixture.  Green they do not know—they seem blind to
it.  They cannot perceive any difference in colour between a stick of red seal-
ing wax and a green table-cover;  between the colour of the scarlet fruit of  the
Siberian crab and the green of its leaves, &c, &c.
   So it was  also with Mary Bishop:  whilst able  to detect 5'ellow and blue she
could not see the difference in colour between the  red roses and  their green
leaves.  It was not until her eyes had become sensible to red that she could dis-
tinguish green.
   5. It seems probable that individuals who  are able to  recognise accurately
the three primitive colours, can also distinguish the secondary ones.  To future
observations must, however, be left  the decision of this question.  But persons
whose  perception of red is imperfect do not  accurately discriminate the secon-
dary colours.
   As the  imperfection in vision  we have  been  noticing is a very curious
one, it may be allowable here to call attention to some further facts connected
with  it.
   It must be remarked that whilst  those  who labour  under this defect natu-
rally are unable to  distinguish certain  colours, though of the most vivid kind,
they can discriminate any marked difference  in shades or degrees of colour,
and often can see minute objects  with perfect distinctness.  It  occurs  in per-
sons whose  point of vision is natural, as was the fact in most of the cases  on
record, and  also in those who are  far-sighted, as Mr. Nicholl's fourth case and
Mr. Colqhoun's second case;  and in those who are  near-sighted, as in Mr.
Dalton.
   This defect appears often to  be hereditary, or at least to prevail in  certain
families. Thus Harris had two brothers who were unable to distinguish colours,
while two other brothers and sisters, as well as his parents, had not this defect.**
Scott's father and one sister had the defect; his mother and another sister were
free from it; but his mother's brother had  it.  The former sister had two sons,
both labouring under  the  defect.   Scott had two children who were  able  to
distinguish colours.ft  In Nicholl's first case the mother and father and his four
sisters were  free from this  defect, but his mother's father had it.   This last had
two brothers and one  sister: one brother  had the  defect,  the others not.|J   In
Dr. Nicholl's second case  several of the family were similarly affected.^  Mr.
Dalton had a brother who laboured under the defect,|||| and he mentions that he

  * Transactions of the Phrenological Society, p. 222.
  + Glasgow Medical Journal, vol. ii. p. 15.         t Brewster's Optics, Am. ed., p. 260.
  I) Am. Journ. Med. Sci„ vol. xxiii. p.  446.         II Optics. Am. ed., p. 260.
  IT The editor of the  American edition of Brewster's  Optics, in  a note, p. 323, says in
relation to this case, "  The Plymouth taylor whose case is described by Mr. Harvey, seems
not to have been entirely blind to red light, and to have been in a measure blind to blue."
He has been,  we believe, misled in the former  inference, by the account of Mr. Harvey,
who was himself deceived by the individual naming scarlet correctly on one or more  oc-
casions, by guess.  A careful examination of Mr. Harvey's statement, will, we conceive,
justify this belief.  This  disposition to guess the names of colours is generally manifested
by persons who have the  defect under consideration; and the errors to which this may lead,
must be carefully guarded against.
  ** Philosophical Transactions, 1777.              tt Ibid, 1778.
  tt Med. Chirurg. Trans., vol. vii. p. 472.        §§ Med. Chirurg. Trans., vol. ix. p. 361.
  HII Mem. Lit. and Philos. Soc. Manchester, vol. v.
        70 
554
INABILITY TO DISTINGUISH COLOURS.
 knows of a family of six sons and one daughter, in which four of the sons were
 unable to distinguish colours*  Tucker's maternal grandfather had this defect;
 Wardrop states that several  branches of a noble family in Great Britain have
 been remarkable for having it ;f and we know of a family in this country similarly
 circumstanced.
   We have often noticed that persons affected with cataract, who were unable
 to discern the form  of objects, in consequence of the irregular refraction of some
 of the rays of light and the  interception of others, could  distinguish generally,
 very accurately, colours.  Connecting  this fact  with the inability to perceive
 colours while forms could be discerned, as observed  in Mary Bishop and some
 other cases of amaurosis, it  occurred to us that we might  derive from this a
 means of diagnosis between the two diseases.  Subsequent investigations have
 not confirmed this idea.   The subject may, however, be  worthy of a more ex-
 tensive examination than we have bestowed  on it.
   Several  theories have been  proposed to explain this defect of vision.  Mr.
 Dalton thinks it probable that the red light is  in these cases absorbed by the vi-
 treous humour, which he supposes may have a blue colour;  but this is a mere
 conjecture, which is not confirmed by the most minute examination of the eye,
 and does not even explain all the phenomena.
   Dr. Young thinks  it more simple to suppose absence or paralysis of those
 fibres of  the  retina  which are  calculated to   perceive red;  but  there  is
 no  evidence of there existing  in the  retina fibres suited to the perception  of
 the different colours,  and this also  does not embrace ail the degrees of the
 defect.
   Sir David Brewster, after analyzing  certain cases, says " In all the preceding
 cases there is one general fact that red light and colours in which it forms an in-
 gredient, are not distinguishable by those who possess the peculiarity in ques-
 tion."  Hence he at one time concluded that the eye is in these cases, insensi-
 ble  to colours at the one end of the spectrum, just as the  ear of certain persons
 has been proved by Dr. Wollaston, to be insensible to sounds at one extremity
 of the scale of musical notes, while it  is perfectly sensible to all other sounds.
 More recently he has offered the following explanation of the phenomena.  " The
 eyes of such persons," he remarks, "are blind to red light;  and when we ab-
 stract all the red rays from the spectrum constituted as already described,!tnere
 will be left two colours, blue  and yellow, the only colours  which are recognised
 by those who have this defect of vision.  To  such  eyes light is always seen  in
 the red space; but this arises from the eye being sensible to the yellow  and blue
 rays, which are mixed with the red light.   Hence blue light will be seen in the
 place of the violet, and a  greenish yellow will appear in the orange and red
 spaces, or which is the same thing, the spectrum will consist  only of the yellow
 and blue spectra."
   This theory embraces only one class of cases,  and even in them it does not
 explain all the phenomena, as for instance, how it is that those who can perceive
 yellow and blue cannot distmguish those colours in a state of mixture ;  for  of
 green they seem to have no  perception.
   Dr. W. Nicholl has proposed a  theory^ which  is, however, so opposed to all
 the facts that it is unnecessary to occupy time in detailing it.
   Mr. Wardrop thinks " it is not improbable that this defect of vision arises from
a greater  sensibility of the retina to the impressions  of the  blue  and yellow-
 making rays, than to those of any of the others."   " This may depend," he ob-
 serves, " upon the refractive powers of the humour, by which the rays  of  these

  * Mem. Lit. and Philos. Soc. Manchester, vol. v.
  t Essays on the Morbid Anatomy of the Human Eye, vol. ii. p. 199.
  t Optics, Am. ed., p. 69.               § Annals of Philosophy, Feb. 1822, p. 128. 
NEAR-SIGHT AND FAR'SIGHT.
555
 two colours are more accurately united on the retina than rays of any other
 colour, and, consequently, the images formed  there  of objects reflecting these
 colours are more distinct than those formed of objects reflecting the other co-
 lours.  When the colour of a body is compounded of several colours, the supe-
 rior correctness of the image formed by the blue and yellow rays reflected from
 it, may cause the sensations which these colours excite to predominate over the
 sensations caused by the other colours, and thus may cause in the mind of the
 observer the perception of that compound colour  to be different from the per-
 ception of the same  colour to another person, whose eye forms images of ex-
 ternal objects differently."*
   It is almost unnecessary to say that this is pure hypothesis and is even con-
 tradicted by some careful investigations presently to be noticed.
   Sir John  W. F. Herschell attributes this state of vision to a defect in the sen-
 sorium, by which it  is rendered  incapable of appreciating exactly those differ-
 ences between rays  on which their colour depends.   This profound philosopher
 observes,  " We have examined with some attention a very eminent optician,
 whose eyes (or  rather eye, having lost the sight of one by accident) have this
 peculiarity,  and have satisfied ourselves, contrary to received opinions, that all
 the prismatic rays have the power, of exciting and affecting them with the sen-
 sation of light, and producing distinct vision, so that the defect arises from no
 insensibility of the retina  to rays of any particular refrangibility, nor to any co-
 louring matter in the humours of the eye preventing certain rays from reaching
 the retina, (as has been ingeniously  supposed,)  but from a defect in the senso-
 rium, by which it is rendered incapable of appreciating exactly those differences
 between rays on which their colour depends."!
   This is essentially  the phrenological doctrine.   According to the phrenologists
 the eye only receives impressions, the power of judging of them resides in the
 sensorium;  and the inability to distinguish colours does not result from any de-
 fect or imperfection of the eye, but upon that particular  portion of the brain
 which they  have named the " organ  of colour."l
   We trust that the  preceding remarks will induce others to investigate the
 curious defect in vision  under consideration.   Opportunities, for this, we be-
 lieve, are of more frequent occurrence than is  supposed, and if advantage be
 taken of them, and the observations be made  accurately and with  a proper
 method, a clue will no doubt be obtained to its explanation.
   The prismatic spectrum, as it is always the same, and thus enables us to com-
pare observations, should be made use of.  The colours should  be shown toge-
ther and separately, and the individual's powers tested carefully.  It is particu-
larly desirable now to ascertain first what primitive  colours the individual can
distinguish, and  which if any of the compound colours.]
                 SECTION VI.--NEAR-SIGHT, AND FAR-SIGHT.


   These are two defects of vision not dependent upon the optic nerve,
but upon the refractive powers of the eye.   They are produced by cer-
tain configurations of  the transparent media, and happen in conformity
to the general laws of optics.   The rays of light are either collected too
soon, brought together before they reach the bottom of the eye, render-


  * Essays on the Morbid Anatomy of the Human Eye, vol. ii. p. 200.
  t Encyclopedia Metropolitan a, Art. Light, p. 434 and 507.
  t Mary Bishop's case would seem  to favour this theory, her affection having been the
sequel of an attack of cerebral disease. 
550
NEAR-SIGHTEDNESS.
ing the person myopic, or  near-sighted ; or they are not brought toge-
ther in front of the retina, the  focus in  which  they would meet being
behind the situation of that membrane, so that the person is presbyopic,
or far-sighted.  These kinds of sight are consequent upon some condi-
tions of the transparent media  of  the  eye, which, in all other respects,
is perfectly natural.   The  eye, being in a great part of its functions a
mechanical instrument, must be subjected to mechanical laws; and we
find, that a given configuration of the transparent media, a certain re-
lation of them to each other, and their position at determinate distances
from,the retina, are  necessary to the formation of a  distinct  picture
upon that nervous expansion.   There is a certain distance from the eye,
which is called the point of distinct vision, at which we  can see objects
in all their details with perfect clearness.  Every eye, considered as an
optical instrument, has its  point of distinct vision;  the latter, therefore,
varies in different persons, and is often different in the  two eyes of the
same individual.  Objects  are not  so distinctly seen, when moved nearer
to, or further from the eye than this point  In ordinary well-constructed
eyes, the distance ranges from about fifieen to twenty inches.   It must
be observed,  however, that they are peculiarly strong  eyes which can
see distinctly beyond these  limits on either side.  Persons who are
obliged to hold objects much closer to the eye than the distance already
mentioned, are called myopic,  or  near-sighted.
  Near-sightedness; myopia.—An  individual who  is myopic, holds  a
book for reading, or any thing that he may wish to examine minutely,
much nearer to the eye than others; he cannot distinguish the counte-
nances of performers on  the  stage, nor the details of pictures when
placed some feet from him ; he cannot read the inscriptions on doors and
houses, nor recognise persons across  the street; if he go into a  large
room in which there are  many persons, he  cannot readily distinguish
those he knows. The cause of this is in the transparent media of the eye.
Probably there is an original difference in the configuration, or the den-
sity of these media,  or in  the  condition of  their surfaces.: Sometimes
the cornea is manifestly more  convex, and the anterior chamber larger
lhan in the normal state.   I have seen those changes, with great  near-
sightedness, as results of obstinate strumous ophthalmia, or other  long-
continued inflammation affecting the  anterior parts of the eye.  The
affection called conical cornea is  attended with  myopia, which becomes
more and more considerable as the affection advances. (See p. 357.) But,
in most cases, the state of the eye appears  quite natural, and we can-
not discover the circumstances on which  the  defect  immediately de-
pends.
  It may be a question whether this state of the  eye is brought on by
the habits of the  individual.   I am inclined to think that  the habitual
mode of employing the organ  has some influence.   Jn persons of a lite-
rary and studious  character, who use their eyes much in reading  or
writing, and  in others who are constantly occupied on minute objects
near the eye, we observe that  the sight is frequently myopic.  I  remem-
ber once attending a book-sale, at which I was struck by the  number
of persons wearing spectacles; having counted them, I found there were
twenty-three gentlemen in the room, and that twelve of the number had
spectacles on.  Mr. Ware endeavoured  to  ascertain  the  proportional 
NEAR-SIGHTEDNESS.
557
 numbers of the near-sighted in the different ranks of society.  " I  have
 inquired," says he, "for instance, of the surgeons of the three regiments
 of foot-guards, which consist of nearly ten thousand men ; and the re-
 sult has been, that near-sightedness among the privates is almost utterly
 unknown. Not half-a-dozen men have been discharged, nor half-a-dozen
 recruits rejected, on account of this imperfection, in the space of nearly
 twenty years; and yet many parts of a soldier's duty require  him to
 have a tolerably correct view of distant  objects."  "I pursued my in-
 quiries at the military school at Chelsea, where there are thirteen  hun-
 dred children, and I found that the complaint of near-sightedness had
 never been made among them until I mentioned it; and there were then
 only three who experienced the least inconvenience from it. After this, I
 inquired  at several of the colleges in Oxford and Cambridge; and though
 there is a great diversity in  the number of students who make use of
 glasses in the various colleges, they are used  by  a considerable propor-
 tion of the whole number in both  universities;  and in one college in
 Oxford, I have a list of the names of not less  than thirty-two out of one
 hundred  and twenty-seven, who wore either a hand-glass or spectacles,
 between the years 1803 and 1807."  (Tracts on the Eye, p. 201, 202.)
   Mr. Ware mentions the case of  a mathematical instrument  maker,
 who had long used  convex glasses for reading.  After  having  been
 employed several hours together, for many successive  days, in looking
 through  a double microscope, he has  been able, repeatedly, for a  few
 weeks, to read without glasses;  this improvement goes  off in a  few
 weeks, and  he is then obliged to resume  his former spectacles.  (Ibid,
 p. 228.)
   From  these facts, together with  the well  known far-sightedness of
 sailors and country people, we may infer, that the habitual mode of em-
 ploying the  eyes has decided influence in rendering them either myopic
 or presbyopic.
   Hence it  may be true, as Mr. Ware surmises, that the smaller propor-
 tion of the near-sighted in the lower  classes arises from  their  not re-
 sorting to means for correcting so slight an imperfection, which  may be
 consequently overcome by the increased exertions of the eye to distinguish
 distant objects.   Hence, also, it is probable that  the defect may be con-
 firmed by the habitual use of concave  glasses,  and even increased if
 the near  sighted person employs those which give him the clearest sight.
 These at first cause uneasiness, which  goes off  under  their continued
 employment; and a deeper glass will be required, after some time, to pro-
 duce the  same effect.
   Near-sightedness is not  observed early in life ;"* persons do not resort
 to the use of glasses until towards the age of fourteen.   The defect may
 exist previously without being noticed, as young persons do not attend mi-
 nutely to  the state of their sight, or compare accurately their own vision
 with that of others.
   We sometimes see  anomalous cases of near-sightedness dependent on
 some change in the state of the eye, which we  are unable to explain.
 Mr.  Ware (Tracts on the  Eye, p. 206,) mentions the instance  of a
youth at school, in whom it came on suddenly after previous anomalous
nervous symptoms.  He was sent into the country for the recovery of
* We have seen several exceptions to this, 
558
XEAR-SIGHTEDNESS.
 his health, with the  recommendation to  postpone  the  use of  concave
 glasses until he returned.  In ten days he died suddenly.  A gentleman,
 who had found it necessary to use  convex glasses at the age  of forty,
 began, when he was fifty, to see distant objects indistinctly,  and was
 obliged to employ a concave glass (number six) for distant sight, though
 he still used convex  glasses  of the first  number for reading.   (Ibid, p.
 225.)  A woman of fifty, who had become presbyopic, was  attacked
 with dimness of sight and slight inflammation of one eye, for which co-
 pious evacuations  were  necessary.   On recovery, she  found herself
 near-sighted, and required concave glasses  of the fifth  number for see-
 ing distant,objects.  (Ibid, p. 226.)   In a lady, who had long been pres-
 byopic, inflammation of the eyes occurred  requiring leeches and other
 means.  When she got well, she could read without her glasses; but the
 presbyopia returned  in a few weeks.  (Ibid, p. 227.)
   The only mode of remedying  near-sightedness is the use of  concave
 glasses; the imperfection of vision is  caused by too great a refractive
 power in the eyes, and we must have recourse to artificial measures for
 lessening it.  Our  object is to enable the  near-sightqd to see distant
 things; indeed, they see  near objects very well, and this circumstance
 has given rise to the notion that  their eyes are strong.   In order to se-
 lect the proper glass,  the 'person must try several, and choose that with
 which he can see a distant object most  distinctly.   If  this is  accom-
 plished without any sense of painful exertion in the eye, the glass which
 will enable him to do so, is that«which he should choose.   He will pro-
 bably find that w7ith a glass rather more  concave, for instance of the
 next number to that which he has chosen, he can see still more  clearly,
 but that after looking through it  for a short time the eye feels  strained
 and fatigued ; he should not allow this slight  advantage in point of vision
 to induce him to  expose the  eye  to an influence that  will be injurious.
 From the use, under proper precautions of such concave glasses as will
 rectify the error in the refractive power, the near-sighted  person need
 not apprehend any injury to the eye ; indeed, the easy exercise of vision
 with the requisite optical aid, seems to me less hurtful than the straining
 and efforts to do without it.   As there is some  reason  for concluding
 that the optical powers of the eye accommodate themselves to the cir-
 cumstances under which  vision  is habitually exercised, I recommend
 near-sighted persons not to wear  spectacles  constantly, but only to use
 them on occasions when they more particularly require such assistance.
 When they have been worn for a  considerable time, the person does not
 at first see  so well on leaving them off as he did before; but this is only
 temporary.   If spectacles, chosen in  the manner I have described, be
 worn only occasionally there  is no fear of the eye becoming more near-
 sighted, so  as gradually to require deeper glasses.
  The eye in  the progress of  age becomes presbyopic, and it might be
 supposed that this natural change in the organ would remedy the excess
 of refractive power in the near-sighted, and enable them to dispense
with their concave glasses: this is not the case; the near-sighted con-
tinue so in old age.  I have known several instances, in which  myopic
persons were still obliged to use their concave glasses, although  greatly
advanced in years.  To the same eflect Mr. Ware observes, that " the
instances are few, if any, in which, if the use of concave glasses has been 
NEAR-SIGHTEDNESS.
559
 adopted, increasing years have either removed or lessened this imper-
 fection."  (Tracts on the Eye, p. 230.)   His  observations, in  another
 part of the same tract, show that the range of vision, which is compa-
 ratively confined in the  near-sighted  originally, becomes still  more  li-
 mited  in advancing years.  Neither is there any ground for the notion
 that near-sight is strong  sight.
   [The following remarks  by Dr. Mackenzie, on  the treatment of myopia are
 of sufficient interest to justify our introducing them here.
   " It is but rarely the case that  the medical practitioner has an opportunity of
 advising those in whom myopia is not yet confirmed, to that course of treatment
 which  might remove the incipient symptoms of this very serious imperfection of
 sight.  If it be correct, that this disease, in  by far the greater number  of in-
 stances, is induced by too much exercise of the eyes upon minute objects, as in
 reading, writing, sewing, miniature painting, engraving, and the like, the cure
 would probably be found in abstaining entirely for a time from such occupations,
 refraining also from the use of concave glasses, and employing the eyes chiefly
 upon large and  distant  objects.   Haller  recommends looking through a small
 aperture, as a remedy for myopia;  but probably this, as well as gradually re-
 moving the book from the eye till it can read at the ordinary  distance, reading
 through convex glasses, and other attempts of a similar  sort, will prove  of
 little use, in comparison of  the good effects to be derived from frequent exer-
 cise out of doors, walking and riding into the country, and travelling through
 new and interesting scenes.
   " If, instead of such a plan of treatment, recourse be had to the employment of
 concave glasses, and the frequent and  long-continued  observation of near ob-
 jects be persisted  in, the disease becomes not only confirmed, but sometimes
 greatly aggravated.
   "' When I first learned to  read, at the usual age of four or five years,' says
 Sir Charles Blagden, ' I could see most distinctly, across a wide church, the
 contents of a table on which the Lord's Prayer, and the Belief, were painted in
 suitably large letters.  In a few  years,  that is, about the ninth or tenth of my
 age, being much addicted to books, I could no longer read what was painted on
 this table; but the degree of near-sightedness was then so small, that I found a
 watch-glass, though as a  meniscus* it made the rays diverge very little, suffi-
 cient to enable me to read the table as before.   In a year or two more the watch-
 glass would no longer serve my purpose ;  but being dissuaded from the use of
 a common concave glass, as likely to injure my sight, I suffered the inconve-
 nience of  a small degree of myopy till I was more than thirty years of age.
 That inconvenience, however, gradually though slowly increasing all the time,
 at length became so grievous, that  at two or three  and thirty, I determined  to
 try a concave glass; and then found, that the numbers two and three were to
 me in the  relation so well described by Mr. Ware; that is, I could  see distant
 objects tolerably well with the former number, but still more accurately with the
 latter.  After contenting myself a little time with No. 2, I laid it wholly aside for
 No. 3; and, in the course of a few more years, came to No  5, at which point
 my eye has now been stationary between fifteen and twenty years.  An earlier
 use of  concave glasses would probably have made me more near-sighted, or
 wrould have brought on my present degree of myopy at an earlier period of life.
 If my friends had persuaded me to read and write with the book or paper al-
 ways as far from my eyes  as I could see ; or if I had occasionally intermitted

  * Sir C. Blagden here employs the word meniscus, (from /unvn, moon,) in a sense, which,
though perhaps vindicated by occasional practice, it were better to  avoid.  A watch-glass,
is merely a segment of a hollow sphere, the surfaces of which are concentric. 
560
NEAR-SIGHTEDNESS.
 study, and taken to field sports, or any employment which would have obliged
 me to  look much at  distant objects, it is  very probable that I might not
 have been near-sighted at all.'*
   " Concave glasses.  When once a near-sighted person has experienced the
 pleasure of seeing remote objects, with that distinctness and comparative bril-
 liancy, which the aid of concave glasses affords, it is not easy to persuade him
 to renounce their use.  Their effect, as  is now universally known, is merely to
 diverge the rays of light before they enter the eye, by this means counteracting
 the over-refractive power of that organ, and bringing the rays of light  exactly
 into foci upon the retina.   The assistance afforded by concave glasses to one
 set of defective eyes, and by convex to another, had been the subject of admira-
 tion and perplexity for several hundred years, till Kepler, in his Ad  Vitellionem
 Paralipomena, published in 1604, cleared up the mystery, by explaining, for the
 first time, the true mechanism of the eye.   It  had  been proposed as a  question
 to Kepler, by his patron, Dietrickstein, in what manner spectacles assisted sight.
 The first answer he gave was, that convex glasses were of use, by making ob-
 jects appear larger, but his  patron observed, that if objects were by them ren-
 dered more distinct, because larger, no person would be benefited by concave
 glasses, since these diminished objects.  The striking resemblance between ex-
 periments with the camera obscura and the manner in which vision is performed
 in the eye, had been pointed out by Baptista Porta, who compared the pupil to
 the hole in  the window-shutter, but fell into the mistake of supposing that it
 was in the centre of the eye ball that vision was effected.!  Kepler, in his work
 above referred to,  showed that the  office of receiving the images of external
 objects  is performed by the retina, and  gave  the first clear explanation, of the
 effects of lenses, whether within or without the eye, in making the rays of a
 pencil of light converge or  diverge.  He  now explained, that  convex  glasses
 assist the sight of presbyopic persons, by so altering the directions of rays di-
 verging from a near object, that they should afterwards fall upon the eye, as if
 they had proceeded from a more remote one, and that cancave glasses benefit
 the myopic, by producing a  contrary effect upon rays which  diverge from a
 distant  object—a  theory to which  no  addition has  been made by  any suc-
 ceeding author.
  " The glasses commonly employed for the assistance of myopic eyes are double-
 concaves, of equal concavity on  each side.   Occasionally, however, the two
 sides  are  made  of unequal  depth.  A  plano-concave glass  might answer;
 and in the use of concavo-convexes (the exterior  surface of the  glass, or that
 which is turned from  the eye, being convex, and having a  less degree of cur-
 vature than the interior, or that which is turned towards the eye,  which is con-
 cave,) there is supposed to be a considerable advantage, in  so far  as they allow
 the eyes a  greater degree  of latitude in  vision, without  fatigue, whence the
 name periscopic glasses, under  which they  were recommended  by Dr. Wollas-
 ton.
  " Myopic persons are extremely apt to adopt the use of a single eye-glass,
against which we ought to put them on their guard.   Spectacles are always
preferable, because by keeping both eyes in action, not only is vision rendered
brighter and easier, but the labour of each eye is  considerably lessened.  Dr.
Wells has pointed  out another reason, why glasses should be employed rather
in the form of spectacles, than singly, which, though it applies more strongly to
the  use  of  convex than of concave glasses, I shall here introduce in his  own
words.

  * Philosophical Transactions, vol. ciii. p. 110; London, 1811.
  t Magi* Naiuralis, sive de Miraculis Rcrum Naturalium, Libri iv; fol. 118;  Anluer-
piae, 1560. 
NEAR-SIGHTEDNESS.
561
   "' In regard to such  spectacles as I have tried  upon myself, I  have always
 found, that, when I looked with them at objects, placed at moderate distances
 before me, my optic axis passed through  the glasses, more inwardly than their
 centres. With respect, therefore, to spectacles for long-sighted people, as the inner
 halves of their glasses may be regarded as two prisms, whose refracting angles
 face each other, to have allowed both my eyes to receive through  them pencils
 of rays from the same point of an object, the intervals of my pupils must have
 been less than was  necessary for  that  purpose in naked  vision.   The conse-
 quence of which would be, an increase of the  refractive  power  of my eyes.
 Again; as the like parts of glasses in spectacles for short-sighted persons, may
 be esteemed to be two prisms, the refracting  angles of which are  turned from
 each other, the interval of the pupils must have been increased, and the refracting
 power of my eyes by this  means diminished, when  I looked at an object through
 them, which was directly  before me.  And effects  similar  to what I have men-
 tioned, must have followed my viewing objects placed obliquely, through glasses
 of both kinds.  Here  then is one advantage, which persons who see with both
 eyes, either do or may enjoy from spectacles, but which they cannot derive from
 using single glasses.  For if they are presbytic, they can see an object by the
 means of them with a higher refractive state of the eyes, than if the optic axes
 met there, as in naked vision ; and if myopic, with a less.   It is also worthy of
 remark, that this advantage does not ultimately tend to increase the evil, which
 first gives occasion for spectacles.   On the contrary, if what every writer upon
 vision asserts be true, that we are apt to become short or  long-sighted, accord-
 ing as we are much accustomed to view near or distant objects, it must serve
 to diminish that evil.  In support of this opinion, I shall mention  a fact, with
 which I have been made  acquainted by Mr. George Adams, of this place, who
 is not only well skilled in the theory of vision, but, from his situation as an artist,
 has better opportunities than most persons, of learning such matters.  The fact
 is this, that he does not know a short-sighted person, who  has had occasion to
 increase the depth of his glasses, if he began to use them in the form of specta-
 cles; whereas, he can recollect several instances, where those have been obliged
 to  change their concave glasses repeatedly, for  others of higher powers, who
 had been accustomed to apply them to one eye.'*
   " Double-concave glasses are numbered 1,2,  3, &c. beginning  with the longest
 focus, or shallowest concavity.!  We must recommend to  the near-sighted per-


  * Experiments and Observations on several Subjects in Optics, p. 99; London, 1818.
  t Concave glasses ought to be distinguished by their focal lengths, and never by num-
 bers, because the gradations of concavity are not always worked to a certain standard, so
 that what one optician calls No. 1, another rates as No. 2, and so on.  I find  No. 1 to be 48
 inches focus in one shop,  and 24 inches in another; No. 12, to be 10 inches focus in one, and
 4£ in another.  Mr. Ramsden made the first number of his concave glasses equivalent to a
 convex of 24 inches focus, i. e. if a convex of that focal length were united to a concave
 No. 1, the combination would be equivalent to a plane, and objects would appear through
 the two glasses neither larger nor smaller than they really are.   No. 2 he made to corres-
 pond to a 21 iHch convex; No. 3 to an 18; and so on.
  The following are the  foci in inches of a set of concave glasses which I keep by me, with
 which to try myopic eyes.
      No. I   - -  48            No. 5  -  -   14             No. 9   -  -  5
          2   . -  36                 6   -  .   12                10   -  -  4
          3   - - 24                 7   -  -    9                11   -  -  3
          4  - -  18                 8.-7                12   -  -  2£
  In Germany, what is called No. 1, is commonly of the focal length of 2£ or 3 inches,
and each following number has an inch, or a certain  number of lines, of additional focal
length.
  The focus of a concave lens may be ascertained, by reflecting from its surface, upon an
opaque  body, the image of  any very distant  luminous object, such as the sun, observing
when the image becomes smallest, and measuring the distance between the centre of the
        71 
562
NEAR-SIGHTEDNESS.
son to be content with the shallowest glass or  lowest number, which answers
his purpose.   If No. 1 enables him to discern distinctly the names on the cor-
ners of the streets, and gives a decided outline  to  objects whose distance does
not exceed about 40 feet, he ought not to have recourse to No. 2.  Objects should
appear clear through the glass which is chosen; but if it makes them less than na-
tural, or  gives them a dazzling or glaring appearance, or if the eye feels strained
or fatigued after looking through it for a short time, it is too deep, and a lower
number should be selected.
   " When a near-sighted person wishes  to  be fitted with concave glasses, the
simplest and surest plan is to try a series of them, at an optician's shop.  It may
happen, however, that an individual in the  country  is desirous  of writing to
town for concave glasses, and wishes to mention the  focus which will be likely
to suit his eye.  This may be ascertained by means  of the optometer, as im-
proved by Dr. Young; but as this instrument is not always at hand, the follow-
ing rules may be adopted.
   1.  " If the near-sighted person is desirous  of assistance in seeing remote ob-
jects, i. e. beyond 200 or 300 yards, the focal distance of the glasses which  he
will require for that purpose, should  be the distance  at which a  small object
appears  distinct to his naked  eye.   For example, if he  reads  this type at  12
inches distance, 12 inches will be the focus of the concave glasses which he will
require for seeing distant objects distinctly..
   2.  " If the  glasses wanted are intended for reading with, or seeing near ob-
jects, let the near-sighted person multiply the distance  at which he is able to read
with  ease with the naked eye, say 4 inches, by the distance at which he wishes
to read, say 12 inches; divide the product 48 by the difference between the two,
which in this instance is 8 ; the quotient, 6, is the focal length in inches of the
glass which is required.
   " It is a very common error with those persons who begin to use concave glass-
es, to tire of those which  they first employ, and have recourse to deeper ones.
To these the eyes do not fail (at least for a time) to accommodate themselves;
but, in the end, the patient, who thus proceeds from one degree of concavity to a
greater, will find it difficult to obtain glasses sufficiently deep to afford him much
assistance, or  he may produce such weakness of the retina, or  amblyopia, as
shall render him unfit to  engage in any ordinary pursuit.  Near-sightedness
generally continues, as has  been already stated, in nearly the same degree
during the greater part of life. Therefore, the same glass will continue, for many
years to  afford precisely the  same assistance, and ought  not  to  be heedlessly
changed for one of deeper concavity.
   " Dr. Kitchener tells us, that he was about fifteen years old, when he first dis-
covered  that he could not discern distant objects so distinctly as people who have
common eyes  usually do.  ' Seeing' says he,' that I  could not see what per-
sons with common eyes frequently pointed out to  me as well deserving my at-
tention, I paid a visit to an optician,  and purchased a  concave eye-glass No. 2.
After using this some little time, I accidentally looked through  a concave No. 3,
and finding my sight much sharper with this than with No. 2, had my specta-
cles glassed with No. 3, which appeared to afford my  eye as much assistance as
it could receive.   After using No. 3 for a few months, I chanced to look through
No. 4, and again found the same increase of sharpness, &c. which I  perceived
before when I had been using No. 2 and first saw through No. 3, therefore con-
cluded that I had not yet got glasses sufficiently concave, and accordingly pro-

reflecting surface and the body upon which the image is received.  Double this distance is
the focal  length of the lens, and is equal to the radius of curvature of its  surfaces, these
being ground on the same'tool.  The two surfaces, however, are not always ground on a
tool of the same radius, so that the one side is sometimes deeper than the other. 
FAR-SIGHTEDNESS.
563
  cured No. 4 ; however, this soon became no more stimulus to the optic nerve
  than its predecessors Nos. 2 and 3 had  been.  I then began to think that the
  sight was subject to the same laws which govern the other parts of our system,
  i. e. an  increased stimulus by repetition soon loses its power to produce an
  increased effect.  Therefore I refused my eye any farther assistance than it re-
  ceived from spectacles glassed with No. 2, which I have worn for upwards of
  thirty-one years, and it is very nearly, if not quite as sufficient help to me now,
  as it was when I first employed it.'*
   " The same author recommends persons who are extremely short-sighted, in
  order to prevent their being obliged to stoop in writing, reading music, and the
  like, to wear spectacles with very shallow concaves, just enough to enable them
  to see the objects required in such cases, at the same distance with other per-
  sons ; but for distant objects, to use a small opera-glass, which having an adjust-
  able focus, if it magnifies only twice, will be infinitely better than any single
  concave,  because it can be exactly adapted to the various distances.
   "It is advisable that near-sighted persons should not wear spectacles constantly,
  but only on occasions when  they more particularly require such assistance.
  When they have been worn for a considerable time, the person does not at first
  see so well on leaving them off as he did before ; but this is only temporary."
  Practical Treatise, p. 784-8.]
   Far-sightedness.—The opposite state of the eye is called presbyopia,
  or far-sightedness; the former word being derived  from  vfi^vs-, an
  old man, because this state of the eye is observed in advancing age, and
  is most  strongly marked in  old  persons.   The eyes undergo certain
  changes in age, which  have the  effect  of diminishing  their refractive
 power, so that the rays of  light are  not  brought to a focus before they
 reach the bottom  of the eye.   The focus of such rays would be formed
  behind the retina.  This is the  opposite  state to  that which we have
 just been considering.  Persons between forty and fifty,  and sometimes
 before that age, generally find that they cannot distinguish near objects
 so well as they have been  accustomed to do.   They find it difficult to
 read  small print, or writing, to cut a pen or pencil, or to do any thing
 that requires  a clear near sight.   The rays of light are more divergent
 the nearer the object is  to the eye; and the further it may be, the more
 do they approach to the  parallel direction; consequently a greater refrac-
 tive power is  necessary in  the  former than  in  the  latter case.   Far-
 sighted persons can see distant inscriptions, or distinguish the  hour by
 a distant church clock,  when they cannot read a common print held in
 their own hands, or see the figures and hands of a watch.   This state
 of the organ must be  remedied  by  the  use of a  convex glass, which
 bringing  together the divergent rays proceeding from near  objects, re-
 medies the deficient refractive power of the eye.  The glasses must be
 chosen under the same restrictions as  I mentioned in the former case \
 they must enable the  person to  see without  straining or fatiguing the
 organ, and should  only  be worn for reading, writing, or the examina-
 tion of near objects.   This being a defective  state of  vision depending
 upon age, gradually increases,  and therefore requires  a  corresponding
 increase in  the power of the glasses employed.
  [The following remarks  by Dr. Mackenzie on the use of glasses are very ju-
dicious.
* Economy of the Ryes, Part I. p. 111; London, 1826, 
564
FAR-SIGHTEDNESS.
  " The assistance," he observes," which the presbyopic eye derives from a double
convex glass, ought neither to be too soon had recourse to, nor too long delayed.
Many injure the sight, by adopting the use  of magnifiers suddenly, and be-
fore they have any need of them; while others, actuated perhaps by a desire of
concealing their age, refrain  from employing  them long after the period when
glasses would not merely have afforded valuable assistance, but have proved a
means of saving their sight.  The presbyopic eye, if refused  assistance, is ne-
cessarily strained by every attempt to perceive near objects, and suffers more in
a few months by forced exertion, than it would do in as many years, if assisted
by such glasses  as would render vision easy and agreeable.
  " It would evidently be absurd to fix upon any period of life at which glasses
should be first employed, or at  which the presbyopic eye  should be assisted by
stronger magnifiers than those  made choice of in the first instance; but it may
be laid down as a general rule, that whenever a person of 45 years of age, or
upwards, finds, that in order to see small objects distinctly, he is obliged to car-
ry them far from his eye ; that he moves, as  it were indistinctively, nearer to
the light, when he wishes to read  or work, or holds  the  book or other object
close to the light, in order to see with facility; that very small objects, after he
has looked at them earnestly for some time, appear confused; that his eyes,
after slight exertion, become so much fatigued, that he is obliged to turn them to
other objects, in order  to give them some  relaxation; and that the  sight on
awakening in the  morning, is very weak, and does not  recover its customary
degree of force  for some hours; then, he may, if he has not hitherto used con-
vex glasses, begin to use them, or if he has  already had recourse  to those of
a very long focus, he may change them for a pair of shorter focus, or, in other
words, of greater refractive power.
  w A double-convex glass improves the vision  of a  presbyopic eye, simply by
lessening the divergence of the rays of light proceeding from near objects, and
thus ensuring their being brought into foci upon  the retina.  To  see distant
objects with distinctness, glasses are in general not required by  the presbyopic
eye; on the contrary, parallel rays being sufficiently converged by the refractive
media of the eye itself, to be brought to their respective foci on the retina, the
conyex glasses  must be  laid aside, when objects at a distance  are to be ex-
amined.
  "As a meniscus will produce the same effect as a double-convex glass, in ena-
bling the presbyopic eye to perceive near objects with distinctness, while it will
allow the eye greater latitude without fatigue, Dr. Wollaston has recommended
the former as a periscopic glass for far-sighted persons.
  " Similar directions must be followed in choosing convex glasses as in selecting
concave ones;  viz. that the lowest power, or  longest focus, which answers the
purpose, is to be chosen; and that as the  concave glasses made use of by the
near-sighted should not make objects appear smaller, neither should the convex
glasses employed by the far-sighted make them appear larger  than natural.*
  " If on trying  the eyes separately, the individual discovers that one of his eyes
only has become presbyopic from  age, while the other is  near-sighted  from an
original difference in conformation, he will find a reading glass,  of about three

  * Convex glasses are kept in Ihe shops, of every focal  length, from forty-eight inches to
six.  It is evident, that no certain estimate can be formed from a person's age, of the focal
length of the glass which he will require; although  perhaps the following may be received
as a tolerable approximation to ;in average, upon this head.
Years of age,......................40 45 50 55 58 60  65 70 75 80 85 90 ]00
Focal lengths in inches,......,.......36 30 24 20 18 16 14 12 10  9  8  7   6
  The focus of a convex glass may bo measured by holding it near the  side of a. room,
facing a window, or opposite to the sun, and moving it slowly backwards and forwards, until
the image of the window frame, or of the sun, upon the wall, becomes smallest und most
distinct.  The distance between the glass and the wall at that moment is the focal length. 
FAR-SIGHTEDNESS.
565
inches in diameter, and of 12 or 14 inches focus, to  answer  him much better
than spectacles.
   " Persons at a distance from  an optician, may determine the focal length of
the convex glasses, which they will require, by means of the following rules.
   " 1. If they have a distinct vision of objects moderately nmote, let them mul-
tiply the distance at which they see minute objects most distinctly, say 20 inches,
by the distance at which they  wish to read by the aid of glasses, say 12 inches,
and divide the product, 240, by the diffeience between the two, 8; the quotient,
30, will be the focal length of the glasses required.
   " 2. If the distance at which the person sees  most distinctly be very great,
then the focal length of the glasses required will be equal to the distance at which
he wishes to see objects most distinctly.
   " Convex glasses of about 36 inches' focus are often used by ignorant people,
under the name of preservers, before their sight has attained  that degree of
presbyopia, which renders the use of glasses necessary. They seem to think that
preservers have some specific  power of arresting the progress of that failure of
the sight, which is the  natural consequence of age.
   " As it is chiefly by candle-light that the  presbyopic patient complains of his
deficient sight, even after he has supplied himself with proper glasses it is advi-
sable that he should  refrain, as  much as  possible, from employing himself at
night in occupations,  which require intense use  of the organs of vision.  The
moment that the eyes begin to feel hot and fatigued, while the individual is occu-
pied in reading, writing, or the like, especially by candle-light, he should take the
hint, and allow them a period of repose."   (Practical Treatise, p. 792-4.)
   Presbyopia is not a defect of old age alone, it  occurs also in young persons,
and if we may judge from the  number of examples which have come under our
observation,  much more frequently than is generally supposed.   Within  the
last six months we have been consulted in two cases, one a lad of nine years
of age, the second a girl of ten.   The  former was supposed to be threatened
with amaurosis, and had been subjected to very severe treatment in consequence.
With a glass  of eleven inches focus he could read sufficiently well, but he  re-
quired for perfect vision one of four and a half inches.  The little girl was still
more presbyopic, seeing best with glasses of three and a half inches focus.  Both
cases seemed to have been congenital, the latter certainly was so.
   Presbyopia sometimes occurs  suddenly.
   A very interesting case of sudden and temporary presbyopia in a young boy,
is related by  Dr. James Hunter, in the Edinburgh Med. and Surg. J. Jan. 1840.
The subject of it was an intelligent boy, 9| years of age, who had been three
years at school, and was very fond of his books.   His sight began to fail about
three weeks before Dr. H. saw him, and was so much impaired in the course of
four days that he could no longer see to read ordinary type with the naked eye.
He had never had inflammation or other diseases of the eyes, nor received any
local injury that could have caused this affection.   His general health had always
been  good, and he  never felt better than at the time  when his sight gave way.
Dr. H., on the most minute examination, could detect no visible symptom of dis-
ease.   There was no  vascularity of the tunics; the size and shape of the pupils,
the motions of the iris, eye-ball and eye-lids were perfectly normal, and he  felt
no pain or uneasiness.  He could see distant objects  as  well as ever, but near
ones  appeared very indistinct.  With the assistance of his father's spectacles,
which were fitted with glasses  of nine and a half inches focal distance, he could
read the smallest print.
   The patient was ordered an active dose of calomel and  rhubarb, and after-
wards an aperient of senna and salts twice a week, a  spare diet, active out-door
exercise—to  be kept  from school,  and not to be allowed to use spectacles.
Exactly three weeks afterwards his sight began to improve, and in the course 
506
FAR-SIGHTEDNESS.
of  two  days was quite restored.   The  medicine  had  purged  freely—no
worms were discharged.  The boy was afterwards able to read as well as ever
without glasses.
  After  discussing the  several proximate  causes  of presbyopia, Dr. H.  very
correctly, we think, considers that, in the present case, it resulted from a de-
rangement of the mechanism for adjustment.
   " All things considered," he remarks, " I think the best explanation  of this
case is to suppose that there was some derangement of the mechanism by which
the eyes are accommodated to the  distinct vision of objects  at  different dis-
tances.   When the eye  is turned from a distant object to the contemplation of a
near one, a short interval elapses before the latter is seen distinctly; this interval
being occupied in the adjustment of  the focus vision.   During this process the
only visible change is a slight contraction of the pupil; but  all physiologists
agree that some other change must take place.  The lens  must either become
more convex, or move forwards, or the antero-posterior diameter of the eye ball
be lengthened, or the cornea become more prominent, or perhaps there  is a
combination of all or of some of these modes  of adjustment.  As all the above
actions imply a power of contraction and relaxation in certain internal structures
of the eye ball, it is very probable that the movements of these parts should at
times be subject to derangement from spasms or from over-relaxation,  in the
same way as other organs  endowed with a contractile power; and therefore, I
think it not unlikely that in the present case, the eyes had temporarily lost the
power of changing from the state necessary to fit them for the  distinct vision of
distant objects to that state required for the distinct vision of near ones: but
whether that change is to be regarded as a contraction of certain parts, such
as the ciliary ligament, as some suppose, or the fibres of the  lens, as believed
by others; or in a relaxation of these or other parts, cannot be determined in the
present  imperfect state of our knowledge of the exact manner in which the eye
is adjusted to distance.   This view of the case is supported  by the following
circumstances:
  " 1. The affection and recovery of the two eyes were simultaneous and equal,
as might be expected if  the presbyopia depended on a spasmodic derangement
of their  adjusting apparatus, which, being destined to act simultaneously and
equally in health, is likely to be similarly affected in disease.
  " 2. The vision of distant objects was perfect, and near objects were seen quite
distinctly with convex glasses; showing the sensibility and other functions of
the  retina to be unaltered, and that the cause of the disease was one that did not
interfere with the functions of the eyes, excepting by depriving them of their
power of adjustment to  distance.
  " 3. Other cases of the sudden occurrence of presbyopia in  young children
have been traced to the existence of various disorders, such as intestinal worms,
epilepsy, and diseases of the brain or spinal cord, all of which are known to be
frequently accompanied by spasmodic affections of different organs.
  " The treatment of the present case was very simple; but I would call par-
ticular attention  to the necessity in all similar  cases  of strictly prohibiting the
use of spectacles in the first instance,  for they  can always be resorted to at an
after period should the affection prove a permanent one; and  I have but  little
doubt that, if the wishes of my patient had been  complied with, and he had
been allowed to  continue to use his father's spectacles, the presbyopia  would
have become a confirmed disease."
  Mr. Ware also mentions the case of a boy eight years of age, who suddenly
became  presbyopic, and was repeatedly punished at school on account of his
incorrect and defaced writing, the  real  cause  being unknown to his master.
After the presbyopia had continued a  fortnight, and different local applications
had been used without producing any sensibly good effects, a cure was accom- 
IRREGULAR REFRACTION.
507
plished by the application of leeches to the temples, and the use  of purgative
medicines.   Two sisters of this patient were similarly affected.  The elder, 20
years of age, had never been able to do fine work, and for three years had been
greatly assisted by convex spectacles.   The younger, a girl of 15, had been
presbyopic for about a year, being obliged to use glasses whenever she read,
or worked with  her needle.  This patient in  the course of six weeks, during
which she totally abstained from the use of glasses, was completely relieved from
the necessity of using them, by the application of two leeches to  each temple
twice a-week.  The elder sister in the same space of time experienced much re-
lief from similar treatment, but was still unable to do fine work without glasses,
partly in consequence of the  long continuance of the infirmity, and partly on
account of her not having abstained from the use of her spectacles with  equal
steadiness.   Philos. Trans. 1813.
   Irregular Refraction.—Besides the two defects of vision dependent upon the
refractive powers of the  eye, described by  Mr. Lawrence, there are  some
others resulting  from the same cause which it may be interesting briefly to
notice.
   For the due performance of its function as an optical instrument, it is neces-
sary that certain parts of the  eye  should be transparent, that the surfaces  of the
cornea and crystalline lens, should present certain regular and definite curva-
tures, and that the crystalline lens should be accurately adjusted both as regards
its own axis, and its relative distance from the cornea and retina.
   So many conditions being  requisite for perfect vision, it is less surprising that
defects should be met with, than that they should ever be absent.   Indeed there
is no structure more wonderful than the  eye, or one which  displays nicer  or
more extraordinary adaptation  of means to the end, or which furnishes stronger
evidences of wisdom, power, goodness and design of an intelligent creator.
   Various deviations from their regular curvature  occur, both in the cornea and
crystalline  lens.   These,  if  considerable, may be  detected by a  catoptric
examination of the eye, when some change will  be observed in the form of one
or of all the three images of a lighted candle.   They may also be detected by the
patient, if he will close  one eye, and  direct the other to some distant, well de-
fined, luminous object, not too bright,—the  horns of the new moon, for exam-
ple,—and  turn his head  in  various directions.   The cornua will then appear
doubled, trebled, multiplied, or variously distorted; and careful  observation of
its appearance, under different circumstances, may lead to a knowledge of the
peculiar conformation of the  refractory surfaces of the eye;  and may suggest
the proper remedy.
   Dr. Young states, (Philos. Trans, for 1801,) that his " eye in a state of  relax-
ation collects, to a focus on the retina, those rays which diverge vertically from
an object at the distance of ten inches from  the  cornea, and the rays which di-
verge horizontally from an object at seven inches distance.
   "Mr. Airy, of Cambridge, discovered a few years ago, that he did not usually
make use of his left eye in reading, and that it was  entirely useless on looking
at any near object.  This  he at  first  attributed merely to habit,  and  thinking
that it might be corrected by calling  the left eye into use, he endeavoured to
read with the right eye shaded, but found that he could not distinguish a  single
letter, at least of small print, at whatever distance he placed  the book.  Some
time after, Mr. Airy perceived  that the image made in the left eye by a bright
point, as a star, or distant lamp, was not circular but elliptical, the major axis
making an angle of about 35°, with the vertical and the upper extremity being
inclined to the right.  With concave spectacles  (through which distant objects
were distinct to the right eye) Mr. Airy found, that, to the left eye, a bright ob-
ject, as those above mentioned, had the appearance of a well-defined line, corre- 
008                      IRREGULAR REFRACTION.

sponding to the major axis of the ellipse seen by the same eye unassisted.  He
also found that  if he drew two lines crossing  each  other at right angles, and
placed the paper  in  a certain position, and at a proper distance, one line ap-
peared perfectly distinct, while the other was scarcely to be seen.   On bringing
the paper nearer to the eye, the fact with regard to  the lines was reversed, the
distinct becoming indistinct, and vice versa.  «All these circumstances indicated
that the refraction of the  eye was greater in  its plane nearly vertical, than in
that at right angles to it, and that, consequently, it would not be possible to see
distinctly  by the  assistance of lenses with  spherical  surfaces.'  Mr. Airy's ob-
ject then was to construct a lens capable of refracting the rays in a certain point
more powerfully than those in the plane at right angles to it; and  after various
ineffectual attempts, his purpose was effected  by a  person named  Fuller, at
Ipswich.  One surface of  the glass is cylindrical, the other  spherical; both are
concave.  Vision is most  perfect when the cylindrical surface is turned from the
eye;  and Mr. Airy can thus read the smallest print with the left eye as well as
with  the  right, and may thus be said to have  recovered the  use  of an organ,
which, but for his own ingenuity, would have been permanently lost."
   Similar defect has been observed by a clergyman in this country, to exist in
both his eyes.   For the following account of this case, by the gentleman himself,
we are  indebted to  our most skilful opticians, the Messrs. McAllisters No. 48
Chestnut  street, Philadelphia.
   " From my earliest years I have been sensible of a deficiency in sight,  which
I was induced to  call near-sightedness, because I was obliged to approach nearer
to objects to see them than most persons, which is still the case.  This deficiency
until I was about sixteen years of age, was accompanied with weakness of sight,
but my eyes are now strong.  I commenced my studies regularly  at the  age of
nineteen,  and  am now twenty-four.  Close study has had no  other effect on
my sight than to strengthen its endurance, but not its precision,  or length.  My
right  eye is, and always has  been, much better  than my left, but the defect in
both is precisely of the same nature.  At the age of- sixteen, I procured a  pair
of plain green glasses, which were some little assistance in moderating the in-
tensity of the light.  I tried  to  get  concave glasses, but  could find none  that
were  any essential assistance.  I afterwards used a small convex lens, of about
ten inches focal distance as a microscope, to assist me  in  reading, which  was
some assistance, but during the five years of studying, I have  used no glasses
whatever.   In November  last, [1825,] I procured a  pair of concave glasses in
New York, about 5 or 6, which will  accompany this letter.   Until then, I  had
never discovered that a change of position had  any influence  on my sight;  but
in looking through these glasses, I found that any object whose length is in a
horizontal direction, appears much more distinct, than a similar object, whose
length is perpendicular to  the plain of the horizon: thus, the cross rigging of a
ship appears much more distinct than the mast and perpendicular ropes.   I have
since  been led to make experiments, first on my naked eye, and then, on it, in
connexion with my glass,  which I send you, and the result at which I have ar-
rived, has been universally the same.
   " Suppose I stand in an  erect posture, then let/ h, e g, [Fig.  39,] be any ob-
        Pig. 39.        ject the parts of which are  equal and  similar, and of
           ^          which/ h is perpendicular and e g, parallel to the hori-
                      zon.   Then the part/ h, will appear plain, but the part
                      p, g, will not.   Now if I turn my head from a perpen-
             _____   dicular to a horizontal position, the  reverse takes place,
                   °  that is, e g appears plain but/ h does not.
                         " Again let a b  c d, [Fig. 40,] be a  circle, then if the
                      above statement  be correct, when I  stand erect the
                      parts a c, and  b d, will appear plain, but  a b c d, will 
CHRUPSIA.
569
 not, which is the fact.   Furthermore if I turn my head a right angle, (that is to
 a horizontal position) then a b, c d, become plain but a c,        Fig. 40.
 b d, do not.
   " It seems almost superfluous to add that a figure like k I
 m n, [Fig.  41,] appears uniform in both the lines  k n and
 / m when the body is in an erect posture.
   " These facts would lead me to conclude that the crystal-
 line lens of my eye is  cylindrically convex,  or perhaps, ob-
 lately convex, and that  its greatest length is in a perpendi-
 cular direction, (that is in a line parallel with the length of my body) consequently
 I would conclude that a glass whose shape resembled the        Fig. 41.
 probable shape  of the  crystalline Jens of my eye, placed
 before my eye, so that its greatest length would be at right   fc\         /I
 angles with the lens of  the eye would produce a  perfect       \.    /
 image.                                                         y/
   " All that I have said in relation to the diagrams above        / \.
 is strictly true in relation to my naked eye, and if I could     /        \^
 here wind up the  difficulty, I should stand in some hope,   ni          n
 but the fact is, the moment I put on  my  concave glasses every thing is ex-
 actly reversed, the line/ h, which before appeared more distinct than the line e g,
 now becomes  as much less distinct, and in  relation to the circle  the parts a c,
 and b d, which  before were more distinct than the parts a b, c d, now become
 as much less so.
   " The figure k I m n, of course, will appear much as it did to the naked eye,
 except, that it  is a little more distinct, and, perhaps, a little smaller, but what I
 mean is that it appears uniform through the glasses as it did to the naked eye.
 If it be true that my eye requires a glass whose shape does not correspond to
 a portion of a true sphere, but  rather to a portion  of a  spheroid or perhaps a
 cylindric, I cannot tell from any observation I have yet made on my eyes, whe-
 ther the glasses should  be of the concave or convex form.  The great difficulty
 is, why should the appearance of objects be  entirely changed, by the interposi-
 tion of a concave glass1?  When I purchased my glasses I was not aware of this
 curious fact, in regard to my eyes, either with or without glasses.   I only knew
 that I got those through which, on the whole, I could see best.  If it  be asked
 whether I consider the  glasses in question an essential assistance to my sight, I
 answer that if my object be to examine a horizontal object they truly are an as-
 sistance, and they are so in the examination of a perpendicular one, provided I
 turn my head a right angle."
   Mr. McAllister provided this gentleman  with a glass ground  plane on one
 surface, and to a section  of a cylinder on the other.  This corrected the irre-
 gular refraction and much improved his vision.
   Mr. Prevost, at  the  age of 81 years, published (Annates de Chemie et de
 Physique.   Tom. LI. p. 210) an interesting account of his own case of double
 vision, with a single eye,  which he thought might  perhaps arise  from a frac-
 ture, bruise, or partial  flattening of the lens, or separation of its laminse. Mr.
 Prevost also communicated with Mr. Babbage, who is  affected  in  either eye
 singly with double vision, a defect, however, which he finds himself able to remedy
 by looking through a small hole in a card, or through a  concave lens.   (Mac-
 kenzie, op. cit. p. 795.)
  We have met with a curious case of change in the refractive powers of the eye,
in which the lenses acquired refractive properties analogous to those of Iceland
spar.   In this case, all perpendicular lines appeared double, while horizontal ones
were seen accurately.   This condition occurred during the progress of a severe
catarrhal ophthalmia, and ceased on recovery from the disease.
  Chrupsia, or coloured vision.—"Patients," Dr. .Mackenzie remarks,  "who
       72
Q 
570
PHOTOrSIA.
are partially amaurotic, complain not unfrequently of luminous objects, as, a
lighted candle, appearing to be surrounded by the colours of the rainbow.  This
symptom has been  called chrupsia, and has been supposed to depend on  some
derangement of the lenses of the eye, by which  the  achromatic power of the
organ becomes impaired.   A young lady whom I attended for choroiditis, saw
brilliant blue, green, and red colours playing over the objects she regarded, such
as the face of a person sitting before  her, or a white handkerchief held in her
hand.  In supposed cases of this sort, it would be proper to guard against our
being deceived on the one hand, by those causes, which might induce a decom-
position of the rays of light by inflection merely, such as contraction of the eye-
lids, and, on the other, by such as might bring on ocular spectra.
   "Another variety of  chrupsia, consists in seeing objects of a different colour
from that which is natural to them.   Some patients see objects as if tinged of a
yellow, green, or bluish colour.  Dr.  Parry relates* four cases of this sort.  In
one of these, an old general,  just before the lighting of the candles in the even-
ing, and for an hour on first  waking  in the morning, saw all white objects of a
deep orange colour, approaching to scarlet.   In another,  a lady often saw
white objects of a very bright blue colour.
   "A patient under my care with prolapsus of the nasal portion of the iris through
an accidental wound of the cornea, saw all objects of a greenish hue."  (Practical
Treatise, p. 801.)
   Photopsia.—Various sensations of light, are sometimes perceived, as the result
of disease in the optic apparatus.  Flashes of light, the appearance of shining
stars, a glittering as if from the  points of innumerable needles  or prisms,  and a
variety of other lucid spectra attend retinitis, and  occur, as has been  already
observed (p. 490,) in the commencement of certain kinds of amaurosis.  " In
some peculiar and  distressing cases," Dr. Mackenzie observes, " the patient is
annoyed by the sensation, as if his eyes were directed towards globes of light
swimming or revolving before him, or as if he were looking at a sea of molten
gold."
   " The distress," he adds, " which patients affected with such false sensations
experience, varies  greatly in degree; but, on the  whole, these lucid  spectra
are  both less supportable by those who experience  them, and ought to  be re-
garded as of a more alarming nature, than the semi-transparent or dark musca,
volitantes, which so frequently occur. Flashes of light are often the precursors
of convulsive attacks, such as epilepsy; subjects inclined to apoplexy, on raising
their heads after stooping, see showers of shining spectra; those who have suf-
fered from  internal ophthalmia are often troubled with such sensations as that
of a luminous wheel rapidly revolving before them; and phrenitis is attended by
false impressions of the same sort, which often continue long after all the other
symptoms have ceased.   In  some instances, photopsia is  merely a sympathetic
effect produced from disordered digestion.   After fever, or any disease in which
the patient  lies long in the horizontal position, photopsia  is liable to occur.  It
generally subsides, as the patient becomes able to sit up.  .
   "It is of great importance, to ascertain the cause of photopsia, and to distinguish
it accurately from  photophobia.  The latter often simulates the former, espe-
cially in scrofulous, hypochondriacal, and  hysterical patients.  The cause of
photopsia being  discovered, the line of treatment  can scarcely be mistaken.
Sir David Brewster tells* us, he knew of a case, in which the patient had con-
stantly the  sensation of a luminous circle before him, in consequence of an ex-
crescence on the inside of the eyelid, which produced a continued pressure on
the eyeball.  The removal of the excrescence would afford a cure in this case.

  * Collections from the unpublished Medical Writings of C. H. Parry, M.  D. Vol. i. pp.
560, 568, and 569; London, 1825.
  i Philosophical Magazine, for  August, 1832, p. 90. 
PHOTOPSIA.
571
 When photopsia is owing to cerebral congestion, depletion will be  necessary;
 when dyspepsia is the cause, purgatives, followed by tonics,will be proper.
   The following interesting case of photopsia has been recorded by  Mr. Ware,
 in the  words of the patient himself, a medical practitioner.
   Case.—"About  10  years ago, when about 48  years  of age, I experienced the
 first attack  of the malady which I mean to describe; and it has repeatedly returned at
 irregular periods, from that to  the  present time.  The first notice that I have of the
 attack  is a peculiar indescribable sensation at the bottom  of the eye, which does not
 amount to pain, and is so slight that its reality is not to be determined, unless I direct
 my  attention very particularly to  it.  After a  few seconds the objects, in a small point,
 nearly  in the centre of the field of vision, become indistinct; and, shortly afterwards,
 invisible.       *********
 In a tew seconds more, that is,  in about half a minute from the commencement of the
 attack, the  point that was invisible becomes lucid, appearing to be a circular spot,
 about the eighth of an inch  in diameter; in which a yellow flame seems  to undulate
 from the centre to the circumference with almost coruscating quickness and splendour.
 This spot increases by the extension of the undulating flame  until it acquires an appa-
 rent diameter of about three quarters of an inch, which  takes place generally in about
 six or eight minutes.  The fiery veil, which  conceals  objects,  becomes then thinner
 in the centre, and objects are there seen through it.   The vision  increases, until at
 lengh a ring of light only remains, which continues to enlarge until it is lost by seem-
 ing  to extend beyond the field of vision.
   " The returns of the attack  have been very irregular.  Sometimes  they have oc-
 curred  daily for a week or ten days together; at other times more than a month has
 elapsed between their appearance.  During one  forenoon they returned almost every
 hour; but of late the intervals are much lengthened  ; and I have been  now exempted
 from the malady more  than three months.
   "At first no pain was felt; but during the last 12  months, a slight uneasiness under
 the  forehead, on the opposite side to that of the affected eye, has generally accompa-
 nied and succeeded the attack.
   "  The disease is common  to  both eyes, though it  has never yet occurred in both at
 the  same time.  My sight is not injured, though the sensibility of the retina appears
 to be  morbidly increased: a strongly illuminated object  producing a more brilliant
 spectrum than it used to do.
   "  About six weeks ago, I first saw the unpleasing  appearance  of a small dark circu-
 lar spot, which,  varying its situation with every motion of the eye, showed how  appro-
 priately the term musca  volitans had been applied to it.   The possibility  of its being
 a  partial paralytic affection, resulting from  the frequent morbidly increased action of
 the  retina, naturally alarmed me; but six weeks having elapsed  without any return, I
 am  become  easy concerning it.   In this instance the immediate  cause of the affection
 appears to have been an  irregularly increased action of the retina; and the remote
 causes  were an over eager exercise of the mind, joined with too long continued em-
 ployment of the eyes, and a  disordered state of the stomach and bowels.
   "  With regard to the  means of  cure, reprehensible as  it  may appear,  I for a long
 time employed none.  About three years ago, however, having been harassed repeat-
 edly at  short intervals, and  sometimes two or three times in the day, by the above-
 mentioned appearances, I called on you, and, by your advice, took a dose of five grains
 of calomel.   After  this the spectrum did not  appear for several  months; and when I
 again saw it, it yielded to a repetition  of the same remedy.  In the following year,
 having travelled two days together, and taken food of an improper kind, and in an
 irregular manner, the attacks on  the third morning were so frequently repeated, that
 I was unable to see my way without difficulty and danger.  I therefore stopped and
 took my dose of calomel; after which the spectrum  immediately disappeared, and it
did not return for many months.   That which was black, as well as those which were
lucid, were  equally removed by the use  of this  medicine; and I have not  now per-
ceived either of them for a considerable length of time."*]

  * Medico-Chirurgical  Transactions, Vol. v. p. 274; London, 1814.  See case of M. Sa-
vigny, Archives Generates de  Medecine, Aout, 1838, p. 495. 
(  5V2   )
CHAPTER XXI.
CATARACT.*
 SECTION I.--GENERAL DESCRIPTION OF THE DISEASE J  ITS CAUSES AND TREAT-
                      MENT ',  VARIOUS OPERATIONS.

   Cataract is a partial or general opacity of the crystalline lens, of its
 capsule, or of the Morgagnian fluid, separately or conjointly, with a
 corresponding diminution of  sight.   Beer includes, in  his definition of
 cataract, all those impediments to vision, which are situated in the pos-
 terior chamber, between the uvea and the front of the vitreous humour,
 (Lehre, vol. ii. p. 279,) whether arising from opacity of the lens, of its
 capsule, or of the aqua Morgagni ; from the effusion of lymph under the
 inflammatory condition of the  iris, and its subsequent organization into
 an adventitious membrane; from the effusion of  blood  or pus; or from
 depositions of the colouring matter of the uvea upon the capsule.  He
 then divides  cataracts  into true and spurious.   (Ibid, p.  285.)  Un-
 der the former head are comprised the opacities of the lens, capsule, and
 aqua Morgagni ;  while the latter comprehends all the others, which he
 has named cataracta lyrnphatica, membranacea, purulenta, grumosa, and
 dendritica.  (Ibid, p. 303.)  Under the last name, or those of cataracta
 arborescens  or  choroidalis, has been designated the deposition of the
 colouring substance from the uvea upon the front of the crystalline cap-
 sule.  See the remarks on this  subject in Chapter XVI. p. 386.
   These false cataracts are various results of injury and disease, affect-
 ing  the chambers of the aqueous humour generally, or  the iris in parti-
 cular :  and their consideration belongs to  other parts  of this treatise.
 To call them cataracts, and thus assimilate them  to the peculiar change
 of the lens and capsule, which has been usually and properly designated
 by that term, is a  combination under a common  name of affections
 totally distinct in their causes and nature, and likely to produce, espe-
 cially with students, confusion and obscurity  in pathology and treat-
 ment.  I therefore employ the word cataract, in its old and more limited
 sense, to denote opacity of the lens, of its capsule, or of the Morgagnian
 fluid, either separately, or combined.
   The most striking circumstances observable  in cataract are, an  opa-
 city placed behind, or in the pupil, and  the impaired  state of  vision,
 which is the result of that  change.  The opacity, however, may be so

  * The Greek word jtsn-afaxi-ac from **T*/>*c-<ra> to throw down violently, was not applied
to this disease, which was called  yxa.vKu>(A.a., v7ro^ufjt.x or uirc%uo-ic. The Latin terms are
equivalent suffusio, the designation of cataract by the Latin writers.  Caligo lentis, gutta
opuca, in contradistinction to gutta serena, are synonymes.  See the notes.'at p. 475 ante. 
cataract.
573
 inconsiderable in extent, as not to  affect sight, though it comes under
 the technical denomination of cataract.   In both the circumstances just
 mentioned, cataract agrees, in  its incipient stage, with glaucoma and
 some forms of amaurosis; but as the treatment is essentially different in
 these several affections, it is necessary to discriminate them accurately.
 In incipient cataract we can do little or nothing; we  must wait until
 the opacity has become complete, before we perform an operation: but
 active means must be resorted to it in the earliest  stage of amaurosis;
 if we should leave  the case to itself under the supposition of its being
 cataract, loss of sight would be inevitable and irremediable.
   Thus it is important to distinguish cataract from other affections;  in
 doing which, under circumstances of doubt, we shall be much assisted
 by artificial dilatation of the pupil.   Hence we  should examine the eye
 in such cases, after the application of belladonna, so that we may obtain
 a clear view of the changes which may have occurred behind the
 pupil.
   Cataract is usually formed slowly, requiring some weeks, months, or
 years, for its  complete development; it may, however, come on much
 more quickly, even in a few hours.   It seldom destroys sight completely,
 even when  fully developed.  Sometimes  sight is  hardly injured.  In
 many forms of the disease a considerable degree of vision remains; and
 in the  worst cases, the patients  can distinguish  light  from  darkness, if
 the retina be sound.
   It may appear in one eye, or  in both.   In the former case, the second
 eye is  generally affected sooner or later.   In  a  few instances the com-
 plaint  is confined to one eye.
   Colour  and situation of the opacity.—The colour  of the opacity  in
 cataract may be described as  grey, passing on one  side into a milk
 white or bluish white, and on the other into a yellowish brown, or the
 colour of amber.  The opacity of the pupil in glaucoma is green, a dull
 green, or  yellowish green.  Incipient cataract sometimes exhibits  a
 similar tint, so that  the mere circumstance of colour is not sufficient  to
 establish the diagnosis  between the two affections.  The situation of the
 opacity is  a better ground of distinction : in cataract it is near the pupil,
 and in many instances immediately behind that aperture: but in glau-
 coma and amaurosis the discolouration is deeper seated;  it looks as if
 it were at the bottom of the eye.   Hence, when we view the  eye late-
 rally in glaucoma, we lose sight of the opacity; it is only when we look
 directly into the opening that we see the  discolouration, which also is
 equally diffused, the pupil appearing uniformly opaque.  The opacity
 has generally a concave appearance in glaucoma, while in cataract it
 is convex.
  Some observations are made on the distinction between cataract and
 glaucoma  in  the  description  of  the latter affection; see Chapter XIX.
 § 3: in the first section of the same chapter, deficiency of the pigment is
 mentioned, causing a change in  the appearance of the pupil, which may
 be mistaken for cataract.
  State of vision.—In cataract the opacity generally begins in the centre
of the pupil,  and extends to the circumference; consequently, it is more
dense in the  centre and less so towards the sides.  Hence light passes
through the circumference of the pupil, enabling the patient to see ob- 
574                          CATARACT.
jects laterally, when he cannot  see  them  directly in front of the eye.
For the same reason the mistiness of vision, accompanying  the early
stages of cataract, is greater in a bright than in a dull light.  Dilatation
of the pupil  by exposing  the margin of the lens, which is  sometimes
transparent when the centre is opaque, and at all events is much thin-
ner, and therefore less densely opaque, improves vision considerably,
especially in incipient lenticular cataract.  Such patients see best in the
dusk or twilight, or when the pupil has been artificially dilated.  They
see best when the back is turned toward the light: in that position, and
with the eye shaded by placing the hand above it, the pupil is so much
dilated that a person with imperfect cataract may  be able to read, while
if he turns round and opens the eye against a strong light, he may be
unable to distinguish a letter.  These circumstances distinguish cataract
from glaucoma and amaurosis; for in the latter affections, the sensibility
of the retina being impaired, the individual sees best in strong lights, his
sight is not improved by dilatation of the pupil, and he sees better when
looking towards the window, than when his back is turned to it.  Such
differences are characteristic, and often sufficient of themselves to esta-
blish the diagnosis.
   The mode in which vision is  impaired by cataract  is this: objects
appear at first as if surrounded  by a mist or fog; the  patient fancies
that something is interposed between  his eye and what he  looks at,
whilst haziness or cloudiness increases  gradually in proportion to the
degree of opacity.   The cloud becomes more dense, and conceals ob-
jects completely, and the affection advances so as to destroy  all useful
vision.   Irregularity and confusion of sight, distortion, and multiplica-
tion of objects,  which are sometimes experienced in the beginning, pro-
bably arise from  the striated or partial character of the opacity in cer-
tain cases.   The various modes in which sight  suffers in  amaurosis
have been  particularized in a preceding chapter.   A cataract patient
sees a lighted candle as if it were involved in a cloud, which becomes
thicker  as the  opacity proceeds, and ultimately shrouds the flame  so
completely, that its position  only  is discernible; to one with amaurosis,
the flame of a  candle appears as if scattered into rays like  a star, or
surrounded  by a halo, or  confused with prismatic colours.   The sight
is impaired in cataract in proportion to the degree  of opacity; but there
is no such direct ratio in glaucoma and amaurosis; for, with only a
slight greenish  discolouration of the pupil, there  may be considerably
impaired vision, such as the opacity would not account for; indeed sight
may be entirely destroyed, when there is only a slight discolouration of
the pupil.
  Iris and pupil.—The iris  and  the figure of the pupil are not affected
by cataract,  at  least in the early period of its formation: the iris con-
tinues to move as usual; the pupil retains its natural figure.  In some
eases the lens is  increased in bulk, which  causes  it to press  upon and
protrude the  iris,  and consequently impede its motions.  The changes
of the pupil  and  iris in amaurosis and  glaucoma  form a striking point
of distinction.  In the affections last mentioned, the pupil  is generally
more or less  dilated, the iris motionless or sluggish, and the  pupillary
aperture not perfectly round, sometimes angular.   In cataract with ad-
herent iris, there may be want of motion in the latter, and irregularity
* 
GENERAL DESCRIPTION.
575
 of the pupil.  It must be observed, however, that  the pupil presents a
 black margin in cases of cataract; and that is to be explained  by the
 circumstance of the white, or greyish white ground, which the opaque
 body furnishes behind the pupil.  The margin of the aperture is black,
 being formed by the uvea;  but as the pupil also is black in the natural
 state, we do not observe this black edge until  some light-coloured sub-
 stance is placed behind it.
   Beer, (Lehre, vol. ii. p. 281,) says that the dark ring round the  pu-
 pil is principally owing to the black edge of the aperture, and hence that
 it is most conspicuous in light irides;  but he adds that the iris throws a
 shadow on  the  cataract  which contributes to the appearance.  This
 shadow is more strongly marked in proportion as the cataract is whiter,
 and placed at a  greater distance behind  the pupil.   In a  large capsulo-
 lenticular cataract, which fills the posterior chamber and projects against
 the iris, no shadow is formed.
   In doubtful cases the nature of the affection is sometimes elucidated
 by its history.   Cataract forms without any uneasiness in the  eye or in
 the head, or any disturbance of the health; it has even been completely
 developed in one eye, without the patient being aware of its existence.
 Glaucoma and amaurosis are often preceded and accompanied  by va-
 rious uneasy sensations, by changes in the state of vision, which attract
 the patient's notice, and by functional disorder in other quarters.
   [In the diagnosis of cataract, the catoptric examination of the eye affords the
 most unerring test.
   In the early stages of lenticular cataract the brilliancy and distinctness of the
 inverted image is  diminished, it has no longer a sharp and well defined margin,
 but its outline appears shaded off.  This image gradually fades with the increase
 of the opacity, and long before the cataract is mature the inverted image is ob-
 literated.  The deep  erect image is also indistinct in  the advanced stages, the
 anterior surface of the capsule giving only a general reflection.
   In capsulo-lenticular cataract  the inverted  image fades much earlier than in
 mere lenticular cataract, a very slight degree of opacity of the capsule sufficing
 to destroy its function of reflection.
   Among the numerous cases, we have seen, in which we have derived great
 assistance in our diagnosis from the aid of the catoptric test, we shall relate two
 which will serve  to  show its utility  and to justify the confidence we repose
 in it.
   In  September,  1839,1 was invited by my friend, Dr. G. W. Norris, to exa-
 mine a  mulatto man named Peter, in the Pennsylvania Hospital, who was sup-
 posed to be affected with glaucoma.  The pupils had been dilated by the appli-
 cation of belladonna.   There was opacity in both  eyes, which was  denser in
 some  parts than in others.   This opacity seemed  more deep seated, than is
 usual in cataract, and its colour was of a greenish grey.  Vision was, however,
 quite as good, perhaps better, than might have been supposed from the degree
 of opacity.
   On holding a lighted  candle  before the  eyes, the three images were visible.
 The anterior upright  image was natural in all respects.  The  deep  seated up-
 right and inverted images were dull, their margins indistinct and of an unusual
 reddish  tint.   The inverted image in one eye, disappeared as  the candle was
 moved opposite to the more nebulous portion  of the lens, and when the observer
looked at the eye of the patient obliquely, the second inverted image  seemed to
have a double point like the letter W.   I did not hesitate from these phenomena
to pronounce it to  be a case of cataract. 
576
CATARACT.
    A few days afterwards this  man died suddenly and we were afforded an
 opportunity of examining his eyes.
    The transparency of both capsules was impaired.   A narrow streak at the
 posterior part of one lens, extending from near the margin to the centre was quite
 opaque, and on applying a needle to this portion we found it quite soft so as to be
 readily removed, leaving a depression.   On carefully washing both lens so as to
 remove their superficial layers which were softened, as well as partially opaque,
 the remaining portion of each was found perfectly transparent and of a beautiful
 amber colour.   This  colour was  the same  whether the lens was viewed by
 transmitted or reflected light.
    The second case was that of a man named Christian  Minster, forty years
 of age, admitted into Will's Hospital, October, 7th, 1841.  This man stated that
 he had recently come from the country, that  he had been admitted in one of
 our public institutions, where he was pronounced to be labouring under cataract,
 and it was determined to operate upon him; but that being unwilling to submit
 to this he had eloped.  A  letter which he showed from his physician in the
 country, also indicated his disease to be cataract.
    The opacity behind the pupil  had certainly great resemblance to that of cata-
 ract.  The degree of vision he enjoyed corresponded to the degree of opacity—
 the independent and associate  motions of the iris were tolerably active—and
 the patient saw best by twilight.
   On applying the catoptric test, however, it was at once found to be a case of
 amaurosis and not of cataract.  The three images were visible and of their natural
 appearance.  The history of the case led me to ascribe the  amaurotic  affection
 to congestion of some portion of the nervous apparatus, and a course of treatment
 corresponding to this view was  directed, consisting of counter irritation to the
 back of the neck,  purging, stimulating pediluvias, &c.  Under this course  he
 improved so rapidly that in a week he could read with one eye a diamond print
 bible.  He subsequently had a  relapse, but  by the application  of cups to the
 head, pustulation with tartar emetic on  the back of the neck, and  afterwards
 ptyalism, he was completely restored.  He was discharged cured in January fol-
 lowing.]

    Various species of cataract.—There are numerous  sorts of cataract;
 different  species more or less distinguishable from each  other.  They
 vary in the seat, colour, and  consistence of the opacity;  in its  compli-
 cation with other  affections of  the eye, or particular states of constitu-
 tion, and according to the age of the individual.   An  attentive conside-
 ration of these various circumstances is necessary, in reference to the
 choice of operation, and the chance of its success.
   The difference  of seat forms a natural basis of arrangement, in con-
 formity with  which, we  may distinguish them into the lenticular, the
 capsular, the Morgagnian, and  the capsulo-lenticular.
   Lenticular.—The most frequent species  of lenticular cataract is  that
 called hard or firm: cataract dura or tenax.   In this state of the lens,
 the opacity has a greyish appearance,  with more  or less of the  yellow-
 ish brown or amber tint toward the centre.  In the firm and darker co-
 loured portion, it resembles wax slightly  softened by heat; the circum-
 ference is lighter  coloured, and softer, being  about the  consistence of
 soft jelly.  The more  we see of the amber colour, and the deeper  the
 tint, the harder is the cataract; the greyer its appearance, the softer is
 the consistence.   What is called a hard cataract, is not in general hard
throughout; the healthy lens  differs  in consistence, the circumference
 being much softer  than the centre, and so it is with the opaque crystal-
line; the central portion is more firm than the rest.  A greyish matter 
GENERAL DESCRIPTION.
577
occupies the external part of the lens, while the centre, or nucleus, is of
a yellowish colour, and  much more firm.  Sometimes  this  brownish
tint occupies the whole of the pupil; and the colour of the lens has even
been  found of a dark brown, like the  husk of  the  chestnut, or dark
mahogany; and  in these  cases it is hard throughout; they are not, how-
ever, very common.  An ordinary firm cataract, when extracted, pre-
sents the consistency and hardness  of wax.  I have never had an op-
portunity of seeing a  cataract of a darker colour than mahogany, but
Wenzel* and Beer| speak of black cataracts; if they mean  cataracts
literally black, I  have never seen any such.J
   The lens may be converted into an  osseous or  cretaceous substance
but such a  case  is  very uncommon, and  can hardly  be said to  come
within the  general  description of the complaint; such  changes  have
hardly been found except  when the eye  has been  rendered amaurotic
or completely disorganized by internal disease.  Further details on this
subject will be found in Chapter XIX. § 5.
   The common  firm cataract, which I have now spoken of, presenting
the amber tint in the middle, gradually shaded off into a grey, is the or-
dinary form of the complaint in advancing age.   We meet with it occa-
sionally in perfectly healthy old individuals, in whom it is a strictly local
affection, the constitution being sound, and no texture of the eye altered
besides the lens and capsule.  The lens is  generally smaller than  natu^
ral, and the capsule being  unaffected, the opaque body appears at a
small distance behind the pupil.   There is a marked interval between
that aperture and the cataract; the iris has  its full play, and the pa-
tient retains the power of distinguishing objects during the formation of
the cataract, by  the passages of light through the less opaque circumfe-
rence of the lens.
   There is sometimes a hard nucleus with a soft circumference, so soft
indeed as  to  be almost  fluid; this  has  been called cataracta  jiuido-
dura.
   Lenticular cataracts are sometimes radiated, the opacity appearing
in streaks  or radii,  with  the intervals  comparatively  transparent.
Those radii generally begin  in  the circumference  of  the  lens;  a
circumstance which forms a striking contrast to  the former species,  in
which the opacity first appears in the centre.  In the ordinary state of
the pupil, we can hardly see the  radiated  opacity, because the centre
remains transparent; perhaps, a small white streak or two may be dis-
tinguished ; it is  not until we have dilated  the pupil by belladonna, that

  * Manuel de VOculiste, vol. i. 109.  Wenzel's Treatise translated by Ware, in Observa-
tions on the Cataract, §c. 3rd edition p. 50.
  t " In very old and thin persons we sometimes find the extracted lens in a stale of maras-
mus senilis, as hard as wood, chestnut-brown, and flattened on its surfaces as if it had been
squeezed.  This, which has been called by some cataracta nigra, is difficult to recognise
before  the  operation, and is often confounded with  amaurosis."—hehre, vol. ii. p. 309.
Rosas speaks of black cataract as being  a blackish-brown or  blackish-grey state of the
lens.—Handbuch, vol. ii. p. 681.
  t The second volume of Ammon's Zeitschrift, part  2, contains an essay on  black cata-
ract, by Dr. G. H. Warnatz.  It is a German version, in a more extended form, of the
inaugural dissertation of Dr. Warnatz, de Cataracta nigra, Leipsic, 4to, 1802.  It contains
a complete assemblage of the facts hitherto recorded on the subject; but it leaves the ques.
tion respecting the existence of literally black cataracts just where it was before.  P. 295
—324, and 411.
       73 
578
CATARACT.
we detect the  opaque streaks in the circumference of the lens.  These
cataracts are  slow in  their progress, occupying two or more years in
rendering the  whole of the lens opaque.   I  have known instances in
which very little change has taken place in the lens in three years.   In
some radiated lenticular  cataracts the lines radiate from the centre,
presenting an  appearance  similar to that which  occurs when the lens
becomes opaque after death.
   Another species is the soft cataract; not  soft in the circumference
only, but the whole texture of  the lens is  changed, having various de-
grees of consistence.  In  firmness, the cataract may resemble cheese
(c. caseosa,)  or jelly  {c.  gelatinosa,) or  milk (c. fluida or lactea.)
These are all degrees of consistence, from the hard to the fluid ca-
taract.
   Soft cataracts are larger than the hard ; they occupy a greater space,
so that they push against  the iris, make its anterior surface convex, and
interfere with its  motions.  Soft cataracts are  grey, greyish-white,
bluish-white,  or milky, without  any mixture of the  yellow or amber
colour.   The  opacity is  not uniform, but presents  a streaked, cloudy
appearance, especially in  the  beginning, so that we can see into, and
almost through the lens.   It is equally diffused through the  latter, and
the  discolouration is  consequently equal  in the whole pupil.  In the
commencement of this kind of cataract, there is a partial reflection of
light from the central or posterior part of  the  lens, producing a partial
yellowish and almost  shining metallic appearance, varying in apparent
position as the light and the eye change  their relative places.  As the
 cataract is large, the opacity extends uniformly to the circumference of
the crystalline; it  intercepts the light more completely than the hard
 cataract does; and the patient at last retains merely the power of dis-
 tinguishing light from darkness.
   In  fluid  cataract the opacity presents an  uniform  appearance
 throughout.   It is as dense in  the circumference as in the centre of the
 pupil.   It presents a dull  grey  cast, like that of thick gruel;  or it may
 be yellowish  grey, approaching to  the  appearance  of  cream.  Some-
 times it is a bluish-white, the cataract being then of milky consistence.
 In fluid  cataracts the heavier parts may subside, so that after rest, with
 the pupil dilated, we can  sometimes distinguish two distinct  strata, of
 which the inferior is the most opaque.
    Cataracta centralis.—The opacity of the lens is  sometimes partial,
 being the form of a central grey spot, like a pin's head;  or it  may oc-
 cupy a  larger portion of  the centre, as one-third or two-thirds of the
 diameter, leaving the circumference transparent.*  This partial opacity
 is only  known as a form  of congenital cataract.  In such cases the pa-
 tient  may see perfectly  with  the  pupil so  dilated,  as to denude the
 transparent  part  of the  lens;  while he will be blind in a strong light,
 when the contracted pupil is completely  obstructed  by the central
 opacity.
    In the ordinary firm lenticular cataract,  where the change begins in
 the centre, and gradually extends, it is sometimes  difficult  in the be-
 ginning to distinguish the case from Glaucoma, especially when the pu-

   * Saunder's Treatise, pi. 4, fig. 3 and 5.  Von Ammon, Klin Darsteliungen, pt. i. lab. 9,
 fig. 13, 14, tab. 10, fig. 5. 
GENERAL DESCRIPTION.
579
 pil is contracted.  Under similar circumstances central opacity of the
 lens may escape observation.   The real state of the  case is easily re-
 cognised when the pupil is largely dilated.  Hence the use of belladonna
 should  not be neglected whenever we find it difficult to  establish the
 diagnosis.
   Morgagnian cataract.—Opacity of the fluid situated between the lens
 and its capsule, has been called Cataracta Morgagniana.  I doubt the
 separate existence of such an affection.  How can we determine that
 this fluid is opaque and the lens transparent?  Can we suppose that this
 fluid could undergo such change, and the capsule and lens remain trans-
 parent ?  I think, therefore, that in a practical consideration of the sub-
 ject, this kind of cataract may be  safely omitted.
   Beer states that the Morgagnian cataract is one of the rarest species;
 that it exists for a short time only  in its pure form, as  an opacity of the
 Morgagnian water;  and that the  lens itself  is  soon  converted into  a
 milky fluid, while the capsule generally becomes opaque.   He says, that,
 according to  his experience, it occurs suddenly, and only in consequence
 of the  immediate influence of mineral acid vapours on the eye.*   On
 another occasion he  mentions, in  addition to these acid vapours, those
 of naphtha and alcohol as capable of acting immediately and powerfully
 in producing cataract; and he then relates  the following case:  "In  a
 woman of fifty-two  I  saw a pure  Morgagnian  cataract, perfectly de-
 veloped within a few hours, from exposure of the eye for not more than
 a quarter of an hour to a fluid of which I did  not know the nature.  At
 the urgent demand of the patient, I operated  on this cataract the follow-
 ing day, when I found the lens  firm, but perfectly transparent, as was
 the capsule also."f   The particulars of this  strange occurrence are not
 stated  in  sufficient  detail  to  enable  us to estimate  it pathologically.
 There can, however, be only one opinion on the extraordinary practice
 of operating  the  day after the cataract appeared, and when it  should
 seem that one eye only wras affected.
   [The following is the only example of a condition of things at all resembling
 the description of Morgagnian cataract, which I have met with.
   Drs. Neil and Kerr brought to me for examination, on the 30th of April, 1840,
 the eye  of a woman, who had died the day before, in the Philadelphia Hospital
 Blockley.   They had not been able to ascertain the history  of the case.  They
 had divided the eye by a perpendicular incision through the centre of the scle-
 rotica ; and being struck with the unusual appearance of the lens, they placed
 the eye in water and brought it to me.
   I found the lens covered with  its capsule, which was more convex than na-
 tural; renitent as if distended by a fluid;  somewhat  opaque and very firm.
 Whilst squeezing it to ascertain what pressure it would bear, it broke and some
 yellowish-white fluid resembling thin pus, or milk and water, and equal in quan-
 tity to about one  fourth the  bulk of the  lens was  discharged.   The lens was
 of a light  amber colour, somewhat smaller than natural  but  perfectly trans-
 parent.
   The opacity of the capsule may possibly have been merely  owing to its having
 been emersed an  hour  or two in  water, but the fact of the capsule being much
 stronger than usual does not favour such a supposition.]

  * hehre, vol. ii. p. 292.
  T Ibid, p. 327.  In the Repertorium he says that he had  twice seen a healthy lens with
opaque Morgagnian fluid, p. 61, 62. 
580
CATARACT.
  Capsular cataracts{memhranacea or capsularis.)—These have been
divided into the anterior and posterior, in which  the front or back of
the capsule alone is affected, and the complete, in which the whole cap-
sule is opaque.   The capsule is  very different in texture from the lens,
and it may therefore be expected that an opacity of the  former will pre-
sent different appearances from that of the latter.   The former does not
begin in the centre, but in any part of the membrane indifferently; it is
not uniform, but in spots or streaks, with less opaque  or transparent in-
tervals.  These opaque portions are  of a glistening  chalky or pearly
white, the dense structure of the capsule giving a different character to
the opacity  from the jelly-like substance of the lens.   The position of
the opaque capsule distinguishes it sufficiently from a lenticular cataract;
the latter is situated at a little distance behind the pupil;  there is a re-
cognisable interval between them ; but the anterior capsular cataract is
on  a level  with the pupillary margin of  the iris, and we  see that the
opacity is on a level with the edge of the  pupil itself, sometimes passing
into  the aperture   The capsule cannot become  extensively  opaque,
without the lens also being affected.   There may be a single streak of
opacity in the capsule  after iritis ; but that does not constitute a cataract:
the capsule may be more extensively but yet partially covered by a new
adventitious membrane, the rest remaining clear.  We know of no such
case  as a capsule generally opaque,  containing a transparent lens.
   The posterior part of the capsule may become  opaque, the  anterior
portion and lens remaining transparent; in this case there  is an opacity
situate at a marked distance behind  the pupil; its situation corresponds
to  the known position of the  capsule.  We can  even  perceive that it
presents a  concave surface, and this  deep-seated concave opacity is in
partial streaks, the intervals  of which  are  transparent.  The small
opaque strias, with which the affection commences, are sometimes found
on the circumference  of the membrane, in a  nearly circular arrange-
ment, and are concealed from view until the pupil  is dilated. The pos-
terior capsular cataract has not that glistening white colour which dis-
tinguishes the anterior, because it is seen through the lens, and thus ac-
quires a yellowish and  rather dull appearance.   This  change in the cap-
sule is followed by opacity of the lens; it may exist,  however, a consi-
derable time before the lens begins to lose its transparency. Although
the affection is comparatively rare, I have seen many cases of posterior
capsular cataract; the patients are still able to read large, or even ordi-
nary print, long after the existence of disease has been clearly ascertained.
They can  see much better when the eye is shaded,  or when the pupil
is  artificially dilated.   In  the latter state  we see distinctly the trans-
parent spaces between the  opaque radii, through which light passes to
the retina.  When opacity of  the lens commences, which may  not be
for two, three, or more years, vision is more seriously impaired.
   Mr. Tyrrell  represents that the radiated  opacity just described is
seated, not  in the capsule, but  in the posterior hemisphere of the lens;
and that he had ascertained the fact in performing the  operation of ex-
traction in cases presenting such appearances.  (Vol. ii.  p. 363.)
   The existence of perfect capsular cataract cannot  be easily ascer-
tained ; for if the anterior portion of the membrane be  opaque, it will pre-
vent  us from knowing whether the posterior be so or not.   With a slight 
GENERAL description.
581
opacity of the anterior, it may be practicable to see also the opaque
posterior part of the capsule.   But the lens will participate in the affec-
tion, and the case may be considered as a capsulo-lenticular cataract.
  [A catoptric examination, when the opacity is slight, will often enable us to
detect these several forms of cataract.]
  A membranous or capsular cataract often remains when the lens has
been absorbed, as in traumatic cases, or after needle operations, when
it constitutes a form of secondary cataract.  The opaque membrane is
of a chalky or milky white according to  its  density; the opacity may
be so inconsiderable, as to present a difficultly distinguishable film ; it
is usually unequal in degree  in  different  parts.  The surface is some-
times more or less irregular.   This opaque membrane is generally near
to the pupil, the  margin  of  which is often adherent at one  or  more
points.   The opaque substance may fill up the entire space behind the
iris, its circumference  being connected to the ciliary body, or it may
be deficient, in a greater or  less extent, from laceration, or detachment
at its circumference.  According to these varieties, there may be either
good vision or loss of sight.
   Capsulo-lenticular  cataract.—The capsulo-lenticular is a very fre-
quent form  of the  complaint.  Partial capsular opacity is frequently
combined with firm lenticular cataract; the two strata are readily dis-
tinguished, not only by their  colour, but also by their position.  Some-
times the lens is soft in capsulo-lenticular  cataracts, and the capsule  it-
self, having been the seat of disease, is  more  or less  thickened and
indurated.   Hence  the  cataract is  generally large, often pushing for-
wards the iris, and making it bulge against the cornea, so as to destroy
for the time the anterior  chamber.  In these  cases there is a combina-
tion of circumstances, which cannot fail to point out the  nature of the
cataract.  The streaky  appearance  of the anterior portion of the cap-
sule is seen on a level with the edge of the pupil; and we distinguish the
opaque lens of a different tint through the less opaque portions of the
capsule.   As the lens is large, and as both it and the capsule are opaque,
vision is completely lost, except the mere distinction of light from dark-
ness.  The motions of the iris are often  impeded by the  bulk and me-
chanical pressure of the  cataract,
   The  capsulo-lenticular cataract is  sometimes caused  by a chronic
and almost  insensible inflammation, or at least determination of  blood
to the eye, accompanied not unfrequently with symptoms  of congestion
in the head, with muscas or flashes of light, and some degree of intole-
rance.   Under this disturbance of the  circulation, the colour of the iris
is sometimes altered, and the capsule undergoes changes  from intersti-
tial deposition, or from effusion of lymph on its surface, which lead to
peculiar subsequent  appearances.  These vary greatly in different  in-
stances,  and have been named as if they were so many distinct species
of cataract;  there is the c. marmoracea  or variegata, with a marbled
appearance; the c. fenestrata,  with bars compared to those of a win-
dow ; the c. striata, or streaked cataract;  the c. slellata, the c. punc-
tata, with spots of the capsule, and so on.
  In severe purulent ophthalmia, especially in infants, the inflammation
sometimes  extends to the capsule of  the lens, and  produces  a single 
582
cataract.
central opaque spot, c.  capsularis  ce?itralis.   (Von  Ammon, tab.  9,
figs. 1—5.
  There is a c. dimidiata, in which one half of the capsule is opaque.
  In  the c. trabecular is {c. capsulo-lenticularis cum zona of  Schmidt,*
cataracte barrie of  the  French,) a thick opaque  bar stretches  across
the pupil, either in  the perpendicular or horizontal  direction, and ad-
heres firmly to the pupil  or uvea.   Beer,| says that this cataract is pro-
duced by violent internal inflammation, and that the bar is firm, or even
cartilaginous.   In a boy of twelve years old, in whom he extracted such
a cataract from each eye, the bar was of osseous texture, and the cap-
sule,  which was almost  cartilaginous, contained  a  small firm nucleus
of lens.
   In  the c. pyramidalis a dense opaque mass of  pyramidal figure pro-
jects  into the  pupil.J
   It  happens, not uncommonly, that  the lens begins to  be lessened in
bulk  by a natural process of absorption ;  and in proportion as it shrinks,
the capsule contracts upon it, and  shrivels  up.   This shrunk capsule,
which is much thickened and  corrugated, more or less separated from
the ciliary body, and containing  a diminished  or small  lens, is  called
cataracta arida siliquata, or the dry shelled cataract, although no ca-
taract can be dry, in the proper sense of the term.§
   In  some instances, where  the opacity of the lens and capsule is com-
bined with other affections of the  eye, the latter not only shrinks  up, but
becomes detached  from the ciliary body, so that a clear black margin
surrounds it.  In this state, it may oscillate backwards and forwards when
the eye moves (c. tremula,  or  shaking cataract;) it may even become
quite loose, floating behind  the iris, or passing into  the anterior  cham-
ber (c. natatilis, swimming  or floating cataract.)   In the latter case
there is generally a tremulous motion of the iris.
   There is a cataracta gypsea, or change of the capsule into a  kind of
cretaceous substance; it forms a thin shell, brittle, and  of a yellowish
hue.   See Chapter XIX. § 5.
   Under the name of c. capsulo-lenticularis cum bursa ichorem con-
tinente, Beer, (Lehre, vol. ii. p. 301,) and Schmidt, (Ueber Nachstaar,
p. 20, 21.,) have described a cataract of yellow colour, in which a cyst
of matter, sometimes stinking,  is found between the lens and the pos-
terior portion  of the capsule.  If the capsule  be extracted, this cyst
comes out of the eye entire, " containing," says Schmidt, " a thick yel-
low  badly smelling ichor."  He observes, that extraction is always  fol-

   * Ueber Nachstaar und Iritis, p. 21.                             t Ibid, 302.
   X Mr. Wardrop has  represented such a cataract in the  2nd volume of his Essays, pi.
 12, fig. 6.  It is " a lateral view of a conical-shaped opaque body, whose base rests on the
 capsule of the crystalline lens, and whose apex reaches the cornea.  The pupil was quite
 moveable, vision was impaired, and both eyes  have been affected from the  time of birth.
 The drawing was taken from a boy four years of age."
   A pyramidal capsular opacity in conjunction with conical cornea is represented by Von
 Ammon, Klinische Darsteliungen, pt. i. tab. 10, fig. 8.
   § This name was given to the cataract in question by J. A. Schmidt, who represents
 that it is found in young persons who have suffered from convulsions in  infancy.   He
 ascribes to the convulsive movements of the eye that partial  separation of the capsule at
 its circumference, to which he refers the peculiarities of the cataract.  The cataracta arida
 siliquata occurs in young subjects, and as a congenital affection; but I  have not traced the
 action of the cause mentioned by Schmidt.  Ueber Nachstaar und Iritis, p. 20. 
GENERAL DESCRIPTION.
583
lowed, in these cases, by iritis and loss of sight, and that such was the
result in eight cases in which he operated.  I have  never seen this ca-
taract, and Benedict states that he has not met with it.   (Handbuch, vol.
iv. p. 64.)
  The varieties now described arise from the partial and irregular dis-
tribution of the newly deposited substance which  causes the opacity;
from partial thickening of the membrane; or from adventitious external
deposites on its surface during inflammation, becoming afterwards or-
ganized.  These changes for the most part render  the  capsule  thicker
and  firmer than in the natural state.  Hence, in operations it is tough,
and  resists the knife, so that we often find a difficulty in dividing it.
   Varieties of colour.—The lens may lose  its transparency in conse-
quence of internal ophthalmia, and present appearances more or less
similar to those I have already enumerated.  It may be of a dull green,
a yellowish green, or a  brighter  yellow colour; sometimes it is of a
dirty white.  All such cataracts  are the consequences of internal dis-
ease of the organ, and in that respect are to be distinguished from  those
changes in the lens and  capsule which  are not  preceded or accompa-
nied by other diseases of the eye.   In the latter, or cases of  simple ca-
taract, the colour of the opacity, according to the foregoing description,
is grey, yellowish  grey, or greyish  brown, to dark  brown, milky  or
chalky white, sometimes pearly or silvery.
   [M. F. Cunier, in a report of the diseases treated at the Ophthalmic Dispen-
sary of Brussels, invites attention to green cataract which is often confounded with
glaucoma, and  the unfortunate patient thus abandoned as  incurable.  M. C.
states that he has met with eight cases of this kind, on seven of which he ope-
rated and in all vision was restored.   L'Examinateur Med. 12 Sept. 1841.]
   In young persons, the cataract is almost  invaiiably white or  grey;
generally of milky of bluish white tint.   When a brownish or yellowish
 state of the lens  is seen in a young person, it may almost certainly be
 ascribed to internal disease of the eye;  for example, to the commence-
 ment of the medullary fungus; although a similar colour in  an old per-
 son would not indicate the existence of any such disease.*
   Varieties in consistence.—The varieties of consistence  in cataracts
 are  of  great  practical  importance,  as they principally determine our
 choice of  operation.  The firm  lenticular  cataract  is the only  one to
 which the epithet hard can be properly applied; the lens is never found
 osseous in cases proper  for operation.   The consistence of the lens  in
 this form of  the  complaint, is too firm to admit of its being divided or
 broken by the needle; and it undergoes  absorption so slowly, that its

   *  Attempts have been repeatedly made to represent in coloured figures the characteristic
 appearances exhibited  by the various species of cataract; for example, by Mr. Saunders,
 in his posthumous Treatiseon  some Practical Points, Sfc. pi. 4—7; by Mr. Travers in the
 Medico-Chirurgical Transactions, vol. iv. pi. 2; by Beer, in his  heitfaden, vol. ii. pi. 3 ; by
 Mr. Wardrop, Essays, vol. ii. pi. 9, 11, 12, 13;  by Von Ammon, in the first part of his
 Klinische Darsteliungen, tab.  9, 10, 11, 12, containing 129 figures;  and by Mr. Tyrrell,
 vol. ii. pi. 4.
   Of the appearances attempted to be represented in these engravings, some are readily ob-
 served and easily depicted; while it is impossible to convey any clear notion of many
 others in this way, since they  are only recognisable in the living body on close inspection,
 even by those who understand the subject. The figures given by Beer and Wardrop are
 the  best on this, as well as on  the other morbid affections of the eye represented by them.
 Those of Beer were coloured by himself.  Among the numerous figures of Von Ammon
 there are several instructive and useful representations. 
584
CATARACT.
removal  by that process is extremely tedious.  The cataracta gypsea
may be enumerated among the hard; and several of the  capsular, or
capsulo-lenticular cataracts are at least dense and  tough, so as not to
be easily torn or cut by instruments employed within the-eye.   The
caseous and gelatinous cataracts form a transition from the hard lenti-
cular to the milky, which is quite  fluid.  The  needle moves freely
through the gelatinous lens, which is milky white;  and the crystalline
is found in this or in a fluid state in infants, and in young persons to the
age of twenty or thirty.
  Mature and immature.—Cataracts have been distinguished as ma-
ture and immature.  The former term may be used when the change
is fully developed, according to the nature of the case.   This distinction,
however, has been made chiefly in reference  to the time for operating;
and a  common notion  prevails, that the operation ought not to be done
till the cataract is ripe.   This opinion is not altogether unfounded; cer-
tain cataracts are the result of vascular congestion, if not of inflamma-
tion, and in these cases it is unfavourable to operate early*  We should
wait until  the change has been completed, and until  all  symptoms of
fulness are at an end.
   Complications.—Cataract may be purely  local, the  morbid affection
being  strictly confined to the lens and capsule; it may be accompanied
with various affections of other parts of the eye, particularly of the iris
and pupil, the vitreous humour, and retina;  or it may be complicated
with unhealthy states of constitution.  According to these differences,
cataracts  maybe  characterized as purely local, locally complicated,
generally complicated, complicated locally and  generally.  These
points must be carefully inquired into before we  can recommend  an
operation, or determine what mode of operating  may be  most  ad-
visable.
   Adhesions of the pupil.—When we consider that the uvea, if it does
not touch the capsule, is separated  from it only by the thinnest pellicle
of  fluid, and  that  the capsule may become inflamed,  thickened, or
covered by an effusion of organizable lymph, we can easily understand
how adhesions may be formed between it and the uvea or pupillary mar-
gin.   Such preternatural connexions take place in traumatic  cataracts,
and still more in those consequent on acute internal ophthalmia.  In the
latter,  the capsule is covered  by a thick tough adventitious membrane,
which is the medium of  a close general union between it and the uvea.
The adhesions consequent  on inflammation  may be partial or general,
and they are often accompanied with change  of colour in the iris.  The
same internal ophthalmia which has produced these effects,  will gene-
rally be found to have caused change of structure  in  the retina, with
great injury, or loss of sight.  For this reason considerable  or general
adhesion  is an  unfavourable complication.  Indeed adhesions, under
all  circumstances, produce more or less  difficulty in  operation.   We
sometimes see slender partial adhesions by dark  threads, from which
we infer that there has been a  slight degree of inflammation, although
it may not have been manifested by other signs.   The large  soft cata-
ract, which pushes  forwards  the  iris is not usually adherent.   Opacity
of the capsule is frequently combined with adhesion, but not necessarily
so.   The pupillary margin is sometimes  connected by one or more
slender dark threads to a capsule  apparently clear. 
GENERAL DESCRIPTION.
585
  Glaucoma.—Cataract may be combined with glaucoma; and this is
a combination of which we can hardly be aware, unless we have seen
the  case previously to the occurrence of the cataract.  The glaucoma
occurs first, and the lens  is affected subsequently ; but a careful exami-
nation of the history of the case will generally lead us to discover the
previous existence of disease in the vitreous humour and retina.  If the
iris  is altered in colour, if the  pupil  is  dilated, and fixed in the dilated
state, if the sight was lost with considerable  headach and  pain in the
forehead, and if it was gone before the  cataract formed, we may fairly
infer that the eye is glaucomatous.
  The existence of synchisis in conjunction with Cataract will be shown
by a tremulous state both of the iris and cataract, by softness  of the
globe, and complete loss  of vision.   Beer, (Repeftorium, vol. i. p. 61,)
however, says that he has extracted  tremulous  cataracts with  a large
efflux of fluid vitreous humour, and recovery of sight.  Of  course  an
operation should not be performed, unless there is clear evidence that
the  retina is sensible.
  Amaurosis.—It is not uncommon to  have cataract complicated with
amaurosis:  in these cases, the amaurosis will be indicated by the com-
plete state  of blindness, by the patient not being able to discern light
from darkness.   This, however, is only seen in  complete  amaurosis:
imperfect vision may remain, the sensibility of the retina being impaired,
but not wholly destroyed.   We must  attend to  the  symptoms under
which the loss of sight has occurred, as well  as to the present state of
the  eye.  In cataract, objects  are concealed  by a mist or  cloud gra-
dually increasing  in density:  the amaurotic  patient is troubled  by the
sight of imaginary objects, of muscee, scintillations, or  other luminous
appearances.  If these latter symptoms have existed, or are still present,
we  may infer  that in  addition to the  cataract there is, or has been,
affection of the retina.  Simple cataract comes on without pain, while
in amaurosis there is often considerable pain in the head, or neighbour-
hood of the eye,  and generally more or less  uneasiness.  In cataract
the  iris has its natural power of motion ; while in amaurosis the changes
in the pupil take place imperfectly, or  are suspended, and the opening
itself is often dilated.   A motionless iris, therefore, would excite suspi-
cion, and lead us  to examine the case minutely, if it should be observed
where the cataract is  not  large, and the pupil unadherent.  A dilated
state of the opening would be an additional evidence of amaurotic affec-
tion.   We  shall generally derive assistance, in estimating the state of
the  retina, from comparing the two eyes.  It  seldom  happens that both
are  affected in the same degree; the earlier stage in one eye may throw
light on the more advanced complaint of the other.
  Varieties dependent on age.—All  ages  are  subject to  cataracts;
children are even born with them,  and  they may occur at any age from
infancy to the remotest period of life ; perhaps elderly persons are most
liable to the complaint, especially at the age of fifty, sixty, or upwards.
Cataracts are never hard in  children; we scarcely meet with a hard
lens below the age of puberty ; they are not always hard  in old persons:
we  may have soft cataracts in the old,  and hard ones in the  middle pe*-
riod of life.
  The complication of cataract with diseases in other parts, and with
       74 
586
CATARACT.
unhealthy states of constitution, is  obvious  enough.  The latter is an
important point in reference to operation and its results.   We must pro-
ceed very cautiously with the gouty, for fear of iritis.
  Causes.—The well-known effect  of inflammation, in producing  opa-
city of parts naturally transparent, would lead us to expect that inflam-
mation  is a common  cause of cataract.  In  some instances it is ob-
viously  the  result of inflammation; internal ophthalmia? will produce
opacity of the lens and capsule; arthritic inflammation of the posterior
tunics will render the  lens opaque.  Wounds of  the lens and capsule
produce opacity of these parts, and as such injuries generally give rise
to severe inflammation, it  might be inferred that traumatic cataract
could be traced to the  inflammation produced by the wound.   The
opacity consequent on  a wound may, however, occur without any evi-
dence of inflammation.   Soft capsulo-lenticular cataracts often form in
consequence of congestion in the organ.  Their formation is attended,
in many instances, with all the  signs indicating an unusual determina-
tion of  blood to the head, and general fulness of the system.  We can-
not, however, generalize the observation, and  say that inflammation is
invariably the cause of cataract; we cannot suppose that inflammation
has produced the cataract which we see in new-born children.  We see
that cataracts are common in old  persons of healthy constitution, who
are not sensible of any uneasiness  in the eye, in whom there is no ap-
pearance of vascular excitement, nor any other disorder.   We cannot
refer the change to inflammation,  and we  must acknowledge  that the
 cause has not hitherto  been  satisfactorily elucidated in  such instances.
In fact, the nutrition of the  lens,  the mode of its  connexion with the
 surrounding parts, and its manner  of growth, are not understood.  The
 lens undergoes some natural changes in age;  its convexity is lessened,
and it loses that colourless  transparency which distinguishes it in the
early and middle periods of life.  Its nucleus is of a light yellow colour
at thirty; the tint gradually becomes deeper, until the lens resembles a
portion of  amber at seventy or eighty.  In most cases of  cataract, the
direct  cause of  this particular change in the lens  is unknown.   Nei-
ther do we know that any peculiar state of constitution is favourable to
its development.
    Treatment.—In central capsular cataract, where the opacity is a
white spot  not larger than a pin's head, vision is not affected, and no
treatment is required.  The  same observation is  applicable to central
lenticular cataract in certain cases.
   The  effect  of the latter on vision will depend  on the extent of the
opacity.  If this is greater than the size  of the pupil in its contracted
state, sight will be imperfect when the eye is exposed  to strong  light,
although it may be perfect under opposite circumstances.  The remedy
here is  in the regular  use of  belladonna, which keeps the pupil perma-
nently enlarged beyond the extent  of the cataract.  If the latter, whe-
ther lenticular or capsular, is more considerable, occupying, for exam-
ple, the central two-thirds  of the pupil, or even more, vision will be still
more imperfect;  the patient will examine objects with his back to  the
light, and will look at them obliquely. Sight will probably be sufficiently
improved under artificial dilatation  of the pupil, to render  an operation
unnecessary. 
GENERAL DESCRIPTION.
587
   During the progress of cataract, especially of the lenticular species,
 more or less benefit to vision will be derived from the use of belladonna,
 which is thus, in such cases, both an aid to diagnosis, and an important
 measure of palliative treatment.
   General or local measures may occasionally alleviate particular symp-
 toms,  or  remove  concomitant affections,  but  they have no influence
 whatever on the cataract.  It may be asserted, without any qualification,
 that no external  application nor internal medicines with which we are at
 present acquainted, can alter the condition  of the opaque lens and cap-
 sule.  When lymph has been  effused  upon  the capsule, as in iritis, its
 absorption may be effected, while it is still recent, by proper means; but
 what I am now speaking of, is the opacity  of the capsule and lens con-
 stituting cataract,  which cannot be changed  by any treatment hitherto
 discovered.  We must  then come to the operation, as the only means
 of restoring vision in such cases.  However, as the state of the eye,  in
 other respects, is so various, and as these several complications of cata-
 ract materially  influence the  chances of success  from  operation, we
 must, in the first instance, inquire carefully into all the particulars of the
 case, to ascertain whether complete or only partial success may be ex-
 pected, or whether there is no reasonable prospect of benefit.
   Prognosis.—The prognosis is completely favourable when the affec-
 tion is confined to the lens or capsule; when the sensibility of the retina
 is undiminished; when the  motions of the  iris are unimpaired: when
 the constitution  of the patient is sound, and  the health  is good at the
 time of operating; and when the patient is of a spare rather than a full
 habit.   Under these circumstances success may be confidently antici-
 pated if the operator understands the subject well, if he selects the kind
 of operation most suited to the particular species of cataract, and pos-
 sesses  sufficient  manual dexterity for performing it  in the most advan-
 tageous way.   The prognosis is particularly favourable  in congenital
 cataracts, in  those  of  young persons,  in  whom,  however,  it  seldom
 arises except in  consequence of injuries, and in the  firm lenticular cata-
 ract of elderly persons.
   It is bad when the cataract is complicated with glaucoma  or amau-
 rosis; with a fluid state of the vitreous humour; with a varicous condi-
 tion of the blood-vessels; with dropsy of the eye, or with a contracted
 or closed pupil.  Indeed some of  these circumstances would form de-
 cided objections to  the operation.  It is  also bad when the cataract has
 been preceded or accompanied  by severe pains in  the head, or in the
 eye, by muscae volitantes, sparks or flashes of fire before the eye;  as
 all these circumstances  indicate affection of the nervous structure.
   The prospect  is doubtful when cataract is the result of internal inflam-
 mation of the eye, or of that  vascular disturbance which comes under
 the head of congestion.
   Adhesions of the pupil are unfavourable,  since the laceration and re-
 moval  of them may excite inflammation in the iris and internal tunics,
particularly in gouty individuals, in whom  such  adhesions  are most
frequent, and who  are the most likely to suffer from inflammation after
the operation.   The prognosis is doubtful in cases of cataract affecting
one eye, when the other is amaurotic or glaucomatous.   If amaurosis 
588
CATARACT.
 or glaucoma  should  have occurred  in one, there is great probability
 that the other may be affected in the same way.  Before advising an
 operation  in  such a case, we  should satisfy ourselves fully that the
 retina is sensible; we should carefully prepare the patient for the opera-
 tion, and speak doubtfully of the result.   If the evidence respecting the
 sensibility of the retina be not clear, it is better not to advise an opera-
 tion, but to put the patient in possession of the state of the case, and let
 him determine between submitting to blindness and trying the doubtful
 experiment of operation.
   The probable result of the operation is in  some measure influenced
 by the age of the patient; the congenital cases are particularly favour-
 able, as inflammation seldom follows; it  is easily controlled if it should
 occur.  In young persons the risk is less than* in those at the middle
 period of life; the latter is perhaps the most dangerous  time, excepting
 very advanced age.
   The result of the operation is so important to the patient, the question
 being whether he shall regain sight or not, that it may seriously involve
 the reputation of the operator.   It is, therefore, necessary that the most
 minute inquiry should be made  into all the circumstances of the case,
 before the operation  is undertaken; the history of the affection and the
 present state of the eye, the constitution, the previous and present state
 of the patient's health, should be well considered before advising or at-
 tempting any operation.
   There are some cases in which it is better for the patient to be con-
 tent even with imperfect vision, than to  submit to an operation which
 may end in total blindness.   The restorative powers  are feeble in very
 old persons; in them, and  in cases where  the  propriety of operating
 may be doubtful for  other reasons, it is best to employ the palliative aid
 of belladonna, so  long  as it will procure any degree of useful vision.
 We should not, therefore, operate in such cases until the patient is quite
 blind; until his sight  is in that state in which the failure of the operation
 cannot make him worse.
   We cannot lay down a uniform  rule respecting the time of operating.
 In general we should wait  until the  patient is  blind,  understanding by
 that expression the  loss of useful vision.  At  all events, in doubtful
 cases,  this rule is absolute.  One exception  may be mentioned, viz.,
 where the cataract is mature in one eye and immature in the other.
 The former may be  operated on,  so as  to give the patient the use of
 that eye, while the  cataract is forming in  the other.  He will thus
 escape the irksomeness and  the injury to health  inevitably consequent
 on passing several months in a state approaching to blindness.
   Another question is, whether we should operate when the cataract is
 confined, to one,eye;  the general rule has been not to do so.   The ob-
jection to operating in this case is, that the patient is no better off after,
 than he was before, and thus that he incurs a risk without an object.
 The other eye generally becomes affected sooner or later, and  it will
be time enough to operate then.   It has been surmised  that the removal
of the cataract, when confined to one eye, may prevent  its formation
in the other.   It would  be difficult  to prove the point; and there is as
yet no sufficient proof of it before the public. 
OPERATIONS FOR CATARACT.
589
  Himly* has questioned the propriety of the general rule.   He inquires
whether  the  occurrence of cataract in the second  eye ought  to be
ascribed  to the continued action of the cause which has produced it in
the first,  or whether it is owing to the sympathetic influence of the dis-
ease in the eye first affected.   If the latter were the case, the removal
of the cataract when it appears in one eye, might  be expected to pre-
vent the disease from occurring in the other.   He quotes two instances,
in which the  removal of the opaque lens from the eye first affected, ar-
rested the progress  of  an incipient opacity in  the other  eye.   Beer
(Repertorium, &c. vol. i. p. 29,) makes the following statement: "For
a period  of  seventeen years I  have closely observed those  cases in
which the operation for cataract had been performed in one eye, before
any sign of the disease had been noticed in the other.  In all such cases,
I have found that the other eye has  remained free from disease to the
present time."  In his last and great work, Beer adheres to  the ordi-
nary rule without even mentioning the other opinion.   I consider that
rule to be well  founded, and act upon it generally.   There may,  how-
ever,  be cases of  exception; for instance, in young persons, especially
females, where personal appearance may be materially affected by cata-
ract in one eye.  I have operated in some such cases, proceeding always
with great caution, both as to the kind of operation, and  the  circum-
stances under which I have done it.
                      OPERATIONS FOR CATARACT.

   Preparation of the patient.—The success of  surgical operations de-
 pends in many cases, on preventing the  subsequent  occurrence of in-
 flammation,  and in none is this more  important  than  in cataract.
 Hence  it is  necessary,  not  only to discriminate  the  several kinds of
 cataract, and know the operation best fitted for each, but also to inquire
 into the patient's health, and bring it into the state most favourable for
 operation.
   The  question is,  what kind of  preparation is necessary 1   One rule
 is very obvious; that is,  not to operate on a patient with a foul tongue.
 A clean tongue shows that the alimentary canal is in a healthy state, and
 consequently leads us to a favourable conclusion as to the general health.
 For some days previous  to the operation the patient should abstain from
 fermented  liquors, and in certain cases from animal food also.  The
 bowels  should  be evacuated by  some mild aperient every other day
 during this time: they should also be cleared on the morning of the ope-
 ration.   These remarks  will apply to the majority of cases ; and, usu-
 ally, this is the only preparation necessary.
   Some patients, however, require other preparatory measures;  in ple-
 thoric subjects, and such as manifest determination of blood to the head,
 direct depletion is necessary.  If the pulse were  full, and the  patient
 young and strong, it might be advisable to take blood freely, and even

  * Soil man den Staar nicht  operiren, so lange  der Kranke noch mit dem andern Auge
gut sieht? in Ophthalmologische Beobachtungen  und  Untersuchungen.  Bremen, 1801,
p. 148. 
590
OPERATIONS FOR CATARACT.
 to repeat venesection before operating.   In general it is sufficient to take
 some blood from the arm on the morning of the operation.  Free de-
 pletion is occasionally necessary even in old persons.  I remember the
 case of a woman, seventy years of age, who had amaurosis of one eye
 and cataract in the other; she was  corpulent, with  a full bloated, and
 reddish countenance.   She complained particularly  of what she called
 weakness and nervousness, which she had endeavoured to  counteract
 by the  free use of  animal food, porter,  and  other stimulants.  She had
 considerable  headach, with trembling hands and  infirm legs; she was
 bled from  the arm, the blood being  strongly buffed,  and cupped.  The
 headach and the nervousness were diminished by the bleeding, and she
 felt  stronger.  I kept  her  fourteen days before she was in a fit state to
 undergo the operation; and during that time she was bled  four times,
 the  first three portions of blood being  buffed, and cupped, and the last
 free from these appearances.   In addition to  this direct  depletion she
 was well purged, and kept on  broth and gruel, with bread.  After a
 fortnight's discipline of that kind  I operated on the  eye, and extracted
 the  cataract, from  which she  recovered without one untoward symp-
 tom, and regained  excellent sight.  Another patient, who exhibited the
 highest degree of  general  plethora and particular determination to the
 head, was obliged to lose nearly 120 ounces of blood before he was in
 a fit state for the operation.  He had not an uneasy feeling afterwards,
 and his recovery was  rapid  and perfect.  These are examples of the
 preparatory measures  which it may be necessary to adopt in particular
 instances.   The great  risk of  failure  is from  the  occurrence  of in-
 flammation ; and in a matter of so much consequence, it is better to err
 on the side of caution.  In some cases  I have  regretted that I had not
 attended sufficiently to these preparatory measures;  but I have never,
 seen reason to consider them superfluous or injurious.
   The operation for cataract is sometimes  required in  those who are
 weak from delicacy of constitution or advanced age; in whom it would
 be inexpedient to institute any preparatory measures of  depressing in-
 fluence.  This remark is particularly applicable where it is intended to
 perform extraction, as  the recovery of the organ requires a certain de-
 gree of constitutional power.   The operation has sometimes failed from
 deficiency in  the restorative processes.    It will  be enough if we take
 care that the tongue be clean and the alimentary canal cleared on the
 previous day or the morning of  the'operation.
   The existence of anxiety or distress at the time of the operation might
 have an unfavourable influence on its result: it would be safer to wait
 till tranquillity of mind was restored.
   The next point for consideration is the choice of the operation.  From
 the time of Celsus, in whose work we find the first account of an opera-
 tion  for  cataract, until the last century, only one method was practised,
 that  of introducing a small needle into the eye behind  the iris, and push-
 ing the lens downwards out of the axis of vision.  That operation, in-
 asmuch  as  it displaces the lens downwards, has been called depression;
it is also called couching.  It is accurately described by Celsus, and his
 manner  of performing  it is nearly the  same as  that now  practised
About the middle of the last century it happened, in consequence of an
opaque lens having escaped through the pupil into the anterior chamber 
extraction of the cataract.
591
that Daviel, a French surgeon, thought of making a cut  through the
cornea to  let it out, which he  did.   Hence he  was led to  propose
and practise  generally this method of removing an opaque  lens from
the eye, which has since been  called  extraction* and much improved.
This operation consists in making an incision through the cornea, lace-
rating the  crystalline capsule, and forcing the lens out through the pu-
pil and the opening made in the cornea.  When this operation was in-
troduced, a controversy arose as  to the merits of  the two operations,
extraction  and depression, each  of which  had its warm advocates.
The writers on this part of surgery have frequently drawn up, in parallel
columns  the  advantages and disadvantages of the  two methods, and
have usually endeavoured to  demonstrate the general superiority either
of extraction or  depression, as if it were necessary to choose one or the
other, and  practise it exclusively.  More recently  a third mode of ope-
rating has  been introduced, and extensively employed, in which the lens
is neither extracted nor depressed, but disturbed or  divided, and left in
its  place to be removed by absorption.  It  is called the operation by
solution or absorption.  In this  latter  mode of proceeding, the needle
may be either carried through the cornea and pupil, or be introduced
behind the iris, as in the operation of depression.   These two methods
are distinguished by the names  of the anterior and posterior opera-
tions.  No person who understands the subject, would advise any one
operation to be employed exclusively.  Each method has its advantages,
and  is eligible under  certain  circumstances; our object  then should
be, not to adopt one operation with the  view of practising it in all cases,
but to consider the circumstances which gives a preference to one or the
other, and to select in each instance that  which is best suited to the
particular form  of the complaint.
              SECTION II.--EXTRACTION OF THE CATARACT.

  The operation has  usually been performed at all times of the year
indifferently; but some operators have confined themselves to particular
seasons.   Mr. Tyrrell expresses himself strongly on this  point.  He
says, " I  am perfectly satisfied that the operation is most hazardous
during the cold  and damp seasons; so much so, that it is  only under
very particular circumstances that I  now operate for extraction, in the
period from October to March;  the proportion of unsuccessful cases has
been very much lessened since I have discontinued to operate in the cold
and damp periods of the year."
  I think it best to operate on  one eye only at a time.   If we restore
sight in one,  it is sufficient for all useful purposes, and the patient will
generally be  satisfied: the other may be operated on afterwards, or be

  * It seems probable that the Arabians were acquainted with extraction.   At all events
it is certain that the operation had been performed in France, long  before the  time
of Daviel. Mery gives an account of its performance by J. L. Petit  in 1708.  De la
Cataracte et du Glaucome, par M. Mery; Mem. de VAcad. des Sciences, 1708, p. 241.  The
honour, however, of expressly proposing extraction, as a regular operation for cataract, and
of introducing it into practice, belongs undoubtedly to Daviel, whose proposal, communi-
cated to the Academy of Surgery, is printed in the second volume of their Memoires; Sur
une nouvellc Methode dc guerirla Cataracte par V Extraction du Cristallin. 
592                 extraction of the cataract.

retained as a reserve in case the restored sight should fail, or  be  lost
by disease or accident.  When both are operated on  together, they are
not necessarily involved in any unfavourable  subsequent occurrences;
yet they are likely to suffer together from common causes, and under
such  circumstances  the patient loses all  chances  of regaining sight.
Again, serious inflammatory disturbance occurring in one eye may af-
fect the other sympathetically.   Thus, in many cases, both eyes, when
operated  on together, have been lost.  On the  other hand, if  things go
on unfavourably, it is a great consolation  both to the patient and sur-
geon to know that one eye only is risked. Supposing the operation in the
first eye to be unsuccessful, the progress of the case  may afford us in-
 Fig. 44.  formation respecting the individual,  of which we may avail
         ourselves usefully in operating on the second eye.
   j       Various circumstances contributing to the convenient and
         easy performance of the operation, and to the patient's com-
         fort after he has gone through  it, consequently exercising a
         more or less direct influence on  its event, should be attended
         to previously; for example, an apartment with good light for
         the operation; a seat or couch on  which the patient may
         sit or lie;  an  airy sleeping room, in  which  the light can
         be  moderated or excluded ;  and  a  provision of bolster or
          Fig. 42.  pillows by which the  shoulders and head can be
                  supported at a proper height.
                     It is a  matter of some consequence to  have an
                  attentive and intelligent assistant.   The duty he has
                  to perform, and the mode of performing it should be
                  clearly explained to him.
                     The instruments employed  in the  operation
                  should  be prepared and carefully  examined before-
                  hand.  They consist  of two or  more  knives  for
                  dividing  the cornea;  two  narrow curved  knives
                  with blunt extremity, one cutting  in the concavity,
                  [fig. 42,] the other on the  convexity, [fig. 43,] for
                  the purpose  of enlarging the incision, should that
                  be required; a curette, [fig. 44,] for opening  the
                  capsule;  it is a narrow, sharp-pointed, and slightly
                  curved steel instrument.  To the opposite  end of
                  the handle,  a minute silver scoop  is attached,
                  sometimes  called the  spoon of Daviel.  A small
                  and fine hook, and a slender pair of probe-pointed
                  scissors may also be required.
                     A  great variety of knives has been  employed:
                  the operation is undoubtedly difficult, and a hope
                  has been entertained  of removing or lessening  the
                  difficulty by  some peculiarity in the instruments.
                  We need not expect to overcome the difficulties in-
                  separable  from the operation by  mechanical con-
                  trivance.   One knife may be better calculated  for
                  the purpose than another, but a  beginner will not
                  find the operation  easy with any instrument, and
                  dexterity can only be acquired by repeated prac-
Fig. 43. 
extraction of the cataract.
593
tice.   The particular form of the knife is per-  FiS- 46-        FiS- 45.
haps  of no  great importance.   Lancet-shaped
knives have been most commonly employed, of
various breadths; such were used by Richter,
Wenzel and Ware.  The  knife first used  by
Barth, the  founder  of the Vienna  School of
Ophthalmic  Surgery, and now more commonly
known as Beer's knife, [fig. 45,] is of triangu-
lar shape,  straight on  the back, with an oblique
or slanting cutting edge, and gradually increasing
in/breadth as well as  thickness, from  the  point
to the handle.   In my opinion it is the knife best
adapted for the extraction  of the  cataract.   It
is ground  lancet-shaped at the point, by which
means it enters the cornea more readily;  but it
is blunt in the rest of the back.*
   Mr. Tyrrell  has judiciously advised  that  the blade of
Beer's knife, retaining the same depth at the shoulder, should
be shortened, so  that the breadth will  increase  more sud-
denly from the  point  to  the shoulder.   "The  advantage of
this alteration is,  that  the section  of  the  cornea  can gene-
rally be completed by a single thrust, before the point of the
knife reaches the  nose; whereas, in using Beer's knife, when
the point  has been  carried as far as the nose will  allow
of, a  considerable portion of the  cornea  still remains to be
divided, beneath  the edge  of the  instrument; and   it  is
difficult  to  complete  the  division of this  part."   (Vol.
ii. p. 392.)   Beer's knife, as figured by himself, (Leitfaden,
vol. ii. pi.  5. fig.  14,)  measures one  inch and  three eighths
along the  cutting edge.  [See fig. 45.]  The corresponding
measurement of Mr. Tyrrell's instrument is one inch." [See
fig- 46.]
   Previous dilatation of the pupil by belladonna, is employed
by some operators, while  others  object to it.   I  think that
the iris is more out of the  way of the knife, when under the
influence of this  narcotic;  however,  the pupil quickly con-
tracts when the anterior chamber is punctured.
   The patient  should be placed  near a window, which af-
fords  a good  steady light: a  northern aspect  is  prefera-      J_L
ble; at all events we must  select  a window which does not

  * Dr. F. Jaeger, of Vienna, has devised a new cornea knife, by which he proposes to ob-
viate the inconveniences and dangers experienced in the ordinary  mode  of opening the
cornea. The instrument is described and delineated by Dr. Loudon, in a quarto pamphlet,
entitled A short inquiry into the principal causes of the unsuccessful termination of Ex-
traction by the Cornea, &c, 1826.   The instrument consists of a Beer's knife fixed to a
handle, and of a smaller blade connected to the  other  by a  button screw, so that it can be
pushed forward upon it, or withdrawn.  This knife is introduced, carried across the eye,
and through the cornea on the opposite side, in  the same way as Beer's.   By pressing on
the button with the thumb, the smaller blade is now pushed forwards, so as to complete the
section of the cornea,  while the globe is kept steady by the fixed blade.
  From the contemplation of this double knife, Mr. Guthrie was led to construct another
of a blunt silver blade, and a lancet-shaped knife to slide along it.  He makes an opening
in the cornea with a large Wenzel's knife; he then introduces his  double knife with the
       75
J 
594
extraction of the cataract.
admit  sunshine.  He must not, however, be exactly opposite the win-
dow; because the light in that  case will be reflected from the centre of
the cornea, so  as to prevent  us  from  seeing  clearly the point of the
knife in its passage across the  anterior chamber; this  inconvenience
will be obviated, if he is placed  a little obliquely, with  the  eye to be
operated on rather nearer to the window.   One window only should be
open; and the lower half must be closed by the shutters, as it is advan-
tageous to have the light from  above.
  The operation may be performed with the patient either sitting or lie-
ing: the latter position  is now most generally adopted.   An ordinary
couch  answers the purpose very well, the end being about the proper
height  for the head.  A convenient position may be easily obtained by
placing a cushion  or  pillow  under the body or head,  or  the patient
may lie on a table, with  a pillow under the head.
  If the sitting position is  preferred, the patient should be seated on
a  chair or  stool,  lower  than  that  occupied  by the  operator, that
the  latter  may have the  free  and  easy  use  of his  arms, without
being  obliged  to elevate them  inconveniently.   The patient may be
placed on a  seat, with  a back or without one;  a chair with a sliding
back is convenient; it can be adjusted to the height of the patient, who
rests his head  firmly against it.   This is a preferable  mode to that of
fixing the patient's  head against  the  breast of an  assistant: it can be
more depended on for steadiness.  The operator easily adjusts his own
height  by sitting on a music stool, or placing one or more books on the
seat of a common chair.   If the operator is in front, he places his legs
one on each  side of the  patient:  if he wishes to give additional steadi-
ness to his arm and  hand, he may rest the elbow on his knee, raised to
a proper height by placing the foot on a stool at the patient's side.  The
patient's head may be so inclined over the back of the seat, especially
if it be  a  sliding one, as  to  allow of the surgeon operating from be-
hind.
   It has been the general practice to bind up the opposite eye, and this
was recommended by Celsus; I believe  it is a matter of little conse-
quence.  It has been said  that if you  keep the opposite eye quiet, that
which  is operated on will remain still also:  I  do not find that to be the
case.  It is  sometimes  advantageous to  leave  the opposite eye  open,
and direct the  patient to look steadily at an object  so situated  as to
bring the eye into a convenient position for the purposes of the opera-
tion.
   Various instruments have been devised for keeping the  eye steady,
specula of different shapes;  they are now entirely abandoned, as not
only inefficient but absolutely injurious.   Some of these  instruments
have been made with little hooks intended to be  stuck into the sclerotic
coat.  Figures of such are to be found in Righter's  elements of sur-
gery, and in other works.  I  can conceive  nothing more calculated to

blunt silver blade towards the iris, and the cutting-blade retracted;  he carries it across to
the inside of the cornea, and  then presses forwards the cutting-blade so as to complete
the section of the cornea.—hecture on the operative Surgery  of the Eye, second edition, p.
344, plate 6.
  These instruments, which take up much room, and are difficult to manage, can hardly
be employed without great risk of injury to the iris. 
                    extraction of the cataract.                 595

alarm the patient, to increase spasmodic action of the  muscles of the
globe, and thus to render the eye unsteady.  Hence all  contrivances
of this sort are now laid  aside, and the operator trusts  to his own fin-
gers, or to his assistant, for giving to the globe the necessary degree of
steadiness.   In accomplishing this point he must act merely on the an-
terior part of the organ, taking care that no general pressure is made
on the globe either by  himself or his assistant.   Such pressure is inju-
rious, both by pushing  the iris  forwards against the cornea, and pre-
maturely forcing out the  aqueous humour, and also by  endangering
the  premature and forcible  expulsion of  the lens, with  the vitreous
humour.
  The operation of extraction  consists of  three parts, the  division of
the  cornea; the laceration of the  capsule: and the removal of the lens
through the openings made in the capsule and cornea.
  The division of the cornea must be ample enough, that  the lens may
escape readily through  it; we divide, therefore, a certain portion of the
circumference, carrying  the  section along the edge of the cornea, as
near as may be to the sclerotic coat.  There are  various reasons for
making the section at  the margin of the  cornea, and the principal of
these is, that we shall  not otherwise  have  sufficient room for the pas-
sage of  the lens.   There is the further  advantage  that  the  subsequent
cicatrix will not  interfere with vision.  The section of the cornea must
embrace an extent corresponding to the transverse diameter of the lens,
and that is nearly equal to the diameter of the cornea itself,  so that the
section of one half of the  cornea is required to allow the lens to escape.

                              Fig. 47.
We must puncture the cornea on the temporal side of the eye, [fig. 47/j
carry the knife across the anterior chamber, bring it out at the nasal
side opposite to its entrance, [fig. 48,] and then continue the incision,
so that the  knife may cut itself out.   The chief difficulty in the section
of the cornea arises from the iris getting in the way of the knife.   When
the anterior chamber is penetrated, the aqueous humour readily escapes,
and then the iris comes immediately against the knife, so that we can- 
596
EXTRACTION OF THE CATARACT.
not carry it on without wounding  that part.   In order to prevent  the
escape of the aqueous  humour, the cornea knives are so shaped as to
fill up the wound; that is, they increase in thickness gradually from the
point to the handle.
  The cornea may be divided in its upper [fig. 48,] or lower half, or in
           Fi 48#              its  lower  and  outer portion,   [fig. 49.]
                              The  lower section is the most objec-
                              tionable : the  aqueous humour escapes
                              easily;  prolapsus   iridis  takes  place
                              readily; and the edge of the lower lid is
                              apt to interfere with the adjustment of the
                              corneal flap.  Against these advantages
                              we may perhaps place the  recommen-
                              dation of its being  rather easier in per-
                              formance.  In the superior section the
                              operator  has  a  more complete control
over the globe; he can fix it  perfectly; the aqueous humour does not
escape so readily, and  the iris is consequently less  likely to fall against
the knife; there is less fear of prolapsus iridis; and the pressure of the
                               upper lid keeps the flap  of the cornea
                               in its right place.  The exterior  and
                               inferior section is equally eligible with
                               the superior.  [Fig. 49.]   This was
                               the method  employed by an operator
                               of great celebrity, Baron Wenzel.
                                 When  the superior section of the
                               cornea  is performed on  the right eye,
                               the patient should be in the recumbent
                               position, and the  surgeon seated be-
                               hind him, so  that the  head is on a
                               level with the lower part of the ope-
rator's chest.  The fore and  middle finger  of the  operator's  left hand
are employed to raise and fix the upper lid, at the  same time steadying
the globe, so that  it  shall  not turn upwards or inwards.  The fore-
finger, placed below the eye-lashes, on the ciliary margin of the lid,
raises it and  presses it firmly against the margin  of the  orbit, keeping
the edge still in contact with  the globe, though without pressure.  The
end of the finger comes against the eye at its lower part.  The middle
finger is in contact with the globe at the inner angle.   The assistant
gently depresses the lower lid by means of his fore-finger placed on the
integuments.  The knife is to be held between the  first two fingers  and
the thumb of the right hand; and the hand  itself rests  on the temple
with the two other fingers half bent* The  hand  is thus steadily sup-
ported,  and we have the free use of  the fingers and thumb for opening
the cornea, which is to be effected  by such a movement, and not by
that of the whole hand.
  The  eye  is often  rendered unsteady by these preliminaries, and we
wait till this goes off.  Perhaps we  engage the attention by a question
or  remark, when the  eye will become  quiet, and assume  a position
favourable for the operation.   This object may sometimes be accom-
plished  by desiring  the patient to  look in a suitable direction with the
 
EXTRACTION OF THE CATARACT.
597
other eye.  It may be well to touch the  cornea slightly once or twice
with the flat surface of the knife, before beginning the section, to give
the patient warning, and  to steady the eye.  We should apprize him
of the painful sensation caused by puncturing  the cornea, recommend-
ing him not  to hold his breath, nor to resist, or contract the lids if  he
can help it.
   The point of the knife should be entered at the margin of the cornea,
[fig. 47,] and the section should be continued, as nearly as  possible, in
the same direction.  If we cut  in front of this  point, the opening will
be insufficient; if behind it, we interfere with the attachment of the iris,
and increase  the probability of prolapsus.
   In making  the incision of the cornea, four points are to be attended
to, viz. the puncture, by which the anterior chamber is entered, carry-
ing the knife  across the chamber, the puncture at the opposite side, and
lastly, the completion of the section upwards.   In entering  the knife at
the temporal side  of the  eye, we must  be  careful to carry its point
through the cornea, directly, not  obliquely.  Without due  caution the
knife may go between the corneal laminae without entering  the anterior
chamber; or  the cut may be so oblique, that the inner line of the section
will be  much  smaller  than the outer, and consequently there will not
be sufficient room for the cataract to pass easily.  The instrument is
then to be carried on, by a continued and  steady movement of the
finger and thumb, with its flat surfaces parallel to the iris, across the
anterior chamber.  The  more quickly this is  done, the less chance is
there of the aqueous humour escaping, and the iris falling  against the
knife.  A  principal difficulty in performing this section of  the cornea
is that the eye-ball is  involuntarily turned inward towards the nose.
To prevent this, we must steady the globe by means of the fore and
middle finger, while the knife is carried through the anterior chamber,
and brought out at the nasal side of the cornea.  Unquestionably the
unsteadiness of the eye, the motions which a person involuntarily makes,
are great impediments  to the performance of this operation.  We must
not be afraid  of  touching  the  globe, but  fix it firmly between the fore
and middle finger, while we are entering the knife, carrying it across,
and bringing it out on the nasal  side; when  the latter point is accom-
plished, there is no further difficulty in completing the section.   Let the
operator puncture the cornea, and traverse the anterior chamber quickly
and steadily,  keeping his eye on the point of the knife, and not attempt-
ing to  cut upwards: as soon as the knife has been brought out on the
nasal side, all pressure on the  globe  must be discontinued;  and it may
be well to pause shortly, that muscular spasm may subside.  We then
push the knife gently onwards, without any remission, towards the nose,
and its breadth should be  such that  it may cut its way out;  but we
generally find that a small portion of the  cornea must be  divided by an
upward motion, unless  we push it onwards, so as to wound  the nose or
the internal canthus.   This must  be  accomplished  by a gentle  sawing
motion of the knife, immediately upon which the lids should  be left free.
It is safer  in some cases to wait a few seconds  before completing the
cut, that spasm of the muscles may subside.
   Some recommend that the knife should be withdrawn before the cornea
is completely divided,  and that  the  section should be  finished with  a 
598                 extraction of the cataract.

narrow curved knife, [fig. 43 or 44.1   It would be better to do this than
to run the risk of wounding the iris.
   The object we have in view, is to make a clean cut of the cornea by
one single incision,employing only one instrument; we thus accomplish
the purpose in a manner the most favourable to subsequent speedy union.
I have already observed, that the presence of the iris affords the princi-
pal obstacle to the easy and exact execution of this  important  step in
the operation.  The  preparatory measures of fixing the lids and ex-
posing the globe, and the act of cutting this very sensible part, bring on
a spasmodic action of the muscles, both of the globe and lids, by which
the aqueous humour is quickly expelled, and the loose floating iris pushed
against the knife, or  even propelled, so as to bulge under its  edge.  If
this should happen when the  point of  the knife has traversed  only half,
or even the whole  anterior chamber, and the point should be completely
enveloped by the iris, it will be best to withdraw the instrument, close
the eye, allow the  section to heal, and repeat the operation  afterwards.
But, if  we should  have  carried the knife not only across  the anterior
chamber, but through the nasal side of the cornea, the iris may then be
forced under its edge; we may complete the section without withdraw-
                             ing the instrument, although we must not
                             immediately  press it forwards, as we
                             should  then shave off a piece of the iris.
                              It is better to rest for a few seconds, that
                              the spasm may subside; then to bring the
                              knife forwards while we gently press the
                              iris back with the fore-finger, and, keep-
                              ing up the  pressure,  slowly complete the
                              section.   As the knife advances, its
                              broader portion enters the anterior cham-
                              ber ; thus the chance of protrusion is di-
                              minished by lessening the space in which
                              it can  occur.
                                When the  section of the  cornea  is
                              finished, it may not  be large  enough to
                              allow  the  easy escape of the lens. A
                              common cause of failure  is in bringing
                              the point  through the cornea, before it
                              has reached  the inner edge; and this
                              arises  from the rolling of the globe in-
                              wards.  We see cicatrices, in which we
                              find that the knife has come out only  a
                              little beyond the centre  of the  cornea.
                              It is most desirable to make the opening
                              of  full size at first; that is to  divide one
                              half of the cornea close to its circumfe-
                              rence.  When, however, this is not ac-
                              complished, what course should be taken
                              to remedy the failure?  Scissors curved
                              on the edge, and with one blade blunt at
                              the end, have been employed, [fig. 50.]
                              They  are  regularly  used in the method
 
EXTRACTION OF THE CATARACT.
599
originally proposed by Daviel, who merely punctured the cornea with the
knife, and did the rest with the  curved scissors.  The contused wound
thus made is less favourable for union by adhesion.  The mode now com-
monly employed, is the best; that of enlarging the incision by means of
the narrow, curved, blunt-ended knife, [figs. 43 or 44.]   This instrument
is introduced  into  the anterior  chamber, keeping its  end against the
cornea, and carrying it in to the full extent;  the cutting is effected by
withdrawing the instrument, and repeating the process until the neces-
sary enlargement is effected.  This method is  sometimes used as the
regular way of operating; a partial section of the cornea is made with
a broad knife, carried across the anterior chamber, but not brought out
on the other side; it is then enlarged in any eligible direction, with one
of these curved knives.
  When the section of the cornea is finished, the great difficulty of the
operation is passed; the rest is easy.   All that remains is to rupture the
capsule of the lens.  The lens  might be  forced out without previously
opening the capsule;  but the vitreous humour would  probably be ex-
pelled with it.
   The capsule  is generally lacerated by the curette.   [Fig. 44.]  This
is introduced under the  flap of the  cornea, with the convexity turned
upwards, till the point is opposite the pupil; we then turn the  point in-
wards, sink it through the capsule, and draw it from side to side, so as
to divide that membrane freely, and withdraw it with the convexity of
the instrument  downwards.
   The third part of the  operation is the removal of the lens; this is ac-
complished by directing the patient to open the eye, and then making a
little steady and gentle pressure upon the  upper lid, with the small silver
spoon at  the other end  of the  curette, [fig. 44,] while we press gently
against the lower lid with the forefinger, until the  lens  rises up out of
its socket.  The pressure must  be  continued gently until we see the
edge of the lens  rising in the pupil and  distending  the iris.  This part
of the process  cannot be performed too slowly and  cautiously.   The
iris is stretched to the  utmost, and appears as if it  must inevitably be
torn  through;  but it yields  gradually, and  allows  the  largest lens to
escape through the pupil.  Bring the upper lid over the  eye, and close
it immediately on the exit of the cataract, otherwise the vitreous humour
may follow the lens.  Sometimes the violent contraction  of the muscles
forces out the lens on the completion of  the corneal  section, and some-
times it escapes spontaneously,  when the  capsule has been opened.  The
operation is now finished: let the eye remain shut for a short time, and
then  open  it  to see that the pupil is round and clear, and the corneal
flap in the right place.   The edge of the  iris  is often engaged in the
wound; gently press on this part of  the eye through the  upper lid, then
open both eyes to the light, and the pupil will recover; or the prolapsed
iris mav be replaced with the silver  spoon.  The after treatment of the
case will be subsequently considered.
   Adhesions of the pupil would prevent the exit of the lens, even where
the  cornea has  been opened  to the full extent.   Their presence is
indeed  a reason against operating  by  extraction, and will  be disco-
vered if the eye is previously  examined, as  it ought  to  be, under the
influence of belladonna.  If, however, the escape of the lens should  be 
600
EXTRACTION OF THE CATARACT.
prevented  by adhesions  discovered at  the time of operating, it would
be proper to enlarge the  pupil by a slight cut with the slender scissors;
or the adhesion might perhaps be separated with the  curette.
  If the section of the  cornea have  been made in the way described,
the lens will pass through  it with great facility;  but it often happens
that a  portion  of the soft circumference of the lens remains behind, so
that the pupil is not of its natural clear black colour.   We are generally
directed to remove carefully from the  pupil or anterior chamber all such
portions of the lens, and  the  little silver scoop or spoon of Daviel was
made for the purpose of  fishing them out.  This is a  bad practice.   It
is  essential  to the success of the operation, that the lens should be
removed with  as little injury to  the surrounding parts as possible;  the
repeated introduction of  instruments is obviously at variance with that
object, and nothing is more likely to  cause inflammation, especially of
the iris, than the contact of those foreign bodies with that delicate tex-
ture.   It is, moreover, unnecessary, because the soft portion of the lens
left behind will be removed by absorption.  Then, again, little forceps
and little hooks have been provided for  seizing and removing portions
of opaque capsule.  If we were to try,  we could not accomplish this,
or at least not without the certainty of letting out the  vitreous humour;
and besides, it must be seen on a little reflection, that the opening in the
capsule, which is sufficient to allow the escape of the  lens, must also be
large enough to  admit of good vision.  If there were  in the pupil or
anterior chamber a considerable mass  of lenticular  substance, and it
could be removed easily, let it be done; but otherwise, make no attempt
of the kind.
  Sometimes the vitreous humour rises up into the pupil under the edge
of the cataract; and if we were to continue pressing on the globe, that
humour would be forced out  instead of the lens.  We must introduce
the curette, or the slender hook, and hook out the cataract.   The escape
of vitreous humour is not to be regarded in itself as a very serious cir-
cumstance.  The space which it before occupied is filled up by aqueous
secretion.  There is no doubt that one-fourth or one-third, and perhaps
even one-half of the vitreous humour may be lost in this way, without in-
terfering with the  result  of the operation.  In many instances it seems
rather  to contribute to success : it lessens the bulk of the globe, and thus
prevents the  tension  which  occasionally succeeds to  the  operation.
Sometimes there is a spasmodic  action  of the muscles, propelling the
vitreous humour against the cornea, and preventing the apposition of the
flap.   I have in such cases introduced the curette through the pupil, and
let out some of the vitreous humour purposely.
  It is desirable not to wound the iris; but a clean cut  of this part is not
in itself of any consequence.   I have seen a portion of it shaved off in
making the section of the cornea, a few times, without any injurious re-
sult ; the case  has proceeded much more favourably than it would have
done if the knife had been withdrawn, and the section completed with
other instruments. The pupil is afterwards larger, and of irregular figure.
If the portion shaved off should not embrace the margin of the pupil, the
new opening and the natural pupil should be laid into one by a snip with
the slender scissors.
  Superior section of the cornea  on the left eye.—If  the operator can 
EXTRACTION of the cataract.
601
 employ both hands equally, the superior  section of the cornea will be
 made on the left side in the manner already described, except that he will
 elevate the upper eye-lid and  fix  the  globe with  the fore and middle
 finger of  the right hand, and hold the  knife with the left.   If he is not
 ambidexter, he will sit in front of the patient, manage  the lower lid with
 the left, and hold the knife in his right  hand, cutting from himself, while
 the assistant raises the upper lid and fixes the globe.  This is not an eligi-
 ble mode of proceeding.  The way of using the knife  is unusual; and
 the globe cannot be  so  effectively fixed by an assistant as by the ope-
 rator.*-
   Exterior and inferior section of the cornea.—Division of the cornea at
 its outer and lower part, [fig. 49,] is equally advantageous in other re-
 spects, with the superior section, and it  presents the  additional advan-
 tage pointed  out by Mr.  Tyrrell, that the pupil, if displaced by prolap-
 sus iridis, is in a position more favourable to  vision  than  in the case
 of the superior section.  It is performed on the left eye, by the operator
 sitting in  front of the patient, and using his right hand, while the upper
 lid is elevated by the assistant.  It may be executed in the same man-
 ner on the right eye,  if the surgeon can use the knife with his left hand;
 otherwise he sits behind the  patient, using the right  hand and cutting
 away from himself.
   The section  of the cornea will  in general be best performed with the
 right hand ; the operator may therefore divide  it above in the right eye,
 downwards and outwards in the left.
   Inferior section of the  cornea.—As the division of the cornea in its
 lower portion is liable to objections, from which the  two  other modes
 of operating are free, it will only be practised in certain cases for par-
 ticular reasons.  It may be  executed with the patient either in the re-
 cumbent or sitting posture.  In the latter case he should be seated on a
 chair or stool, rather  lower than that occupied by the  operator, that the
 latter may have the free and easy use  of his hands, without  being
 obliged to  elevate them  unpleasantly.  The operator should be seated
 at such a height that he may be able to  use his hands with perfect fa-
 cility at the level of the patient's eyes.  Further directions  respecting
 the relative positions of the surgeon and patient have been given already
 at pages 594 and 595.
   The duty of the assistant is to fix the head, to keep it perfectly steady,
 to elevate the upper lid, and to keep it  elevated, without pressing on the
 globe while the section of the cornea is made.   If a chair with a sliding
 back be employed, all the assistant has to do is to elevate the lid; other-
 wise the assistant must fix the patient's head against his own breast by
 one hand placed under the chin, while he elevates the lid with  the other.
 The assistant should  be aware of one point,  which should be decided
 upon between him and the operator before the  operation is commenced,
 namely, to let the lid go before the section of  the cornea is completed;
 and the operator should just give a sign or  motion to the assistant as
 soon as he has nearly finished the section.  In elevating the upper lid,

  * [It seems to us that the operator will not experience any more difficully in fixing
the eye, when operating by this method, than by Ihe former.  Fige. 47 and 48, show  tlv
method of proceeding under such circumstances ]
      76 
602
EXTRACTION OF THE CATARACT.
one finger is generally sufficient; let the assistant fix the lid against the
upper margin of the orbit, the end of the finger being placed on the cili-
ary margin of the lid : he should hold it firmly against the orbit, until the
operator tells him to let it go.  The end of the  finger should  project
over the margin of the eye-lid, towards  the upper and inner part of the
globe, so as to prevent the eye from rolling in  that  direction  when the
section of the cornea is begun.   It is not material whether the assistant
employs his right or left hand; but it will be less in the way if he em-
ploy the hand opposite to that which the operator is using.
  In operating on the left eye, the surgeon depresses the lower lid and
fixes the globe with the fore and middle fingers of the left hand, holding
the knife in the right.  As the eye would roll inwards when the knife
touches it on the  temporal side, the operator must not be afraid to fix it
effectively by the fore and middle fingers of the left hand.  The inferiorsec-
tion of the cornea must be performed on the right  eye with the left hand.
   Operation of extraction without an assistant.—Some operators per-
form  extraction of the cataract without an assistant, fixing the lids and
the globe with the fore and middle fingers of one  hand, and using the
knife  with the other.*  There is an obvious advantage in having the
combined movements necessary to accomplish  a  single  purpose exe-
cuted by one and the same individual, if it can be done effectively ; and
we know that extraction can be performed in this way most success-
fully ; for it is the plan followed by Mr. Alexander.  To acquire this
method, great manual dexterity and abundant opportunities of practice
are necessary.   It increases the difficulties of an  operation  in itself dif-
ficult, and therefore is not likely to meet with general adoption.  At all
events,  the best course for beginners will be to operate with the aid of
an  assistant.
   Treatment  after the operation.—Our object  is too keep the flap of
the cornea in its place, so that the wound may unite by adhesion.  The
eye therefore must be perfectly at rest, and the  occurrence of inflam-
mation  must be prevented.   After the operation is concluded, the lids of
both eyes must be closed, and kept in that  state.  The  coverings ne-
cessary for this purpose should be light.   Sound  eyes would be heated
and rendered uneasy if thickly covered.  A soft  rag, doubled and wet-
ted may be placed over each eye, and gently confined by the simplest
bandage.  This consists of a stripe of linen doubled lengthways.  The
middle  of it should be pinned to the back of the night cap; each end is
then  brought  forward along the  corresponding  side  of the head, and
obliquely across the eye and forehead;  the two ends, after crossing on
the forehead, being pinned to the  sides  of the cap.   The patient may
find it more comfortable to have the rags confined  by a simple circular
band  carried across  the forehead, so that there shall be no  pressure on
the eyes.
  Nothing can be more objectionable than the method  recommended
by  Beer, and  followed  by many German operators, of  closing the
lids by stripes of sticking-plaster carried  from the  forehead to  the
cheek.

  * This method is strongly advocated by Mr. Guthrie in a pamphlet on the operation of
Extraction ; London, 1831, 
EXTRACTION OF THE CATARACT.
603
  The application of bandage to the eye is not to be regarded as an es-
sential point of  treatment;  it is rather employed to keep the eye quiet,
and to guard it from any slight accident.  On  this account gentle  con-
finement  during the night  is expedient; but the part may be left un-
covered or  with a damp rag over it, while the patient is awake.  The
rag may  be moistened occasionally, if the patient  should  find it com-
fortable.  If, however, the eye is cool and easy, this will not be neces-
sary; nor should the  application of  cold in this way be persevered in,
unless the patient's feelings indicate its propriety.  The bandage should
be immediately removed, if heat or pain come on.
  Soon after the conclusion of the operation, the patient should go to
bed, and  lie with the head and  shoulders raised, in  order  to moderate
the flow of blood towards the head, and to  facilitate its return.  The
apartment should be darkened; at least the light should be sufficiently
excluded to produce no unpleasant effect on the eye.  Mr. Tyrrell has
suggested that, when the patient has  the advantage of a good attendant,
he might remain for a few hours on a couch or easy chair; that he will
be less likely to fall asleep than in bed, and  thus have a better  chance
of sleeping at night.
  The food should be soft, not requiring mastication, that the muscles of
the jaws may not be called into action.   For the same reason,  the pa-
tient should not talk.
  Considered merely as an operation, extraction of  the cataract  is  a
slight affair, not serious, nor attended with much pain.  Patients  have
often expressed to me that they had suffered  as much  pain from vene-
section.   It is, however, a most important matter in its consequences,
involving the alternative of restored  sight or continued blindness.  Anx-
iety and alarm must often be felt; the patient will be nervous and agi-
tated, and restlessness may come on towards night, with pain in the or-
gan not dependent on  inflammatory excitement.  An opiate, in tolera-
bly full dose, is the best  remedy for this  state.   We  may administer
from twenty to  forty minims of laudanum, or the liquor opii sedativus,
one third or one half a grain of the muriate of morphia, with a little of
the spiritus etheris sulph. comp.   Where opium has  been found  to disa-
gree, hyoscyamus, although a less certain and efficacious narcotic, may
be substituted.
   An uneasy sensation will be experienced in the eye, a kind of smart-
ing or aching,  for twenty-four  hours  after the operation or  longer;
sharper pain will be felt  on any movement, sometimes with the feeling
of  a foreign body.  Fluid  will escape occasionally, leaving the eye
easier.  These, in various degree,  are the usual results of the opera-
tion, and indicate nothing unfavourable.
  The lids should be gently cleansed with tepid water, and freed from
any mucous secretion, from time to time.   This must be done slightly,
with the  softest sponge or rag, and  without any pressure on the lids.
  The bowels should be effectively  cleared on the morning of the ope-
ration, so that the  patient may not want to  move, on  this account, for
the next  day or two.  Then, if they should  not act naturally, a  mild
aperient should be  given, to empty the canal without purging.
  If things go on favourably for four or five days, the eye being free 
604
EXTRACTION OF THE CATARACT.
from pain, and the upper lid neither swollen nor red, we may conclude
that the operation has succeeded.  We may gently raise the lid to as-
certain the state of the organ:  it will be a great satisfaction to the sur-
geon and patient  to find that  there  is no unnatural redness, nor pro-
lapsus iridis, that  the pupil  is regular, and the vision  good.   We just
try the latter point, and then close the eye again.  Bandage and cover-
ings may now be  laid aside; at least a light rag pinned to the night-cap,
allowing it to hang over the eye, or a common green shade, will be
sufficient.
   The patient may now leave  his bed, and  sit in  a moderately lighted
room, walking about occasionally.   He  may go on thus  for ten days
or a fortnight more, opening the eyes now and then for a short period.
The long confinement to bed, heretofore enjoined after the operation of
extraction,  is unnecessary, and must  be injurious  to health.   The
patient should remain in bed for the first twenty-four hours;  he may
then in many cases sit up during a part of each day; and there can be
no advantage generally in confinement to bed for more than four or
five  days.
   If things go on  favourably, the eye may be opened in a weak light,
in a week or ten  days, and may be used  more  freely as  it becomes
stronger.   After some time, generally in about a month, it is expedient
that the  patient should  be suited with spectacles;  the loss of  the lens
diminishes the refractive power of the organ, so that it becomes neces-
sary to supply its place by convex  glasses.   The patient must select
those with which  he can see best.  He will require two pairs of spec-
tacles, one for ordinary vision, the other  for reading, writing, and the
other purposes in which accurate near sight is required;  the latter must
be more convex than the formor.  Some  weeks should  still  elapse be-
fore the patient begins to use his glasses, and he should at first proceed
cautiously.   Indeed, he will act prudently in employing the  spectacles
at all times sparingly; in many cases  the cataract is not the sole imper-
fection in the eye,  and vision may decline  and be lost  at  some length of
time after the operation, without any obvious reason.
  Attention should be paid for some time to  the  state of the bowels,
the diet, and the general health;  the eye should not be much used, nor
exposed to strong light, nor should the patient run any risk of getting
cold;  the organ remains weak  and  irritable after the  operation, and
therefore liable to  inflammation from slight causes.
  The wound of the cornea is considerable; there is a large  surface to
be united  and oicatrized, and numerous red vessels will be  seen upon
the conjunctiva and sclerotic opposite the section;  these enlarged  ves-
sels are employed in repairing the breach made in the corneal structure,
just as is observed in the healing of an ulcer of the cornea.
  I have  supposed that  every  thing  is going on favourably after the
operation; however, we unfortunately find, as we might expect, that so
large a penetrating wound of the globe often produces serious  inflamma-
tion.   If the patient should not  have been bled before hand, he should
lose from eight or  ten to fourteen or sixteen ounces of blood on the  eve-
ning of the operation, unless there be a reason to the contrary.  If, how-
ever, there should  be pain of the eye, or head, with accelerated circula- 
EXTRACTION OF THE CATARACT.
605
tion and general heat, a large venesection is absolutely necessary.  This
is a safe kind of precaution; I have never seen it injurious; but in some
cases I have had occasion to regret that it was neglected.
  Bleeding should on  no account  be neglected under  such  circum-
stances ; and it is  necessary either  that the operator should do it him-
self, or that he should entrust  it to some one in whom he can place
confidence.  If the pain should not be removed, or if it should recur, the
bleeding must  be repeated, and  the further use  of cupping or  leeches
may be necessary.  The greatest attention should be paid to the patient
for the first forty-eight hours after the operation, the object being to pre-
vent the occurrence of inflammation.  It will not do to wait till inflam-
mation arises, and then adopt measures for reducing it.  If this  process
be allowed to take place, the success of the operation is either frustrated,
or rendered less perfect.
  The occurrence most to be dreaded after the operation is that of ac-
tive inflammation, attended with sharp pain in the eye, swelling, red-
ness, and great tenderness of the upper  eye-lid.   Sometimes the local
action necessary for  adhesion fails, and inflammation of more  chronic
character occurs, with pain in  the  organ, and swelling  of the eye-lid
without redness.  The pulse is  small and feeble; the patient depressed
and restless.   Stimuli with opiates, cordials and  good nourishment are
required in such cases, and are employed with the most favourable effect
both on the general and local symptoms.   In the two cases now under
consideration the disorder and the treatment are of opposite character.
The consequences of a mistake would be  serious; hence, under doubtful
circumstances, the organ should be carefully examined, while the state
of the constitution is  attentively considered.
  When we consider the violent distention of the iris in the  escape  of
the lens, its exposure by the large section of the cornea, and the  mecha-
nical irritation which it sometimes undergoes from the contact of instru-
ments used in  the operation, we shall not wonder that iritis should oc-
casionally follow the operation.  It generally commences  about the
fourth day, with severe pain in the head; this pain is aggravated during
the night, remitting in  the day.  The iris changes its colour, lymph is
effused into the pupil, there  is  great sensibility to light, and  increased
lachrymal discharge.   Closure  of the pupil, or obstruction of it by an
adventitious membrane, are  its consequences if it is  not arrested.  Free
venesection  in  the beginning, when the  pain is first felt, cupping and
leeches, and afterwards the  active use of mercury, are the best means
of combating this affection.   But the latter remedy is not so efficacious
here, as in iritis from internal causes.
  Prolapsus of the iris occurs not unfrequently  in  connexion with ex-
traction.   It may happen at the  time  of the  operation, the  iris being
distended to the utmost, and then forced through the opening in  the cor-
nea by the advance and the exit of the lens.   It may be replaced, at the
moment by gently rubbing the upper lid, and  then  opening the eye  so
as to cause contraction of  the pupil;  or  it may  be pushed  back  under
the flap of the  cornea  into  the anterior  chamber with the small silver
scoop.   If  the iris should be forced  out again, while continued spas-
modic action of the muscles prevents the correct apposition of the cor-
neal flap, it may be expedient to let out a little of the vitreous humour. 
606
EXTRACTION OF THE CATARACT.
This may be done by introducing the curette through the pupil, and la-
cerating the crystalline capsule.   Great care is necessary to  prevent
too large an escape of the humour.
  Prolapsus of the iris often takes place within the first three or four
days after the operation, in consequence of some sudden incautious or
involuntary effort, such as that of coughing or sneezing, or, without anv
accidental  cause, from internal changes, probably of congestive or in-
flammatory character, producing general fulness, and distention of the
structures towards the front of the eye.   The prolapsus is  followed by
pain and irritation in a greater or less degree.   The  protruded  part
suffers from the pressure of the opening, and causes an inequality of sur-
face, which irritates the lids.   We  endeavour to tranquillize the eye,
and thus to prevent the increase of mischief.  When the organ is in a
quiet state, the prolapsus may  be punctured with a cataract needle, so
as to let out the aqueous humour.   This lessens the  protrusion, and fa-
cilitates cicatrization; it may be repeated with advantage.  In this way
the case will  be brought to a favourable termination, the iris remaining
adherent to the cicatrix of the cornea, and the pupil  not  being much
contracted or displaced.   If it should appear that adhesion of the iris to
the cornea has not taken place, after puncturing the prolapsus, we may
touch it with the nitrate of silver, or apply a strong solution to the part
with a camel's hair pencil.  The escharotic should not be employed
without necessity; in the majority of cases the means before mentioned
accomplish all we want.   A protrusion sometimes  takes place from the
cicatrix of a thin  delicate membranous substance, which may be dis-
tended with aqueous fluid.  According  to  circumstances, it may be
punctured with a cataract needle, touched with a solution of nitrate of
silver, or snipped off with scissors.
  Cases for extraction.—The operation of extraction is particularly ap-
plicable to cases of  firm cataract, especially in persons advancing in
years.   The cataract being hard and less susceptible of absorption, is
removed from the eye; the incision  of the cornea  may be  healed in
twenty-four or forty-eight hours after  the operation, the object of which
is then accomplished, though it would not be prudent to employ the eye
at that time.   Thus  the advantages of the operation are the complete
removal of the cataract, and the speedy restoration of sight.
  Cases in which extraction  is unadvisable.—Under certain circum-
stances, there  are objections to extraction, whether employed for hard
or any other cataracts.   A small anterior chamber increases the diffi-
culty of the operation ; it is not easy to make an adequate section of the
cornea without wounding the iris.  The cataract is sometimes so large
as to push  forwards the iris, so that a very small space is left between
the latter and the cornea;  but as  firm cataracts are generally smaller
than natural,  this objection does not usually apply to  such cases.
  A sunken eye is  unfavourable  for  the  operation of extraction; and
the eye may be in this state either from an  absorption of the  adipous
matter in the orbit, or  from a  great projection of the brow : the globe
cannot be denuded sufficiently for the easy execution of the operation,
or at least not without  subjecting it to pressure.  Unusual smallness of
the palpebral  fissure may cause similar difficulty.
  Very advanced  age is  unfavourable for the performance of extrac- 
EXTRACTION OF THE CATARACT.
607
 tion;  the restorative powers of the system are enfeebled, and the union
 of the cornea does not readily take place.  A weakened state of con-
 stitution, independently of age, would form  an analogous  ground of
 objection.  I have seen some cases, in which no progress towards union
 was observable four or five days after the section  had been made.  It
 would be difficult to specify any exact age at which we might deem it
 objectionable to perform the operation; we should  rather consider the
 general powers of the individual, for some persons are  as young at
 seventy as others are at sixty.   I performed extraction on a late mem-
 ber of our profession at the  age of ninety-two; the cornea united as
 quickly and favourably as it could have done  in the youngest subject,
 and the patient subsequently enjoyed the  power of reading with a suit-
 able glass the smallest print with perfect facility.
   Adhesions of the pupil prevent the  exit of  the lens, and thus render
 extraction ineligible.   Extraction would  be contra-indicated by affec-
 tions  of the chest attended with cough or difficulty of breathing.
   Another objection to the operation of extraction has reference rather
 to the operation than to the patient; it is  the difficulty of performing it,
 the degree of manual dexterity required for its successful  execution.
 Unless  a person  has frequent opportunities of operating, he will  not
 become familiarized  to  the various difficulties of  the proceeding, nor
 acquire that confidence which is essential to success.  The unsteadiness
 of  the eye, the little control which the  patient has over it, the alarm
 which the dread of the operation, and still  more the preliminary mea-
 sures  occasion, and the convulsive or  spasmodic  exertion which the
 actual contact of the  instrument often  excites, are sources of real diffi-
 culty.  The eye is rolling incessantly from  one side to the other, and it
 immediately turns away from the  instrument, so that the greatest care
 and caution are  necessary even to perform'the section of the cornea.
 Undoubtedly extraction  is an operation of considerable  nicety;  and
 unless it has been  frequently performed on the dead  eye, the expectation
 of  success on the living subject would  be as absurd, as the  attempt
 would be unjustifiable.  The operation of depression, on the other hand,
 is easy, and requires no particular practice before hand.
  Bebr, who is a great advocate for extraction, mentions the following
 circumstances as contra-indications of the operation, and consequently
 as  reasons for preferring depression  or reclination.  A  considerable
 adhesion of the iris to the cornea.   A  very flat cornea, in  consequence
 of which the anterior chamber is so small, that an opening of sufficient
 size cannot  be made.  A very  broad arcus senilis, which we  cannot
 venture to divide, because the wound will not heal.  Habitual contrac-
 tion of  the pupil  {myosis.)  Deeply lying eyes with narrow fissure of
 the lids.  The eyes very unsteady, and  easily thrown into convulsive
 movements.   Excessive and insuperable  timidity of the patient.  Early
 age or great stupidity, rendering the patient unmanageable during  and
 after  the operation.  (Lehre, vol.  ii. p.  364,  365.)  I have found  by
 repeated experience,  that the notion expressed above of the corneal
 section not healing when it has been made in the arcus senilis is incor-
rect. 
608
DEPRESSION, OR COUCHING.
SECTION III.--DEPRESSION, OR COUCHING.
^
  The patient should be  prepared for  this operation in  the same way
as for that of extraction.  In  all instances, before operating with the
needle, it  is expedient to dilate the pupil by belladonna: this enlarge-
ment of the aperture enables us to  see exactly what we are doing.
Permanent dilatation after the operation is generally advisable, in order
to allow free access of the aqueous humour to the lens, as well as to
prevent adhesions of the pupillary margin.
  Various needles  have been  used for depression:  the spear-shaped
 Fiff  52  Fio- 51    needle, which has been commonly employed, is made
                  straight, and terminates at the  end in a spear point.
                  The needle  employed  by the  late  Mr. Saunders is
                  straight also, but instead of being spear-pointed is
                  ground flat at the extremity, [fig. 51: The small figure
                  at the side, is a lateral view of the  same instrument:]
                  it is just such  an instrument  as might be made by
                  grinding a knitting  needle flat at its end, and giving
                  it a sharp point: the sides of the end are also sharp.
                  The needle of  Scarpa is slightly curved at the end
                  and is sharp upon the edges of the curve, [fig. 52.]
                  There is a needle strongly recommended by the late
                  Mr. Hey, but it is now out of  use; it is the worst of
                  all I have tried.  I  think that Scarpa's needle will be
                  found to answer the purposes of the operator best.
                    The patient  is placed on  a low seat, and the ope-
                  rator  occupies a rather higher one in front of him.
                  The assistant,  standing  between,  supports the head,
                  elevates and fixes the  upper lid.   The operator de-
                  presses the lower lid and steadies the globe with one
                  hand, while he uses the needle with the other.
                    The needle should be carried through the sclerotica,
                  at the distance of a line and a half or two lines be-
                  hind the margin of the cornea, and nearly, but not
                  exactly, in the middle of the  eye, because the long
                  ciliary artery runs  on  each side along the middle;
                  the  needle, therefore, should be entered a little above
                  the  middle line.  It is to be introduced on the tem-
                  poral side of  the  globe, [fig. 53,] and then  carried
                  forwards and  upwards, so as to place it on  the up-
                  per and front part of the lens, and then the business
                  of depression begins.  The needle must be steadily
                  pressed upon  the  cataract, so as to  move it down-
                  wards and backwards, out of the axis of vision; and
                  this is to be done, not by any sudden  motion, but by
                  a slow and  gentle  pressure, continued until  the lens
                  sinks  below the pupil.  The needle should be held on
                  the lens for a  short  time  to   fix  it steadily in that
                  position, and then having been gently rotated to dis-
                  engage it from the  lens, it should  be lifted up a little
y 
DEPRESSION, OR COUCHING.
609
to see if the lens rise; if it do not, the needle is withdrawn.   If the lens
should rise, it must be again depressed and kept down for a short time,
after which the needle is withdrawn.

                               Fig. 53.
  Reclinaiion.—In  the modification of depression termed reclination,
the lens is not pushed downwards in a straight direction, but is turned
on its axis* so as to be placed horizontally in the vitreous humour, be-
hind the lower part of the iris.   When this kind of displacement  has
been effected the posterior surface of the lens is turned downwards, the
anterior upwards; the superior  margin is backwards, the inferior for-
wards.  In order to operate in  that way* a particular instrument was
devised by Weinhold.*   It consists of two needles, which; when closed
together, appear, and may be used as a single needle.   It is employed
in this state to puncture the sclerotica;  but when  the instrument  has
entered the eye,  and  been  brought in front of the lens, the operator sepa-
rates the two component parts, of which the junction corresponds to the
puncture of the sclerotica, and then there are two needles placed in front
of the lens, by which we  can completely command it, and recline it, or
place it in the situation already described.  The reclination maybe ac-
complished  with the Common simple  needle,  but the lens may revolve
under the  needle instead of taking the desired direction.
  In reclination the curved needle is carried through the tunics in the
same situation as in depression,  the  convexity being forwards.   It is
then brought over the upper edge of the crystalline  in front of that body*
and  placed a little  above its centre,  with the  concavity backwards.
The needle is now moved slowly  backwards, so as to place the lens in
the position already  described, care being taken to prevent it from rol-
ling under the instrument.  The needle should then be rotated between

  * Anletung den verdunkelten Krystallkbrper in Auge der Menschen sammt seiner Kap-
set umzulegen with two plates, second edition, Meissen, 1812.  Reclination had been already
proposed in preference to  depression by  VVillburg;  Bctrachtung uber die bisher gewohn-
lichen Operationen des Staares, sammt  einer leichten und verbesserten  Art dieselbe zu
machen. Nurnberg, 1785.
       77 
610
DEPRESSION, OR COUCHING.
the finger and the thumb to disengage it; and further pressure may be
made on the centre of the lens, so as  to sink it  just below the level of
the pupil.   If the inferior edge of the lens should have come too far for-
wards, in the process of reclination, so as to  press against the iris or ci-
liary processes, it should be moved gently backwards before the needle
is taken out of the eye.
  Scarpa's mode of depression.—The operation of depression as per-
formed by Scarpa is nearly the same as that which  I  first described;
his needle is to be introduced with its convexity forwards, the point of
the needle is then carried in front of the upper part of the lens, when it
is to be depressed, pushing the lens downwards and backwards; having
done this Scarpa turns the needle, and carries it quite through the front
of the capsule into the  anterior chamber, and makes a point of lacerating
the capsule very freely, so as to let the  aqueous humour upon the de-
pressed lens; and he advises the removal of any soft or loose fragment
of the  cataract into the anterior  chamber.
   The advice of Scarpa in the last  two points is by no means judicious.
When performed in the most careful manner, and confined to the sim-
ple object of removing the cataract from the axis of vision, depression
often excites serious  and dangerous inflammation.   This will be more
likely  to occur  when  we add  to the displacement  of  the lens lace-
ration  of its  capsule, and the passage of fragments  into the anterior
chamber.
   After-treatment.—In the operation of depression, there is a punctured
wound through  all the coats of the eye, and a forcible displacement of
the lens; the cells of the vitreous humour are lacerated, the capsule of
the lens is torn, so that the internal structures of the organ  are exten-
sively injured.  Although the operation at first sight appears to be simple,
it  cannot be unattended with the risk of inflammation ;  indeed inflam-
mation is at least as common after this operation as after extraction.
The inflammation too, occurring in the most internal part of the organ,
is  generally serious; consequently the patient requires as much care as
after extraction.  It is necessary to pay strict attention to the state of
health previously to the operation, and the treatment for the removal or
prevention of inflammation must be equally active.   Internal inflamma-
tion commencing in the iris, and proceeding slowly is a common  oc-
currence after depression; it must be treated actively by antiphlogistic
measures, and afterwards by the use of mercury.
   Pressure on the retina is a further source of danger.   We must take
great care to prevent this.  There is  but  a small space to move the
needle in, and we must not depress the lens further than is absolutely
necessary to clear the edge of the  pupil.  Pressure  of the lens on the
retina would probably produce amaurosis.
   When the controversy existed between the advocates of extraction
and depression, among the disadvantages of the latter was enumerated
the subsequent rising of the lens; and this was considered a formidable
objection to depression.  If such a circumstance should happen, which
is seldom the case, the operation  may be repeated.   Depression admits
of repetition; in extraction, on the contrary, the fate of the eye depends
on one effort;  if that  fails there is no further chance.   The operation 
DEPRESSION, OR COUCHING.
611
with the needle may be performed many times, and the eye will bear it
without any serious injury, so that we may accomplish ultimately what
we have  failed to effect in the first instance.
  The hard nucleus of the lens may pass, at a shorter or longer period
after the operation, into the anterior chamber, where  it excites a most
painful inflammation, which goes on as long as  the cause of irritation
continues  to act.  I saw a gentleman, in whom depression had been
performed twelve or fourteen months previously: theoperation had suc-
ceeded perfectly, and vision  had been excellent  until within a recent
period.  A small, amber-coloured portion of lens, in the shape of a flat-
tened disc,  now lay in the bottom of  the anterior chamber.  For some
time it caused little inconvenience, but  inflammation  slowly arose with
great pain, and serious sympathetic disturbance of the opposite eye.   I
found it necessary to open the cornea  and take out the  cause of  ir-
ritation.  The eye recovered, excepting partial nebulous opacity of the
cornea, and the  pupil was clear; but vision was nearly lost.  A lady
who had cataract in one eye, the other being unaffected, was persuaded
to undergo an operation with the needle.   Not long  after  its perform-
ance, the centre portion of the lens passed into the anterior chamber, and
there excited violent inflammation with excessive irritation and pain.
There was the greatest intolerance of light, so that neither  eye could  be
opened, and the patients sufferings were incessant, day and night, hard-
ly mitigated by any of the various measures used for  her relief.  I saw
her after many weeks of suffering.  Although the state of the eye, from
inflammation  and  intolerance* was  very unfavourable to  such a pro-
ceeding, I opened the cornea and removed a hard nucleus of lens.  The-
operation was followed by immediate relief: the inflammation and intol-
erance of light, however, abated  but slowly, and a  considerable time
elapsed before they were completely at an end.  Contrary to my expec-
tation, tolerable vision was recovered.
  Absorption of the  depressed lens.—The old opinion that the lens,
when removed from the axis of vision, and sunk in the vitreous humour,
remains unchanged, so that it may at any moment, by rising up again
and resuming its place behind the pupil, deprive the patient of sight,
seems to have been  implicitly adopted  by Beer,  who  thereupon repre-
sents depression  and reclination as mere palliative proceedings of un-
certain ultimate result.  " Depression and reclination," says he, " offer
only a palliative cure in cases of perfectly hard or intolerably  firm ca-
taracts, in the cystic, and the tough membranous cataracts.  For none
of these are ever dissolved  and absorbed  after the operation, but they
remain in the eye as unorganic foreign bodies, capable of rising on any
occasion, and thus again destroying sight partially or completely."   In
a note on this passage he makes the following additional statement.   "I
have  neglected no opportunity of examining carefully after death the
eyes of those who had undergone depression or  reclination during life.
Some of the cases had been operated  on twenty years and more  pre-
viously.  In almost all, I have found the firm undissolved lens generally
much diminished, either with or without  capsule.  Membranous cata-
racts have been but little  corrugated; they have completely lost their
toughness, and been converted into a firm white mass.  In  a living per-
son I saw the cataract, which had been depressed thirty  years before 
612
DEPRESSION, OR COUCHING.
by an itinerant operator, Hilmer, raised again by a fall on the head.  It
was small, angular, and floated from one chamber into the other when
the pupil was dilated.   It was  successfully  removed by  extraction,
being then nearly ossified.  In 1805,1 extracted  for  a  woman forty
years old, a large, hard, yellowish white lenticular cataract, which had
been in the anterior chamber twenty-six years.   It was  displaced by a
blow on  the eye from the bough of a tree.  I have never seen even a
half firm cataract dissolved  and absorbed.   Before I can  believe the
possibility of the occurrence, I must have  ocular  demonstration that
a  depressed hard  cataract  can  disappear."  (Lehre, vol. ii. p.  363,
364.)
   Some  of  the expressions in this very quotation partly admit the fact
which Beer is arguing against.   But the investigations made by others
completely contradict Beer's statements; show that the displaced lens
becomes absorbed, the process requiring a longer or shorter time in pro-
portion to the firmness or softness of the body; and consequently prove
that the fear of  its rising again  into its original position is in a great
measure groundless.
   Acrel dissected  the eye of a  peasant who died some time after he
had undergone  depression.   The lens had completely disappeared.
(Chirurgische Vorfalle, vol. i. p.  109,)
   Scarpa examined the eye in three instances after depression.  " The
first was in a nobleman of Pavia, aged  sixty, who  died  precisely a
year after he had undergone the  operation of couching for a cataract in
the right eye ; the other was in a woman forty-three year of age, who
died three years after depression of the cataract: and  the third, in a
man fifty-seven  years of age, who died about three years and  a half af-
ter the same operation had been  performed.   In the first of these three
subjects, I found the crystalline,deeply imbedded in the vitreous humour,
and reduced to about  one-third its natural size; and  in  the other two
in which the  crystalline was deeply situated in the  vitreous humour
below the axis of vision, there was only the nucleus remaining of a size
a little larger than the head of a common pin.   (Treatise,  &c. p. 326,
327.)
   Dr. William Soemmerring has examined several eyes after the ope-
ration of depression, and has described what he found, in an interesting
work,* to which he has added a  series of beautiful figures, representing
most satisfactorily the  changes  observed.  In eight  years and a half
after the operation the lens  had completely disappeared.  In  another
case it was  completely absorbed in three years.  After two  years, the
firm nucleus of the lens, as large as a  lentil, was found at the bottom of
each eye:  and  it was  in the same state  in another  eye at the end of
thirteen  months.
   Mr. Jules Cloquet found the  crystalline reduced to one-third  of its
natural volume in two years after the  operation.!
   For the lens  to be absorbed in these cases, it is  necessary that it
should be  exposed nakedly to  the vitreous humour.   If it continue
covered  by its capsule,  no  absorption  occurs.   In  a case where the

   * Beobachtungen uber die organischen  Verdnderungen im Auge nach Staaroperationen;
mit drey Steindrucktafeln.  Frankfort am Mayn, 1828.
   t Pathologic chirurgicale, p. ]35, plate  x. fig.  15. 
THE OPERATION BY ABSORPTION.
613
operation had  been performed three years before death, Dr. William
Soemmerring* found the lens completely inclosed in its capsule, situated
between the lower edge of the pupil, and the margin  of the retina,
unaltered as to size, but  rather  unequal  on its surface.   M. CLoQUETf
observed an analogous fact at the end of two  years.  The  absorption
of the lens in the anterior chamber, is equally prevented by the presence
of tthe capsule, as is seen in  the case mentioned  at p. 169.  In the  in-
stance of non-absorption  in the anterior chamber  mentioned by Beer in
a recent quotation at p. 611, the lens was probably covered  by its cap-
sule.  This  membrane seems to be little, if at all, susceptible of ab-
sorption.
  An interesting  physiological fact was  observed by Dr. W. Soemmer-
ring in his examinations; viz., that when, after depression, the capsule
remains in its place, and with its natural connexions, a partial repro-
duction of the lens takes place.  When  the eyes were recent, he saw
no appearance of capsule or lens; but after they had  been immersed in
spirit, the capsule became very obvious,  and it was found to contain a
varying quantity of soft gelatinous matter, analogous to the exterior
substance of the lens, and rendered opaque by the spirit.    Messrs. Coc-
teau and Leroy D'EtiollesJ  had already shown that the lens  is repro-
duced in animals, as in the rabbit, cat, dog.  This reproduction took place
to a considerable extent  in six weeks after the part had been extracted;
but it was still more complete at the end of six months.  In a rabbit killed
at that period  after extraction of the lens on both sides, " the crystalline
capsules were  perfectly transparent, and no cicatrix could be discovered:
they contained crystallines perfectly  similar in size and consistence to
those which had been extracted.   To be more certain of their nature,
we plunged them in boiling water, when they became opaque, hard and
friable, just like  the original lens."§
   The cases,  to which depression is best suited, are the hard cataracts,
in which, for  some of the reasons before mentioned, extraction might
not be advisable;  or, when the operator does not feel sufficient confi-
dence in himself to perform the last-mentioned operation.   The advan-
tages of depression are its facility, the less degree of risk to the organ,
and the power of repetition.
        SECTION IV.--THE OPERATION BY SOLUTION OR ABSORPTION.

  It was found by casual observation, that the lens occasionally disap-
peared from the pupil without being depressed.   For instance, in some
cases  in which depression had been  attempted, but not accomplished,
on leaving the eye quiet for  a certain  time, the cataract disappeared.
Mr. Pott and Mr.  Hey, who were  advocates for depression,  found,
when  attempting to  operate on  soft cataracts, that  the  needle passed
through them; and they observed in these cases, in which the operation
was supposed  to have  failed, that after a time  the pupil became clear:
this of course showed that absorption went on after the capsule  had

  *  hib. cit. p. 36, plate ii. fig. 5.                  t Ibid, p. 135, plate x. fig.  14.
  t Experiences relatives a la Reproduction du Crislallin, in the Journal de Physiologie,
torn. vii. p. 30.
  § Ibid, p. 43. 
614
THE OPERATION BY ABSORPTION.
 been lacerated, and the aqueous humour admitted to the lens.  Hence
 arose the  idea  of operating designedly in this manner, viz., to disturb
 or break the lens, and perhaps to  lacerate its capsule, and then leave it
 for absorption.  This mode was afterwards called the operation  by
 solution ; it might, perhaps, be more correctly called that by absorption.
 The lens  is neither depressed nor extracted, but  placed  under such
 circumstances, that it disappears from the eye, being  either  dissolved
 in the aqueous humour, or taken up directly by the absorbents.   It is a
 very useful operation, and easy of performance.
   The mode of proceeding  is to  introduce the instrument in  the same
 situation as for depression.  We generally use  a needle which cuts a
 little further on the  sides than that of Mr. Saunders, [see fig. 51;] the
 only difference between that  and the former being the addition of a cut-
 ting edge extending not more than a quarter of an inch from the point.
 The object is to divide the anterior layer of the crystalline capsule.  If
 the cataract be fluid, its contents  will pass into  the anterior chamber,
 and render the aqueous humour turbid: but if it should be only soft, not
 fluid, we move the needle gently once  or twice through it, after having
 freely lacerated the  capsule, and  then withdraw the instrument.  The
 object is to lacerate the anterior  capsule, without displacing the lens
 from its natural situation.
   This  operation may be followed by inflammation, just as any other
 punctured  wound of the  globe; but  if we  proceed carefully, and are
 content to  do little at  a time, it does  not  excite  much inflammation.
 The absorption of the lens goes on to  a certain extent: probably some
 of its exterior soft substance will pass through the opening in the cap-
 sule into the anterior chamber, and then be absorbed.  After a lapse of
 some weeks we may operate again, dividing the  substance of the lens,
 but taking care not to dislocate  it.   We may at  last  proceed more
 freely, breaking up what  remains into fragments, and carrying them
 into the anterior chamber.
   The points to be attended to in this mode of proceeding are, first, not
 to displace the  lens; for if we do, it will bulge  against the iris, press
 upon and irritate that part, and thus occasion great mischief; secondly,
 not to attempt too much at once, but rather to repeat the operation, and
 at last, when the lens has  been  diminished  and softened by absorption,
 to divide the capsule more extensively, and  perhaps after breaking  up
 the  lens to carry the  fragments through  the pupil  into the anterior
 chamber.
   The cases particularly fit for the operation by solution are fluid and
 soft cataracts;  in them it is sufficient to lacerate the capsule, and let in
 the aqueous humour upon the lens.   It is also applicable  to caseous
 cataracts;  and may even  be performed on  those of firmer consistence.
 But in the latter, much longer time is required for absorption, as  might
 naturally be expected.  The  operation, however,  is objectionable  in
 such cases from the  possible passage of a hard portion of lens, after the
 softer substance has  been absorbed, into the anterior chamber, where it
 would excite serious inflammation.   The less inflammation  is excited,
the more rapidly does  absorption go on.   The removal even of  a soft
 or caseous  lens is often tedious; and this  circumstance forms  a real
objection to the operation.  Patients are anxious to get sight restored, 
THE OPERATION BY ABSORPTION.
615
and the surgeon is equally desirous of accomplishing the point.  Delay
is, however, unavoidable in this method of proceeding, in which weeks,
and even months, sometimes elapse before the cure  is finished.   The
only compensation to the patient for the extension of time, is the dimi-
nished risk  of inflammation.
  In attempting  to  remove cataract by absorption, it may be advan-
tageous to begin  by  simply puncturing or slightly lacerating the anterior
portion of the capsule.  This is done by the anterior operation, or kera-
tonyxis, which will be described presently.   We carry the point of the
needle through the capsule, make a small perpendicular laceration, and
then withdraw the instrument.   When the size and firmness  of the lens
are diminished by the absorption thus excited, we may operate behind
the iris, and divide the cataract more freely.
   Whether the lens  is removed by absorption  or solution.—It is not yet
determined whether the  lens is removed from the  chambers of the eye
by absorption, or whether it  disappears  by solution in the aqueous
humour.   Removal  by the absorbents is a matter of common occur-
rence in  other parts of the body; but I know no instance in which  a
solid is dissolved.   Analogy would therefore lead us to consider the
occurrence as an exemplification of  absorption.   When a portion  of
lens is in the anterior chamber, no changes occur in it like the action
of a solvent; nor is the  transparency of the aqueous humour affected.
The solvent action,  if it be such, is very different from  ordinary solu-
tion ; for fragments of lens lie in the supposed menstruum often for weeks
or months with little change.   Sometimes, however, the lenticular sub-
stance gradually wastes and  is removed at  points where it  is not in
contact with any surface, as  in  the case of a  fragment protruding
through the capsule and pupil into  the anterior  chamber, also on the
upper surface and  sides of  fragments resting  in  the  bottom of the
chamber.
   However the  process  is effected, it goes on  more actively, and  is
therefore accomplished more quickly in  the anterior than  in  the poste-
rior chamber.   Some time ago I operated on both eyes of  a boy, be-
tween two  and three years of  age, for congenital  cataracts:  they were
lenticular and gelatinous, the crystallines being of their natural size, and
of a pure milky-white.   In the eye first operated  on, I divided the cap-
sule and lens with  the  needle, and  gently disturbed  the latter, which
remained in its situation behind the pupil.   At the end of a fortnight I
operated on the other eye.  The lens revolved when I pressed  the needle
against it for the purpose of dividing it, and passed entire into the ante-
rior chamber, which it  nearly filled.  Slight irritation occurred on the
second or third day, requiring the application of  three or four leeches;
there was no subsequent redness or  uneasiness, and the  removal of the
lens was complete by the end of the sixth week, leaving a clear  black
pupil, an iris with full power of motion, and perfect vision.   The opaque
body still filled the pupil  in the opposite eye, apparently but little dimi-
nished.   "  I saw,"  says Professor Walther, " an entire firm dirty yel-
low lens pass into the anterior chamber, in a young man: it was com-
pletely absorbed in  seven weeks.  The presence of the foreign body at
first excited considerable inflammation; and I thought it would be neces-
sary to imitate the proceeding of Daviel,  and extract it.  But the parts 
616
THE OPERATION BY ABSORPTION.
gradually became accustomed to the irritation ; the inflammation passed
off, and I enjoyed with my pupils the  interesting spectacle of an entire
firm lens undergoing gradual removal by absorption, which was  fol-
lowed by complete recovery of sight."*
   We must, however, proceed cautiously in passing fragments of opaque
lens into the anterior chamber, because they act as foreign bodies,  and
often excite considerable and obstinate inflammation, during which the
process of absorption is suspended.  This is particularly the case when
the fragment is of firm consistence:  a small particle of hard lens  will
cause so much irritation  as to render its  removal by a section of the
cornea necessary, while even a considerable piece of the soft or gelati-
nous kind may be introduced into the  chamber with impunity.
   The mischief  produced by the passage of a hard lens into the ante-
rior chamber is exemplified by  a case related and figured  by  Dr.
Farre  in  the work  (Plate 7, fig.  6,  and page  231,)  quoted  be-
low.  "Fig. 6 is added to show the  effect of making too large an
aperture in the anterior lamella  of the capsule.  Wheatley, admitted
into the infirmary in  1810, was  dismissed with  a free  aperture in  the
capsule, and a lens partially dissolved, so as to leave a segment of the
pupil  clear, the eye  was perfectly free  from inflammation, and his vision
was very useful: but as the solution went on, the large nucleus lost its
support, and dropped  into the  anterior chamber, as  it is  represented.
From that moment inflammation was excited, and has been kept up in
different degrees for more than twelve months, by which the process of
solution has not only been considerably retarded, in consequence of the
effusion of coagulable lymph around this nucleus, but the cure has been
rendered doubtful."   In the figure, to which the preceding account re-
fers, a  lens not much below the  natural  size  is seen in  the anterior
 chamber of an inflamed eye.
   The  opaque capsule does not  undergo  absorption  behind the  iris;
perhaps because it retains more or less completely its  natural connex-
ions.   Thus we see it remaining in the eye unaltered for years.  From
the case, related  at p. 169, it should seem that the capsule is not liable
to absorption even in the anterior chamber. In his account of Mr. Saun-
ders's operation for congenital cataract, Dr. Farre states generally that
the opaque capsule is never removed  by absorption : " all that is capa-
 ble of being absorbed, nature herself  removes, and she only fails to ac-
complish her purpose, because the capsule cannot be destroyed by this
 process."f  In the same  work, the 1st and 2nd figures of the 6th plate,
" represents the eyes of  Chapple, a girl twelve years old, in whom the
central  aperture was effected in both  eyes; and as  the cataract was
capsular, the aperture would have been enlarged, if the capsule had not
been  so tough as to render it impossible.  This thickened capsule  is in-
capable of being dissolved or absorbed.  A margin of it behind the pu-
 pil, and  some portions  of it which were detached  into  the  anterior
 chamber,  presented the  same appearance at the end of  three years
 which  they did immediately after  the operation."!   I nave seen lnis

   * Merkwiirdige Heilung eines Eiterauges, &.c. p. 59, 60.
   t 1 Treatise on some Practical Points, &c. by the late J. C. Saunders, 2nd edit. p. 156.
   I Ibid, p. 225.                                         »       F 
THE OPERATION BY ABSORPTION.
61?
  patient more  than once, many  years after the  description just quoted
  was written:  the fragments of capsule remained  unaltered in the ante-
  rior chamber.

    Kera.tonyxis.~The operation by solution or absorption, has been some-
  times  performed by introducing the needle through the cornea, and la-
  cerating  the capsule of the lens.   This, which is called keratonyxis, was
  first practised by a German surgeon  named  Conradi.*   It was  intro-
  duced into practice in this country by Mr. Saunders.   It is  an  essen-
  tial circumstance in  the  performance of keratonyxis, that the  pupil
  should be fully dilated by belladonna.  Mr. Saunders, who  employed
  this mode of proceeding in congenital cases, proposed to make an open-
  ing in the centre  of the capsule, and having slightly acted on the lens,
  to leave it for absorption.   He  used  his straight sharp-pointed needle,
  which should  be carried through the  cornea  at a  small distance  from
  its margin, with the flat surfaces directed forwards and  backwards: it
  should be so constructed as to  fill the wound in the  cornea, and thus
  prevent the escape of the  aqueous humour.  Langenbegk extended  the
  use of this method, and resorted to it for the  purpose of depression and
  of breaking up the lens for absorption.  He used a curved needle, nearly
  like Scarpa's, cutting  on  its edges, and  filling  the puncture  as it en-
  tered.   He introduced this needle from below.  In a  tract on the sub-
 ject in which  the mode of operating  is  minutely  described and  illus-
 trated  by figures,  as well as by numerous cases, Langenbeck gives the
 most favourable account of the operation   and its results, f  It  has not
 been viewed in the same light by others.   Beer  tried it extensively soon
 after its proposal by Conradi ; but his  cases turned out badly ;J and the
 result of the several trials by Jaeger§ was equally unfortunate.  There is
 much less power of acting  on the lens  and  capsule, whether for de-


   * Gleize opened the capsule with a needle introduced  through the pupil, when  he had
 been foiled in an attempt at extraction ; a sudden movement of the patient having with-
 drawn the eye from  the knife after the cornea had been punctured.   The cataract was
 completely dissolved by the  twentieth day.  He subsequently repeated this proceeding in-
 tentionally in other cases, and always with good result.  The solution of the lens takes place
 in fifteen to fifty days; the  softer the cataract  the shorter is the time required for solu.
 tion.  He observes that depression might be accomplished in this way.—Nouvelles Obser-
 vations parti que s sur les Maladies de I'QUil et leur Traitement.—Paris, 1796.
  Conradi, who was stadt-physicus (town-physician) in Northeirn, proposed the introduction
 of the needle through the cornea as a regular mode of operating, in his I'orschlag zu einer
 einfachen Methode den Staar zu stechen, contained in his Chirurgische Beobachtungen, printed
 in Arxema.n's Magazin fur die Wundartzney-wissenschafts, vol. i. stuck i. 1797.  He was
 obliged to withdraw the knife after opening the cornea in an attempt at extraction; he punc-
 tured the capsule with  a needle, and in eight to twelve  weeks  the pupil was clear.  He has
 stated fairly the advantages  of the method, and observes  that if the cataract does not dis-
 solve, any other operation may be performed.  He operated on a woman of seventy; at the
 end of twenty months  there was  no change. Probably it wasa hard  lens.   Buchhorn
 gave to  this method the name  Keratonyxis  (from  xtpx;,  horn, and vt/|«,  puncture,)
 and made it the subject of his inaugural dissertation at Halle in  1806, under the title
" De Keratonyxide, nova  Cataracta aliisque oculorum morbis medendi methodo chirur-
gica."  He afterwards published a full account of the  subject in the German  language;
Die Keratonyxis, eine neue gefahrlosere Methode dengrauen Staar zu operiren.—Magde-
burg, 1811.
  t Priifung der Keratonyxis, einer neuen Methode den Staar durch  die Hornhaut zu ope-
riren, ihn zu zerstuckeln fyc.—Gottingen, 1811.
  t Einige praklische Bemerkungen, ifc. in Arneman's Magazin, vol. i. stuck 3.
  § Diss, inaug. de Keratonyxidis usu, Vienna, 1812.  It is reprinted  in Radius, Scrip-
tores ophthalmologic Minores, vol. i.
        78 
618
THE OPERATION BY ABSORPTION.
Fig. 54.
    Fig. 55.
1
n
pression or division, when the needle is  introduced through the cornea
in the anterior operation, as keratonyxis is also called, than in the poste-
rior, when it is entered behind the iris.   This method, therefore, is alto-
gether  ill suited to the  purposes of  depression or division of  the lens.
Escape of  the  aqueous  humour  at the puncture of the cornea often
occurs,  being  followed  by  protrusion  of  the  iris  and  lens  against
the needle, and sometimes by dislocation of the  latter.   At  least it
prevents us  from  prosecuting the operation.  That it frequently gives
rise to  severe internal  inflammation  is  shown by  the cases  in the
dissertation  of Professor Jaeger.   The same  point is illustrated by
the  circumstance  of an essay*  having  been  written  expressly  to
describe  the phenomena  and  treatment of a chronic  iritis frequent-
ly  consequent  on the operation.  It appears clearly that the  author
had seen the affection repeatedly.   I think that the anterior operation
             should be abandoned  as a general mode  of proceeding,
             that  it should  be confined to the laceration  of the  cap-
             sule,  and the consequent  admission of the aqueous hu-
             mour to the substance of the lens, as the first step in the
             proceeding by absorption or  solution, the operation  being
             subsequently completed by the needle introduced  behind
             the iris.
                [Dr. Jacob of Dublin has contrived a needle which he con-
             ceives particularly applicable to the anterior operation, and which
             Dr. Mackenzie pronounces to be preferable to  all others; com-
             bining the advantages  of a small blade, with great strength and
             fine temper, inflicting so minute a wound that no mark remains
             in the cornea, capable of effectually opening up  the texture of
             the lens, and from its conical form, not permitting the aqueous
             humour to escape during the operation.    (Practical Treatise,
             p. 713.)
                This instrument consists of  a common needle  of the size
             " known in the shops, as number seven, being the forty-fourth part
             of an inch in diameter, about one half the size of the finest Saun-
             ders'  needle  which is made.  The point can be  turned to the  re-
             quisite curve by means of a pair of cutting forceps, or the ward
             of a small key; of course without heat, which would destroy the
             temper. It must not however  be expected that all needles are so
             soft as to be bent  thus cold:  there may not be  ten in a hundred
             of this temper, but when once turned they retain the curve with-
             out any danger of bending or breaking, and certainly possess  a
             degree of strength and temper never observed in needles separately
             forged and  finished by the  best  cutlers.   They  should always
             be tried before use, by passing  them repeatedly through thick
             calve's-skin leather. After they have received the requisite curve,
             the point should be cut flat on each side, on a fine hone, and care-
             fully examined with a magnifying glass, to ascertain that it is
             perfect.   [See fig.  54.   Figure 55, represents a  magnified
             view, of the  point, and  a part  of the blade.]  The extent  to
             which the point should be curved, may  be left to the  choice
             of  the surgeon,  reminding  him that the greater the  curve
             the more effectual the  needle will be when introduced, but the
u
  * Commentatio ophthalmica de Iridite chronica ex Keralonyxide suborta, a H. B. Schin-
dlkr ;  Vratislavix, 1819. An abstract is given in LiNGENBecK's Neue Chirurgische Bi-
bliothek, vol. ii. 
THE OPERATION BY ABSORPTION.
619
 difficulty of introducing it through the cornea will also be greater.  I therefore
 recommend those who use it for the first time to choose one slightly curved. After
 the point has been turned, the needle, held in the jaws of a pair of pliers or a
 vice, is  to  be  run down  into a cedar  handle,  without cement, leaving  only
 half an inch of blade, which I have found  to  answer every purpose.  If the
 blade be left longer it will  yield and spring when opposed to ajesistance.  The
 handle should be about a fifth of an inch in diameter, and four inches long.  I
 use the handles made  for camel-hair pencils, and find that  a metallic ferule,
 which increases the weight, is unnecessary and  objectionable.   A needle thus
 constructed, and preserved free from rust, will retain its point for a great length of
 time: I have used the  same  one a dozen times without sharpening.   (Dublin
 Hospital Reports, Vol. IV.)
   Dr. Jacob operates with this instrument  in the  following manner:
   "  The surgeon, provided with such a needle, places himself in the usual position
 with respect to the patient, availing himself of whatever assistance he  may find
 necessary to secure  the lids.*  He then brings the point of the needle within a
 very short distance of the eye, and when the  cornea is brought into an advan-
 tageous  position, he suddenly strikes the needle into it  near its circumference.
 As I do not apprehend any opacity from the wound, I am not very particu-
 lar with  respect to the precise  point,  where the needle pierces; I generally, how-
 ever, enter  it sufficiently near the margin to obviate  defect from this cause.
 The point of the needle once fastened in the  cornea, the surgeon has complete
 command of the eye; no action of the muscles can disengage it, and there is no
 danger of the  needle slipping into the anterior  chamber;  an elevator or  oph-
 thalmostat is therefore altogether useless.  The operator now pushes the needle
 through  the cornea, which frequently yields like wet leather, and the eye of-
 ten turns so much toward the  inner canthus  that the pupil is hid, and he must
 rely upon his knowledge of the  course which the needle necessarily takes, in
 order to conduct it to the lens.   This is the principal difficulty to be surmounted.
 If the surgeon  does not now  steadily push the needle forward, whatever resist-
 ance he may feel, he will find, when the eye returns to its proper position, that
 the point of the needle is still merely entangled in the cornea.   This also is the
 period of danger to the  iris: if the operator does not keep the flat of the needle
 to that membrane, with  the  point  down, and  the convexity up, he will be
 very liable  to  injure it.   Should  it happen that the point of the needle  has
 passed  through the iris, it may be easily extricated by gently drawing back
 the  instrument without  removing  it from  the  eye.   After  the needle  has
 been fairly entered, and  that the operator sees its point at the opposite side of the
 pupil, he brings the cornea forward, merely by pulling it upon the needle, to which
 it is completely secured, in consequence of the blade being wedged into its texture.
 He now turns the point directly back, and gently tears open the capsule, picking
 and  scratching  the surface of  the lens with a rotatory or drilling motion of the
 instrument; not with the lever or cutting movement, which is necessary when
 Saunders' needle is used.  If  the lens be soft  and friable, the fragments fall like
 snow into the anterior chamber, and the  surgeon may deal very freely with it,
 pushing the needle deep into its structure, and twirling the point round so as to
 mash it into a pulp.  If however it  proves  hard, and that he attempts to  deal
 thus with it, he fixes his needle in its tough  and glutinous structure, turns it
 out of the capsule, drags  it against the iris, and makes it necessary either to
 extract  it or force it back into  the vitreous humour.   If  the cataract be

  * "Some ophthalmic surgeons recommend that the left hand be employed to operate on
the right eye, supposing the operator to sit in front of the patient.  I operate on the left
eye sitting opposite to the patient, on the right standing behind him with the head resting
against my chest; this latter position I find by far the most favourable and convenient." 
620
CONGENITAL CATARACT.
hard, the capsule should be  opened, and the centre of the  lens cautiously
  Fig. 56.   scratched with the point of the  needle,  so  as to expose its tex-
           ture to the contact of the  aqueous  humour, by which it is soft-
           ened and fitted for breaking  up  on a future occasion.  In with-
           drawing the needle the surgeon has to  encounter the same de-
           scription of difficulty which attends its introduction; it is tightly
           held by the cornea, requiring to be turned on its axis in order
           to extract it as an awl is drawn  from leather.   It must not how-
           ever be forgotten that  this  wedging of the instrument is attended
           with the great advantage of  enabling the surgeon to operate on
   Jk      the most unsteady eye without an ophthalmostat or  elevator."—
           Dublin Hospital Reports, Vol.  IV.
             We  have ourselves always employed  in this operation,  either
           a small Scarpa's needle (fig. 52,)  or one  such as is represented in
           the accompanying fig. (fig.  56,) both of which have cutting edges,
           and therefore  operate more  favourably in cutting up  the lens and
           capsule, when a rotatory or drilling motion is given to the instru-
           ment, than Dr. Jacobs, which under such circumstances present
           its flat sides.   Dr. Jacobs' instrument would perhaps answer bet-
           ter if it were ground above  and below  instead  of on each side.
           A good edge is not so readily however given to it in that way,
           but perhaps this might be accomplished by grinding it before bend-
           ing-]
              Operation when the capsule is opaque, and the  pupil adhe-
           rent.—In cases of capsular or  capsulo-lenticular cataract
           complicated with adhesions of the pupil, Mr-Tyrrell (vol. ii.
           p. 464—476) has frequently employed with advantage a modi-
           fication of the anterior operation by solution, which he calls
           the operation of drilling.  A  fine straight needle is carried
           through the cornea near  its temporal  edge, it penetrates the
           capsule, and enters the lens to the depth of about one-six-
           teenth of an  inch.   The  handle of the needle is then rotated
           between  the  finger and the thumb so as to make the point
           act like  a drill;  and  the  instrument is withdrawn.   The
           operation is  repeated every three, four, or  five  weeks, the
           capsule being punctured,  if it can  be so  managed, in a
           fresh  place on  each occasion.  It  has usually  been neces-
           sary to repeat the operation seven or  eight times.  It causes
           no inflammation, but excites  absorption, by which the lens
           is slowly removed,  the  pupil being in  many cases cleared
           and vision restored.  If  the retraction of the pupil  is con-
siderable, it  may be  necessary, after the lens  has been absorbed, to
make an artificial pupil.
                  SECTION V.--CONGENITAL CATARACT.

  This is sometimes lenticular, but  more  frequently capsulo-lenticular.
The lens is usually opaque throughout, generally of  its natural consist-
ence, which is gelatinous, sometimes softer or even fluid, but seldom, if
ever, hard.  After losing its transparency, the crystalline frequently un-
dergoes absorption: hence we often find it lessened,  reduced to a small 
CONGENITAL CATARACT.
621
fragment, or  as  thin as  a wafer; it may even be removed entirely.
Central opacity of  the lens seems to be known  only as a form of con-
genital cataract.   Here,  one-fourth, or a larger portion of the diameter
presents a greyish  opacity, and the circumference  is completely trans-
parent, so that, when the pupil is  dilated, there  is good, or even perfect
vision, although  under  other  circumstances the  patient is nearly blind.
This partial central opacity sometimes presents exactly the appearance
of a small opaque lens, surrounded by an opaque capsule:  this appear-
ance, however, is quite deceptive;  the  opacity in  such cases affects
only the nucleus of the  crystalline, and it is surrounded  by  the  rest
of the organ in  a transparent  state.  In this  form of the affection the
lens retains its natural magnitude; it does not become reduced by ab-
sorption.
   The lenticular cataract of  infants is generally attended with opacity
of the capsule, which, as in the adult, is usually partial, in streaks, dots,
or specks.  Sometimes there is an opaque central portion, more or less
considerable, and thick, so as  to  project above the  general level.  In
proportion as the lens  is  absorbed, the  anterior  and posterior  layers
of the capsule  approach each other, shrink, and  become corrugated.
At last  a  thick  tough  capsule alone  remains {cataracta  arida  sili-
quata.*)
   I am not able  to state whether the  affection  is  strictly congenital,
not having seen  it either  within a  few hours or  a few days of birth. In
the cases which  I  have seen, the  complaint has not been  discovered till
some weeks after birth.
   In a recent number of his  interesting Journal of ophthalmology, Pro-
fessor Von Ammon  has recorded some cases, which not only remove all
doubt on the subject, but also elucidate the pathological anatomy of the
affection.f
  Case I.—The eyes of a female  child  were observed by the midwife to have a dull

  * The kind of cataract was noted by Mr. Saunders in forty-four cases; and the following
enumeration exhibits the relative numbers of the different species :—
Solid opaque lens, with or without opacity of the capsule.  Three single, two double
    cataracts.   .      .      .      .      .     .      •                     5
Solid lens, opaque in the centre, transparent in the circumference, with capsule in the
    same state.  Five double.        .      .     .      •     •      •      .5
Soft opaque lens,  with or without opacity of the  capsule.   Two  single, two
    double.    .........
Soft opaque lens, with solid nucleus.  One single, two double.
Soft opaque lens, with dotted capsule; the spots white, the spaces transparent.   Two
    double.     .....••••
Fluid cataract, with opacity of the capsule.  Tsvo single.    .     .      .
Fluid cataract, with opacity of the capsule, and closed pupil.  Two double.  .
Opaque and thickened capsule, the lens being completely absorbed, or the remains o
    it being thin and squamose. Six single, twelve double.  .
Opaque and thickened capsule, with only a very small nucleus of the lens in the cen
    tre.   Two single.  ....••••
Opaque and thickened capsule in the centre, remains of the lens in the circumference
    One double.       ....•••■
—Lib. cit. p. 159.                                          ,     .      .    ,
  The expression " solid lens," in the foregoing enumeration, must  be  understood to de-
note that the crystalline possessed its natural consistence; for it does not become firmer in
congenital cases.                                           .
 t Die angeborne Cataracta in pathologisch-anatomischer in pathogenetischer und in opera.
tiver Hinsicht.  Zeitschrift fur die Ophthalmologic, vol. iii. p. 70. 
622
CONGENITAL CATARACT.
appearance immediately after birth.  The child was consequently shown ten days af-
terwards to Von Ammon, who found a venticular cataract in each eye.   It died at the
age of eight  months, and the  eyes were  examined.  The capsule was perfectly
transparent in both.  The lenticular substance was gelatinous, opaque, and large, with
some firmer semi-transparent portions here and there.   No trace could be observed of
red vessels or  spots, or red colour of any kind in the lens or capsule. The retina, iris,
and choroid were perfectly natural.
  Case II.—Professor Haase, director of the lying-in-institution of Dresden, saw cata-
racts in the eyes of an infant born  in the establishment, and gave Professor Von Am-
mon an opportunity of examining them immediately after birth.  There was a lenti-
cular cataract in  each  eye;  in the left, the  lens exhibited the threefold  division
which  belongs to firm cataract.  In the right there was a soft lenticular cataract,
with slight capsular opacity.   The  child  died  when four  months old.   In  the
right eye  there were  nebulous spots on the anterior portion of the capsule: por-
tions of the lens towards its middle, were  opaque, but the circumference possessed
its natural consistence and transparency, and the corresponding portion of the capsule
was transparent.  Four entozoa of the genus Distoma were found in the lens under
microscopical  examination.  The capsule was transparent in the left eye.  The centre
of the lens, which had exhibited the threefold  division, constituted an opaque and al-
most horny nucleus, while the circumference was transparent and of natural  consist-
ence.   Professor Von Ammon had two opportunities of examining congenital central
capsular cataracts in the eyes of the fetus.   Both were born about fourteen days before
their time; one lived a few hours, and  the other came into  the  world dead.  The
opacity was a  central speck in the  anterior portion of the capsule,  without any eleva-
tion of surface: the opaque part was, however, thicker than the rest of the meinbrane.
The lens in both cases was transparent, but of reddish colour.
   It often appears in more than one child of the same family.  It is
stated by Dr. Farre that sixty cases were submitted to  the care  of Mr.
Saunders.   " Of these, two brothers, between whose ages  there was a
difference of  six years,  were both affected with congenital cataracts.
In a second family, two  brothers, twins, became blind with cataracts at
the age of twenty-one months, each within a  few days of the other.   It
is remarkable that the four cataracts had precisely the same character.
In  a  third family, a brother and two sisters  were   born  with this
disease.  The eldest sister was affected  with it  only  in one eye, the
brother and youngest sister  in both eyes.  In a fourth family, three
brothers  and a  sister had  all congenital cataracts.   (Lib. cit. p. 158.)
   I had  under  my care, at  St. Bartholomew's, two brothers, between
two and  four years old, with cataracts.   They were lenticular in one,
the crystallines  being of their natural  size;  in the  other, the lens was
diminished  on each  side  to a  thin scale, the  capsule presenting in
each eye a thick dense central opacity, and a few small spots scattered
around it.
   Congenital cases  differ much in the degree of vision enjoyed by the
patient.  In central lenticular or  capsular  cataract there may be good
sight,  especially  when  the pupil is dilated.  In some cases, objects  and
colours can  be distinguished ; while  in  others the patient  can  merely
distinguish light from darkness.
   Operation  on infants*—While extraction is  not  only  altogether

  * On the use of the Couching.needle in Infants of a few months old, by B. Gibson : in
the Edinburgh  Medical and Surgical Journal,  vol. vii. 1811, p. 394.
  On the operation of largely puncturing the Capsule of the crystalline humour, in order
to promote  the Absorption of the Cataract,  by Mr. Ware, in his Observations on the Cala-
ract, $c. 3rd. edit. 1812, p. 363.
  On the Congenital Cataract, by Mr. Saunders, in  his  posthumous work edited by Dr.
Farre,  chap. vi. 
CONGENITAL CATARACT.
623
unsuitable to the various forms  of congenital cataract, but absolutely
impracticable without the greatest  risk, or rather certain destruction of
the organ, the cure  can be accomplished  with  facility and  safety by
means of the needle.  The smallness of the palpebral fissure, the unsteady
movements of the eye, and the resistance of the child to all attempts at
opening the lids, produce some difficulty in fixing the head and denuding
the surface of the  organ sufficiently for the purpose of the operation:
this indeed is the only real  difficulty in the process.  The pupil should
be fully dilated by  the previous application of belladonna.
  A narrow table is the most convenient for the operation.  The child
must be laid on its  back, with the head on a small pillow, which should
be so placed that the head  may fall rather over it, in order that we may
have a good light on the eye.   One assistant must hold the legs and
lower part of  the trunk;  another, the arms and chest;  while a  third,
placed behind, fixes the head between his  two  hands, applied  one on
each side.  A fourth assistant, who depresses  the  lower lid with the
forefinger of one hand, may also, if necessary, use  the other under the
chin, to prevent any forward movement of the head.   The operator,
who is placed behind the  head,  raises the upper lid by the elevator of
Pellier, with which he holds it securely against the margin of the orbit:
it cannot be  so properly elevated and securely fixed  by the  fingers.
With the other hand, he pierces the tunics with the needle in the same
situation as in  the  operation of depression.   A small, .straight, sharp-
pointed needle  cutting on  its  edges for about  one-eighth of an  inch,
should be employed.  The purposes of the operation may, however, be
accomplished with Scarpa's needle,  which was  used by the late Mr.
Gibson.  {Edinb. Med. and Surg. Journal, vol. vii.  p. 398.)
  In operating on  the right eye, the  elevator  is held in  the left  hand,
and the needle in the right; when we proceed to the left eye,  the em-
ployments of the hands are reversed.   If  the surgeon should prefer it,
he may place himself in front of the patient to operate on the left eye;
he will  then  depress the lower  eye-lid with his  left hand, and hold the
needle in the right, while  an  assistant, placed behind the patient, ele-
vates the upper  eye-lid.  I consider the first-mentioned  method  to be
preferable, because the operator, holding the speculum, can exert with
it a  little pressure, so  as to steady the  eye, if it should  be  necessary.
If the speculum is entrusted to an assistant, he must not venture to press
on the globe.
  After the coats have been punctured, the instrument must be passed
through the thin edge of  the cataract into the anterior chamber, and
carried on till its point reaches  the opposite edge  of the pupil.   The
lens  and capsule  may now be divided transversely by a  backward
movement of the instrument, with which we may still further break up
the lens, and push  the fragments into the anterior  chamber, where, on
account  of their  softness, they excite  little  or no irritation, and  are
speedily  absorbed.
  Operation  on opaque capsule.—When  the lens has been removed
by absorption, an  opaque capsule  usually remains, occupying more or
less of the pupil, proportionally  impeding  vision, and requiring another
operation.   If the capsule is transparent, sight may be restored by one
operation.  In the case of this secondary membranous cataract,  or 
624
CONGENITAL CATARACT.
where we  have to operate in  the  first instance on  an opaque capsule,
we proceed in the infant as we should do in the adult. There are various
modes of proceeding applicable to the circumstance of different cases.
The membrane that  we have to operate on is found in different states.
In texture it is usually firm; it may be thin, semitransparent, and easily
lacerable; often  it is of considerable thickness, particularly in its shrunk
and collapsed state, after the  spontaneous absorption of the lens.  It
may be densely opaque, tough and strong, so as to resist the instrument,
and" to require considerable force before its division or detachment can
be accomplished.  It may be  a continuous membrane, filling the space
behind the  iris, or it may occupy that  space only partially.  There may
be  openings in it, or it may consist merely of one or more  larger or
smaller shreds.   Not  unfrequently it  is thick and  perfectly opaque in
one part, thin  and semitransparent in others.  It may be  attached at
the circumference, and consequently tense; or it may be separated  to a
greater or less extent, so as to be loose, and even to  move backwards
and forwards.  The edge is  usually fixed to the ciliary body; it may
be attached to the pupil also, or solely; and this pupillary attachment
may be general or partial.
  A central opening may be made in the capsule, with the needle, in-
troduced either through the cornea or the sclerotica, in the mode recom-
mended by Mr. Saunders for the operation on congenital cataract.
  Another  mode of proceeding is to make a straight transverse incision
through the opaque  capsule  with the cutting needle, leaving its con-
nexions at the circumference undisturbed.  Indeed, care must be taken
not to detach it from  the ciliary body.   The edges of the incision
retract  and separate,  so  as  to leave ultimately a sufficient pupillary
aperture.
  A third method consists in introducing the needle with cutting edges
behind the iris, detaching the opaque membrane at its circumference on
the upper part and  sides, for about  three-fourths  or four-fifths of its
whole  extent,  separating it as  completely as  we  can from the ciliary
body, and depressing  it.  When thus detached and depressed, it rises
up after the needle is removed, and seems to fill the pupil as before: but
it shrinks when no longer connected at the  circumference, and is  gra-
dually withdrawn behind the lower edge of the pupil.
  The greatest difficulty is experienced in dealing with a loose or float-
ing capsular cataract.  We can depress it;  but  it rises again.  If we
can pierce  it  with the curved  needle, and especially if we should be
able to carry the  needle through it twice, we can roll it up by rotating
the needle between the finger  and thumb, and in  this  state it will be
removed from the axis of vision as the instrument is withdrawn.
  The anterior operation, or  keratonyxis,  may  be performed on the
infant;  and was  generally preferred  by Mr. Saunders.  Pressure on
the globe must be carefully avoided in adopting this  method, as it would
favour the escape of the aqueous humour,  an occurrence which either
renders further proceedings difficult, or prevents them altogether.   The
power of acting on the lens and  capsule, for the purposes just described,
is so much  less in this method  than  in the posterior operation, that  I
consider it particularly unsuited to congenital  cases, and  have conse-
quently long abandoned it in them. 
CONGENITAL CATARACT.
625
   The operation of keratonyxis was well enough suited to the particular
 object which Mr. Saunders attempted  to accomplish  in congenital ca-
 taracts ; viz. the formation of an opening in  the opaque capsule.  His
 mode of  proceeding is thus described  by Dr. Farre.  " The surgeon
 gently introduces the bow of  the speculum under the upper eye-lid, his
 assistant at the same time depressing the lower, and at the moment he
 is about to pierce the cornea, he fixes  the eye by resting the speculum
 with a moderate pressure on the eye-ball.  The position of the operator
 enables him to do this with perfect safety; and by that consent which
 can only exist between the hands of the same person,  he not only dis-
 continues the pressure, by using the speculum merely as an elevator of
 the lid, as soon as his  purpose is accomplished, but he with facility re-
 news or regulates the  pressure at any moment  in which  it may be re-
 quired.   He  penetrates  the  cornea as  near  to its junction with  the
 sclerotica as will admit the flat surface  of the  needle to pass, in a direc-
 tion parallel and close to the iris, without  injuring  this membrane.
 When the point of the needle has arrived  at the centre of the dilated
 pupil, he does not boldly plunge it through  the capsule into the lens, and
 perform any depressing motion; it is a material object with  him not to
 injure the vitreous humour or its capsule; neither does he lift the capsule
 of the lens on the point of the needle, and  by forcibly drawing  it for-
 ward into the anterior chamber rend it through its whole extent.  Such
 an operation would dislocate the lens, deliver  it into the anterior cham-
 ber, or  leave it  projecting  in  the pupil, and  stretching the iris; and,
 although its soft texture in the child should exempt him from any dis-
 organizing inflammation, the most favourable result will be a permanently
 dilated  iris, deforming the eye.   He  proceeds with  a gentle  lateral
 motion, working with  the point and shoulders of the needle only on the
 surface and centre of  the capsule,  in a circumference  which does  not
 exceed  the natural size of the pupil.   His object is  permanently to
 destroy this central portion of the capsule: merely to pierce it would not
 answer his intention, because the  adhesive process will speedily close
 the wound.   Having acted on the centre of the anterior lamella of the
 capsule to the extent which he wishes,  he  gently sinks the needle into
 the body of the  lens, and moderately opens its texture."*  " A  single
 operation  sometimes suffices,  and the cure is completed in the space of
 a few weeks ; but if the  process does not advance with sufficient ra-
 pidity, the  operation may be repeated  once or  oftener, interposing at
 least a fortnight between each operation.  If  the adhesive process has
 counteracted his former operation  on  the  capsule, he may take care
 now  to effect the permanent aperture  in the  centre, and he may use
 greater liberty than at first in opening the  texture of  the  lens.   (Ibid,
 p. 166.)
   Mr. Saunders acted in the same manner on the lens and capsule, when
 he introduced the needle behind the iris.  " As  soon as the needle has
 penetrated the tunics, he gently depresses its handle, so as  to  direct its
 point  towards the capsule'through the thin edge of the lens; and steadily
 projecting its flat surface between the capsule  and lens, he arrives at the

  * A Treatise on some practical Points relating  to the Diseases of the Eye, by the late J.
C, Saunders, p. 163—165.
       79 
626
CONGENITAL CATARACT.
centre of the capsule, which he opens, taking the same precaution as in
the anterior operation, not to rend it extensively, lest he should dislocate
the lens.   He  now cautiously opens the texture of the  lens, and with-
draws the needle.  In  his subsequent operations he will complete the
central aperture in the  capsule, and then loosen the texture of the lens,
suffering the floculi to fall into the anterior  chamber, but not projecting
into it any considerable portions of the lens, for the process of its solution
and absorption is  best accomplished in its natural position."  (Ibid,
p. 170.)
   If the operation on the infant be performed with  the requisite gentle-
ness,  it is rarely followed by inflammation.*   Hence both eyes may be
operated on at the same time.   The patients, however, must be closely
watched ;  their bowels  must be kept open, and leeches must be immedi-
ately  applied if redness and pain should supervene.   A cloth dipped in
cold water may be kept on the eyes, if it can be easily done: but if its
application annoys the  child,and the eye is not inflamed, it need not be
persisted in.
   Permanent dilatation of the pupil  should  be kept up  after the ope-
ration by applying the  moistened extract of belladonna on the brow.
   Two or more operations are sometimes necessary to accomplish the
point  of clearing the pupil.  Dr. Farre recommends that a fortnight at
least should intervene between each operation.  (Lib. cit, p.  166.)  Mr.
Ware tries to promote absorption  "■ by dropping  on  the eye once or
twice in the day a small portion of powdered sugar !"   If this should
not succeed, he operates again at the end of a week or ten days; and
repeats the operation, if necessary, after a similar interval.  (Lib. cit. p.
375.)   I consider both  these periods to be much too short.  If the lens
be left iii  its situation behind the iris, its absorption will occupy  many
weeks.
   What is the proper age for the operation ?
   It was formerly the practice to  defer the operation, in  cases of con-
genital cataract, till patients had grown up; at least, until they had at-
tained an  age at which  they might be supposed to understand the neces-
sity and importance of  the operation, and be able to exercise self-con-
straint in submitting to the proceeding.   Unfortunately, however, when
a person is born blind, the  eyes oscillate irregularly from  side  to  side.
They seem to be equally acted on by various muscles, which, from the
want  of external perception do not acquire the power of directing them,
or fixing them on objects sufficiently for distinct vision.   If the  blind-
ness continues  long after birth, this  unsteady rolling motion becomes
confirmed and inveterate, so that, even if we succeed in giving sight by
the operation, the patient has  not the power of controlling the muscles
of the eye by the exercise of volition.  Years may  elapse without any
progress in gaining such a power; and probably persons thus circum-
stanced never become able to fix the eyes sufficiently for good vision.  I
operated at the London Ophthalmic Infirmary, for congenital cataracts,
on a girl fourteen years old,   The operation  was completely successful,
and both pupils were as clear as if she had  been born with perfect eyes.

  * If  the patient suffer much pain cither during the  operation or nfter it, it may be ad-
visable to take blood from a vein in the arm, or by leeches from the temple; but in my own
practice I have not found this once necessary in infants, and, very rarely, in persons un-
der twenty years of age."—Mr. Ware, in the book before quoted, p. 374. 
CONGENITAL CATARACT.
627
 At the  end of some months the rolling motion still continued, so that
 vision was not of much use.  In a  case mentioned by Dr. Farre, he
 says, " the disadvantage of a protracted  operation was very manifest;
 It was performed on both eyes at the age of ten years* but such a tremu-
 lous motion of them had been acquired, that she  cannot even  now, al-
 though  three years have elapsed since she w'as cured, direct her eyes to
 objects with  sufficient precision."  (Lib. cit. p. 225.)   While this sheet
 is passing through the pressj I have seen a youth of fifteen, in whom the
 eyes were operated on seven or eight years ago;  they still oscillate ir-
 regularly from side to side as before the operation.
   Dr. Farre also thinks that the power of the retina becomes impaired
 by want of exercise.  " The  retina too, by a  law common to all  the
 structures  of an animal body, for want  of  being  exercised, fades in
 power.   Its sensibility, in many of  the  cases cured at the ages  of four
 years and under, could not be surpassed in  children who had enjoyed
 vision from birth; but at eight years or even earlier* the sense was evi-
 dently less active ; at twelve it was still  more dull; and from the age of
 fifteen and upwards, it was generally very imperfect, and sometimes the
 mere perception of light remained."   (Ibid, p. 176.)
   Mr. Saunders operated on five cases, at different ages from  two to
 nine months; and  on nine, from thirteen months to two years.   His
 other patients, amounting altogether to sixty, were of various ages from
 that lastmetioned to twenty-eight.   " The greatest success attended the
 operation between the ages of  eighteen months and four years; and if
 any intermediate time be selected* the Editor is inclined to recommend
 the age of two years*  The parts have then attained a degree of resist-
 ance which enables the  surgeon to operate with greater precision than
 at an earlier period, yet  the capsule has not become so tough and flexi-
 ble as it does at  a later period* after  the lens has been more completely
 absorbed."   (Lib. cit. p.  175.)
   I have operated with perfect success on infants of six  weeks: in
 general two  months would be early enough.  Thinking  it of conse-
 quence that the education of the eye should begin early,  and wishing to
 avoid all risk of the involuntary movement of the globe  becoming con-
 firmed, I have always operated in the first year, when  I have had the
 choice.
   Secondary cataract.—When an opaque body is seen in the pupil  after
 an operation for  cataract has been performed, the case has been called
 secondary cataract.  In  the proceeding  by absorption  or solution, the
 lens is generally left in its situation, and consequently is seen behind the
 iris after the operation : this is not called secondary cataract^ that name
 being given to opacities in or behind the pupil subsequent to extraction,
 depression or reclination. A fragment of lens, or more frequently some
 of its exterior soft substance, may remain in or behind the pupil  after
either of the operations  last-mentioned:  they will  be  removed  sooner
or later  by absorption.   After the lens has been removed from the axis
of vision, an  opaque capsule may remain behind ;  or the capsule may
become  opaque  after the operation.  Such secondary membranous ca^
taracts must be  treated  in  the manner  already described  (see p. 623.)
In the case of a floating piece of capsule, which can neither be depressed
nor disposed of in any other way, if it should impede vision, we must 
628
INFLAMMATION OF THE GLOBE.
Fi?- 57-              make an opening in the cornea, and
tioned of operating for capsular cataract, or by the operation for artifi-
cial pupil.
                       CHAPTER XXI.

                  GENERAL AFFECTIONS OF THE GLOBE.

        SECTION I. — INFLAMMATION OF THE GLOBE (OPHTHALMITIS.)

  Common inflammation may attack both the external and internal struc-
tures of the eye at once.   This affection which is by no means of fre-
quent occurrence, is called by Beer ophthalmitis idiopathica.  It occurs
chiefly in robust individuals of full habit under the influence of some se-
rious exciting cause; and it is most  frequent in the right eye.*
  Symptoms  and progress.—When  this general  inflammation  of the
globe is fully developed, it is characterized by very considerable pain,
increased external redness, and more or less swelling of the part; by in-
creased lachrymal discharge, and by redness and swelling of the upper
lid.  In the earliest stage we can see the sclerotica red as well as the
conjunctiva ; the pink redness of the former membrane, and the distended
net work of its vessels  are seen  through the latter.  But vascular con-
gestion rapidly increases  in the conjunctiva;  its texture swells, and thus
the fainter pink tint of  the  sclerotica is  concealed.   The conjunctival
redness, at first slight, becomes deeper and deeper, and at last  reaches
the full intensity  and brightness of scarlet cloth.
  The pain is always a leading  symptom, and one to which the patient
immediately adverts.   It is exceedingly severe, and is described some-
times as acute, sometimes as of a dull aching kind, and sometimes  as
conveying a  sense of throbbing  and  burning.   Very commonly the
patient feels the eye tight, as if it were too large for the orbit, and about

  * This seems to be the case with ophthalmic inflammation generally.  Of one hundred
and thirty-four cases commencing in one eye, ninety-five began  in the right, thirty-nine
in the left. Mr. Macgregor  observes of purulent ophthalmia, " It is found  that the right
eye is more frequently affected than the left.   It is also in general more severely affected,
and the sight of it is more frequently lost."—Transactions of a Society for the Improve-
ment of medical and Surgical Knowledge, vol. iii. p. 55. 
INFLAMMATION OF THE GLOBE.
629
 to burst from it.  The pain is by no means confined to the front of the
 eye, but is deep seated, and  extends to  the  surrounding parts, as the
 brow, cheek, temple, and  back of the head.
   The redness is inconsiderable at the commencement, but it gradually
 increases, and ultimately the  surface of the eye assumes a bright red
 colour.
   The conjunctiva, which is  at first the seat of mere vasculur  fulness,
 begins to swell from effusion into its texture, and into the copious cellu-
 lar tissue, which connects  it to the sclerotica.   It is raised above the
 level of the cornea, forming a broad firm ring on the front of the eye;
 it rises higher and higher, often over-lapping the edge of the cornea, so
 as to hide a part of it.   This bright scarlet, broad, and elevated ring of
 conjunctiva projecting beyond, and  surrounding the cornea, is acutely
 sensible; it is technically called  chemosis, and in the affection which I
 am now describing it may be termed true inflammatory chemosis.  The
 distention of the  conjunctiva  is limited in front by  its adhesion to the
 corneal laminae, behind by the pressure of the surrounding parts; hence
 its form of a broad ring on the front of the eye, where the swelling of
 the membrane is not effectively opposed by the  lids.  The appearance
 depends on an interstitial effusion of lymph or fibrine from the vessels of
 the  inflamed  membrane   under high  excitement,  analogous to that
 which takes place in other acute inflammations; the swelling therefore
 is firm.
   The tumid  state of the conjunctiva is not owing to the effusion of
 blood into the cellular texture, as Scarpa* very unaccountably supposes,
 confounding the  inflammatory symptom called  chemosis with ecchy-
 mosis.  He has, upon  this erroneous supposition, proposed the making
 of incisions through the tumefaction to allow the escape of effused blood.
 There is  in some treatises a distinct chapter upon chemosis, as if it  were
 a particular disease of the eye; it is however merely an effect of acute
 inflammation affecting the conjunctiva,  and its characteristic form is
 derived from the loose sclerotic  and firm corneal adhesions of the mem-
 brane.  In the present case, the  tumefaction is caused by the interstitial
 effusion of fibrine, and is firm: when inflammation of the conjunctiva is
 less active, the effusion is  serous and the swelling less firm.
   The access  of light is offensive to the patient in general inflammation
 of the globe;  the pupil contracts  to exclude it, and the palpebra are
 spasmodically closed.  The motions of the eye and  lids are interrupted
 or prevented;  the whole external surface becomes  exquisitely sensible,
 and as the slightest attempt at exertion occasions great pain, the patient
 keeps the eye, as much as possible  at rest.  The surface of the organ,
 at the commencement of the  affection, is rather stiff and dry; but this
 dryness goes off, and is succeeded by increased flow of tears, especially
 if the eye is exposed to light or any external irritation.  A little mucous
 discharge may be seen about the edges of the lids and the eye lashes.
   Such are the circumstances which characterize inflammation of the
 whole  globe in its  first stage; as it proceeds to the second period, we
 begin to see various alterations of structure.   The iris becomes changed

  * Treatise, translated by Briggs,  2nd  ed.  pp. 115 and 148.   Trattato delle principali
Malattie, &c. Ed. 5. v. i. pp. 191 and 193. 
630
INFLAMMATION OF THE GLOBE.
 in colour, loses its brilliancy, and no longer exhibits its usual motions.
 The pupil contracts, and loses its clear black colour.  The cornea be-
 comes more or less opaque, and vision  is lost.  The alteration in the
 cornea, and in  the state of the pupil, would account for imperfection or
 loss of sight; but, as  the latter often occurs while the cornea is suffi-
 ciently clear for the transmission  of light, and the pupil is still open, it
 must be explained by inflammatory disturbance and consequent change
 of structure in the retina.  The patient still sees, or fancies that he sees,
 luminous sparks and flashes of  fire  before his eyes, when there is  no
 light in the chamber, or during the night, in consequence of the disturbed
 state of the retinal circulation.
   As the inflammation continues, the globe swells, and the sense of  its
 being too large for the bony cavity in which it is contained is not erro-
 neous.  We cannot say  positively that all the internal tunics of the eye
 are in  a state of inflammation, because we cannot see them; but when
 we find that the  globe  is actually  increased  in size, that the iris  is
 changed in structure, and that the retina has lost its sensibility, there is
 little reason to  doubt that the internal parts of the eye generally are in-
 flamed.  The congestion within distends the globe, and causes the sense
 of bursting.
   The internal swelling, joined  to the chemotic tumefaction, occasions
 the globe to fill up the front of the orbit, protruding the lids, everting the
 inferior, and appearing externally as a red fleshy mass.  Motion, which
 is impaired in the early stage, is now quite lost, for the swelled globe is
 fixed, and the upper lid is so protruded and swoln as not to be moveable
 by the patient's will.
   The eye-lids swell from the beginning.   They are at first red on the
 edges.   The conjunctiva palpebralis  becomes inflamed like that of the
 globe,  hence the  internal surface of the lids is intensely red.   The in-
 teguments become red, and effusion occurs into the cellular  texture of
 the lids generally, effacing the fold of the upper, and raising it into a
 convex protuberance.
   In a  local disease of such violence, affecting a very vascular, nervous,
 and  highly sensible organ, situated in the  immediate vicinity of the sen-
 sorium, marked constitutional sympathy may  be expected ; accordingly
 we find inflammatory fever of a decided character from the commence-
 ment of the affection.   General indisposition is felt at the very outset.
 The appearance of the local symptoms is preceded by a longer or shorter
 attack of shivering, followed by general heat of skin, thirst, pain of the
 head, and lassitude.  When the complaint is developed, there is a quick,
 hard, and full pulse, dry and hot skin; a white and rather dry state  of
 the tongue, deficiency  of appetite, severe head-ach, restlessness, and
 generally want  of sleep at night.  The face is flushed, and perhaps
 swelled on the affected  side, with a sensation of throbbing in the neigh-
 bourhood of the  eye.
   Effects.—If the disorder is not checked, the local pain, and the feverish
state of the  constitution  proceed to  a great height.   Under such an
aggravation  of  the  local  and  general symptoms, the pain changes  in
character, it becomes throbbing, rigors are felt,  and suppuration of the
globe takes place; the cornea turns of a dull white and then yellow, and
the globe is  ultimately converted  into an  abscess.  The occurrence  of 
INFLAMMATION OF THE GLOBE.
631
suppuration does  not  produce the relief usually experienced from that
change, in consequence of the firm, unyielding nature of the sclerotica
and cornea; the pain, together with the sense of bursting and throbbing,
continues for some days, until the cornea bursts externally, and  gives
an exit to the matter contained in the interior of the eye.  The patient
then experiences relief; matter is discharged for a  time; the tunics of
the eye collapse into a small space, shrink into the orbit, and the original
form of the organ is lost.  The vitreous and crystalline humours of the
eye generally escape when the bursting of the globe first gives an exit
to the confined  matter.
  Such  is the  termination of this affection  in its worst form; when it
does not  proceed so  far, and when its progress has been checked by
treatment, the  cornea becomes opaque, and remains so;  the pupil is
either closed or very much  contracted, and the aperture filled  by a
newly-formed adventitious substance, the consequence of effusion into
the opening during the inflammatory stage, and  the subsequent organi-
zation of the effused  matter.  In this case vision is either impaired or
completely lost, but the form of the eye remains.   The most favourable
termination that can be expected is the recovery of the organ, with the
cornea clear and the pupil open;  still, in this case, the retina has gene-
rally suffered so much as to  produce  greater or less imperfection of
vision.
  Diagnosis.—The affection which I have now described may be con-
sidered as common, true, or proper  inflammation, seated in the whole
eye-ball;  for  the  circumstances which  I have enumerated sufficiently
prove that all the  component parts are inflamed.   It is characterized by
commencing at one and the same time in the external and internal tunics
of the eye.  Internal inflammation may  spread to the external coats, or
external inflammation may extend inwards: but, in this affection, both
sets of parts are inflamed at the same time.
  This common, or idiopathic inflammation, is  distinguished from the
specific, or sympathetic inflammations by the following circumstances:
—1st. The principal  symptoms,  that is, redness, pain, swelling, in-
tolerance of light, and lachrymal discharge, are equally developed, and
present a  correspondence in degree.   In the specific inflammations one
symptom  is commonly predominant over  the  rest.   Intense external
redness is often seen in catarrhal ophthalmia without pain or intolerance
of light; in scrofulous cases, the highest intolerance, with hot and  acrid
lachrymation and spasm of the palpebral muscles, with hardly perceptible
redness;  in the arthritic and  syphilitic, severe pain in the eye and its
neighbourhood, with  the other phenomena in a slight degree.   In the
forms just enumerated the swelling is inconsiderable in comparison to
the particular symptoms now pointed out; but it is excessive in the pu-
rulent and gonorrhoeal ophthalmias  2ndly.  The symptoms commence
at the same time, and in an  equal  degree, and  continue in this  equal
proportion to each other throughout.  Each  symptom also exhibits this
uniformity in degree and extension.  The redness occupies equally the
whole surface  of the  organ.   In catarrhal  and strumous cases it is
partial, consisting in distention of some fasciculi of vessels, or confined
to some  part of the organ.   In syphilitic, rheumatic, and arthritic oph-
thalmia;,  the redness  is in the sclerotic coat, and usually forms a zone 
632
OPHTHALMIA CONSEQUENT ON PHLEBITIS.
 round the cornea.  The pain in ophthalmitis occupies the whole globe
 and orbital region, and  thence  extends  equally to all the surrounding
 parts.  In other ophthalmias it is often less in the eye itself than in the
 parts  round the orbit.  3rdly.  The course of the complaint is very
 regular, proceeding, when it  has once begun, without  intermission or
 remission,  to  its full development, unless  it should be interrupted by
 active treatment.  In the other  ophthalmiae, the complaint altogether,
 or particular symptoms,  often undergo increase or diminution; in some,
 remissions,  and  in  others  complete  intermissions  are  observed.   In
 catarrhal cases the patient is often free from suffering during the day,
 the symptoms return in the evening, and are again less severe in the
 morning.  The symptoms of syphilitic ophthalmia undergo a marked
 diminution during the day, and show themselves  again  in severe noc-
 turnal paroxysms.   Scrofulous  patients, on  the contrary, suffer in the
 day, and are  greatly relieved towards evening.   In these  cases, too,
 recoveries  and relapses  often occur suddenly, and succeed each  other
 frequently.   4thly. True  ophthalmitis is  attended  with considerable
 constitutional disturbance of inflammatory character, while the sympa-
 thetic ophthalmiae are generally without fever, even in many instances
 where the inflammation runs high.
   Treatment.—The active inflammatory character of both the local and
 general symptoms demands the most energetic antiphlogistic measures;
 and if, by their timely employment, we should succeed in checking  the
 vascular disturbance, the subsequent  administration of  mercury may
 prevent injurious changes of structure, and thus enable us to restore or
 preserve sight.   If however the pupil should have become closed by an
 adventitious membrane, vision  is  extinguished without hope of recovery;
 while, if the globe should have suppurated, its very form is destroyed.
  When general suppuration of the globe has occurred, in consequence
 of acute ophthalmitis, and we see the anterior chamber full of matter,
 the evacuation of it by a free  opening of the cornea will put a stop to
 the patient's sufferings, which  would be protracted if we left the matter
 to make its own way through the firm  textures of the  sclerotica and
 cornea.  As the  eye must inevitably be lost, we need not be deterred
from adopting this course, by the injury to the form of the organ which
it involves.
  Ophthalmitis arthritica.—This name is given by some writers to the
disease described in Chapter XIX. § 3, as arthritic inflammation of the
internal tunics.  The disease commences in the latter, and is for some
time confined to  them in  milder cases; in  its more acute form, the ex-
ternal coverings are either affected from the beginning, or soon become
involved  in  the inflammation.
SECTION II.--INFLAMMATION AND  DESTRUCTIVE  SUPPURATION OF  THE  EYE,
           OCCURRING AS A SECONDAK.Y EFFECT OF PHLEBITIS.

  Mr. Arnott has pointed out the connexion between this affection of
the eye and phlebitis, in his  comprehensive and valuable Pathological
inquiry into the secondary effects of inflammation of the veins, published
in the fifteenth volume of the Medico-chirugical Transactions. 
OPHTHALMIA CONSEQUENT ON PHLEBITIS.
633
  In a patient, who had undergone the operation of cutting out a portion
of varicous vein in the right leg, inflammation of the posterior saphena
ensued, and the case terminated fatally on the ninth day.  It had been
observed, the day before, that the  eyes were kept constantly closed; the
conjunctiva was found red, and the cornea opaque on both sides.   The
following circumstances were noticed on examination of the body: the
vein partly plugged  with lymph, partly filled with pus; fluid pus in
several muscular branches.  Deep-seated abscesses  under the fascia of
the  left fore-arm and leg, and sero-purulent effusion between the muscles
of the right fore-arm.  A recently formed abscess in the upper lobe of
the  right lung. Serous infiltration of the pia mater, particularly towards
the  basis of the brain.  Effusion of lymph round the trunks of the carotid
arteries.  The nerve of the third pair on the left side flattened, and softer
than that of the right; a similar change, to a greater extent, in the fifth
nerve of  the right side.   " It has been remarked, that during  life great
opacity of both corneae had taken place; the surface of which had be-
come rough.  On removing  the  right eye, destructive changes were
found to have taken place within the globe; the crystalline was so soft
as to yield to the slightest touch; the vitreous humour was of a reddish
yellow colour, and red vessels could be distinctly seen  traversing its
membrane.   The retina was of a  deep red colour."  (London Medical
Gazette, vol. ii. p. 284—286.)
  The following case is related by Mr. Arnott :—" A  young man had
a ligature placed on  the  left carotid artery, for an aneurismal disease
of one of its temporal branches.  Considerable difficulty was experienced
in passing the needle round the vessel.  Venous hemorrhage took place
during the operation, recurred at night, and occasionally afterwards for
nine days.  On the fifth day after the operation, the patient had a severe
rigor, succeeded by heat of skin and  general febrile symptoms.   These
increased, the pulse  rose to one  hundred and  twenty, and the consti-
tutional disturbance assumed a very violent character.  About the tenth
day, the vision of the left eye became impaired, and was quickly lost;
the pupil  was contracted, the  iris immoveable, and the cornea had a
somewhat hazy appearance; effusion took place under  the conjunctiva,
and the eye-lids were greatly swoln, giving the appearance of the globe
being much protruded;  at the same time, there was a degree of deaf-
nessrconsiderable stupor, with occasional slight delirium.  In the course
of a few days, the coats of the eye sloughed at the upper part, and its
contents were evacuated.   Whilst these changes were  occurring in the
eye, collections of matter formed, without pain, in different parts of the
body, in both shoulders above the insertion of the deltoid muscles, over
the  sacrum, &c.   The constitutional disturbance abated, the collapsed
eye healed over, but  he never recovered his health.  Five months sub-
sequently he  died, labouring under lumbar abscess, and worn out by
hectic.  On examination of the body, a portion of the jugular vein, to
the  extent of two inches, was  found  wanting;  the upper  and  under ex-
tremities  being shrunk, ligamentous, and gradually lost  in the cellular
substance.   On  opening the  head, pus was  found  effused  in  great
quantity between  the tunica arachnoidea and pia mater, along the base
of the brain, and the whole length  of the spinal cord.  The intermus-
cular cellular substance of the loins was loaded with pus.  The viscera
       80 
634
OPHTHALMIA CONSEQUENT ON PHLEBITIS.
of the abdomen and chest were not examined." (Med. Chir. Trans, vol.
xv. p. 118—120.)
  When this narrative is compared with the circumstances of the case
previously quoted,  we shall  have no difficulty in  concurring  with  the
conclusion  suggested  by Mr. Arnott, that  the affection of the eye, in
this instance, was a secondary effect of inflammation in the vein.
  In a case of puerperal ophthalmitis seen by Mr. Mackenzie, the affec-
tion of the eye was ushered in by rigors, followed  by fever and feelings
of  sinking,  with quick  irritated pulse.   The conjunctiva  was much
chemosed, the lids swoln, and the  lower everted.  " There  was severe
pain in  the eye and head, and excessive intolerance of light;  so much
so that  she  was obliged to  keep her face covered with a handkerchief,
although the window shutters  were constantly closed.  At first tears
ran from the eye, but, after a time, purulent matter.  The cornea became
opaque, but the eye did not burst."  The patient died, but an examination
was not allowed.   {Practical Treatise, ed. 3. p. 511.)
   Dr. Graves saw severe inflammation of one eye  in a case  of phleg-
masia dolens consequent on parturition.  The patient had also bronchitis,
with great disturbance of the stomach and intestinal canal.  On awaking
one morning,  she experienced  intense  pain in the  eye-ball, and com-
plete blindness, so that she  could not distinguish  light from  darkness.
The  cornea was  almost  concealed by  immense nearly white serous
chemosis, so exquisitely tender that touching the lids could not  be borne:
the cornea was opaque, as  far  as it could be seen.  This case ended
fatally.  The popliteal,  femoral, iliac veins, and the inferior vena cava
as high as the junction of the renal veins, were thickened and lined with
fibrine.  On examining  the eye, the iris was found changed  in colour,
and covered, on both surfaces,  with long flakes of lymph.  Portions of
 lymph  were floating in  a turbid aqueous humour.  The  lens was light
 brownish  and opaque; the vitreous humour, dull yellow, thick,  and
ropy.  {Ibid,  from London Med. and Surg. J.  Vol. iii- p. 360.)
   In another  case, observed by Mr. Mackenzie, phlegmonous  erysipelas
 of the upper extremity was  induced by  whitlow.  Rheumatic pain
 supervened, after which the erysipelas subsided.  Now dimness of sight
 came on without pain.  The irides were  inflamed, the pupils contracted
 and hazy: in  three or four days from the commencement, deposition of
 lymph  was observed  in the bottom of each anterior chamber.  Protru-
 sion of the eye, and great chemosis occurred successively in  both eyes,
 both of which remained completely amaurotic.   (Ibid, p. 512.)
   Death ensued in another case after the successive occurrence of
 scarlatina,  phlegmasia  dolens,  typhus, and ophthalmitis.   Protrusion of
 the eyes had occurred, and purulent matter had been seen in the anterior
 chambers the day before  death.  The  adipous and cellular  texture of
 the orbit were indurated and infiltrated  with serum ; the cornea trans-
 parent; the sclerotica reddish and thickened; the aqueous humour red-
 dish and containing flaky matter.  The pigment of the iris and choroid
 deficient, and  some portions of  lymph  effused in  the latter.  Reddish
 fluid, with  whitish puriform flakes effused  between the choroid and
 retina.  The  latter and the hyaloid membrane  closely adherent and
 forming a whitish thickened mass, inclosing a small quantity  of reddish
 fluid, the remains of the vitreous humour.   (Ibid, p. 513.) 
SYMPATHETIC OPHTHALMIA.
635
  The inflammation of the eyes in the cases now under consideration,
which has received from Mr. Mackenzie the appropriate name of phle-
bitic ophthalmitis, is analogous in its nature to the  other secondary in-
flammations consequent on  phlebitis.   It  leads to  similar effusions  of
pus and lymph;  and,  as these occur in  the important internal parts of
the eye, for example,  the  chambers of  the aqueous  humour,  the iris,
choroid, retina and vitreous humour, serious disorganization is quickly
effected.  The prognosis is  most unfavourable.  The cases generally
terminate fatally from causes independent of the ocular affection; if this
should not happen, complete amaurosis results.
  The treatment would consist of antiphlogistic means, mercury, and
counter-irritation, employed in such manner and extent, and with such
combinations as  the local  symptoms and  the  general state of power
might indicate.
               SECTION III.--SYMPATHETIC  OPHTHALMIA.

   The intimate connexion between the two  eyes,'consensus oculorum,
 as it has been commonly called, is so frequently manifested in disease,
 under circumstances of ordinary occurrence, that it is hardly necessary
 to mention, and certainly not to enlarge upon the subject.  Whenever
 disease shows itself in one  eye, there is great  probability that it will
 occur in the other also, especially if the causes or circumstances, under
 which the first affection appeared, are continued.   And there is some-
 times a curiously exact coincidence  in nature between the diseases of
 the two eyes.
   The sound eye does  not suffer invariably under  such circumstances.
 There are many instances  in which, after one  eye has been  lost, the
 other, although used unsparingly, retains its powers unimpaired through
 life.  Beer makes  the following statement: " I know many  persons,
 who have lost one  eye from the most painful affections, in which the
 whole head  and the other  eye suffered greatly at the  time;  yet they
 see most perfectly, even after ten, twelve, and fifteen years.  A minia-
 ture painter in this city, in advanced age, paints  the smallest miniatures
 with the greatest excellence, though  he  lost  the left eye by painful in-
 flammation and suppuration seventeen years  ago.   Yet it is true, more
 particularly in cataract and amaurosis, that  both eyes generally either
 suffer at  once, or within a short  time of each  other."   {Repertorium,
 vol. i. p. 29,)
  The intermixture  and partial decussation of the fibres of the two optic
 nerves  mav  probably  account for the sympathy  between the eyes.
 There is no such connexion  between  the ears, the nerves of which are
 completely distinct in their whole course.
  Penetrating wounds of the globe, unless judiciously managed from the
 very beginning, are  generally followed by internal inflammation, which
destroys sightfand not unfrequently ends in atrophy of the organ.  Often
the sound eye is  attacked by similar  internal  inflammation,  which
affects  the iris, lens, retina, and  vitreous humour, and thus  may be
arranged among the general diseases of the globe.
  This sympathetic ophthalmia may come on during the active period 
\
636                   SYMPATHETIC OPHTHALMIA.

of the original disorder, or after its cessation.  The former is likely to
occur if the injured eye be neglected, and especially if employment and
exertion of  the sound  organ be continued.   The  constitution, state of
health, and habits of living, will also influence the result.   The sympa-
thetic disorder  generally comes on slowly, and with  symptoms at first
not strongly marked;  but it may be more acute.   It is characterized,
when fully developed, by redness of the sclerotica, change of colour in
the iris, contraction and adhesion of the pupil, cataract, diminution  or
loss of sensibility in the retina.   Atrophy of the globe is often the ulti-
mate  result.
  I have already alluded to this subject, and mentioned some cases in
illustration, in Chapter III. at p. 159—163, where  I have also pointed
out the  protective precautions in respect to the sound eye, which ought
to be observed  for  a considerable time  in all the  serious injuries, that
might otherwise lead to such lamentable results.  Our efforts should be
directed to prevention  of  this  sympathetic  affection, which, when it
has once occurred, generally proceeds to the destruction of sight.   Its
serious  consequences are  sufficiently evidenced in  the cases which I
have already shortly .mentioned in Chapter III.  Mr. Mackenzie, who
has seen and recorded several instances, gives the following discouraging
view  of the subject: " The prognosis is  so unfavourable, that it is our
duty to  guard the patient  who has  suffered  any severe injury of one
eye, against the exciting  causes of  sympathetic ophthalmia, from  the
very first.   When this disease is actually present, even  the most active
treatment is generally ineffectual.   Indeed, I have never seen an eye
recover from sympathetic ophthalmia.  Renewed attacks have generally
terminated in extinguishing vision."   (Practical Treatise, p. 533.)
  The  only probable chance of saving  the  second eye is to  make a
free incision in the coats  of that which  has been injured, so that they
may collapse, and the eye consequently shrink in the orbit.   Where one
eye had been lost by disease, and the other had suffered  from sympa-
thetic irritation so much as  to induce apprehension that  more serious
mischief might ensue, I have had recourse to this proceeding in two or
three instances  with the best  effect,   Mr. Barton, of  Manchester,
opened  the cornea largely, and  excised  a part of it where portions of
percussion caps had penetrated and  remained  in the eye.  (See ante,
p. 160.)  This operation was not only completely successful in its im-
mediate object  of removing the foreign substance, and thus  arresting
the inflammation, under  which the  wounded eye laboured;  but,  by
causing collapse of the globe, it effectually relieved the  sound eye from
the sympathetic affection, which was always serious, and had been in
one instance fatal to vision.
  Mr.  Wardrop has described  an internal inflammation incidental to
the horse's eye, in which  vision is lost by opacity of the  lens and cap-
sule, and other changes of  structure.  It affects the two eyes succes-
sively.  He says, " It occurred  to me that if the eye first  affected were
to be altogether destroyed, the  progress  of disease in the  other would
be arrested, and one eye  thus  preserved.  An opportunity of making
the experiment  soon occurred.  A valuable race-horse  had one  eye
considerably injured  from  repeated  attacks of this disease, and the
other eye, during one of these, appeared tender.   I made  an  incision 
HYDROPHTHALMIA.
637
through the cornea of the bad eye with a sharp-pointed bistoury, through
which  the aqueous humour escaped.  The lens was then squeezed out,
and along  with it  the  whole  vitreous humour, which  seemed in a
healthy state.  A poultice was applied  over the eye-lids, the eye sup-
purated, and  ultimately  completely sunk.  The other eye resumed its
natural lustre and transparency, and I heard of  this horse upwards of
six  years  afterwards, when  he was a very valuable  hunter;  the eye
having remained perfectly well.  Since  making this experiment I found
that there was nothing new in the observations I had  made; for many
conversant  with horses were aware, that if one  eye be so severely
affected that it is  quite destroyed, they consider  that  there  is a great
chance of the other  remaining sound.  I have even heard some farriers
remark, that if the bad eye happen to meet  with an accident, and  the
injury hasten  its destruction, the other will be saved;  and further, that
aware  of this, some have even ventured  to adopt the practice of des-
troying the diseased eye, which they have rudely done by putting quick
lime between the eye-lids, or  by thrusting  a nail into the eye-ball, so as
to excite  violent inflammation, suppuration,  and destruction  of  the
organ."  The operation  consists in making an opening in the cornea,
at its circumference, sufficiently ample to allow of the lens and vitreous
humour being evacuated.*
                    SECTION IV.--HYDROPHTHALMIA.

  The globe of the eye may be enlarged, partially or generally, by in-
 crease in  the  quantity of the humours, or by effusion  of an aqueous
 fluid.  The affection is called dropsy of the eye, hydrops oculi; hydroph-
 thalmia,  hydrophthalmus.   Systematic  writers  have divided it  into
 three kinds:—1st, Dropsy of the cavities containing the aqueous humour;
 hydrops cameras, anterioris; 2nd, Dropsy of the vitreous humour; hydrops
 corporis vitrei; 3rd, General dropsy of the eye-ball; hydrophthalmia,
 properly so  called ;  hydrops oculi mixtus; buphthalmus (ox-eye, from
 fiovs, ox, and otpsctxpor, eye, to denote the enlargement of the organ.)
  The name of dropsy, which has been applied to this state of the eye,
 from the  mere circumstance of the globe containing  a collection of
 watery fluid, has misled some  writers  into  the  supposition, that  the
 causes and nature of the disease are like those of other dropsies, that it
 owes its origin to a morbid state of constitution, and  requires the use of
 anti-hydropic remedies.  " Dropsy," says  Beer, " arises in  the eye, as
 it does in  any  other part of the body, from a disproportion between the
 processes  of secretion and  absorption.  Hydrophthalmia seldom exists
 as a local disease;  it is at least always connected with  a more or  less
 obvious cachectic state of body;  or it is symptomatic of a previously-
 existing dropsy, for example, of anasarca, of external or internal hydro-
 cephalus, of dropsy in the cerebral ventricles.  Sometimes it appears in
 chlorotic girls as a symptom of that cachexia."  (Lehre, vol. ii. p. 616.)
In his further remarks on the particular species of the complaint, he enume-

  * Essay on the Diseases of the eye of the Horse and their treatment; in the Communica-
tions to the Board of Agriculture ; vol. i. new series. 
638
HYDROPHTHALMIA.
rates, among their causes, the sudden healing of cutaneous eruptions, par-
ticularly tinea capitis and itch, and the unhealthy states  of constitution
produced by'scrofula, syphilis, and scurvy. In the same way Juengken re-
gards it as resulting from morbid states of constitution, such as the scrofu-
lous, rheumatic, and gouty, from severe colds, from serious abdominal
disturbances, particularly those connected with menstruation in women ;
from disorders of the abdominal viscera, hemorrhoids,  the healing  of
ulcers of the legs, and the suppression of perspiration in the feet, in men.
He also considers that it may happen from metastasis.  (Lehre von den
Augenkrankheiten, p. 540, 541.)  The facts which  have come  under
my observation, have not  afforded the slightest  support to these patho-
logical views, nor to the measures of treatment founded  on them.
  Dropsy of the cavity containing the aqueous humour, is considered in
Chapter XV. § 6.
  Dropsy of the vitreous humour.—I know no external signs, by which it
can be determined whether  enlargement of the globe, at its posterior
part is caused  by an effusion of watery fluid, or by increase of the
vitreous humour.  In an example of the latter kind, which came under
my observation, I did not  discover  the nature of the case, until  I had
made a puncture behind the cornea, for the purpose of lessening the size
of the globe.
  In all the other instances  of hydrophthalmia which I  have seen, the
globe has been distended with  aqueous fluid, my experience, therefore,
would coincide with that  of Scarpa, as expressed in the following pas-
sage.  " The generality of surgeons teach, that the immediate cause of
the dropsy of the eye is sometimes the increase  of the vitreous, at other
times of the aqueous humour.   In  all the cases of  dropsy of  the eye,
which I have operated upon, or have examined in the dead body, in diffe-
rent stages of the disease, I have constantly found the vitreous humour,
accordingly as the disease was inveterate or recent, more or less disor-
ganized and in a state of  dissolution; nor have I been able in any  in-
stance to distinguish, on  account of the  increased  quantity, which of
these two humours, vitreous or aqueous, had had the greater share in
the formation of the disease."   (Treatise, &c. p. 418.)
   General hydrophthalmia.—Dropsical enlargement of  the globe gene-
rally, to which the terms  hydrophthalmia and hydrops  oculi  would  be
properly applicable, results from changes of structure caused by serious
and long-continued inflammation, such  as the strumous, variolous, and
purulent.   The  cornea is partially  or  generally opaque;  the external
tunics are distended and  rendered  thinner;  the front of the  enlarged
globe, which sometimes protrudes between the  lids, is often irregularly
protuberant.  The interior  is usually filled with aqueous fluid.  This
state of the globe is attended with  the same inconveniences as staphy-
loma, and with equal or greater deformity.  By its enlargement, irregular
figure, and unusual protrusion, it causes irritation of the lids, or experi-
ences mechanical irritation from them; and  the inflammation thus  ex-
cited irritates and weakens the sound eye.  Under such circumstances,
we may try the palliative relief of evacuating part of the fluid by punc-
ture of the cornea or sclerotica.  By repeating this proceeding, we may
produce a sufficient diminution of the enlarged globe.  If this plan does
not succeed, we must perform  the  same  operation as  in staphvloma; 
ATROPHY of the eye.
639
the coats of the eye will then collapse, and the deformity may be reme-
died by the adaptation of an artificial eye.
  I lately saw a child, four years old, in which both eye-balls were
dropsically enlarged.  The cornea and anterior chamber on both sides
were nearly twice  the normal diameter.  Through the cornea, which
was a little hazy, the iris with  an enlarged pupil could be seen pretty
clearly.  The back of the globe was enlarged, though not to so great a
degree as the front.   The child could merely perceive the presence of
light.   The parents said that the child  could see until the age of three
months, when  the  eyes began to alter.  They had been occasionally
inflamed, and had  slowly enlarged.   The  child was thin, with a pallid
and sickly look.   The head was rather misshapen, as if there had been
some watery effusion  within; but there had been no  symptoms to indi-
cate such an affection.
  In morbid conditions of the globe fluid has been  effused  sometimes
between the sclerotica and choroid, sometimes between the choroid and
retina.
                  SECTION V.--ATROPHY OF THE EYE.

  A kind of change exactly opposite to that last considered is not un-
frequently observed in the eye;  the organ undergoes absorption, and is
slowly reduced in size, without suppuration, or any obvious alteration
of structure: all the textures are equally diminished, so that the globe
is lessened in all its dimensions by this kind of shrinking, which is called
atrophy  of the eye (atrophia, aridura bulbi.)  It frequently occurs in
consequence  of internal inflammation following penetrating wounds
(see page 175.)  Sometimes it  is an effect of serious  internal oph-
thalmia, arising from other causes.  As  soon as the absorption com-
mences, the globe loses its natural  tension;  it is soft and flaccid when
felt through the upper eye-lid.  A diminution of the ordinary convexity
and prominence is  obvious, when the lids are closed.  The shrinking
goes on  till the organ is reduced  to the size  of a nut or a bean, in which
we still perceive the proper  component parts of the eye in miniature.
There is a perfectly transparent cornea, one-half or one-third of the
natural size, with an  iris  behind it, of which  the pupil  is closed.  The
state of atrophy, which only takes place when the internal textures have
been so changed as to destroy vision, is not an unfavourable termination,
inasmuch  as the shrunk globe  is no longer subject to inflammation,
and therefore never produces in that way, or by sympathetic influence
on the sound  eye, those inconveniences which are often experienced
from staphyloma, or  hydrophthalmia.  There is no remedy for atrophy
of the globe.   We can neither  arrest the  progress of absorption, nor
restore the diminished eye to its normal dimensions.
  Collapse of the globe from  suppuration.—Atrophy is  quite a different
state from the diminution of the globe consequent on general suppuration
of its interior, which has been called, phthisis, or consumptio pur u lent a
oculi.  In the latter case, the coats  collapse, and  the  eye  shrinks to a
small size, the cornea being scarcely, if at  all, distinguishable.   Tlie
small tubercle, to which the shrunken eye is now reduced, is subdivided 
640
EX0PHTHALM1A.
into four parts by four superficial impressions, corresponding to the situ-
ation of the four recti muscles, and meeting together in the centre.  The
same collapse of the tunics, and fourfold division, of the tubercle, which
they form, is seen after escape of the humours consequent on sloughing,
general suppuration, or extensive ulceration of the cornea, as in purulent
or gonorrhceal ophthalmia; also after the operation for staphyloma or
hydrophthalmia.
  In a collapse of the  coats  from suppuration,  the deformity may be
remedied by  wearing an artificial eye.   I have not seen this proceeding
adopted in cases of atrophy.   Beer says, that it is prejudicial in such
instances, and that the  mechanical irritation of the foreign body causes
pain and more rapid diminution of the globe.  (Lehre, vol. ii. p. 271.)
  After general suppuration or extensive ulceration of the cornea, the
remains of the texture, which are opaque, adhere to the iris; the anterior
chamber is abolished, and the front of the eye is flattened.  This state
has been called consumptio purulent a cornece.   If the united iris and
cornea are pushed forwards by the collection of aqueous humour behind,
staphyloma is produced.
                     SECTION VI.--EXOPHTHALMIA.

  When the eye is pushed out of the socket, and more particularly when
it has been thrust between the lids,  so  as  no longer to be covered  by
them, the case is called exophthalmia: it  has sometimes been denomi-
nated proptosis.  The eye may be suddenly displaced by a  penetrating
wound with the introduction of a  foreign body into the orbit (see Chap.
XXV.;)  it may be  more gradually protruded by suppuration  in the
orbit, or  by changes of obscure nature in the parts behind it (see Chap.
XXV.;)  and  a still  slower displacement may  result from enlargement
of the lachrymal gland (see Chap. XXVI.,) from adventitious growths of
various kinds within the orbital cavity (see Chap. XXV.,) from disease
of its parietes, or from preternatural growths originating in the neigh-
bourhood, and making their way into the cavity.   Further, the eye may
be so enlarged by the various malignant diseases  (see Chap. XXIII.,)
or by dropsical distention (see  Section IV. of  this chapter,) as  to pro-
ject between  the lids.  Thus it appears that  exophthalmia is not a par-
ticular disease, but merely a change of position, which may be produced
by various dissimilar causes.   The  term denotes an effect, but gives us
no information respecting the cause.
  Beer proposes to call the affection exophthalmus, when the protruded
eye is in its natural slate; exopththalmia, when it is inflamed; and oph-
thalmoptosis,  when the displacement is caused by division of the nerves
and muscles of the orbit, or by paralysis of the latter.
  I have mentioned  the  displacement  of the globe, in  describing  the
symptoms of those affections  to which it is incidental.
  In the twenty-fourth chapter, on  diseases of the orbit, I have men-
tioned protrusion  of the  globe as caused by changes in the soft parts
around and behind it.                          » 
(  641  )
CHAPTER XXIII.
                  MALIGNANT DISEASES OF THE EYE*

  Of the inflammatory affections incidental to the eye and the changes
of structure which they produce, many are injurious to  the organ, so
far as vision is  concerned;  but they are not dangerous  to life.   The
eye is subject to  other diseases, which not only impair and put an end
to its function, but  completely disorganize  it;  and, by the progress of
the local mischief, by the appearance of similar  disease  in other con-
tiguous or remote parts, and by the constitutional disturbance connected
with these  changes, either separately  or combined, ultimately destroy
life.  It may be affected with cancer, and with those peculiar changes,
in which the component tissues are converted, either into a  texture some-
times resembling the substance of brain, or into a soft dark black  mass.
In these affections there is ultimately more or less change in the figure
of the globe, more particularly by the appearance, on its anterior sur-
face, of unnatural  protrusions denominated fungus.   Hence has arisen
the somewhat vague and indefinite expression of fungoid  diseases.
  There are affections of the eye, attended with the formation of fun-
gus which are not of malignant character, though they commonly prove
destructive to the part as an instrument of vision.  I shall first describe
some of these.
 SECTION I.--DISEASES IN WHICH FUNGOID OR OTHER GROWTHS, NOT OF MALIG-
   NANT CHARACTER, TAKE PLACE FROM THE ANTERIOR PART OF THE EYE.

  Sometimes innocent fungous  excrescences  arise from inflammation
 affecting the  anterior part of the globe.  After external ophthalmia,
 more or less  severe, a fleshy vascular substance may spring up from
 the surface of the sclerotic coat,  from the orbiculus ciliaris, or from the
 cornea; or such a production may proceed from the iris, and cause ul-
 ceration of the  cornea.   Vascular or fungous growths, arising in this
 way, may assume a formidable appearance for  some time, and then
 gradually subside, the eye going into a state of atrophy.  After the ex-
 istence of severe inflammation,  a bluish  prominence  may arise  in the
 seat of the orbiculus ciliaris, apparently proceeding from within out-
 wards, so as  to inddce  the suspicion that it may be a fungus arising
 from the interior of the globe. This swelling may become yellow, break,
 and discharge matter;  after which  the  globe  shrinks, without further
injury to the patient.  In the following instance, such swellings subsided
without giving way externally.
       81 
642
FUNGOUS GROWTHS, NOT MALIGNANT.
   Case.—Acute ophthalmia, with the formation of yellow prominences in the situa-
 tion of the ciliary body; spontaneous disappearance, and atrophy.—A child about six
 years old came under my care at the London Ophthalmic Infirmary, with serious ex-
 ternal inflammation of one eye, attended with so much swelling of the palpebrse, that
 the exact state of the globe could not be ascertained.  Quickness of pulse, heat of skin,
 furred tongue, great pain in the  eye  and head, restlessness  and  want of sleep,
 showed  that the local  inflammation must be  serious.   At  the  end  of three or four
 days, when this had been reduced by leeches and suitable internal means, I succeeded
 in obtaining a view of the eye, in which  there was vivid external redness, with a dull
 state of the cornea ;  the iris was pushed  forwards and the pupil partially opaque.  In
 spite of the antiphlogistic measures, the child continued to suffer.  A tumour gradually
 arose behind the  edge of the  cornea;  it was of a  yellowish  colour, and acquired  the
 size of a horsebean.  Subsequently two or three other projections took place, of smaller
 size, arranged with the first, in a regular series, at a short distance from the margin of
 the cornea.  The inflammation continued severe, although leeches and aperients had
 been frequently used.   The mother said that the  child  still suffered from " inward
 fever," which did not yield to the measures  employed.  When  several weeks had
 elapsed the inflammation abated ;  the pain bacame less, and  the  protuberances round
 the cornea diminished in size.  x\t last, the latter completely shrunk,  the eye became
 atrophic, and the child recovered without any further ill-consequences.
    Two cases are quoted in Chapter XVII., from the work  of Mr. Saun-
 ders,  of fungous  excrescences from the iris and corpus ciliare coming
 to  a natural termination:  see p. 414.
   The following two cases, related by Scarpa, (Treatise on the principal
 Diseases  of the Eyes, p. 515—518,) were apparently analagous to those
 just mentioned.
  Case.—Pietro Campari, aged forty-eight, a husbandman of unhealthy constitution)
 subject to  intermittent fever, and afflicted with chronic rheumatism, was suddenly
 attacked with pain in the left eye, which he  attributed, without reason, to the entrance
 of some extraneous body between the eye-lids.  Violent  inflammation  soon took place
 in the  eye, and was succeeded by total opacity of the cornea.   Shortly afterwards, an
 excrescence of the size of a split bean  arose from  this opaque membrane, surrounded
 by blood-vessels highly turgid.  In the course of a fortnight, the sarcoma increased to
 such a degree, as to project beyond the edges of the eye-lids.   In this 6tate the patient
 was brought into one of the wards of the hospital, where the excrescence was removed
 by means of the ligature, and afterwards the application of caustics and the ointment
 of Janin.  The patient went out, supposing himself cured; but in  a short time after-
 wards the sarcoma returned, and became larger than before, with an  extensive base,
 which, however, was soft and flexible in  every part of it.  Darting pains, extending
 to the head, disturbed the  patient  night  and day, notwithstanding the use of opium
 internally,  and externally of anodyne  cataplasms.  In order to  remove the disease
 effectually, Scarpa considered  the excision of the anterior hemisphere of the eye-ball
 necessary.   The  operation  was performed by the late  Professor Jacopi.  The  re-
 covery was speedy and permanent.  The state of the excised  portion is not mentioned.
  Case.—Giovanna Gandini, a peasant  girl, fourteen years of age, of weak consti-
 tution,  had  experienced in her sixth year a  violent  inflammation of the left eye, fol-
lowed by complete opacity of the cornea  and staphyloma.  Lately, after a still more
 severe  inflammation,  the anterior  hemisphere  of the eye had  been converted into a
 reddish painful fungus, of cancerous aspect, except that it was every where soft and
 yielding.  Complete extirpation of the globe was performed by Professor Morigi.  The
cure was completed in two months, and no return of disease  had occurred at the end
of a year and a half.   The soft  fungus was  found to be confined  to the conjunctiva,
cornea, and a portion of the sclerotic  coat anteriorly; and  the fundus of the eye, sound
 in every respect as  to its  membranes, contained only a limpid fluid  instead of the
vitreous humour.
  Scarpa, (Lib. cit.  p. 518—521,) quotes  from other writers four  in-
stances, more or less similar to the preceding, in which extirpation of the
globe was practised.   The view which he takes of the subject is, that the
fungous excrescences from the conjunctiva and cornea, although indolent 
fungous growths, not malignant.
643
 and benign at their commencement, become when left to themselves or
 empirically treated, in process of time, malignant, and really cancerous.
 (Lib. cit. p. 512.)   He says, that even in the course of six months, such a
 complaint may pass from the state of softness to that of scirrhous indu-
 ration with hard warts, and afterwards  of carcinoma, contaminating
 the lymphatic glands behind the angle of the jaw and in the neck, and,
 finally, in  this short period, rendering  the bones  of the orbit carious.
 Hence he  considers it important not to neglect the opportunity of extir-
 pating the disease in its early stage.  (Lib. cit. p. 525.)  This notion of
 cancerous disease beginning with acute inflammation, and with the pro-
 duction an excrescence, which, being at first innocent, afterwards acquires
 malignant characters, is totally at variance with my experience, and with
 the course of the disease in all the recorded instances of carcinoma, where
 its progress  has been followed throughout.  I consider the  treatment
 founded on it to be equally objectionable.  A comparison of  the cases
 observed by Scarpa with that which I have related previously at p. 642,
 and with  those quoted  from Mr. Saunders in another chapter, p. 414,
 will lead to the strong suspicion that the operations performed in  the
 former were  unnecessary; and that the disease in these cases would
 have come to a conclusion  from the resources of nature, alone, or aided
 by antiphlogistic treatment.
   Partial or entire extirpation of  the globe, may however be advisable
 in some fungous growths which are not malignant.  An example of this
 kind, in which a congeries  of dark purple roundish masses grew from
 the cornea, is quoted from Mr. Travers, in Chapter XII., at p. 319.
   Mr. Travers has also mentioned a case  in which the globe was ex-
 tirpated by Sir Astley Cooper,  and has given a figure representing the
 appearance of the  part on a section.
   The patient, fourty-six years of age, and the mother of nine children, had generally
 enjoyed good health.  Two years before she underwent the operation, the cornea of
 her left eye  had  become opaque from chronic  inflammation.   " In this case, after a
 severe attack of fever, the surface of the eye began to  throw up a vascular fungoid
 tumour.   On her admission it was of  the diameter of a shilling, covering the cornea
 and a part of the sclerotica,  and protruding between the eye-lids.  It was slightly
 lobulated, of a dark purple colour mingled with red : it sometimes bled, but was never
 painful."  The  recovery from the operation  was speedy.  Dissection of the eye.
 The tumour  is situated without the globe: it appears pulpy, vascular, and of an un-
 equal dark colour. It is of a  square figure, formed of various lobes, separated by deli-
 cate fibrous bands, and adheres to the sclerotic and the margin of the cornea. These
 two membranes  could  be traced entire beneath the tumour.  The globe being divided,
 the vitreous  humour escaped  in a liquid  state and of a yellow colour.  The lens had
 disappeared.   Within  the globe  and  opposite to  the outer tumour, is another and a
 smaller morbid growth, which has no communication with the former, and is of a softer
 and very vascular substance.  It  occupies the lower and anterior part of the globe,
 raises and compresses the retina,  and is distinctly situated between the layers of the
 choroid coat." (Synopsis, &c. p.  416,  417, plate vi. fig. 2.)
   The same point  is illustrated  by an example recorded by Mr. Ward-
 rop, in which it is to be  regretted that the exact nature of the disease
 was not ascertained.  He says, " I have  had an opportunity  of seeing
 other diseases of this organ, at  a  time when my attention was  not par-
 ticularly directed to the investigation of the present subject, which were,
 perhaps, neither of the nature of fungus haematodes nor cancer.  I am
 led to form this opinion from  the  final result of the cases;  and from
thinking it highly  probable, from analogy, that when  the  eye bursts, 
644
carcinoma of the eye.
tumours may arise from its internal parts, resembling more some kinds
of polypi, than either fungus haematodes or cancer.  There are several
cases of tumours of this kind described and delineated by Beer ; and in
the works of Fab. Hildanus, there is an accurate account of a case,
which was successfully extirpated, in which a prodigious tumour grew
from the eye-ball.   A  remarkable case, very analogous to  that  given
by F. Hildanus, I had the opportunity of seeing, ten years ago,  under
the care of Dr. Wardrop.  A gentleman, who resided in England, con-
sulted many respectable surgeons about a very large excrescence which
grew from the eye-ball; but as they supposed it to be of a cancerous
nature, and as the disease had extended far, they declined making an
attempt to remove the diseased parts,   When he came to Edinburgh,
a very large excrescence was found projecting from the orbit, and ex-
tending beyond its bony margin,   As Dr. Wardrop was assured, from
a careful examination  of the  parts, that the whole diseased mass was
within the reach of  the knife, and doubtful of its cancerous nature, he
undertook to  extirpate it.  The operation was accordingly performed,
and, the eye-lids being excoriated, they were also  taken away  along
with the tumour.  The parts healed in the most rapid manner, and the
gentleman returned  home to England -in  a month after  the operation.
A short time ago, Dr. Wardrop heard that the disease had not returned.
No account was taken  of this case; but Dr. Wardrop particularly re-
members, that the optic nerve was found quite sound.  (Observations on
Fungus Haematodes, p. 88—90.)
   Morbid productions, sometimes under the form of fungus, may arise
from the conjunctiva (see the remarks on polypi, warts, and other ex-
crescences of the conjunctiva, in Chapter XII. at p. 319;) from the
sclerotica (Chapter XIII. p. 33, on cysts and tumours of the sclerotica;)
from the iris or corpus ciliare (see the observations on fungous excre-
scences from the iris and ciliary body, and on tumours growing from
the iris in Chapter XVII, pp. 414,435.)   If the apparent cause, the origi-
nal seat and progress of the malady, and the condition of the eye in other
respects be investigated with even moderate care, there can be no risk
of confounding such cases with malignant diseases of the organ.
   The active inflammation preceding  and accompanying some of the
affections now alluded to, sufficiently distinguishes them from malignant
affections, which exhibit no marks of vascular excitement in their early
stage; and, although  often very painful, are  not usually accompanied
by active inflammation at any period.
   Cancerous  ulceration of the eye-lids has  been already described in
Chapter II, § 3, p. 127.
                 SECTION II.—CARCINOMA OF THE EYE,

  If the eye-ball is susceptible of  scirrhous induration and  subsequent
cancerous ulceration; that is, if it can undergo changes similar to those
which  characterize cancer of the female breast, the disease  is very
rare, and has not as yet been clearly described or delineated.  I have
seen the globe converted into an  apparently scirrhous mass, having a
knotted surface, with enlarged vessels distributed over it, in which there 
CARCINOMA OF THE EYE.
645
was  no trace of the natural  structures.  There was no material in-
crease of size, nor was the altered globe more fixed in the orbit than in
the natural state.   An excavated ulcer, about as large as a shilling,
had taken place, but without offensive discharge.  The disease was of
long  standing, in a person of middle age, and did not  disturb  the gen-
eral health.   The palpebrae were free  from disease, and there was no
reason to suppose that the  other  contents of the  orbit were altered in
structure.
  " I much suspect," says Mr. Wardrop, " whether cancer ever affects
the globe of the eye  in its  primary form; at least, I  have never met
with an example  of this kind.   I have had repeated opportunities of
observing a cancerous sore, beginning  in the integuments of the eye-
lid or tarsi, and spreading  along the conjunctiva, till  it reached the
globe of the  eye, the structure of which  is  ultimately destroyed, and
contaminated  the  neighbouring absorbent glands;  but I  have  never
been able to obtain an accurate account of a single case, where any of
the coats or contents of the eye-ball were  the primary seat of cancer."
{Observations on Fungus Hcematodes, p. 87.)
  We may conclude that the  affection  is rare from the circumstance
of its not being noticed in the work of Mr. Tyrrell: Mr. Middlemore,
however, speaks of it as if it were of frequent occurrence.  He gives
a long general account of  the subject, without any details  of cases  or
dissections.  The result of  his experience is stated shortly in the fol-
lowing  passage:—"Of the many thousand persons,  whose  diseased
eyes I have examined and treated, I have never yet seen a single case
of genuine carcinomatous  ulceration of the globe of the eye,  but I
have, on several occasions, witnessed a state of disease, which I have
termed scirrhus, because it is attended with  great local pain, occurs in
advanced  life, is connected in the general when of  long continuance,
with a constitutional affection, has a tendency to  involve  surrounding
parts, and is, from the first, characterized by a shrinking and  uncom-
mon  induration of the affected organ.  The term scirrhus of the eye-
ball  is, then, intended to  apply to a shrunken, indurated state of the
eye-ball, which, on minute examination, is found to be converted  into a
solid  compact  mass, the  section  of which  exhibits  the membranous
striated  appearance so peculiarly characteristic of scirrhous induration
in other situations."  (Treatise, vol. ii. p.  370.)
   We have no pathological materials for  a history of the disease; the
structure  in which it begins, its progress and  ultimate effects on the
globe and on  the constitution are not known  to us.  I  am  not ac-
quainted with any well-marked histories and dissections of true cancer
of the eye-ball.
  The following  case, recorded  by Dr, Farre, may have  been  carci-
noma ;  but the exact nature of the change, which the structure of the
globe had undergone, is not pointed out, either, in the description  or
delineation, with  sufficient  clearness for us  to determine the point, or
to decide positively whether it ought not to be referred to fungus hae-
matodes.
  "In the year 1803, Mrs. L. gradually, and without any pain or apparent disease,
lost the sight of her right eye.   About two years after, she was attacked with  violent
pains in that eye, and in the head, on the same  side; and, from this time, became sub- 
646
CARCINOMA OF THE EYE.
 ject to occasional ophthalmia.   In June, 1807, the ophthalmia was extremely severe,
 attended with violent pain both in  the head and right eye.  The cornea was con-
 siderably opaque, the iris was rather contracted, not perfectly circular, and quite im-
 moveable ;  though the eye was sensible to the action of light.   The  other eye was
 also, at the same time, slightly inflamed.   The inflammation and pain in  the latter
 soon subsided, and were removed in the former in about a month;  and no more was
 heard of the patient  till the latter end of April, 1808.  There was then a very per-
 ceptible and rapidly  increasing enlargement of the contents of the orbit of the eye.
 The cornea had lost all its transparency, and was thickly covered with minute red
 vessels.  The inflammation of the conjunctiva had obscured almost the whole of ihe
 sclerotica; but a distinct view of a small segment of its circumference, clearly showed
 the globe of the diseased eye to, be smaller than that of the sound one.  This circum-
 stance,  when combined  with  the great prominence of the diseased eye,  furnished
 strong reason for suspecting that it  was constantly pressed  upon  and protruded by a
 tumour in the interior of the  orbit.  In this state of the disease an operation was
 judged  the only means  of relieving the excruciating  pains  of  the patient, which,
 though in some degree constant, experienced the most violent  exacerbations  every
 evening.  On the 9th of January, 1809, the whole contents of the orbit  were removed
 by Mr. Saunders, with the greatest care and ability: on this occasion the os unguis
 was found  slightly diseased.  For two days after the operation  the patient enjoyed
 perfect ease.  On the third day some pains in the head returned;  and though the
 parts healed well, were  considerable, till  within  the last  seven weeks of her life.
 About that  time, after a sleepless night, in  which she  had experienced  much  more
 pain than usual, all pain suddenly  left her, and she  sank into a state of mental imbe-
 cility, in which she  was often unable clearly to  distinguish  her most intimate ac-
 quaintance.  The appetite was excellent, and her sleep sound, but more than natural;
 when awake, she was animated with such high spirits, as generally induced her to ad-
 dress and reply to her friends in a facetious, though not always  appropriate or com-
 pletely intelligible manner.  This state continued till she died, on the llth of  July,
 1809, in the seventy-seventh year of her age. (A Treatise on some Practical Points,
 &c.  p. 150—153.)
   Figure 5, of Plate  III. represents  a section  of  the  extirpated mass.
 The sclerotica is  nearly filled  with  the  morbid growth:  it  has under-
 gone  absorption  at  one  part, near  the optic  nerve,  and  the disease,
 passing through this opening, has been communicated  generally to the
 adipous membrane in which  the eye is imbedded.   The medulla of the
 nerve is discoloured at the point where it had been cut through; but it
 was sound between this point and the globe.   (Lib.  cit. p. 218.)
   Beer gives the  following description of scirrhus and  cancer affecting
 the  eye.   As he does not mention fungus haematodes, or melanosis, we
 cannot receive this account as applicable to carcinoma of the eye-ball,
 in the limited sense in which  I  have employed that designation.   No
 cases corresponding to these descriptions  have come  under my obser-
 vation.
   " Scirrhous exophthalmia attacks the  proper  textures  of the  eye,
 and destroys entirely, or  in  greater  part, their normal structure and
 form.   It is characterized by an unequal and very hard swelling of the
 entire globe, which is  of a reddish white colour, by a  troublesome
 sense of weight, impaired or  destroyed motion of the part, without pain
 or fever.   Glandular swellings, in various parts, as in  the neck, axilla,
and  breast, often  accompany  the complaint in the  eye.   A perfectly
scirrhous eye-ball  consists of a brownish, very  firm mass,  in which the
proper textures  of the eye-ball are lost, or at least some traces of the
sclerotica  only can be distinguished.
  "  Carcinomatous exophthalmia, which  is usually developed  from a
preceding scirrhous change  of structure, rapidly involves  all the tex- 
CARCINOMA OF THE EYE.
647
lures, to such  a degree, that in a  short time  no trace of the original
organization remains.  The cases are more rare, in which this formida-
ble degeneration of the globe, which sooner or later destroys the patient's
life, commences with the development, in the conjunctiva corneae, and
scleroticae, of single, wart-like, very painful, and dark red tubercles, which
have been called, by writers on  ophthalmology, papulae, or caruncula
malignce or rebelles.  When  carcinoma proceeds from scirrhous ex-
ophthalmia, it does not immediately break out into an open sore: acute
lancinating pain is previously felt in the scirrhous eye, and extends into
the head; vessels are seen on the surface of the diseased organ, and in
the eye-lids, in  a  state of  varicous enlargement; the part constantly
increases  in size, and becomes exquisitely  sensitive to  the slightest
touch, while the addition  to  these  symptoms of considerable  fever,
denotes the complete formation of  an occult cancer.  This, sooner or
later, breaks out into one or more true carcinomatous ulcers, marked
by the ordinary characters: the pain now becomes intolerable, experi-
encing only short, occasional  mitigations, by spontaneous  and active
bleedings  from the distended  vessels.   Such  hemorrhages may be so
profuse, as to  cause fainting, with considerable  subsequent debility;
and, commonly, the  fatal termination  is immediately produced  by an
occurrence of this  kind.  The  strength is  further exhausted by the
daily and hourly excessive discharge of a stinking  sanies, streaked with
red and  green, from deeply corroding  ulcerations of the  eye, with
hard, leaden-coloured, uneven, and everted edges, whereby the cachec-
tic state of the constitution is aggravated, and the slow, hectic fever is
kept in a state of constant progression."   (Lehre, vol. ii. p. 225—227.)
   The opinion  of Mr. Travers will be  seen  from the following quota-
tions.  " I had formerly been led to suppose, that the malignant disease
termed cancer, affected  the ball or globe  of the eye.  Such  is the
doctrine  of  most  writers on  the  subject.  I have, however, satisfied
myself that as regards the eye, this disease is peculiar to the lachrymal
gland, conjunctiva, and eye-lids;  and  I  have classed  it accordingly."
(Synopsis of the Diseases of the Eye, p. 216.)—" There is a malignant
fungus of the  conjunctiva, for,  like the  mucous  membrane of other
parts, this is sometimes the seat of carcinoma; and, excepting the lachry-
mal gland, I  believe no other texture related to the organ of vision is
ever primarily so affected.  I have  removed the  contents of the orbit
for a painful tubercular fungus, with ulcerated depressions containing
an ichorous discharge.  The coats and  humours of the eye were for
the most part  absorbed, the lachrymal gland scirrhous.  The  disease
afterwards returned upon the palpebrae, and destroyed the  patient.   I
have  at this time  a similar case  under  my observation.  The  fleshy
tubercles grew from the conjunctiva, both on the cornea and sclerotica,
and the inferior palpebra is  extensively ulcerated.  It is accompanied
by lancinating pain in the  supra-orbitar region, and an  unhealthy dis-
charge."  (Ibid, p. 100.)                                .
   The appearance of the disease in the last-mentioned case is delineated
in Plate II. fig. 1, which I  should  have supposed to represent the  car-
cinomatous affection of the eye-lid already described.  I conclude, in-
deed, from the further description by Mr. Travers, in the Medico-ChU 
648
CARCINOMA OF THE EYE.
rurgical Transactions,* that the cancer of the eye-lids, which he repre-
sents as an affection originating in the conjunctiva, is not different from
the  disease in the same  part, which I have found to commence in  the
skin.  For he strongly represents one striking feature of the complaint
in its advanced period, namely, the resistance of  the  globe  to the pro-
gress of the destructive disease.  " For a long  time the globe remains
(I have even seen the cornea and humours clear) suspended,  as it were,
geometrically in the centre of the ruin."   Other points of this descrip-
tion have not, however, been exemplified in the cases which I have seen;
such are, a luxuriant fungus overshooting and burying the eye; expo-
sure of the malar and temporal bones; and an  immense fungous mass
encircling the orbit, and in part springing from  it, everted over the  su-
percilium, nose, temple, and cheek.
  Causes.—On this subject I may refer to the remarks  already made,
in reference to  that point,  in speaking of carcinoma of the eye-lids,
and particularly in regard to its supposed origin from  injuries, external
irritants, common inflammation, or the consequent thickening and indu-
ration.
  Treatment.—Internal remedies  and  external  applications are of as
little avail in cancer of the eye, as in other affections of similar nature.
The only  question is,  whether extirpation  can be  undertaken, in an
early period of the disease, with reasonable prospect of success.  The
operation would not be advisable, unless the affection were confined to
the globe, and that were freely moveable in the socket.  If the  disease
should have extended to the surrounding parts, and the eye should have
become fixed, the operation would be unavailing; at least relapse of dis-
ease might be confidently expected.   Such was the unfavourable termi-
nation of cases operated on by  Desault,! Scarpa,J and Mr.  Travers.§
When the  eye, although altered in texture is not much enlarged, when
it is still moveable in the orbit,  when the palpebrae  and  the absorbent
glands are unaffected, and the general health is good, the removal of
the diseased organ  may be proposed, although we cannot guarantee
the permanence of the cure.  After mentioning  that he had  found me-
dicines altogether useless in  scirrhus of the globe, Beer proceeds to say,
that extirpation remains  as the only resource.  " However," he adds,
" I  cannot positively promise  a  completely favourable result, even un-
der the most auspicious circumstances.   Knowing that  this operation,
although performed by excellent surgeons with  the  greatest care, has

  * Vol.xv. p. 234, 235.     + QHuvres Chirurgicales, par Bichat, torn. ii. p. 115—117.
  t  In the  preface to the  first edition, Scarpa says, that he  had seen  only two in-
stances of cancer of the eye.  The first, in a boy of thirteen, seems to have been an example
of fungus hsmatodes; "In the second, that of a man fifty years old,  robust,  and perfectly
healthy in all other  respects,  the cancerous fungus included not only the globe, but also a
portion of the upper eye-lid.  I removed, with the greatest accuracy, the contents of the
orbit and the upper eyelid, cutting along the edge of the orbit, where the parts  appeared
perfectly healthy.  Every thing proceeded very favourably till the fortieth day, and the ci-
catrix was advancing  gradually from  the margin of the orbit towards its fundus.  The
wound now became stationary, and at various points, fungous growths  shot up, which I
endeavoured in vain to destroy with  powdered savine and  caustic.  Severe pain of the
head and nervous fever came on: the patient lost his senses, and died."—Saggio di Osser-
vazioni, 8fc.  Pavia.  Prefazione, p. 9, 10.
  § Synopsis, p. 100. 
FUNGUS HAEMATODES OF THE EYE.
649
 generally turned out unfortunately; and  having experienced failure in
 two cases out of seven, where I had undertaken it on the clearest indi-
 cations, I  can place no  great confidence in its essential benefit to the
 patient,  unless a  temporary relief from a change of structure; attended
 with great deformity, should be regarded as such."  (Lehre, vol. ii. p.
 230.)  The conclusion in this passage, is singularly at variance with the
 premises.  Five  cures  out of seven cases, if they were permanent, con-
 stitute an encouraging result, and would justify a much stronger recom-
 mendation of the operation than  could be warranted by general expe-
 rience.  Perhaps Beer may have  intended to speak merely of recovery
 from the operation:  I  can hardly suppose that permanent cure would
 have been effected in so large a proportion of cases truly cancerous.
   If the case should have proceeded  so  far, that we do not think the
 operation advisable, we can only palliate the mischief* mitigate  the pain
 and distress of the patient, and thus  render his condition more comfort-
 able.  When the suffering is considerable, we must administer narcotics,
 increasing the dose in proportion as  the constitution becomes habituated
 to them.   The local application of opium often gives relief, especially
 in the ulcerated stage, and the liquor opii sedativus of Mr. Battley is
 a form well suited to the  purpose.   We may begin with two drams to
 an  ounce of  distilled water, and gradually increase the strength, until
 we  use  at last the undiluted liquor.   Lint, moistened with the fluid,
 may be applied to the part under  a  dressing or poultice.  Opium may
 be  used  in the form of ointment, made  by incorporating one  or two
 drams of it finely powdered, with an ounce of lard.  The internal use
 of the same remedy is necessary to relieve pain.   The progress of these
 cases is  often slow: the  affection may be clearly marked and completely
 developed, and yet continue much longer than might have been expected,
 without  destroying life.  In a patient who used to come to the  London
 Ophthalmic Infirmary, cancer of the globe had existed for a long time.
 During three or  four years  that  I saw him occasionally, it made but
 little progress.  We are not therefore  to infer* because this disease de-
 stroys life, that it does so rapidly.
  Scirrhus of the caruncula lachrymalis and of the lachrymal gland.—
 What I have to remark on these affections will be found in the  chapter
 on diseases of the lachrymal organs.


              SECTION III.--FUNGUS H.EMATODES OF THE EYE.

  Of the malignant affections, incidental to the organ of vision, this  is
 by far the most frequent;  its nature,  progress,  and fatal termination
 being similar in  all essential  points, to what we observe when the
 disease attacks other parts of the body.  The globe of the eye is  gradu-
 ally converted into  a soft texture, approaching more or less nearly,  in
 colour, appearance, and consistence, to  the substance of the brain. This
 adventitious growth, after distending and enlarging the globe, makes its
 way externally through the cornea or sclerotica, and appears as a fun-
gus, distending the lids,  or projecting between them.   Ulceration and
sloughing ensue, with fetid discharge, hemorrhage, and great pain ; and
these, with severe constitutional disturbance, soon destroy the  patient.
       82 
650
FUNGUS IliEMATODES OF THE EYE.
The absorbent glands are generally affected; and secondary affections,
similar in character to the primary disease, are usually found after death
within the cranium and in other parts.
  The morbid  growth, which  appears first at the back of the globe,
gradually comes forwards, and makes its way externally by ulceration
of the cornea or sclerotica.   In the first stage of the affection, the pupil
exhibits  a deep-seated,  whitish, yellowish,  amber-coloured,  or even
greenish discolouration of brilliant  appearance, causing a reflection of
light, as if a metallic  plate were at the back of the  eye, and  soon  no-
ticed even by unprofessional persons.   In the  very early period, this
discolouration is so small, that its limits can be distinguished.  We soon
find that it is owing to an adventitious deposite in the eye, of which the
surface is usually uneven, and sometimes exhibits vascular ramifications,
which have been supposed to be those of the central vessels of the retina.
At  first the iris may be sluggish, and the pupil  large; the latter soon
becomes fully dilated and fixed.  There is no change of figure in  the
globe, no unusual vascularity, nor  any evidence of pain ;  but vision is
destroyed.  In the second  stage, the diseased production increases  in
size, distends the globe, advances to the front of the eye, pushes the lens
and iris against the cornea,  and destroys the transparency of the for-
mer, which assumes a light amber-colour; the tint of the iris also is more
or less changed.   The sclerotica is manifestly distended ; it has a bluish
or leaden colour, and  partial  bulgings are sometimes seen on its anterior
part.  The distention of the globe is further evidenced by  enlargement
of the cornea, which loses its clearness.   The eye is now inflamed and
painful, and sympathetic disturbance of the constitution takes place: in-
flammation and pain sometimes  occur at an earlier period; they may be
removed for  a time and come on again.   The  fungus growth, which
most strongly characterizes the affection, is now lost sight of, being con-
cealed by the opaque  state of the lens.  " In this stage of the  disease,"
says Mr. Wardrop, " I have  known two cases which were mistaken for
cataract, and  in  one of them  an  experienced  surgeon attempted  to
couch it."*   He observes further, that "in some cases a quantity of
purulent matter collects between it (the  adventitious growth) and  the
cornea."
  In the third  stage,  the inflammation of the eye increases, with aug-
mented vascularity, and lachrymal discharge, with redness, swelling,
vascular distention of the lids, severe pain of the eye and head, excited
circulation, hot skin, restlessness, and want of sleep, white tongue, thirst,
and loss of appetite.   Having caused more or less considerable enlarge-
ment of the globe, the tumour now makes^ts way externally, the cor-
nea or the sclerotica, after previous distention giving way by absorption,
with temporary relief of the local and general suffering.  The escape
of  the crystalline  lens through the  cornea, just before the external ap-
pearance of the tumour, has  been sometimes observed.f  A soft reddish,
reddish white, grey, brownish or livid fungus now  protrudes from the
surface of the eye, and  the  organ, increasing in size, but without any

  * Observations on Fungus Haimatodes, p. 11.
  t Observations on Fungus Haematodes of the Eye, by Mr. Middlemore.-hondon  Med.
Gazette, vol. vi. p. 879. 
FUNGUS HAEMATODES OF THE EYE.
651
trace of its normal structures, projects between the lids, if it should not
have done so previously.  The fungus, which is  soft  and easily lace-
rated bleeds spontaneously or on the slightest injuries; it discharges a
fetid ichor or sanies, which excoriates the lower lid and cheek.  Por-
tions of the most prominent part slough away with increase of the dis-
charge and fetor, the separation being often attended with profuse bleed-
ing.  Under the various combinations of ulceration, sloughing, and he-
morrhage, with the presence of discharge, or blood in a fluid or dried
state, the colour and external appearance of the disease may exhibit
considerable varieties.  It increases rapidly,  soon acquiring the size  of
a small apple or of an  orange; it may become as large as the fist,  or
even attain a greater magnitude.
  If the fungus should burst through the sclerotica, it will distend the
conjunctiva, and thus acquire  a mucous covering, under which it may
enlarge considerably before  ulceration, and  the subsequent processes
of sloughing and bleeding commence.   It grows more  slowly in this
case, and  sometimes greatly distends the lids, without  projecting be-
tween  them.
  The disease may have  its origin exterior to the globe, which it par-
tially surrounds and pushes forwards.   The  tumour is covered by the
conjunctiva, and in the centre of its anterior prominence  are  seen the
cornea and iris not much altered.  It grows  slowly, expanding and en-
larging the  lids, then  pushing  out  between  them,  acquiring  a  great
magnitude  without ulceration.   When  it is larger  than the  fist, the
cornea and iris may still be recognised of their natural size, and nearly
normal structure.    Mr. Travers gives a coloured engraving  of such
an affection in an infant of eight months, in whom the disease was con-
genital, the eye-ball having been as large as a  walnut  at the time of
birth, and equal to the  fist when the figure was taken.   He  observes
that " the disease in this infant, from the central position of the cornea,
and from  the enormous  protrusion and equal  figure of the ball, was
supposed to  be  seated  on the orbitar appendages.  It  is remarkable
that the  child was well  nourished, and apparently suffered  little con-
stitutional disturbance.   The  other eye was sound."  (Synopsis, p. 205
and 410.  Plate v. fig.  2.)
  Although it seems probable  that, in  the  cases  now  alluded to, the
disease is of  the same  nature as in those where  the growth begins in
the  globe, the point has not yet been ascertained by dissection; nor  do
we  know at what  period, nor in what manner or degree, the proper
textures of the eye may become involved in  a disease which is at first
foreign to them, supposing our notions on that subject to be correct.
  The neighbouring lymphatic glands sometimes enlarge, and become
diseased;  sometimes they are  unaffected.   Those which  I  have seen
diseased have been on  the cheek in front of the parotid, under the lower
jaw, and at  the side of the neck over the large  blood-vessels.  They
have sometimes formed tumours of considerable size.   Mr. Wardrop
says " The absorbent glands become also affected during the progress
of the  disease; they swell and inflame, and sometimes grow to  an enor-
mous size.   In some cases the  swelling of the glands commences at a
very  early  period, whilst in  others  they are  not affected  until  the
disease is  far advanced.  Most commonly  those glands  swell which 
652
FUNGUS H^MATODES OF THE EYE.
lie in the immediate neighbourhood of the parotid gland, or lower jaw.
In two cases, I found a small hardened gland  close to the optic nerve;
in a third case, glands were found near the nose, and on thesupercilia;
and, in  another  case, a diseased gland was  found adhering to the  os
malae, within the margin of the orbit.*"
  " I have not," says  Mr. Middlemore, " often seen the superficial
glands much  affected; they have been  in two instances  slightly en-
larged and tender, but it  has not fallen to  my lot  to  witness them
changed into  a medullary mass, or  proceed  to ulceration.  Such  an
occurrence seldom takes place, and then  only, as far as my observation
extends, at the close of the disease."   (Lib. cit.  p. 882.)
  When the disease has  reached the ulcerative stage, the child soon
sinks  under the profuse discharge and  bleedings, the  severe pain, and
constitutional disturbance,  and dies emaciated.  Affection  of the brain
may come on  in the  latter stage and cause convulsions: more fre-
quently it is of comatous  character, and the patient dies insensible:
sometimes the sight  of the sound eye  has been lost, either gradually
or suddenly, before death.   These circumstances are explained by the
extension of disease through  the back of the orbit  into the cranium,
and by the internal disease being sometimes so  situated, as to press  on
the opposite optic nerve.
  Seat and nature of the disease.—The examination of eyes  affected
with fungus haematodes, in its early  period, has led to the conclusion
that the disease consists in organic change of the retina, or in a growth
from  the retinal extremity of the optic  nerve.  This would  account
satisfactorily for the appearance, exhibited in the commencement, of
an adventitious growth in  the fundus of  the  eye, and for  the  simulta-
neous loss of sight.
  Mr. Saunders examined, after death,  a case in which  the  left eye
had become affected with fungus haematodes at the age of nine months,
and the right at that of fifteen months.   The  child died  soon after the
latter period, when the left eye  had  become  completely disorganized,
but the disease on the other side was still confined to its original seat
in the vitreous  humour.   In  this eye, which is figured, both   in Mr.
Wardrop's Observations  on  the Fungus Hccmatodes,\ and in  the
posthumous work of Mr.  Saunders,J the optic nerve, sclerotica, and
choroid were sound, the latter being  thin.  The retina had degenerated
into a soft  mass of lobulated appearance, connected  only  to the optic
nerve.
  Mr. Wardrop removed  the eye-ball in an  infant under three years,
in whom  the  morbid  growth was still  confined to the interior of the
globe.  A fleshy-looking mass, about the size of the little  finger, sur-
rounded  the optic nerve, adhering firmly to it, and to the adjacent part
of the sclerotica.  A  section was  carried through the diseased mass

  * Observations on Fungus Haematodes, p. 13, 14.  The first plate of this work contains
two figures, representing the external appearance of the disease.  In one, where it had re-
turned after extirpation of the globe, there are three glandular swellings, in front of the
parotid, and below the jaw, as large as walnuts.  In the other, the  absorbent glands un-
der the jaw are increased to a mass half as large as the child's head, although the original
disease is not of large size.  See p. 33 and 43.
  t Page 193 ; the case is given at p. 47.
  J Page 145—147 ; fig. 6 of plate 2. 
FUNGUS HAEMATODES OF THE EYE.
653
and the eye-ball.  The former and the optic  nerve were now seen  to
be distinct: the nerve was larger and firmer than usual, and altered in
colour; "after the nerve entered the sclerotic coat, nothing like retina
could be distinguished, but  it seemed to swell out and form  a  mass
resembling that which surrounded it externally.   This mass filled the
posterior chamber in such a  manner, that the choroid coat was pushed
from its natural situation towards the anterior chamber, in the form of
an irregular  shaped bag."—The tumour could be separated from  the
sclerotic  coat at every part, except near the entrance of the optic nerve.
There it adhered  to  it so firmly that it could not be  dissected from it
without being torn.   The different parts of the mass much resembled
common  medullary matter, intersected in an irregular manner with cel-
lular fibres, which rendered it rather firmer, and less easily divided than
brain."   (Lib. cit. p. 37; plate ii. fig. 1.)
  Mr. Ware extirpated the left eye of a child six years  old, on account
of fungus haematodes.  The disease  soon  returned with glandular en-
largements on the face near  the parotid, and in the neck, and the  right
eye began to  exhibit the same affection, which, however, had not pro-
ceeded beyond its first stage, when death ensued.   " The right eye did
not appear to be enlarged; but on cutting through its  tunics, almost the
whole space,  usually occupied by the vitreous humour, was found to be
filled with a steatomatous substance, which in general  was of  a white
colour, but in some  few places was red and  bloody.   When this sub-
stance was removed, a white smooth tumour was discovered behind it,
perfectly distinct  from the  steatomatous  substance above  mentioned,
and appearing to  be a morbid alteration of the tunica retina itself.   The
tunica choroides had very little of the nigrum pigmentum  spread over
its surface.   The  crystalline humour, as  well as  its  capsule, was per-
fectly transparent; and the optic nerve and every other part connected
with the eye,  appeared to be in  a healthful  state."   (Remarks on  the
Ophthalamy,  &c. p.  229—232.)
  The following description of an eye removed during the first  stage
of the disease is given by Mr. Mackenzie.  " I have now before me an
eye, extirpated by the late Dr. Monteath, during the first stage of this
disease.  Immediately after  the operation, I  divided  the  cornea and
sclerotica by  a crucial incision, and laid back the four  flaps.  The iris
and choroid were entire.  I  divided them in like manner, laid  them
back, and along  with  the choroid, I found that  I  reflected  also  the
retina, which, though broken, and here  and there deficient, is still suffi-
ciently entire to give a white coating to the whole internal surface of
the choroid, and has evidently nothing  to  do  in  this  instance with the
medullary tumour,  which occupies  the whole space  of the vitreous
humour and  crystalline lens, and springs  from the optic nerve  as from
a root.  The  tumour, enveloped  in a membrane similar to the hyaloid,
was of the  consistence  of  brain, and  of a yellowish white colour.
The optic nerve,  exterior to the sclerotica, did not appear diseased."
(Practical Treatise, p. 547.)
  "The retina," says Mr. Wardrop, "becomes so completely changed,
that  in no instance  could I detect any remains of its  natural  appear-
ance ; and a tumour is formed in the posterior chamber, extending from
the entrance of the  optic nerve forwards, in such a manner as to dis- 
654
FUNGUS HjEMATODES OF THE EYE.
place and promote an absorption of the vitreous, crystalline, and aque-
ous humours.   (Lib. cit. p. 14.)
  Professor Panizza examined an eye which had been extirpated in an
early period of the affection, and found an adventitious growth imme-
diately involving  the  retina, although  that tunic  and the optic nerve
were not changed in structure.   The case was that of a lively, robust,
intelligent infant,  twenty months old, of swarthy complexion, in whom
fungus haematodes had existed for a month in the left eye, having origi-
nated from a serious internal inflammation of short duration, following
severe suffering from  dentition on the corresponding side of the upper
jaw.  The eye was  natural in  size, motion, and state  of  vessels; the
pupil excessively dilated and motionless.  Behind that opening appeared
a spot of pale yellow, or  canary colour, divided into three tubercular
eminences, with a red vessel creeping between them.  It was best seen
by looking laterally at the eye, when it appeared near the pupil; while
to an observer placed in  front it seemed in  the  fundus of  the globe.
Vision was extinct.  The  diseased organ was removed by Dr. Done-
gana six weeks after  the  beginning  of the disease.  The result was
most favourable, and  the child from  that  time enjoyed perfect health.
The globe was perfectly natural in size  and  form, but rather firmer
than usual;  no change was  observable in the optic nerve.  Through
the  cornea, which was still  transparent, the discolouration  behind the
pupil was visible,  as before the operatiog.   The removal of the cornea,
which allowed the escape of the aqueous humour,  and that of the iris,
which was healthy, exposed the crystalline in its capsule, still perfectly
transparent.  On  looking  through the  lens, the yellow spot  seemed in
the  fundus of the  eye; but when it was removed, we were surprised to
see  the diseased mass immediately behind, forming part of the excava-
tion  in which the  posterior convexity of the lens is lodged.  The sub-
stance was soft and elastic, and its three eminences could be separated
a little by pressing with the end of a probe.   In order to ascertain more
exactly  its origin  and  nature, a portion of the sclerotica and choroid
was removed from the back of the eye.
  As soon as the  latter  tunic was opened, a yellow fluid escaped with
some force, and the tubercular eminences became less prominent.  The
fluid was yellowish and glutinous; it coagulated in spirit so as to form a
pale yellow homogeneous  mass.   The  eye was now placed in spirit to
prevent  the further escape of this substance.  After removing a portion of
the  sclerotica and choroid, both of which were natural, the interior of
the  eye  seemed full of  the yellow matter, which was granular, and re-
duced into a fine powder by rubbing between the fingers.  As the retina
did  not  come into view after removing  the choroid, it seemed as if that
tunic had degenerated into this yellow matter, which appeared contin-
uous with the optic nerve  at its entrance  into the globe.   Indeed, on
lifting the nerve gently, it appeared  like a cord gradually expanding
into  the yellow mass.   On carefully removing  the latter, I found in the
midst of it the retina, shrunk, folded, and reduced into a conical form,
extending from the entrance of the nerve to the eminences already de-
scribed, which were merely prominences of the tunic caused by pressure
of the yellow fluid.   Hence  it appeared that the yellow spot was not  a
change  of structure  in the  retina, but produced by a yellow fluid col- 
FUNGUS HAEMATODES OF THE EVE.
655
lected between it and the choroid, and pushing the retina towards the
middle of the eye  and forwards.  The  vitreous  humour became di-
minished in  proportion  as the morbid deposite  increased, and the eye
contained only a very small portion.  The firm connexion of the retina
to the  corpus ciliare  prevented the  yellow  fluid  from  entering the
posterior chamber.   We can thus perceive how the retina, pressed on all
sides by the morbid deposite between  it and  the  choroid, was pushed
forwards so as to form the three tubercular prominences which caused
the yellow appearance in the pupil.*
   In an eye examined by Mr. Wardrop, appearances were found analo-
gous to those described by Professor Panizza in the foregoing  case.  I
have subjoined an  account of the dissection, although there  is some
obscurity in the statement respecting the situation and connexions of the
morbid growth.
  Case.—A boy, two years and eight months old,  became  dropsical, arid died after
having been twice tapped.  It had been remarked some weeks previous to his decease,
that there was a peculiar appearance in the left eye; the bottom of the posterior cham-
ber having a metallic  lustre produced by a  yellowish  opaque body.  The dropsical
fluid had been contained between the laminae of the great and lesser omentum.  "The
optic nerve of the affected eye was found to be perfectly similar to that of the opposite
side, from the thalamus till it entered  the globe.  The consistence or density of the
sclerotica was not perceptibly altered.  The  choroid coat appeared rather  paler than
natural, and being lacerated at one small point, during  the dissection, a quantity of a
creamy fluid escaped.  On turning back the choroid coat, the posterior chamber ap-
peared filled with an opaque white mass, on the anterior  part of which  lay the crys-
talline lens.  By immersion in spirits the retina  was rendered more  opaque than the
new production, and was found of its natural appearance, and enveloping the diseased
growth.   The hyaloid membrane also surrounded the tumour, and had become opaque
in a few points where the diseased production was found firmly adhering to it.  This
presented a mass consisting of granules or lobules, united by fine reticulated membrane.
It seemed to have commenced at the point where the optic nerve pierces the sclerotic
coat, at least it was connected to that point by a small pedicle, which was continuous
with the larger mass attached to the hyaloid membrane, the structure of  the whole
being perfectly identical; viz. small granules, about the size of a millet-seed, connected
together by reticulated  membrane."  (Lancet, vol. xi. p. 87.)
   In all the cases of genuine fungus haematodes, which I have seen, and
in all the recorded instances, which have been examined with sufficient
care  and accuracy  to convince us that nothing had been overlooked or
mistaken, except the two cases last quoted from  Panizza and Mr. War-
drop, disease has been found in the optic nerve  or  retina, or the latter
could not be traced  at all, its place being  supplied by the morbid growth.
In Mr. Wardrop's there seems to  have been  a morbid  change of the
vitreous humour; in that recorded  by Panizza the disease was anoma-
lous; I think it was not fungus haematodes.
   The posthumous  work of Mr. Saunders contains a figure representing
the section of an eye removed on account of organic disease developed
in the globe.  (Plate ii. fig. 4. p. 147—150. 207.)  The diseased growth,
which occupied nearly one half of the common  seat of the  vitreous
humour,  " seemed  to  be composed of  a yellow  coloured coagulable
lymph, streaked with black, and  to  have originated from the inner part
of the sclerotica, for the choroid coat was ascertained by dissection to
quit  the sclerotica,  and  pass on  the inner side of the tumour."   The
  * Sul Fungo midollare dell' Occhio, appendice,  Pavia, 1826.  Page  9—13,  tab. 1, fig.
3—7. 
656
FUNGUS HiEMATODES OF THE EVE.
 exact condition of the optic nerve and retina cannot be satisfactorily
 ascertained either from the figure or the description.  The age of the
 patient, (thirty-five,) and the  black streaks  of the morbid growth, lead
 to the suspicion that the case may have been melanosis.
   Mr. Travers is of opinion  that the origin of fungus haematodes is not
 confined to any one texture of the eye.  He says, " sometimes one, and
 sometimes another  of the proper textures appears to be the matrix of
 the  disease.   The fungus, in one  instance, adheres intimately to  the
 sclerotica, and detaching the choroid and  retina, throws these and the
 vitreous humour to the opposite side of the globe.   Frequently it splits
 the sclerotica into two lamellae, distinctly originating  in  the interstitial
 substance of that coat."  " But in other cases, the disease unquestionably
 begins in the choroid, and  that  tunic  gradually degenerates  into  the
 diseased mass, which occupying a large portion of the  globe, is through-
 out  deeply tinged with the black pigment.   Sometimes  the sclerotica
 has a morbid growth externally, and  the choroid in the interior."  Some-
 times  these tunics are only affected secondarily, the vitreous humour
 being the nidus of the diseased growth.   " The iris and the corpus ciliare
 evidently degenerate in the same manner  as the choroid.  Again, the
 disease has seemed  to originate  at the point of entrance of the optic
 nerve into the globe, pushing the humours before it; and the nerve itself
 has upon dissection been found diseased, both contiguous to the sclerotic,
 and  at the distance of three quarters of an inch from that tunic, where
 the intermediate portion has preserved its healthy aspect."  " It appears
 to me, therefore, that this is not a  disease of this or of that texture, as
 writers would insinuate, but of all the textures, the crystalline and cornea
 excepted, which yield to its progress, but never exhibit a specific change
 of texture.   (Synopsis of the Diseases of the Eye, p. 220—222.)   Mr.
 Travers represents  that the  choroid is  the most strongly disposed to
 assume this diseased action, the retina the least so.  He considers that
 the common nidus of the morbid deposit is the cellular structure, whether
 that  of the adipous membrane, the common, connecting  tissue, or that
 belonging to an organ.  Hence it may be deposited  either on  the sur-
 face or in the substance of the various  tunics, or in both situations at
 once.  (Lib. cit. p. 421—423.)  The varieties in colour, texture, rapidity
 of growth, and  other characters, are referred by Mr. Travers to the
differences of texture in the source of the disease.  " The  deep blue and
black tubera characterize the  choroid fungus; the  medullary, the sub-
 stantia alba  of the optic  nerve or brain ; a more dense fibrous brown
 tuber, clear of'stain, is the production of the sclerotica."  (Lib. cit. p.
 222, 223.)
  In explanation of  these opinions, it must  be observed that, under the
name of fungus haematodes, Mr. Travers includes melanosis, a change
of structure incidental to the adult, and differing, essentially from the
medullary disease of children.  Also, that the dissections, from which
these conclusions have been drawn, seem to  have been made principally
in cases of comparatively advanced disease, which were less calculated
to show the primary seat of the affection, than to illustrate its rapid and
destructive extension to contiguous parts.
  The growth of the morbid substance alters in various ways the form
and relative position of the parts within the globe, sometimes pushing 
FUNGUS HiEMATODES OF THE EYE.
657
forwards the choroid and vitreous humour, sometimes distending the
former; sometimes destroying entirely or in great part the characteristic
appearances of  that tunic, and causing partial or general absorption of
the vitreous  humour.  The sclerotica suffers the least, retaining its na-
tural structure even when the disease has  made considerable advance,
and though the  morbid  growth may cover and closely adhere to both
its surfaces.  The crystalline lens is  merely pushed forwards by the
growth  from behind.  As the pressure increases, it becomes opaque,
having a light brownish or amber tint.   It may be found in this state,
and  a  little  flattened, on  dissection of the disease before the period of
ulceration; and its escape when the cornea gives way, may sometimes
be observed.
   In the advanced siage of the affection, the contents of the orbit, and
the projecting fungus, constitute a  mass of morbid substance, in which
we can  trace little or nothing of the normal structures.   The sclerotica
can still be detected; some remains of  muscle may be discovered; the
optic nerve may be distinguishable, or lost in the morbid structure.
   The diseased  production itself as in the analogous affection of other
parts, approaches in colour and consistence to the substance of the brain.
It is  whitish, yellowish, or reddish; firmer on the  exterior, and softer,
even to the consistence of cream, internally.  Portions thus differing in
consistence may be found in various parts of the mass.   A soft creamy
matter may  be squeezed or scraped  from the cut surface of the firmer
part.  Mr. Wardrop observes, that " like brain, it becomes a soft pulp
when exposed for a short  time to the open air, mixes readily with cold
water, and dissolves in it, and it becomes firmer and harder when boiled,
or when immersed in  alcohol or acids.  When  the softer parts are
washed away in water, or when the mass is  forcibly compressed, the
more firm and solid parts remain.  These consist of a filamentous sub-
stance, resembling cellular membrane, which  varies in its quantity, and
in the closeness of its texture."  (Lib. cit. p. 16, 17.)
   The optic nerve exhibits various  changes  in size, colour, and con-
sistence, being  generally softened,  and  even pulpy; it may be enlarged,
and  confounded with  the surrounding diseased mass: the neurilema
and  inclosed  medullary matter are confused together, and it  is generally
redder or yellower than natural.
   The alteration in the nerve extends to the part within the cranium. In-
deed, after passing the foramen opticum, it sometimes is lost in a  mass
of medullary disease developed within  the skull, and  pressing  upon, or
otherwise involving the neighbouring portions of the  basis of the brain.
This internal disease may extend towards the middle of the basis cranii,
and  pressing upon the united optic nerves, cause blindness of the op-
posite eye.   The  thalamus nervi  optici, or  some contiguous part of
the brain, may  be diseased and pulpy, with coagula of blood inter-
mixed.                                                            c
   I have seen depositions of the morbid structure in a pulpy state, ot
grey colour,  both  on  the exterior and interior surface of the skull, at
various points, the bony texture being rough and discoloured.   A con-
siderable growth of the same kind has been met with on the surface of
the dura mater, covering the sphenoid bone behind the orbits.  In a case
mentioned by Mr. Wardrop, there appeared, on the external surface of
       83 
658
FUNGUS HiEMATODES OF THE EYE.
the dura mater, two  dark red coloured spots; and two spots similar to
them were also observed in  the corresponding portions of the pericra-
nium.   Between the tunica  arachnoides and pia mater, there were nu-
merous white spots, scattered in a very irregular manner over almost the
whole  surface of the brain, which, when cut into, were found to be small
bags, or abscesses, containing a viscid white fluid  like cream.*  Von
Ammon has delineated the external appearance in the cases of a child,
of a year  and a half old, who had fungus haematodes of both eyes, and
has also represented the change of structure in one of the eyes as well
as in the  frontal  bone.   On  both  surfaces of   the  latter there was
an extensive  deposition  of medullary  structure,  principally of red
colour.f
   When the absorbent glands are affected, the morbid change is closely
analogous to that  of the original affection ; the  texture  of the gland
being  gradually converted  into a medullary mass of pulpy, or  even
creamy consistence.  These secondary swellings although similar in
nature to  the primary disease, do not ulcerate and throw  out  fungus.
But the integuments have inflamed and sloughed from distention in some
instances, where the swelling had reached  an unusual magnitude.
   Medullary depositions have  sometimes been found in  the viscera of
the abdomen and thorax; particularly in the liver; and I have seen the
diseased substance deposited on the surface of the ribs.  Our informa-
tion on this subject is scanty, as this important circumstance in the pa-
thology of the disease has been hitherto strangely neglected.   The ex-
amination was confined to the eye and head  in  all the cases recorded
by Mr. Wardrop, as well as in those mentioned by Mr. Travers, and in
the  posthumous work of Mr. Saunders.
   Diagnosis.   Cancer and  Melanosis.—When we consider the charac-
teristic features of this  formidable disease, namely, the formation of a
soft adventitious production  of white or yellow colour, within the globe,
its progress by ulceration through the front of the organ, so as to form
a fungus which bleeds, ulcerates, sloughs and produces a fetid discharge,
there seems no probability of its being confounded with cancer, in which
there  is a succession of induration and  ulceration, or with melano-
sis, in  which  the  morbid growth is  first dark livid and subsequently
black.
   Age of the patient.—A further ground of distinction may be drawn
from the age of the patient.  Cancer and melanosis attack those in the
middle period of life, or persons  advanced beyond that  age.   Fungus
haematodes occurs in children: it has been  seen  as a congenital affec-
tion, (See ante, p. 651,) it has commenced in a few months after birth,
and has usually appeared in the  five or six first  years of life.   I have
seen it in the incipient state, in  a  healthy infant at the age of six months.
Mr. Middlemore (Treatise, vol. ii. p. 387,) saw it fully devoloped at the
same age, having ruptured  the cornea and  projected externally.  Mr.
Wardrop says, that in a list of twenty-four cases, which had  come to
his  knowledge, twenty were under  twelve years  of  age.   It may be

   * Lib. cit. p. 23 ; sec also case ii,
   t Klinische Darsteliungen, pt.  1, lab,  21, fig. 11; tab. 22, fig. 1  and 2; and fig. 6
and 7. 
FUNGUS HiEMATODES OF THE EYE.
659
doubted whether  the  disease in the four older subjects was fungus hae-
matodes, because Mr. W. does not  distinguish  between this affection
and melanosis.  Thus  of the  seventeen  cases, either related from his
own observations, or quoted from others, in his observations on fungus
haematodes, only two were  above twelve years of age.  In one of these
cases, (case xvi.) the affection was obviously melanosis; and it is almost
equally clear, that the other case (case xvii.) was of the same character.
" I have never yet," says Mr. Middlemore, " seen fungus hsematodes of
the eye occur in  an individual more than five  years old."  (London
Medical Gazette,  vol.  vi. p. 880.)
  In the posthumous work  of Mr. Saunders, three cases of malignant
disease affecting the eye-ball, in persons more or less advanced in years,
are related.   In an unmarried lady thirty-five years of age, disease be-
gan with loss of vision and slight dilatation of the pupil in  the middle of
August,  1809.   On the  15th  September, a tawny substance,  covered
with a vascular plexus, was observed behind the pupil, and the eye was
extirpated on the 21st.   The cavity  of the globe was half filled with a
morbid growth, of which the consistence and origin are not clearly de-
scribed.  " It seemed to be composed of a yellow coloured coagulable
lymph streaked with black, and  to have originated from the inner part
of the sclerotica, for the choroid coat was ascertained, by  dissection, to
quit the sclerotica and pass on the inner side of the tumour."   In this
patient, who was supposed to have recovered,  unpleasant symptoms
subsequently  occurred, and the following particulars of her state were
noted on the 26th of February, 1811.  " Frequent giddiness; pain of
the head shooting into the left orbit, from which there is a considerable
discharge; a tumour on the eye-lid, several tumours in the breast, three
on one side of the abdomen, and  one on the other, one at  the scrobicu-
lus cordis, and another at the bend  of the elbow; shortness of breath,
cough, great pain in the  right kidney."*   The origin  of the affection in
the interior of the globe, its first  appearance behind  the pupil, its rapid
growth, and  the subsequent formation of secondary tumours in various
situations, prove  this to have been fungus haematodes.
   In  another case, which I have  already quoted,  (see page 645,) where
disease commenced at  the age  of  seventy-one, and six years before
the globe was extirpated,  I consider that the disease was not fungus
haematodes.   The details of a third  case, in which disease commenced
at  the age  of sixty-six, and  ended fatally  at seventy-four, are too
scanty  to enable us to form any  satisfactory  conclusion respecting
the exact nature  of the affection.  (Lib.  cit. p. 153.)  The external ap-
pearance is shown in plate 3, which exhibits an enormous red fungous
mass, with  tubercular  prominences and  fissures projecting between
the lids.                           .            ,             .  ,
   Effusion of lymph from inflammation consequent on injury.—A.  deep-
seated yellow shining opacity, which is sometimes seen in the pupil, after
the internal inflammation consequent on penetrating wounds of the globe,
cannot be distinguished by its appearance from the medullary fungus m

   * Treatise on some Practical  Points, Sfc, p. 147-150. 217.   The appearance of the
pupiSe the operation, and a  section ot the globe after its ext.rpat.on, are represented
in plate ii. fig- 3 and 4. 
660
FUNGUS HAEMATODES OF THE EYE.
the same situation.  A boy, about ten years old, came under my care
at St. Bartholomew's Hospital, a year ago, in consequence of a wound
in the eye received three or four days previously, for which nothing had
been done.  The point of a table fork, which had been thrown at him
by his sister, had passed through the upper eye-lid and the cornea.  The
eye was  inflamed  and painful, and  the  pupil was  occupied by a thin
greyish film, which I  supposed, on the  first cursory  inspection, to be
opacity of the lens  caused by the accident.  The  use of  leeches and
other antiphlogistic measures lessened the inflammation and removed
the opacity from the pupil.  The  inflammation however recurred, and
soon after a bright  yellow appearance was seen, which  gradually ex-
tended over the whole fundus of the globe.   The iris was changed in
colour, the pupil fixed in the middle state and clear; vision  extinct.  In
a short time, the globe felt soft and began to shrink, and  atrophy was
considerably  advanced, when the  lens became opaque and completely
concealed the change in the back of the eye; the globe became com-
pletely atrophic.
   " A young lady," says  Mr. Travers, " was brought to town  from
Northamptonshire, in  whom it was so strongly marked, viz. the fawn-
coloured resplendent surface with red vessels arborescent upon it, that I
should certainly have  considered  it the nascent  malignant disease, but
for the circumstance of its having followed a wound with a pair of fine
scissors a fortnight before.  The instrument had passed between the
margin of the iris and the  ciliary body obliquely.  Deep-seated inflam-
mation ensued, and blindness, after three days, became complete.  The
lens remained transparent,  so as to permit the observation of the appear-
ances described for months.  At length a cataract with a constricted
pupil ensued  upon the chronic inflammation of the iris, and  the eye-ball,
which had never  enlarged, gradually shrunk."   (Medico-chirurgical
Transactions, vol. xv.  p. 237.)
   Cases, in which a bright yellow or greenish yellow appearance has
been seen in the interior of the globe after accidents, have been recorded
by Messrs. Mackenzie (Practical  Treatise, ed. 3, p. 607,) and Arnott,
(London Medical Gazette, vol.  xxiv. p. 21.)  In the latter instance, at
the bottom of the eye, a yellow substance was observed, over the sur-
face of which a number of the most  delicate red vessels could be seen
running.
   The origin of the affection in a  serious injury, the preceding and ac-
companying  inflammation, the circumstances of the globe never being
enlarged and soon passing  into the opposite state of atrophic diminution,
will sufficiently distinguish this bright yellow discolouration  which is
probably caused by effusion of lymph, the consequence of inflammation,
from the change in the pupil caused by fungus haematodes.
   Effusion of ptis from  spontaneous internal inflammation.—Mr.
Mackenzie has related a case of acute internal inflammation,  proceed-
ing to suppuration, in which  the appearances were so exactly similar
to those  of the medullary fungus, that the operation  of removing the
eye was  recommended.   The  patient,  eleven years  of age, was° ad-
mitted at the Glasgow Eye Infirmary on September 27, 1832, with an
inflammation of the eye, which had existed  ten days.  Four days be-
fore its commencement he had been exposed to a storm of thunder and 
FUNGUS HAEMATODES OF THE EYE.
661
lightning, and much frightened, being attacked immediately afterwards
with pain in the right  side of the head.  The conjunctiva and sclero-
tica were injected, the cornea hazy, the pupil dilated and fixed, the iris
changed from bluish grey to yellowish brown, the  anterior chamber
enlarged; Vision extinct;  a tawny appearance in the fundus of the eye,
exactly similar to  that in the incipient stage of medullary fungus.   Mr.
Mackenzie and his colleagues recommended extirpation of  the eye, to
which the mother would not consent; calomel and opium  were admin-
istered.  On November  10, the  external redness had increased; the
eye-ball was enlarged; the lens projected  against the cornea, and there
was a bulging towards the internal canthus.  The eye-ball  continued
to enlarge,  so that the lids could  not be brought together;  the promi-
nent part gave way on December 31, and a quantity of thick purulent
matter was discharged.  The  eye subsequently  became atrophic.
   In acute internal inflammation with suppuration, the inflammatory
symptoms are violent from the  first.  In fungus haematodes, the change
of colour in the pupil is unattended with  vascular disturbance  or pain
for weeks or months.   When at  last the globe suffers from distention,
the redness and other inflammatory symptoms are comparatively mild.
   Change  of structure in  the vitreous humour.—A singular case of
such change, in which  the appearance in the pupil could not be dis-
tinguished  from  that of  fungus  haematodes, is  mentioned in Chapter
XIX. p. 469.
   Yellow appearance  in the pupil  of unknown seat and nature.—In
other cases, where the nature and seat of the affection  has not been
ascertained, a brilliant discolouration has been seen in the back of the
globe, and the disease has been considered fungus haematodes.   The
affection after some  time has  become  stationary;  the eye has not in-
flamed or  enlarged as in fungus hsematodes, nor  has  the crystalline
become opaque or been protruded;  on the contrary, atrophy has taken
place.  Examples of this kind  came under my observation at the Lon-
don Ophthalmic Infirmary;  and  Mr. Travers communicates his expe-
rience on the same subject in the  following passage.  " I  have since
seen several cases of a convex (?) and permanently dilated pupil, with
a deep-seated opacity of a splendid yellow tint in children, and doubting
from the preceding history, and  the child's freedom from  indisposition,
that such appearances indicated  a  malignant disease, I  have abstained
from operating.   To  my surprise, the  appearances have  continued
stationary  for years, unaccompanied with any  disorder of the  health.
One, a child of four years old, I have  very recently examined, having
seen it at  intervals  during that period, since the  first  notice of the
disease at  the a^e of  three months.  I can  discover no difference  in
the appearance of the eye at this time, from that which it then assumed.
The bright yellow tint occupies  the temporal hemisphere of the  globe,
supposing  it were bisected in  a vertical direction; the figure of the
globe is slightly conoidal, the  pupil much dilated,  as if from pressure,
not perfectly circular, and  its  edge apparently everted, forming  a nar-
row white line, while small  detached flakes of the pigment  lie  behind
it next the lens.   The pupil of the other  eye is constricted, and closed
by an opaque capsule.  The child is well  grown and in perfect health."
(Lib. cit. p. 203,  204.) 
662
FUNGUS HAEMATODES OF THE EYE.
   On an another occasion, (Medico-chirurgical Transactions, vol. xv.
 p. 235, 336,) Mr. Travers observes, in  reference to the same subject,
 that "the peculiar metallo-lustrous or tapetum-like  appearance of the
 fundus of the eye is not diagnostic:  this is a  fact highly important to
 be known.  I have seen several cases, in which that appearance was
 stationary, and the eye-ball dwindled, which  might therefore fairly be
 presumed not to have been instances of malignant disease.  It so hap-
 pened, however, that long alterative courses of mercury, or protracted
 salivations, had been used in these cases, and the fact was consequently
 open to another explanation, viz. that they were examples of malignant
 disease, which had been arrested by this treatment.  That the appear-
 ance I allude to is very analogous to that of the  medullary tumour,
 wTill be inferred, when I inform the society that, (in the case of a lady
 who several years since, recovered with the loss of sight, but is still in
 perfect health,) at a consultation, including some eminent  members of
 the profession, the  extirpation of the organ  was  over-ruled by one
 dissentient, although I had sat down to perform  it on two several
 occasions."
   Von Ammon has represented, in several figures, the successive stages
 of a disease in the eye-ball, bearing all the characters of fungus haema-
 todes  strongly marked.   After a certain time the vascularity abated,
 and the enlargement began to subside.   The  globe  gradually shrunk,
 and was in a state of complete atrophy at the  end of six years.  (Kli-
 nische Darsteliungen, pt.  i. tab. 21, fig. 1—10.)
   We cannot establish the diagnosis between  such cases as those now
 described, and  true  fungus haematodes  in  its  early stage; though we
 cannot but believe that they are essentially different.   The stationary
 condition of the former, with the absence of enlargement and inflamma-
 tion of the globe, will sufficiently distinguish them from the malignant
 disease in the second period.
   The opaque substance growing in the situation of the vitreous humour
 in the  medullary  disease,  presents an appearance so  totally different
 from  the simple discolouration of the very back of the globe in  the
 amaurotic cat's eye, and from the slight semi-transparent greenish and
 greyish appearance behind the pupil in glaucoma, which is lost sight of
 in looking at the eye laterally, that the disorders  could not be con-
 founded, even if the  ages at which they respectively occur did not suf-
 ficiently distinguish them.
   The  colour and situation  of the opacity distinguish  cataract from
 fungus haematodes.  When opacity of the lens  supervenes on the latter
 affection, the nature  of the case is clearly pointed out by the preceding
 development of  the fungous growth behind the lens, by the protrusion
 of the latter, with the  iris, against the  cornea, by the concomitant
 inflammation, and  by the dull yellowish or amber tint of the part, which
 forms a strong contrast to the pure white of simple cataract  in chil-
 dren.
   Treatment.—This disease has been, generally considered as intracta-
 ble as  cancer, and equally, or rather more, destructive.   External and
internal remedies may relieve particular symptoms and  palliate suffer-
ing, but they have little  effect  on the progress  of the disorder, which
proceeds usually to the destruction of the organ,  and ultimately of  life
itself. 
FUNGUS HiEMATODES OF THE EYE.
663
  The practical question of principal importance  is, whether extirpa-
tion of the globe is advisable; and if so, at what period it ought to be
undertaken.  Our present experience is very discouraging, and leads to
the inference that the operation, even in an early stage, is unavailing.
  Mr. Wardrop extirpated the globe in an infant twenty-seven months
old, in whom the disease had begun at the age of twenty months, and
had not, at the  time  of operating, made its way through the front of
the eye.  The optic nerve was surrounded by a  mass of disease, which
was divided with the nerve in the operation: the part left behind could
be felt passing into the foramen opticum.  The child died in twenty-five
days with symptoms of diseased brain, and reproduction of  disease in
the orbit; the sight of the opposite eye having become imperfect a few
days  before death.   Small deposites of soft matter were found on both
surfaces of the  cranium, and under the arachnoid coat.   From the dis-
eased mass filling the orbit, the optic nerve proceeded through the optic
foramen, and then  was lost in a medullary tumour as  large  as a hen's
egg, extending  into the brain towards the thalamus  nervi optici of the
affected side, from which it was separated by a cavity containing black
blood.*
   " In all those cases," says Mr. Wardrop, " in which I have removed
the eye-ball, and in those, the  history of  which I have  been able to
learn, where the operation has been resorted to, it has been attended
with the  same  unfortunate failure, excepting in one doubtful  case—[an
example  probably  of melanosis;] and even in this, as only ten months
have  elapsed since it was performed, we  cannot speak  of  its  effects
with certainty."   He adds;  " but as we know of  no  instance of the
operation being performed at a very early period  of the  disease, or in
any case where the  optic nerve was found in  a healthy state, there is
still room to hope  for success under such  circumstances.  It is an ex-
periment, at all events, which well merits trial;  and were I in any case
to be  assured of the  existence of the disease in the early stage, I would
have  no hesitation in urging  the performance of the operation.  Past
experience proves the impropriety of attempting  any operation, when
the disease has advanced so far that the posterior chamber is filled with
the diseased growth.  An operation at this period has, in  many instances,
alleviated the patient's sufferings, but  I have  no hesitation in  saying,
that it has, also, in many cases, hastened  the patient's death."f
   In  the  following  passage,  Mr. Travers bears  a similar  testimony,
from  his own experience, to  the constant failure of the operation.  " I
have  extirpated the  eye  affected with  medullary  cancer in several in-
stances ;  but I  am not acquainted with any case  in which the  patient,
who has survived two years, has not been revisited by the disease."J
   In the nineteenth volume of the  Edinburgh  Medical  and Surgical
Journal, Mr. Wishart has published a case of fungus hcematodes of the
eye-ball,  cured by  extirpation of the eye$

  * Lib. cit. case  ii. p. 35__40.  The appearance of the extirpated eye (which  has been
already described at"page 652) is represented in plate ii. fig. 1; and that of the united or-
bital and cranial tumours, in a figure inserted in page 40
  t Lib cit p 90__92.           t Medico-Chir urgical  transactions, vol. xv. p. MS9.
  § Article vii. p. 51—55. 
661
FUNGUS H.EMATODES OF THE EYE.
  The patient, a  boy nine years old was seen by Mr. W. on the 12th of May. 1821.
The left eye was dull, and presented a  general turbid appearance:  the cornea was
transparent, but numerous vessels passed into it over the sclerotica.   The pupil was
moderately dilated and fixed; its margin slightly serrated.  In the posterior chamber
an opacity was observed, resembling a yellow dusky membrane, lining the whole pos-
terior part of the eye-ball, and perceived more distinctly when  the  eye was viewed
laterally.  Vision  was nearly extinct;  lachrymation and pain were  produced by ex-
posure to light; and there was occasional shooting pain in the upper edge of the orbit.
The pulse was natural and the general  health good.  Two months previously a blow
had been received on  the eye. He felt no uneasiness the same afternoon, but great
pain came on the next morning, and vision was almost entirely lost.   The effects of
the injury were apparently removed by antiphlogistic treatment, and  he returned to
school.  About the 10th of May the eye again became inflamed and painful: leeches
were twice applied:  opening medicine was administered, and afterwards a grain of
calomel night and  morning.  19th of May: The mouth is considerably affected.  The
red vessels are  large  and numerous, especially at the upper part of the eye-ball.
Pain has been experienced in the eye and orbit: there is slight effusion of fluid in the
anterior chamber.  13th of June: The pupil is smaller, and its edge more irregular.
The opaque substance has  advanced close to the iris, which is nearly in contact with
the cornea.  The  intolerance of light continues, but pain is gone, and the health is
good.  3rd July:  The inflammation, intolerance  of light,  and  pain  are increased;
and febrile symptoms have come on. Blood  was taken by venesection and leeches,
and aperients were administered, 9th of July: The inflammation is less, but the disease
increases. The iris is in contact with the cornea, and the pupil completely closed by the
opaque matter.  The removal of the globe, which had been previously determined on,
was performed this day. The recovery was rapid and favourable, and the patient conti-
nued perfectly well at the end of eighteen  months.  The appearance presented in a
section of the globe is said  to have been precisely similar to that delineated in a figure
of Mr. Wardrop's work, (p. 193.)   " The origin of the disease in the retina was finely
and satisfactorily illustrated.   The optic nerve was quite healthy.  The sclerotica and
choroid coats were of natural  texture.  The cornea  was a little softer than natural, and
not perfectly  transparent.  The lens was pushed  into contact with  it, and seemed
6maller than natural and flattened.   The diseased mass, into which the retina had been
converted, connected only to  the optic nerve, floated  loosely in various  folds, occupying
both chambers of the  eye.  The eye-ball did not appear to be at all enlarged."

   When the result of a single case seems to contradict the  uniform tenor
of experience in  all other  instances, we naturally examine the details
closely, to ascertain whether the  exception is real or only  apparent.   If
the narrative of Mr. Wishart be thus scrutinized, a doubt arises whether
the disease described by him was fungus haematodes, and  the want of a
precise description  of the morbid  appearances leaves us in the dark on
this subject.   In its origin from the violent inflammation consequent on
injury, and in the  circumstance of the globe not having been enlarged,
the case is  more analogous to  those  instances of  brilliant deep-seated
discolouration following serious accidents,  than to the unequivocal ex-
amples of the medullary fungus.
   Professor Panizza has recorded a case in which the eye  was removed
at a very early period of the  disease;  he   says,  that the  success was
perfect, (see page 654.)   The operation was performed in December,
1822, and his work bears the  date of 1826.   He gives no particulars;
not even mentioning whether the child was alive when he wrote.   The
state of parts found on  examination of  this eye, was so different from
what has been noticed in any  other instance, that a doubt may be enter-
tained whether the  disease was fungus haematodes.
  Our present experience warrants the conclusion,  that the operation of
extirpation  would  not be justifiable except in a very early  period of the 
FUNGUS HAEMATODES OF THE EYE.
665
 affection; and that the result of the case even then would probablv be
 fatal.                                                           '
   Mr. Middlemore considers the disease to be an affection of the retina,
 confined in the first instance to that tunic, and strictly local:  he there-
 fore recommends removal  of those  parts only which are implicated in
 the mischief, as soon as the disease is detected, observing that they can-
 not be removed too soon.   He states that  " Mr.  Wardrop has recom-
 mended the excision of the entire organ, as being most likely to ensure
 the patient's safety, on the  presumption, probably, that a portion of the
 optic nerve ought to be removed as well as the retina;  an operation so
 painful and so hazardous to the patient, (at that period  of life, at least,
 when, to render it at all useful, it must be performed,) and so revolting
 to the feelings of friends, is not likely to be permitted; and as so exten-
 sive a removal of parts is, in many instances, unnecessary, I have thought
 it advisable to recommend merely a section of the cornea, (rather larger
 than that usually made in the operation of extraction,) and the evacu-
 ation of the humours,  and the choroid and  the retina ; or, if the fungus
 be large and the cornea be small, the whole of it, (that is, the cornea,)
 and a portion  of the  surrounding  sclerotica, may be taken away; an
 operation  so  little painful,  and not at  all dangerous, and by a skilful
 surgeon so easily performed, that  it would require, in  the majority of
 instances,  very little rhetoric to recommend it to the majority of parents,
 who would at once refuse to allow the extirpation of the  entire organ.
 It is only necessary to state to them that it will be less painful, danger-
 ous, and disfiguring to their infant, than the continuance of the disease,
 to obtain generally their consent  to the performance of an operation,
 which, at the outset of the  malady, has all the advantages without the
 horrors of that usually had recourse to; and,  if. performed at a later
 period, does not preclude the extirpation of the eye-ball, if that measure
 be deemed necessary."*
   It remains for future experience to decide on the merits of  this  pro-
 posal, which had not been reduced to practice at the time of its publica-
 tion, and has not so far as I know, been tried  since.  One objection to
 it is, that in some cases of the disease, the morbid growth has been found
 exterior to the globe, as well as within its cavity, and that the optic nerve
 has been diseased, even in incipient cases.  Again, in operations on ma-
 lignant diseases, it  is an imperative rule to  remove not only all the al-
 tered structures, but some of the surrounding healthy parts; unless this
 is satisfactorily accomplished, the patient has not a chance of safety.
 How can we feel satisfied on this important  point  in such a mode of
 proceeding 1
   The bare proposal of cutting out the eye is repugnant and almost re-
 volting  to  the feelings  of the surgeon and the patient's friends; and we
 could not think of subjecting a child to this frightful operation unless
 compelled  by necessity, and encouraged by the certain prospect of bene-
 fit; unless  fully convinced  that  the painful mutilation will not only re-
 move or prevent suffering, but be effectual in preserving life.   The ope-
ration is not, however,  dangerous according to my experience.  On the

  • Observations on Fungus  Hamatodes of the Eye.  London Medical Gazette, vol.  *i. p.
914.
       81 
666
FUNGUS HAEMATODES OF THE EYE.
 other hand, to cut away the front of the globe, and scoop out its con-
 tents, does not  appear to me so completely free from all risk  of un-
 pleasant consequences, so slight and unobjectionable  a proceeding, as
 Mr. Middlemore represents.
   The strong objections to an operation in cases of fungus haematodes,
 are, the circumstance of its having failed to save life in most, if not all,
 the instances in which it has been performed, and the spontaneous ces-
 sation of  disease in many patients, in whom the eye had  presented ap-
 pearances not distinguishable from those of fungus haematodes.   (See
 page 659 to 663.)  If we are not warranted in concluding that an ope-
 ration is absolutely hopeless in all cases of fungus haematodes affecting
 the eye-ball, we could consider it justifiable only in a very early period
 of the affection.  Complete removal of the orbital contents seems to me
 the only proceeding of this kind that offers even a chance of permanent
 cure, while, in respect to  pain and  other immediate results, as  well
 as to danger, it is not much more objectionable than the  minor opera-
 tion.
   Mr. Travers recommends a surgical proceeding in order to discover
 the nature of the affection, in cases where that may be doubtful. Speak-
 ing of fungus haematodes,he says, "deeply-seated disorganizing inflam-
 mation is very liable  to be mistaken for this disease.   The deep trans-
 verse section of the globe  from the outer to the inner canthus, so as
 completely to evacuate its contents, and sink the enlarged eye-ball, is an
 efficient remedy in this case, which is one attended with great disfigure-
 ment from protrusion, excessive vascularity of the conjunctiva, and
 agonizing sympathetic hemicrania on the same side with the diseased
 eye.  In the medullary cancer this proceeding is of no avail.   But, if a
 doubt of the nature of the case exist, it should be practised.  In the ma-
 lignant disease the globe remains firm, and the section is followed by a
 small discharge of blood and black pigment or coagula stained with it;
 but if a discoloured fluid escapes, and  the  globe  collapses, the disease
 is not malignant, and  the  cure  is  complete."   (Medico-Chirurgical
 Transactions, vol. xv. p. 239.)   I consider this severe proceeding alto-
 gether inapplicable.   In suppuration of the globe, which I never saw in
 a  child, and which can never be confounded with fungus haematodes,
 relief may be afforded by opening the cornea; but where can  matter be
 confined, to require for its evacuation a section of "the cornea, iris, ci-
 liary ring, and some extent of the sclerotica?"  (Synopsis of Diseases
 of the Eye, p. 306.)   The  cases  of deep-seated discolouration  in  the
 pupil resembling  that caused by fungus haematodes, are  not  attended
 with excessive  vascularity, protrusion, or disfigurement;  while in  the
 latter assemblage of circumstances,  the  deep  incision  which  Mr.
 Travers recommends so freely, could be neither necessary nor advan-
 tageous.
  If the  result of experience,  and the other considerations now  ex-
plained, should  lead us to  think the operation of  extirpation unadvisa-
ble in cases of fungus  haematodes, we must be contented with palliative
 measures, or with a trial of mercury.   Occasional attacks of inflamma-
tion may require leeches, lotions,  fomentations, and other antiphlogistic
treatment.  In the stage of ulceration, narcotics, especially opium, will
be required both internally and  externally.   For  the latter  purpose, 
FUNGUS HiEMATODES OF THE EYE.
667
 the liquor opii sedativus, diluted or otherwise, has  appeared to me  the
 most advantageous.  I have found it completely effectual in controlling
 the severe pain attendant on the sloughing and ulceration of the fungous
 stage.  For correcting the fetor, which is often very offensive, the chlo-
 rides may be used in the form of lotion, but  not in immediate contact
 with  the ulcerated surface.
    Use of mercury.—As the changes behind the pupil, which belong to
 fungus haematodes, are also found in  other affections not of malignant
 character, we conclude that the internal parts of the  eye are subject to
 disease, which, although in  our present state of knowledge not  distin-
 guishable by external  appearance, are quite  dissimilar  in their nature.
 Hence we may properly make trial of such means as are found  effica-
 cious under other circumstances.  Among these mercury holds the fore-
 most rank.  If the morbid appearance in the  fundus of the globe  be  the
 result of common or of  scrofulous inflammation, this remedy may pro-
 bably put a stop  to the mischief; and  it is  worth  while to give it a fair
 trial, even in the fungoid disease.  The milder preparations should be
 selected, and they should be administered in small doses so  as  to avoid
 all risk, of injuring the health: the quantity may be  gradually increased
 if  the patient bears it well.   With the mercurial plan we should  com-
 bine a nutritious but not stimulating diet, and such  other means,  as  the
 local or general symptoms may require.   In the following case the dis-
 ease, which was seated in the retina, and had all the characters of fun-
 gus haematodes, was completely arrested by this treatment.
   Case.—In October, 1835, it was accidentally discovered that a boy, nearly six years
 old, who had always enjoyed excellent health, and  who had at the time every  appear-
 ance of health and strength,  had  lost the sight of the right eye.  He had felt no un-
 easiness in the part, nor had any change in the appearance of the organ been observed
 by  his parents.  I saw him at this time,  when the only visible alteration was a light
 yellow discolouration of the pupil, not very readily  discovered.  After the application
 of belladonna, a morbid growth was seen rising up in the back of the  globe, with tuber-
 cular irregularity of surface, and red vessels ramifying on it.  Mr. Travers, who was
 consulted in the case, agreed with me in thinking it an unequivocal example of fungus
 hsematodes;  indeed, no other opinion could be entertained. A mild mercurial course
 was directed, and followed up for  several months.  In less than a  year the lens and
 capsule had become opaque, the eye presenting in other respects a natural appearance.
 He was attacked with violent pain in the head in December, 1836,  the case being re-
 garded as acute inflammation of the membianesof the brain.  Free  leeching, blisters,
 and mercurial medicines were the remedies employed, without any apparent effect for
 three weeks: the symptoms gradually abated, and the patient  left his room at the end
 of six weeks. He continued  well for three months, when he had influenza, and suf-
 fered severely in the head.   No violent seizure occurred subsequently until the time
 of death, although headach was occasionally  experienced.  No farther  change took
 place in the eye.   Mercurial powders were  given occasionally until a year before
 death, when they were discontinued on account of his being in perfect health.  A vio-
 lent headach, which  was experienced ten days  before the fatal event, was quickly
 removed by an active aperient. On the day before  he died he  was examined by an in-
 telligent and well informed surgeon, who told his father that the eye was so little dis-
 figured, and the health so good, that there would be no risk in sending him  to school.
 The following day (May 30, 1840,) he had a  little  headach after breakfast: the pain
 increased, and he seemed  inclined to doze. The surgeon who saw him in the middle
of the day found him feverish, faint, and incoherent.   The bowels were freely relieved.
At four o'clock the pain was very  severe, particularly at the back of the neck, and  the
patient urgently requested that very cold water might be  poured on the head.   He
died at five o'clock.              #
  The  left lateral ventricle contained two ounces of coagulated blood; at  its lower 
668
FUNGUS HjEMATODES OF THE EYE.
part the cerebral substance was soft and of reddish colour.  In this softened part there
was a firm oval tumour about an inch in length: it was a tough but thin cyst, with
dark contents, like coagulated  blood.   The right ventricle  contained  blood, which
seemed to have entered from the left side; and the cerebral substance was pulpy and
discoloured at its lower part.  There was considerable effusion of blood at the basis of
the brain, between the arachnoid and pia mater.  The form and size of the affected
eye, and the  sclerotica were normal: the choroid was of reddish colour.  The whole
retina was thickened and opaque.  In its posterior portion, around the insertion of the
optic nerve, there were six or  eight white tubercles of cartilaginous.hardness: the
largest wag equal iq size to a radish seed.  The vitreous humour was fluid ;  the lens
and capsule opaque; the iris and uvea natural.  The optic nerve was smaller  from the
eye to the point of junction, but not otherwise altered.
   The use of mercury in these  affections has been strongly  recom-
mended by Mr. Tyrrell.   He details two cases of fungus haematodes,
in an infant and in a boy three years and a half old, in which the pro-
gress of the complaint was checked, and a decided diminution of all the
symptoms ensued  under  the gentle  but long-continued use of mercury.
The complaint  was ultimately fatal  in both cases.   (Vol.  ii.  p.  165
and 172.)
   In two adult patients, affected with amaurosis and with a deep  yellow
discolouration behind the pupil, similar to that of fungus haematodes, the
disease  ceased under  the action of mercury, and  the eyes remained
shrunk and amaurotic.   (Vol.  ii.  p. 179 and  182.)
   Mr. Tyrrell states farther  that he has "  known several other cases
In children, in whom the  disease has  subsided, and  the globe has be-
come  atrophized, under steady mercurial treatment, with great attention
to the oondition of the general health; and, in all cases, the cure has
been very gradual; in very few  of these cases has a full  mercurial in-
fluence  been established, or  has the remedy  even affected the  mouth;
for it has not  been pushed, after a decided change has been perceived
in the local disease; and this has generally taken place before mercurial
actioq could be detected  by the mouth."   (Vol. ii, p. 185.)
   A few cases are subjoined, to  illustrate particularly the  symptoms,
progress, effects, and character of  the disorder.
   Case I.—Fungus hatmalodes in an infant of one month.-^-" James  Taylor, one
month old, a  fine healthy-looking child  of robust parents, has a peculiar shining ap-
pearanpe of the right eye, which I noticed  whilst examining  the eyes, in consequence
of an attack of purulent ophthalmia: on viewing it attentively, it seemed to be situated
at the bottom of the eye, to occupy only a  small space, and to yield an extremely bril-
liant appearance; the iris was sluggish  in its action, and the pupil  rather large; but
the sclerotica was not discoloured, nor was the eye-ball at all altered  in figure.   The
mother of the infant said she had had many children before, all of whom were healthy,
and that her  baby only wanted my advice for the running of the eyes; and certainly,
judging from appearances, no  child could  be in better health, (with the exception of
the ophthalmia,) or in possession of a stronger constitution.  I could not convince the
woman of the importance of her child's disease, and the propriety of a trifling opera-
tion  for its removal,  and she  accordingly left me under the belief that I wished to
make her child the subject of some  extraordinary experiment." In  the course of a
fortnight the child died of small-pox, and was not examined.*
   As  the operation alluded to is that described at page 665, consisting
in a large opening of the cornea, or its entire removal with  part of the
sclerotica,  and the subsequent scooping out of the contents of the globe,

  * Observations on Fungus Haematodes of the Eye, by R. Middlemore.  hondon Medical
Gazette, vol. vi. p. 878. 
FUNGUS HiEMATODES OF THE EYE.
669
it may not be thought by every one so trifling as it seems to Mr. Mid-
dlemore.   Some may deem it  a  serious proceeding, and  one of doubt-
ful  propriety.   As it has not yet  been tried, its employment in any case
may not improperly be called  experimental.   The  refusal of  the pro-
position  by the parent, in the  foregoing case, does not seem to me to
have been  altogether unreasonable.

  Case II.—Fungus hcematodes of the right eye, with tumours of the scalp and tem-
ple, and protrusion of the left eye.  Extensive medullary deposite between the bone
and dura mater at the base of the skull;  disease of the ribs, liver, kidnies, and me-
senteric glands.—" William Foreman, six months old, has several  small slightly
elastic  tumours beneath the scalp, unattended with cutaneous discolouration; con-
siderable enlargement at the front and upper  part of each  temple, and protrusion of
each eye-ball.   The child is generally  drowsy, and becomes qpite comatose when the
temporal tumours  are compressed.   On examining the eyes, that on the left side ap-
peared healthy, although evidently pushed forwards by some substance behind it;  the
pupil of the right eye  was exceedingly large, the iris inactive, and the crystalline
lens slightly opaque, and pressed against the neural [concave] surface of the cornea
by  a yellow shining  substance, of a rugged uneven appearance; the sclerotica was
generally of a dark-brown colour,  and  irregularly enlarged; the cornea attenuated,
and so  extended as to appear twice the  size of that in the opposite organ.  The mother
says that her former children were quite healthy, and that the patient in question was
also a fine strong  child for  many weeks after  its birth ; she does not remember that
the infant has received any blow on the eye,  but had remarked a peculiarity of ap-
pearance, as if something bright was in the eye, (occasioned, as 6he thought, by the
sun,) before it enlarged, and long before  the  appearance of the  swellings  about the
head;  she further stated, that when four  months  old, it  had a fit in  the night,  and
since that time has  been getting gradually more drowsy, the eyes have  been pro-
truding, and the tumours  of the scalp have been  increasing in size, being prior to
that period so small as almost to escape notice. In a few days the attenuated  cornea
gave way, allowing the evacuation  of the lens, (which  was  slightly diminished in
size, and  somewhat opaque,) and  the  protrusion  of a soft red  fungus, which occa-
sionally bled.  Although the patient's sufferings were by  this means slightly relieved,
the irritation and discharge, joined to the occasional hemorrhage, quickly exhausted
its  vital energies."
  After death, nodules of medullary  structure, somewhat firmer than brain,  white
and homogeneous throughout, were found, connected by cellular  membrane  to the
pericranium.  "At the back of the orbit  on each side, and covered by, or rather ex-
ternal  to, the dura mater, was a reddish medullary  mass, in some places of a deep-red
colour, surrounded by an irregularly formed circle of a fainter appearance; the orbitar
plate of the frontal  bone was partially absorbed, and  the remainder of it altered, as
though partaking of the same morbid character as the surrounding  parts.  The bulk
of  the  tumour in  each  orbit was about the size of  a very small orange, connected by
a transverse portion of the same diseased structure, which extended backwards,  still
covered by the dura mater, (which was raised from the  bones,) as far as the anterior
clinoid processes;  and on the right  side to the petrous portion of the temporal bone.
I could discover no trace of the optic nerve of the right side, except where it  was
united to the sclerotica; it was then a soft and reddish mass, at the ocular extremity
of  which  was a similar substance,  slightly altered by incipient mortification.  The
sclerotic coat appeared healthy, but the major part of its contents had sloughed away
a few  days  before ;  indeed no part of the eye-ball remained, with the exception of
the ruptured and attenuated cornea,  the sclerotica in many places thin and sacculated,
and the medullary and partially mortified mass attached to the extremity of the optic
nerve.
  "The  heart, lungs, and pleura were healthy; many of the ribs on each side, as far
as their cartilages, were red and swollen,  and when cut into were found soft and pulpy.
evidently approaching to the state of medullary change, which has just been described
as affecting the interior of the eye-ball and the bones of the orbit.
  "The  liver was enlarged, and converted in  many places info a medullary mass of a
pale red colour; both kidneys had undergone  the  same kind of alteration, and were
greatly enlarged; the mesenteric glands,  although somewhat augmented in size, had 
670
FUNGUS HiEMATODES OF THE EYE.
 not  experienced  much change of structure;  the other viscera were  moderately
 healthy."  (Mr. Middlemore, lib. cit. 679.)
   Case III.—Fungus haematodes in the left eye  in a child three years old.  Extir-
pation of the eye and return of disease—the united portion of the optic nerves con-
 verted into a medullary tumour.—A female child, three  years old, was said to have
 received a blow on the eye a fortnight before Mr. Wardrop saw her; but the eye had
 previously appeared sore and painful.   " On examining the eye,"  says Mr. Wardrop,
 " it was slightly inflamed, and had the  peculiar expression of a blind eye.  But what
 appeared remarkable was, that the pupil was much dilated, and that behind it, and at
 the very bottom of the posterior chamber, there was a  tawny,  yellow-coloured, flaky-
 looking mass, the surface of which was unequal,  and  formed  into folds, and a large
 blood-vessel, which I supposed to be the central artery of the retina, was seen running
 across the pupil.  The anterior chamber  had lost its natural transparency, apparently
 from the aqueous humour being slightly tinged with blood."   The eye was inflamed
 and painful.  At  the e§d of eight  months, the new growth in the eye  had moved for-
 wards, so as to  be on the same plane with the iris; it appeared like a layer of lymph.
 The eye-ball was irregularly swollen,  the sclerotic dark-blue, and the pupil exces-
 sively dilated.  In five or  six months more, the globe was so swelled that the eye-lid
 could not cover it;  the boundary between  the cornea  and sclerotica  was  no longer
 visible; a small spot of purulent matter was observed behind the cornea, which ulce-
 rated, and in  a  few days a small  tumour rose out from the ulceration, which  bled
freely.  The globe was now extirpated.
   The whole anterior chamber was destroyed, and occupied by a soft fungous mass,
 having no defined structure.   The optic nerve was enlarged, firmer and darker than
 usual, and showed no distinction between neurilema and medullary fibres.  The scle-
rotica was unaltered, and separated readily from the choroid; the latter was unusually
red, and could not be separated from the retina; it adhered firmly to a solid substance,
 on the surface  of which  nothing  like nervous expansion could be  detected.   On
 making a vertical section  of the globe, the  posterior chamber was found to be com-
 pletely filled with a solid mass, having  the general appearance  of brain.  Some parts
were pulpy, and easily washed away in water, leaving behind a  filamentous substance,
like loose cellular membrane.   On tearing  the mass, some parts were much harder
and firmer than others, and at one point there were many gritty particles.   The por-
tion of the tumour occupying  the  posterior chamber had  very much the character of
medullary matter; but the anterior portion forming the external fungus, was as soft
as jelly.
   The case went on favourably;  but in six weeks, the  lids began to be elevated, and
pain occurred in the orbit.  The swelling gradually increased, produced by a morbid
growth in the cavity,  which soon  projected beyond the  palpebrae.   A glandular swel-
ling now appeared on the  cheek, in front  of the ear, and  two smaller ones under the
lower jaw.  These swellings, and the orbital tumour gradually  increased, the general
health failed, and death ensued about six months after the operation, having been pre-
ceded by a state of stupor.
   The lateral ventricles contained  between four and five ounces of transparent colour-
less fluid.  The optic thalami were natural.  At the union of the optic  nerves in front
of the sella Turcica, a tumour was formed as large, as  a chestnut.   It was nearly
globular, more yellow than common medullary substance,  a little unequal, but smooth.
On removing a  delicate transparent membrane, which surrounded the  tumour, it was
found to consist of a white pulpy matter.  It soon became softer on exposure to air,
and was readily dissolved in water.  Nothing resembling nerve could  be found in it;
although the optic nerves  were seen entering it at one  extremity, and  passing out at
the other, to go into the foramina optica.  Where  the nerve of the left side had been
divided, in removing the brain, a similar  matter issued from the  divided extremity.
The contents of the orbit were a mass of diseased structure   containing portions of
blood and round masses of soft matter like that of the tumour in the sella Turcica.
The glandular swelling contained  pulpy matter exactly similar to that of the tumour
within the skull.*
   Case IV.—Fungus hamalodes of the eye in an infant; operation of extirpation  ;
relapse of disease and death; various morbid changes in the brain and membranes.—

  * Mr. Wardrop's Observations on Fungus Hcematodes, p. 30—35.   Plate i. fig.  2, and
plate ii. fig. 3. 
FUNGUS HAEMATODES OF THE EYE.
671
 In this case, which was that of a child twenty months old, the progress and symptoms
 nearly resembled those of Case 111.  There was the same brown or yellowish colour
 observed in the bottom of the posterior chamber, with  great dilatation of the pupil.
 The disease had existed seven months  before the globe  underwent change of figure.
 At last, however, it enlarged so that the eye-lids could hardly cover it; the conjunc-
 tiva became inflamed, and the opaque body approached very close to the cornea, having
 the same deep yellow tinge as when it was first observed.  At this time the operation
 was performed.  In removing the ball a firm mass was cut through adhering to the optic
 nerve; and a continuation of it could be felt with the finger passing through the  optic
 foramen.  The dissection of the eye-ball is described at  page 652-3.
   In ten days violent convulsions occurred, but did not return.  A few days after, the
 formation of a tumour in the orbit was apparent.  Twenty-five days after the operation,
 death ensued, having been  preceded  by symptoms of violent cerebral disorder.  Some
 days before death, the vision of the left or sound eye became indistinct.  On  the ex-
 ternal surface of the cranium, there were several circular white spots, and two of deep
 red with the bone rough, the pericranium  thickened and easily separable.  In the dura
 mater and  arachnoid there were morbid  depositions, described at  page 658*  On re-
 moving some of the cerebral substance contiguous to the thalamus of the right optic
 nerve a cavity was brought into view containing a considerable quantity of black blood,
 and a  tumour could be  felt in this cavity, composed of a firm substance, about the
 bulk of a hen's egg, the upper surface  of which formed the bottom of the cavity.  As
 this tumour was firmly connected to  that in the orbits, the parts were removed in one
 mass, and then divided by a perpendicular section.  The cerebral and orbital tumours
 were connected by the  optic nerve.  The posterior part of the former was soft, and
 resembled common brain, but the rest consisted of a reddish vascular mass of firm con-
 sistence, very much like  liver in  appearance.   Nothing  like nerve could be distin-
 guished in  any part of the mass, until it approached the optic foramen, at which  point
 there was an indistinct appearance of nervous structure.  The portion of nerve, con-
 tained  in the bony canal, seemed to have been prevented from enlarging by the con-
 finement of the  bone.  The  tumour  in the orbit  resembled the firmer portion of
 the other.*
   Case V.—Fungus haematodes of the left eye; secondary disease of the brain, ribs,
 and liver.—A boy, six or seven years of age, was under my care at the London  Oph-
 thalmic Infirmary for an affection  of the left eye, attended with a bright yellow ap-
 pearance behind the iris, dilated and fixed pupil, loss of vision, and intolerance of light.
 After some time the crystalline lens  lost its transparency, and the yellow growth was
 concealed; the vessels  of  the conjunctiva  and  sclerotica became turgid.  The  globe
 soon enlarged and distended the lids; the cornea then  ulcerated, and gave issue to a
 bleeding fungus, which increased  rapidly and  soon  projected between  the eye-lids.
 Partial slouchings occurred with copious discharge of fetid ichor.   In the early stage
 there was little suffering: severe pain was experienced,  with irritability and impaired
 health, before the  cornea gave way; and these symptoms were much aggravated in
 the ulcerative stage, when ease could only be procured by covering the fungous growth
 with a lotion of the liquor opii sedativus.  The pain was completely controlled by this
 remedy, and regularly recurred within a certain time, if the application was  not re-
 newed.  Febrile  symptoms with delirium came on  three weeks before death, and  it
 was found that the child could not see with the right eye.  The cerebral disturbance
 increased, and death occurred at last rather suddenly.   The fatal  termination took
 place in a few weeks after the appearance of the fungus.
   The arachnoid  and pia mater were somewhat thickened by serous infiltration; thr;
 substance of  the  brain  was soft; and the lateral ventricles contained more than four
 ounces of fluid.
   The fungus  and the orbital contents  formed  one mass of medullary structure, in
 which nothing could be  seen of the normal parts except a trace of one or two muscles,
 the sclerotica, and the  optic nerve.  The latter was  enlarged and  converted into me-
 dullary texture.  The enlargement increased as it  proceeded towards  the thalamus.
 The thalami, corpora striata, pons Varolii,  and  adjacent parts, were so  softened by
 medullary degeneration, that no detailed description of them can be given.  The  right

  * Wardrop, lib. cit. p. 35—40.  Plate ii. fig. I.  The cerebral and orbital  tumours are
represented  in'a small engraving inserted  in page 40. 
672
FUNGUS HiEMATODES OF THE EVE.
 optic nerve  was not diseased;  it was quite  distinct  from the  left.  The mem-
 branes at the basis of the  brain were inflamed,  with partial purulent infiltration.
   The absorbent glands, in the course of the internal mammary vessels, on both sides,
 were enlarged and converted into medullary texture.
   The pleura lining the fourth, fifth, and sixth true ribs on the right side was thickened,
 highly vascular, and raised into a small swelling, which was found to consist of a red-
 dish grey soft medullary deposite.   This growth, arising from the substance of the rib,
 which was much diminished, had made its way through the periosteum.  The interior
 of the other ribs was unnaturally red.   The liver was of a pale yellow colour; the
 other viscera were healthy.*
   Case VI.—Fungus haematodes of the right eye, with extensive disease of the brain.
 —A boy, born of unhealthy parents, (the father being advanced in years with unsound
 viscera, and occasionally suffering from fever; the mother  scrofulous and cachectic)
 was slender, but reached the age of six without much illness.  In the summer of 1818
 he had considerable external ophthalmia  with  headach.   Weakness of sight, redness
 of the conjunctiva, and  dilatation  of the pupil remained in the right eye after this
 attack.   The headach increased, his  strength diminished, and he passed  the winter
 with gradual loss of flesh, diminution of sight in the right eye, and  dilatation of the
 pupil, behind which an opacity was observed.   The motions  of the globe became im-
 paired, and squinting took place.  A surgeon, who saw him  in the spring, pronounced
 the case to be cataract.   Pain  in the head was still severe; vision became more im-
 perfect and  was entirely  lost in August.  Imperfection of sight began to be observed
 in the left eye, which appeared quite  healthy;  this affection increased, and sight was
 lost  by Christmas.   The  right  eye now began to enlarge  and project;  it became
 knotted on the surface, and the cornea was rendered opaque, so as to conceal  the pro-
 gress of the internal  changes.  Feverish symptoms came on with  further loss of
 strength; the boy gradually became taciturn, stupid, and sleepy, and represented, when
 questioned on the subject, that his pain  was seated in the head, not in the eye.  The
 latter in the  mean time enlarged, and the palpebrse became everted  by the swelling
 of the conjunctiva.  Early in February, the cornea, which  had been prominent and
 opaque, gave way, with a copious discharge of bloody fluid  and temporary relief: a
 fungous substance then issued from the opening, and  continued to yield an ichorous
 discharge.  He  was received into the hospital of Pavia in March, 1820, that is, about
 a year and a half after the beginning of the complaint.  At  this time, there projected
 between the lids a tumour equal in  size to a large nut, deep red, with one or two black
 points in the middle, which was fissured, and poured out a sanious ichor.  It was soft
 to the touch, and frequently bled; it appeared to belong to the conjunctiva rather than
 to the globe of the eye.  The other eye was perfectly blind although apparently healthy;
 the boy was deaf and deprived of taste,  taking indifferently sweet or the bitterest fluids;
 he had also lost the power of articulation; for he merely uttered cries in the first three
 days after he came to the hospital, then fell into a  state of coma, which lasted till his
 death on the 29th of March.
   There were no external glandular tumours.  The contents of the thorax and abdo-
 men were healthy,  excepting  the mesenteric glands, which  were enlarged to four or
 six times their natural size, and might have been truly called strumous, both from their
 consistence and the atheromatous substance which  they contained.
  The bones of the cranium were very thin, particularly at the coronal suture.   The
 membranes, and the brain viewed externally, presented the normal appearance, except-
 ing an extraordinary volume transversely in  the situation of the sella Turcica.   The
 ventricles contained between four and five ounces of bloody serum.   A large adven-
 titious growth was developed in the middle and anterior part of the  brain, under the
ventricles.   Its superior surface projected into those cavities, forming a considerable
tumour on each side between the corpus striatum and thalamus nervi optici, pushing
 the fornix and septum lucidum upwards, and separating the  optic thalami  from each
other, so that they were half an inch  apart at the  point where they  are naturally in
 contact.  The morbid  growth occupied below a  large part of the anterior cerebral
lobes, the  union of the optic nerves, the inferior surface of the corpus callosum and
third ventricle, a part of the right  middle lobe, and the  interval between the crura
cerebri.   Its colour differed in different  parts;  it was generally whitish, particularly

  * The morbid parts mentioned in this  case; that is, the contents of the orbit, the diseased
brain, and  the swelled ribs, are preserved in Mr. Langstaff's museum. 
MELANOSIS OF THE EYE.
673
between the optic thalama, where it presented small roundish elevations, in some parts
yellowish, and in others red.   Its consistence  was less firm than that of the brain,
particularly at the basis of the right corpus striatum, where it gave way when touched
with the finger, giving issue to some thin fluid  with portions of soft cerebral matter.
On  a section  it was found to be composed of an inorganic (!) matter, marbled with red
and white.  It seemed to be a fungous degeneration of the  medullary and cineritious
substance of the basis of the corpora striata, of the inferior surface of the third ventricle
and of the parts  near the optic thalami.  The right optic nerve, enveloped in the dis-
eased portion of  the middle cerebral lobe, was enlarged, red,  and very soft: the left
was quite natural.   The united portion  was  expanded to twice its ordinary breadth,
changed into  a soft reddish substance, and firmly adherent to  the dura mater.   The
right optic nerve presented  within the orbit an  enlargement of oval form equal in size
to a small walnut.   It consisted of a reddish  substance, without any trace of nervous
fibres, soft and pultaceous in the centre, firmer at  the circumference, and covered by
the usual fibrous sheath.  The left nerve had a similar enlargement.   On dividing it,
the nerve was found in the centre, of natural size  and colour, while the tumour con-
sisted of a soft caseous matter  deposited between the fibrous sheath and the surface of
the nervous filaments.  The left eye was sound; the right enlarged, changed in struc-
ture, ulcerated, and pushed forwards by morbid deposition in the cellylar substance of
the orbit.  On a section  of the eye, its cavity  was found filled with a very soft, whitish,
and reddish substance, which probably consisted of the retina changed in structure:
for no trace of that membrane could be discovered, although the sclerotica and choroid
could be clearly made out; and the morbid growth was continuous with the anterior
extremity of  the optic nerve.  The nerves of the third pair, pressed  upon  by the
tumour, presented, each  of them, a small oval enlargement near their origin.*
   Malignant growths of  medullary structure may occur in the  orbit as
distinct tumours.   Such cases are related  in Chapter XXV. on diseases
of the orbit.
                   SECTION IV.--MELANOSIS OF THE EYE.

   In this disease a soft adventitious  production is developed within the
globe which it distends and enlarges;  it then makes its way outwards by
gradual absorption of the tunics, and presents a dark livid or black fun-
gous mass, which ulcerates, sloughs, and bleeds. The affection is parti-
cularly characterized by the dark livid colour of the new formation  in
its earliest period, and by its deep sooty blackness in the fungous stage;
hence its name of melanosis (from peXxf, gen. a«a«v<j«-, black.)
   The occurrence of the affection is often ascribed to injury; but it may
appear independently of any external cause; and we are quite unable  to
assign the circumstances, which impress on the disease its peculiar cha-
racter.
   It begins  with inflammation of the eye and pain in the head;  amau-
rosis comes on.   The  globe begins to swell,  and the sclerotica, as far
as can be judged through the  plexus of distended vessels covering it, as-
sumes a dark livid cast.   The lens loses its transparency, and, together
with  the iris, is pushed forwards against the cornea, the latter becoming
dull.   The enlargement of the globe increases, and  deep livid tubercles
show themselves on its circumference at various points.f  The morbid

  * Annotazioni Anatomico-Chirurgiche sul Fungo midoRare delV Occhio, e sulla depres-
sione delta Cateratta di  B.  Panizza;  Pavia, 1821, p. 8-19.  The various changes in the
brain and the optic nerves are represented m three plates.
  f The appearances of the  disease, in its earliest stages, are represented by Mr. Iravkrs,
in the first, third, fourth, fifth, and sixth figures of his fourth plate
  Professor Von Ammon has devoted  to this  subject a plate (pi. 23,) containing several
        85 
674
MELANOSIS OF THE EYE.
mass, in which all appearance of the normal structures  is now lost, is
deep livid, or black throughout, distending the lids, or passing between
them.  The ulcerative or  sloughing  processes now begin, and a thin
dark-coloured ichor, or thick black fluid, as if produced by dissolution
of the texture, is discharged abundantly.  Masses of the  growth  are
separated at intervals by sloughing; great pain in the eye and head, and
constitutional irritation accompanying the process; symptoms of cere-
bral affection frequently occur, and the patient dies comatous or insen-
sible.
   The absorbent glands have not been affected in the cases which I have
seen.
   When an eye, which has been thus disorganized, is examined, we find
the globe with  other contents of the orbit, converted into a morbid mass,
which in texture and consistence is analogous to the medullary growths.
Some part may even have the  greyish  colour  of fungus haematodes.
But it is principally, if not wholly, of the deepest sooty black; at all
events, the anterior fungous portion is of this colour, though the posterior
or deeper-seated part is lighter.  The tumour imparts a black slain to
the finger, or to white paper;  it breaks  down readily under pressure,
and communicates to water a dark  turbid  discolouration, like  that of
Indian ink, after which the substance presents a loose fibrous texture of
brownish hue.
   The optic nerve is sometimes  discoloured in an early period of the
affection, before the figure of the globe is changed.  Its substance, as
exposed in a vertical section, is seen of a blackish grey, like that of the
morbid growth within the globe, in the first figure of Mr. Traver's fourth
plate.
   When the orbital contents have undergone the change of structure just
described, the  disease spreads through  the  foramen opticum into the
skull, and leads either to the formation of a melanoid tumour under the
anterior lobes  of the brain, or to the production of similar growths in
the interior of the organ.   At the same time the disease shows itself in
various other parts of the  body, such as the  contents of  the thorax and
abdomen, the bones and skin.  These secondary affections may appear
as tubercular  masses, more or less  firm in consistence, as depositions
 of black substance in a  nearly fluid state, or as infiltrations of the tex-
 ture  of an organ with the  same matter.
   I have not seen melanosis before the age of thirty; it usually occurs
 at or after the middle period of life.  Its progress is more rapid than
 that of scirrhus;  it may go through its whole  course in twelve or
 eighteen months.
   As melanosis agrees with fungus haematodes and cancer in  pursuing
 its destructive progress in spite of our  treatment, whether internal or
 external, the  only questions are, whether the diseased parts  may be
 removed with  a reasonable chance of  permanent cure; whether life
 can  be prolonged by the operation; at what period it may be performed
 with the greatest advantage;  and under what circumstances  it would
 be hopeless.   There is  every reason to believe that the extirpation  of

 figures, which represent the commencement and progress of the disease, with sections of
 melanotic eyes.  Klinische Darsteliungen. pt. i. 
MELANOSIS OF THE EYE.
675
the disease has been permanently successful in many instances;  hence
the prognosis of operations is by  no means so unfavourable in mela-
nosis of the eye, as  in fungus haematodes.   The earlier it is performed,
the better is the patient's chance:  the most favourable time is  before
the coats of the eye have given way, when the disease, being confined
to the organ, admits of entire removal.   When a sloughing and  ulcer-
ating fungus  has projected  externally, there is great fear that the optic
nerve may have become diseased, that morbid changes may have taken
place within  the skull, or in some internal organ, or that disease may
recur  in the  orbit.   As  we cannot  be secure against these various
sources of risk, we  should only undertake the operation under a doubt-
ful prognosis.   In  some instances, patients have died soon  after  the
operation,  apparently from the  existence of  secondary disease  in  the
liver;  in other cases death has ensued after a longer period  from mela-
nosis of the brain.
   Case I.—Warren, a native of Ireland, rather more than thirty years of age, came
under my care  at St. Bartholomew's Hospital  in May, 1825.  Although  he stated
that the eye had been diseased for nearly two years, the morbid structure had not yet
Bhown  itself externally.  The globe  was  somewhat enlarged; this circumstance
being distinctly observable  when the two  eyes were compared,  with the eye-lids
closed.  An  opaque lens of muddy brownish  hue  was pushed into the pupil,  and
closely squeezed, together with the  iris, against the  cornea, which was dull.   A dark
discolouration was obscurely perceptible on the  surface of the globe, at some distance
behind the cornea: it was completely covered by a dense arrangement of large  ves-
sels, apparently filled with venous blood.*  Although the form of the globe was not
altered, and its  size but little increased, and  although the morbid structure could not
be actually seen, I could only  refer the appearances  just enumerated to the develop-
ment of melanoid disease within the globe.   The dark discolouration behind the  cor-
nea, and the  plexus of  large turgid  livid vessels covering it, were appearances that I
had not before seen, and indicated, as I thought, organic disease in the eye; while
the state and situation of the  lens and iris showed the existence of some distending
and protruding  cause in the back of the globe.   The patient readily assented to my
proposal of removing the eye, which was performed in the usual manner.  The  pro-
gress of the case after the operation was favourable, and the patient was soon able to
leave the hospital.   I saw him in June, 1826,  when the contents of the orbit were
sound, and the general  health excellent.
   A vertical section was made of the eye, which is preserved in the museum of St.
Bartholomew's  Hospital.  The sclerotica  presents its normal appearance, except  that
it is a little prominent at two or three points, and that it has undergone absorption in
one situation, not far from the optic nerve, so as to allow a small knotty protrusion of
the internal growth, as large  as a horse-bean.  The cornea is natural; the lens and
iris are in contact with it.   The cavity of the globe behind the latter is filled with a
tolerably firm adventitious growth, the section of which exhibits a somewhat lobulated
arrangement: it is generally black,  but one  or two points are of a dusky grey.  This
melanoid deposite, which distends the sclerotica, holds the place  of the textures na-
turally contained within that  tunic.   An imperfect remnant  of the choroid  is dis-
cerned on its surface; but there is no trace  of retina or vitreous humour.  The optic
nerve was sound at the part where  it had been cut through.
   Extirpation  of the  eye, on account  of melanosis in a rather more
advanced stage, was performed by Mr. Tyrrell at the London Oph-
thalmic Infirmary, in the year 1825.   The patient recovered favourably
from the operation, and  was in good health in the  country at the  dis-
tance of a year from her convalescence.

  * The first figure in the plate of Professor Von Ammon before quoted, represents tolera-
bly well the appearances exhibited in the eye of  this patient, except that it does not suf-
ficiently pourtray the close arrangement of large venous vessels which covered  the  dark
protuberant portions of the sclerotica. 
676
MELANOSIS OF THE EYE.
   Case II.—Melanosis of the eye; operation; death from disease of the liver.—In
 1825, I removed, in St. Bartholomew's  Hospital, the eye of a patient sixty-five years
 of age, in whom the organ had become enlarged, and was completely disorganized by
 melanosis, so as to present a  livid, and  black  mass, with projecting inequalities and
 partial ulceratiop.  The patient's countenance was sallow and unhealthy, like that of
 a free liver.   The disease had existed about twelve months at the time of the opera-
 tion,  which  was performed at his own request.  He went on well for tea days,  when
 his strength  began  to fail, without any obvious cause, and  he gradually sunk.
   The sclerotica and the optic nerve  were the only parts of which any trace could be
 observed in  the extirpated mass.   The latter consisted of a dull  greyish texture ap-
 proaching to the medullary character, with a slightly marked lobular arrangement,
 surrounding  and compressing the remains of the sclerotica.  This greyish and  toler-
 ably  firm substance, was gradually changed towards the front into a softer deep black
 melanoid texture, which composed the anterior tubera and fungus.  At some points a
 slight infiltration of the black matter is observed in the morbid mass.  The  cavity of
 the sclerotica is filled with melanoid deposite.  The optic nerve on the operated side
 was diminished in size as far as  the  commissure, behind which both nerves were na-
 tural. There was no disease in the brain or membranes.  The liver was enlarged
 to at least twice  its ordinary size,  and diseased throughout, being filled with adventi-
 tious deposites, varying in size from that of a  pea to a large orange.  In  texture and
 consistence they resembled the depositions of fungus hasmatodes.   Some were white
 or reddish, some of the deepest black, and others presented all the various intermediate
 shades.
   No disease was  discovered  in any other part.  The eye, a portion of the  basis
 cerebri, and  specimens of the liver, are preserved in the museum of St. Bartholo-
 mew's Hospital.
   Case III.—Melanosis of the eye ending fatally; melanoid tumour within the skull;
 disease of the liver.—A  corpulent woman, forty-five years  of age, came under my
 care at the London Ophthalmic Infirmary, for melanosis of the eye, by which the or-
 gan had become enlarged and  disfigured by projecting black tubera.  The globe was
 moveable in  the socket, and I  proposed  extirpation, to which she would not  consent.
 At the end of some weeks, when she  was willing to undergo the operation, I deemed
 it unad visable from the great increase  of bulk in the disease. The globe was now more
 than half the  size ofmy fist, distending the palpebrse enormously, and projecting between
 them. It had ulcerated, and a thick black fluid  flowed  from the part.  The general
 health was not much disturbed  until a few weeks before death, when symptoms of
 cerebral disease came on, and  the  patient died comatous about eighteen months from
 the commencement of the complaint.
   The globe and other  orbital contents were  converted into a uniform soft mass of
 sooty blackness, from which a thick fluid could be scraped or squeezed out, similar to
 that which had flowed from the fungus during  life.  The skin or  linen applied to the
 cut surface of the morbid growth, became soiled with an inky mark.   The disease was
 continued by the optic nerve into the skull,  The nerve itself was converted into a soft
 black substance, and expanded, after passing  the foramen opticum,  into a tumour of
 similar character, as large as a small  orange, situated under the anterior lobe of the
 brain, and partially penetrating into its substance.  In the liver we  found two deposi-
 tions of melanoid nature, one about the size of a walnut the other that of a  pea.*
   Case IV.—Melanosis of the left eye; extirpation of the globe; relapse of disease;
 secondary affections of the liver and other parts.—A female, forty-one years of age,
 of delicate constitution  and sallow complexion, found  the sight of her left eye imper-
 fect two years and a half before she came under the care of Mr. A. Burns; a milki-
 ness was at  this time observed behind the pupil.   The opacity of the lens increased,
 and in four months the vision of that eye was lost.  Two months after the eye became
 inflamed without  any obvious reason.  By the  use of leeches  and other means, the in-
 flammation was lessened, but the redness and pain did not cease entirely.  Six months
 before the operation a tumour began to form on the lower part of the sclerotica, just
 behind the cornea,   It was as  large as a musket-ball, and numerous  red vessels were
 seen on its surface.   There was hysteria with pain in the back, and severe lancinating
 pain in the eye, which interrupted  sleep.  In four months after, there was confirmed

  * The diseased mass which filled the orbit in this case, and the melanoid growth  within
the skull are preserved in Mr. Langstaff's museum. 
MELANOSIS OF THE EYE.
677
hectic, with emaciation, debility, and broken state of health: Ihe patient had been con-
fined to bed two months.   The cyst had increased to the  size of a  pigeon's egg, and
formed a solid fungous mass, covering the under eye-lid.   Towards the external angle
there was a hard tumour, adhering firmly to the bone.  The eye-ball  was extirpated,
but the tumour adhering to the cheek-bone  could  not be  completely  removed, the
bone itself being  carious.
  When the eye-ball and optic nerve were  divided, a thick viscid matter of dark
brown colour covered  the knife.  The tumour seemed  at first  sight composed of
a similar dark-coloured matter,  which was of the  consistence  of thick oil paint;
it soiled the fingers of a dark brown colour,  and  dissolved readily in water, leaving
the solid  parts more distinct.   The cornea and sclerotica were sound, but the  lat-
ter  had given  way opposite  to  the  malar  bone so as to  allow the substance within
the globe  to pass out and form an  externa]  tumour.  The lens was opaque and
amber-coloured.   There  was no  trace of the iris, or of  the retina.  The choroid
was thickened and  more vascular than in the natural state.  The contents of  the
eye-ball, and of the  tumour exterior  to it, consisted  of pulpy substance,  variously
tinged in  different  places by the dark  brown colouring matter.   The  medullary
substance  of  the  optic nerve was of  black  colour, like that of the matter in  the
globe.
  The patient, who had been greatly emaciated, regained appetite, flesh, and strength,
after the operation.   The orbit gradually filled up with a soft substance of dark colour,
which skinned over.   Her health soon declined again ; she experienced most severe
pains in the loins, which confined her  to bed;  and an elastic fungus began to protrude
the lower  lid, and to project between the lids.   This disease caused no uneasiness: but
the pain in the back and loins was so excruciating, as to make her scream from agony.
After lingering two or three months, with the tumour below the orbit increasing, and
the pain of the loins not relieved, she died extremely emaciated, having become sud-
denly comatous twenty-four hours before death.
  The tumour in the orbit proceeded from the antrum, the parietes of which had given
way above and in front.  The morbid growth also projected into  the nostril.  It pre-
sented externally small knobs of dark livid colour.   It was composed internally of a
soft matter, of inky colour, intermixed with a  greyish substance and ragged fragments
of bone.   The floor  of the orbit  was elevated so as to be nearly in contact with the or-
bital plate of the frontal bone; the fungus was therefore  exterior to the orbit.  The
substance of the optic nerve, from the point where it had been divided, was of black
colour.  Within the cranium, the nerve was  as large as  the  little finger, and black.
The junction of the nerves was enlarged into a tumour, which projected into the third
ventricle.  The dark colour was continued beyond the union, along the nerve of the
same side.  On the opposite side the nerve was natural in  size and colour, and the two
were only connected by cellular shreds.
  The liver contained tumours similar in structure to the contents of the eye-ball, and
a cyst filled with grumous purulent matter.   Above the kidneys, there were conside-
rable tumours of similar nature.   The uterus was of cartilaginous density.  (Mr.
Wardrop, in lib.  cit. p. 74—80, and plate iii. fig. 1.)
  Case V.—Melanosis of the eye; extirpation of the organ ; death from secondary
affection of various parts.—In the spring of 1822, John Henston, a shoe-maker, aged
fifty, laboured under a severe affection of the right eye, attended with pain in the orbit
and head, for which extirpation  was deemed necessary.  There was no return of dis-
ease or pain in the part after the operation.  On the 18th of March, 1823, he was re-
ceived into the Royal  Infirmary of Edinburgh, with symptoms of pleurisy, for which
he was bled, blistered, and purged with considerable benefit.  The symptoms had dis-
appeared on'the 23rd, excepting a cough, which yielded in a few days to  gentle means.
On  the 1st of April  he complained of weakness merely, for which generous diet with
wine was ordered; but he died in the course of the night, without any suspicion of se-
rious organic disease having been entertained.
  In the extirpated eye,  "the situation of the vitreous humour was completely occu-
pied by a black-looking fibrous mass, pushing  the choroid  coat and retina into the pos-
terior chamber.   These tunics had  undergone no sort of alteration, and the sclerotica
was entire  The cornea had sloughed;  but  this was to  be attributed 1o  the general
distention of the globe, and  by  no means to any alteration in the  texture of the tunic,
since it was nowhere in contact with the morbid matter lodged behind the iris.   There 
678
MELANOSIS OF THE EYE.
was a considerable mass of black matter lodged posteriorly to the globe, and deep in
the orbit, apparently in the fat and cellular tissue surrounding the optic nerve.   When
we examined the orbit after death, we observed  that the disease had been reproduced
in its old situation, and at the expense of the cellular tissue; for the muscles and nerves,
so far as we could trace them, had undergone no alteration."  There were " a number
of black globular bodies lying in the cellular tissue, between the pectoral muscle and
third and fourth ribs of the left side, about the size of peas, and some of them adhering
to the periosteum.   The substance of the rib itself was completely black, as was also
the sternal third of the clavicle of the same side;  but these bones were in no other way
altered from their natural state.  Upon opening  the chest, the  pleura was found stud-
ded with similar tumours, here  and there insulated, but in general aggregated, so as
to resemble a cluster of purple grapes.   The last-mentioned phenomenon  was particu-
larly remarkable on the right lung, along the bodies of the vertebrae on both sides, and
upon the surface of the diaphragm on the  left.   Many of the tumours were hardly
raised above the pleura,  but others had long slender necks, so that they were like
polypi.  In colour most of them were jet black,  others of a deep purple, or  even of a
reddish  hue, while a third sort seemed to contain portions of a peculiar white colour,
blended with black.   The lungs were extensively beset with these tumours; and se-
veral of an exceedingly small size were  detected under the mucous membrane of the
bronchi©.   The pericardium, and the very substance of the heart were studded with
melanose  bodies.   As the cause of the symptoms  under which the patient  laboured
during life, upwards of three pounds of fluid were found in the cavities of the pleura,
and there  was a thin pellicle of albuminous matter covering the surface of the lungs.
In the abdomen, the liver, spleen, kidneys, omentum, and peritoneum in different places,
were affected in this manner; but the tumours  in the liver contained a considerable
portion of  white cerebriform matter.  Similar tumours were found connected with the
internal table of the skull, where they had formed for themselves little excavations; in
the subcutaneous cellular substance of the thorax and abdomen, so as to be discernible
through the integuments; and, lastly, among the fibres of the intercostal muscles."
"The tumours consisted of a cyst, separated by a loose cellular tissue from the  sur-
rounding textures, and containing the peculiar black matter of the disease in different
states of consistence.  In some pretty large tumours the matter was nearly solid ; and
in others,  those exceedingly small, nearly  fluid.   No external differences were to be
observed in these two species; there was no regular gradation in size, no difference in
vascularity, that could have led us to suppose they were different slates of the same
disease, or in different states of development. In  the liver only a remarkable variety
was noticed.  The tumours here were as large as  chestnuts, some of them white, con-
sisting of cerebriform  matter, others were pure melanose;  and  others again contained
melanose and cerebriform matter together;  but all  of them had cysts tolerably distinct
from the surrounding hepatic texture."*
   The history and dissection of a case, in many respects analogous to
the  foregoing, form  the  subject  of an interesting  narrative  by  Mr.
Fawdington, illustrated by several lithographic figures, which represent
with great fidelity the characteristic appearances of the disease.
   Case. VI.—Melanosis  of  the eye; extirpation of the globe; death from secondary
affection  of various  textures and organs.—The patient, Thomas  Peckett, thirty
years of age, a robust, healthy-looking man, was at  first under the care of Mr. Wilson,
surgeon to the Manchester Eye Institution, whom he  consulted in January 1824, for
a violent and incessant pain in the  left eye.  Six  months previously he had received
a blow on  the organ, which caused little pain and no alteration in the  external ap-
pearance of the part.  A fortnight after the accident a sensation of fulness with im-
perfection of vision was experienced, and  gradually increased, the former to a  most
distressing degree.  The vessels of the conjunctiva, and sclerotica were distended, and
the latter  tunic seemed  to be undergoing  absorption, as the  dark choroid was just
visible towards the internal canthus.  The iris was  dilated and immoveable, and a slate-
coloured opacity occupied the centre of the pupil.  The symptoms were relieved by
antiphlogistic means ; but the pain returned, and became violent and incessant.  At

  * Cullen and Carswelx on Melanosis, in the Transactions of  the Medico-Chirurgical
Society of  Edinburgh, vol.  i. p. 271-275. 
MELANOSIS OF THE EYE.
679
the end of March, the sclerotica had become very thin at the upper and inner part of
the globe, and the bulging part was covered by the choroid.  The opaque appearance
in the pupil had now a dirty red colour.   Mr. Wilson  removed the contents of the
orbit on the 19th of April.
  A section of the eye-ball  discovered a black  pultaceous tumour, occupying more
than  one half of the  interior of the globe, in the situation of the vitreous humour, of
which no trace could be discovered.  There were two cavities filled with a brownish
red fluid, one at the side of the tumour, the other between  the front of it and the lens.
The  choroid was entire,  except at one  part, where it was blended with the  tumour.
The sclerotica was reduced to an  extreme degree of tenuity.   The retina was sepa-
rated from the choroid by the interposition  of the disease, and gathered into  a folded
mass, placed in the axis of the  globe, and connected anteriorly to the back of the
crystalline capsule.  The lens was opaque and amber-coloured.  The optic nerve was
sound at the part where it had been divided.  He recovered from the operation.   In
August small black tumours, about the size of a shot, appeared in the skin of the face
and back, and he became affected with pain in the side, cough, and difficulty of breath-
ing.  The abdomen soon  began to enlarge; melanose tubercles showed themselves on
the face, scalp, and lower  lid of the extirpated  eye, where it threatened ulceration  ;
blue elevations, apparently from subcutaneous melanosis, appeared all over the chest
and abdomen ; the abdomen became exceedingly  protuberant from enlargement of the
liver, and death took place in November.
   The  subcutaneous stratum of adipous substance was beautifully  granulated  with
melanose matter, in small encysted masses, up to the size of a pea.   The liver was
four times its natural size, and filled with melanose masses of various bulk, as well as
with black infiltration.   On making a section  through the diseased  organ,  several
ounces of dark fluid escaped, resembling deep chocolate paint in colour and consistence.
This softer matter occupied the centre of the diseased masses.  The peritoneum lining
the parietes was covered  with minute black dots; and melanose tubercles were found
abundantly in the cellular tissue on the spine, in that of the various duplicatures formed
by this membrane and in the omentum, around the kidneys, and on the concave surface
of the diaphragm.  The pancreas, spleen, and kidneys were thickly studded  with black
spots, some of which, especially in the pancreas, were as large as a Spanish nut; and
similar depositions had taken place under  the serous membrane of the stomach and
intestines.  The back  of the sternum was superficially spotted.   The cellular sub-
stance  of the mediastinum and that connecting  the pleura costalis to the parts which
it covers contained melanose tubercles.   Groups of small black  cysts with slender
pedicles were scattered over the  pleura  costalis.  Melanose matter was deposited in-
sterstitially and in spots under the pleura pulmonalis, and in tubercular masses through
the lungs.  Almost the whole surface of the heart was covered with black spots.  The
brain was not examined.   No disease was observed in the  nerves or blood-vessels.*
   Case VII.—Melanosis of the right eye; extirpation of the diseased organ; death
at the end of three years from secondary melanoid disease of the brain.—The right
eye of a farmer, fifty-five years of age, having been diseased  for ten years, and con-
verted  into a growth completely filling the bony cavity, was removed by Mr. Ward-
rop.  No  remains of any of the natural structures of the globe  were recognisable,
except the sclerotica, which had burst  asunder, and was distended by the different
portions of the tumour.   This consisted of a dark brown or blackish substance, rather
firmer  than brain, but in some parts so soft as readily to be washed away  with water.
The patient recovered quickly after the operation, and remained in good health about
two years.   He  then  had a  fit, which left no effect but that of weakness, and on the
following day he went about his farm as usual.  Six  months  afterwards he had a
second fit, which was followed by great weakness, and some difficulty of speech.  In
a few months he had a third fit, followed by paralysis of  the  right arm  and  loss of
speech. The  fits now became more frequent; the  right  leg was paralyzed, and the
limbs of the left side, excepting the right hand,  which was never affected, and which
he employed in making signs till the time  of his death, at the end of fifteen months
from the first attack.   The vessels of the meninges were  distended.   The substance

  * A case of Melanosis by Th. Fawdington, London, 1826.  There are eight lithographic
plates representing the primary disease in  the eye, and the secondary affections of the skin,
liver, kidneys, intestines, pancreas, heart,  and lungs. 
680
EXTIRPATION OF THE EYE.
of both hemispheres at their posterior part was unusually soft, and readily yielded to
slight pressure with the finger.   In the left hemisphere, on a level with the corpus
callosum, a large mass presented itself of dark bloody colour, having  at first the ap-
pearance of coagulated blood, but found, on minute examination, to be  of firm consist-
ence, with numerous small vessels passing through its substance.  This mass seemed
to have no connexion with the surrounding brain, which was quite natural, and formed
a sort of bed  for it.  By immersion  in water a quantity of blood was extracted, and
the mass which remained was of a dark brown colour, consisting of very loose cellu-
lar tissue.  In the substance of the right hemisphere there were several dark-coloured
masses of the size of a pigeon's egg, very similar in texture to that found on the left
side.   The optic nerve on  the right  side, from its bifurcation  to the orbit, was much
wasted, having no medullary matter, and seemed to consist only of neurilema.  At
the extremity of the nerve, where it had been divided during the extirpation of the
eye, there was a hard black granular tumour of the size of a small nut.  (Lancet, vol.
xi. p. 88.) It seems that the cavities of the thorax and abdomen were not examined.
  Case VIII.—Extirpation of the eye for melanosis; relapse at the end of two years.
—Mr. Wilson, of Manchester, has shortly mentioned a case analogous to the pre-
ceding, in which relapse of the disease took place at the end of two years.  He says:
" Two years ago I removed the  eye-ball of a  middle-aged man affected with mela-
nosis; and 1  entertained sanguine hopes that  no other organ would  become affected,
as such  an interval  had elapsed; but last week  he called  upon me,  complaining
of great general debility, loss of flesh, and mentioned  that he had experienced  fre-
quent discharges per anum of a dark-coloured fluid.   Upon examining the orbit,
from which the globe had  been removed, I perceived upon the granulations a portion
of black matter the size of a currant,  of a pyriform shape.  He said he had at times lost
some blood from the orbk, but very trifling in quantity.  Upon dividing the peduncle,
two or three drops of dark blood, if  blood it could be  called, issued  from the wound.
The case is still under my  observation, and I hope at 6ome future time, to be enabled
to communicate it to the profession."  (Mr. Fawdington, Case of Melanosis, p. 3.)
                  SECTION V.--EXTIRPATION OF THE EYE.

  Careful preparation of the patient, by regulation of diet and atten-
tion to the state of the bowels, for  some days previously, is advisable,
in order to prevent the occurrence of inflammation, which, if produced,
would probably extend from the orbit to the  important connected and
contiguous parts.
  The operation  itself, although  its  bare  mention  is distressing and
shocking to the feelings of patients  and their friends, is neither difficult,
tedious,  nor dangerous, when executed  properly, and  under  the requi-
site precautions of previous measures and subsequent management.  The
lids must  be divided  at  their external commissure, and turned back so
as to expose completely the anterior opening of the socket; the conjunc-
tiva must then be cut  through at its  reflexion from the palpebrae, and
the diseased mass must be detached from the socket, to which it is con-
nected by cellular tissue, more or less loose; the  third and last portion
of the operation consists in severing the orbital contents  thus  insulated,
at their  posterior  attachment, by cutting through  the  muscles of the
globe and the  optic  nerve.   The instruments required  are scalpels and
forceps;  some of the  former should be double-edged and pointed; a
strong curved needle, armed with a stout thread;  a double-edged  knife,
curved on the flat; and a pair of strong scissors similarly curved.
   The patient should  be placed in  the recumbent  position, with the
head a  little raised  on a  pillow.   The separation  of the eye-lids, at 
EXTIRPATION OF THE EYE.
681
their temporal junction, would be expedient, in order  to  give room,
even if the globe were of its natural  size, but it is absolutely necessary
in the more or less considerable  enlargement, which exists' almost  in-
variably  when  the operation  of excision  becomes necessary.  This
point is accomplished by a straight incision, which should be an inch
or an inch and a-half long, or  at  least sufficiently extensive  to admit
of the palpebrae being completely turned back so as to expose the mar-
gin  of the orbit.  After  dividing the  commissure of the lids, they
must be dissected from the base of the tumour above and below, by a
few strokes of the knife, by which the conjunctiva  is divided more or
less completely, at its reflexion over  the globe.  The curved needle is
now carried through  the diseased mass, and the ligature thus introduced,
held either by the operator or an assistant, allows  of its being moved
in any convenient direction as  the dissection proceeds.   The eye being
drawn  gently upwards, a semicircular  incision is carried from one
angle to the other, along the inferior  margin of the  orbit, and we pro-
ceed, by cutting  in the  same  direction, to detach the contents of the
orbit from the bony  cavity, as far as we can conveniently carry the
knife.  In this dissection, we cut through such part  of the conjunctiva
as had  not been divided  in  turning back the  eye-lid and the inferior
oblique muscle.  The two extremities of this first incision  are now
united by a second semicircular  cut  carried along the upper edge  of
the  orbit, and the mass  is detached  above;  here we first cut through
the  conjunctiva, and  then the tendon  and pulley of the trochlearis mus-
cle.  The object is to remove the entire orbital contents, which is most
effectually and conveniently accomplished  by dissecting close  to the
bone, and employing a double-edged  scalpel.  As the roof of the orbit
is naturally as thin as paper at some  points, and as it sometimes under-
goes absorption in consequence of pressure, especially  when long con-
tinued, the cavity of  the cranium might  easily be penetrated  by the
sharp point of the knife, if it were used incautiously.  To avoid this risk,
the  eye should  be drawn downwards, and the dissection conducted
very carefully at the superior part of the  orbit.   When the diseased
mass has been detached  all round, it merely remains to  cut through the
muscles and optic nerve behind; and  this division may be accomplished
with the straight scalpel, the curved scalpel, or the curved scissors.  As
the external side of the orbit slants from without inwards, while the inter-
nal  goes directly backwards, this last step of the operation can be ac-
complished most conveniently by introducing the  instrument  at the
outer side of the cavity.
  The surface of the orbit should  be gently and  carefully examined
with the finger;  if the lachrymal gland, or any portion of the disease
has  been left behind,  it should  be removed.
  The  vessels divided in the operation bleed freely; when the wound
is sponged, it fills again directly with blood, so that we cannot direct
our  dissection by the immediate  sight of  the  parts, which we  are  di-
viding.  Profuse hemorrhage generally takes place from the ophthalmic
artery; it usually ceases spontaneously;  but if it should proceed to  an
alarming extent, it must be stopped by pressure.   A piece of lint rolled
firmly into the shape of a conical plug may be held on the vessel until
the  blood ceases to  flow, when  it  may  be gently removed.   If the
       86 
682
OSSIFICATIONS.
bleeding should require it, a compress of folded linen might be placed
over the plug, and secured by a circular bandage for a  short time.
  The practice, sometimes recommended  and followed, of filling the
orbit with lint, sponge, or other matters,  seems to me decidedly ob-
jectionable.   From this  introduction of extraneous substances into a
recent wound, we can expect no other result than irritation and inflam-
mation.  We should use  every precaution to avert such results, which
would become dangerous in this case  from the direct connexion be-
tween  the sheath  of the optic nerve, the periorbita, and the dura mater,
and the immediate contiguity of the brain  and its membranes with a
large portion of the wound.  It will be  sufficient to unite the divided
commissure of  the lids by one or two sutures, to cover  the part with a
soft rag dipped in cold water, renewing it as often as  it becomes dry
or warm.   The patient should be kept quiet in bed, and restricted to a
spare diet, until  all  risk of inflammation  is  past.  The bony cavity
granulates, and becomes filled, to a certain  extent, with a newly-formed
vascular mass; the eye-lids sink inwards, and become concave. There
is no support for  an  artificial eye, nor  indeed sufficient cavity for its
reception; a green  or  black patch  must therefore be worn over the
orbit to conceal the deformity consequent on the operation.
                     CHAPTER  XXIV.

     OSSIFICATIONS.  CALCULOUS CONCRETIONS--ENTOZOA IN THE  EYE.

        SECTION I.--OSSIFICATION OF VARIOUS PARTS OF THE  EYE.

   Most of the textures  belonging to the eye, if not all of them, have
been found converted into bone, more  or  less extensively; the change
having seldom been observed, except in eyes which  had been  seriously
disorganized by acute inflammation many years before death, and had
then remained collapsed, shrunk, or at all events deprived of  vision.
The subject therefore, generally speaking, is of no practical importance.
The recorded instances  of these ossifications have been, for  the most
part, collected by Schon, in his work on the Pathological  Anatomy of
the Human Eye;  (Handbuch der pathologischen Anatomie  des men-
schlichen  Auges;  8vo.  Hamburg,  1828,)  and some of the  following
references have been borrowed from him.
   Cornea.—In the opaque cornea  of an eye changed in form, Mr.
Wardrop found, between the laminas, a small piece of bone.   Another
was met  with  between  the choroid and  retina of  the same eye.   In
another case, Mr. W. found gritty particles and inequalities on the in-
ternal surface of the  cornea.  In a case, communicated to him by Mr.
Anderson of Inverary, a substance of  whitish appearance was seen in
the under part of the globe of  the eye, arising from the inside of the
sclerotic coat, and extending upwards behind the cornea, over a great
part of the iris to  very  near  the pupil.  It had  begun  to  grow fifteen 
OSSIFICATIONS.
683
 years before, in consequence of a blow on the eye from a fall, and had
 been attended with much irritation  and pain, which had increased  so
 as to render relief by operation necessary.  Mr. Anderson therefore
 made a section  of  the  cornea, as  in extraction of the cataract, and
 then readily turned  out a small piece  of  bone, which  was  as thin  as
 paper above, thicker, porous, and brittle below.   It adhered slightly  in
 the lower  part, but  was  unattached above.   (Essays on the Morbid
 Anatomy of the  Human Eye; vol. i. chap. 10 ;  p. 74—77.)
   Walther found a small piece of bone in the cornea of a man, sixty
 years of age.  (Anat. Museum, Th. i. 139. No. 274.)
   A case recorded  by Monod, (Nouvelle  Bibliotheque Med. May,
 1827,) of ossification of the entire cornea,  in an  old man, is mentioned
 by Schon, as the only instance of the kind.
   Sclerotica.—According  to  Schon, only one instance has  been ob-
 served ; it is recorded by Blasius in a rare work.  (Observationes me-
 dicae rariores; Amstelod. 1677; p. 78.)
   Choroid coat.—" I have met," says Mr. Wardrop, " with  a few in-
 stances where a thin cup of bone was found between the sclerotic coat
 and the retina.  The ossifications in all these cases were exactly simi-
 lar.  At the bottom  of  the  cup, there  was a small round perforation,
 through which the retina  passed to expand  on the interior surface  of
 the osseous shell.  The retina was in immediate contact with the in-
 terior surface of  the bone, but between the sclerotic coat  and the ossi-
 fication there was a  very thin, tender, and pale-coloured  membranous
 expansion, the only  vestige of the choroid coat."  (Lib. cit. vol. ii.  p.
 69; plate xiv. fig. 3.)
   Walther found the posterior half of the choroid ossified in the eye
 of a man thirty years old, who  had  been  long blind;  the eye being  in
 other respects healthy.  In a man of sixty, who had been blind twenty-
 eight years, the  globe was collapsed, and the interior  portion of the
 choroid ossified.  In another instance, where the bulb was diminished,
 the choroid formed a firm excavated hemisphere, in  which there was
 a hole for  the passage  of the optic  nerve.  In an older  man, the
 choroid was completely ossified  in both  eyes.  (Lib. cit.  Nos.  292, 293,
 294, 295.)
   Iris.—Two instances of its ossification are mentioned by Walther.
 (Lib. cit. p. 146 and 148.)
   Retina.—Ossification of this part has  been  already mentioned in
 two notes at page 487.   Schon  speaks of this change as a rare occur-
 rence, and quotes, besides an instance mentioned  by Morgagni, {Epis.
 xiii. No. 10;) another related by Zinn in the  Hamburg  Magazine, vol.
 xix. p. 441.
   L^ns and  capsule.—Ossification of these  structures is spoken of in
 Chapter XIX. §5, p. 471.
   Membrane of the  aqueous humour.—Mr.  Wardrop saw  a case in
 which thin laminae of bone, which he supposes to have been formed in
 this  membrane, were discharged from  the anterior chamber through
 ulcers formed in the cornea.   He mentions, that in a patient, under the
care of Mr. Wishart, that portion of the capsule of the aqueous humour,
which  is reflected over the iris, was almost  entirely converted into  a
bony shell.  (Lib. cit. p. 18.) 
684
CALCULOUS CONCRETIONS.
  Vitreous humour.—This humour and the membrana hyaloidea may
become ossified.  " In  one case," says Mr. Wardrop, " besides the
capsule of the lens being ossified, I found several large, but thin, scales
of bony matter, dispersed in an irregular manner throughout the vitreous
humour, which,  in  all  probability, were  ossifications of  the hyaloid
membrane."   In another  eye, extensively  disorganized by serious dis-
ease, and  shrunk, the cavity of  the globe,  within the choroid and iris,
was occupied  by an irregularly-shaped bony-mass, composed of two
distinct portions, slightly connected.  The anterior was spherical, and
consisted of a thin hollow shell of  bone: it appeared to be the capsule
of the lens ossified.   The  other, occupying the situation of the vitreous
humour, was unequal on its surface, and composed of numerous osseous
laminae irregularly disposed.  (Lib. cit, p.  128, plate xiv., fig. 1.)
                 SECTION II.--CALCULOUS CONCRETIONS.

  Calculous concretions have been met with in the eye.  Scarpa has
described and delineated an adventitious formation of this kind.  The
globe was shrunk to one half its natural size.  The sclerotica and cho-
roid were nearly natural.  Within the latter, there were two  calculous,
cup-like substances {scodelle,) of  which one occupied the back of the
eye, the other was in the situation of the ciliary body and the lens.  The
optic nerve, degenerated into a  thread, went through an opening  in
the centre of the posterior calculous portion, and was then continued  as
a soft cylinder, through the  axis  of the globe, and was fixed  to the an-
terior calculous mass.*
  Haller met with a  similar change of structure, which  he has des-
cribed in his  Opuscula Pathologica, Obs. 65, under the title of lapideus
scyphus in oculo, that is, a cup-like calculous concretion in the eye.   In
dissecting the nerves of the eye, he observed that the cornea was opaque,
and the globe hard.  " Within  the choroid, and concentric with that
tunic, in place of the retina, there  was a hollow, osseous, or rather stony
hemisphere, for no bony fibres were  discernible, to which the choroid
adhered, as it  usually does to the  retina: it consisted of two layers, and
was excavated on  one  side so as  to form two small recesses.   That this
sort of cup was the retina, in an indurated state, was further  proved  by
the circumstance of its being perforated by an  accurately round open-
ing at the entrance of  the optic  nerve.  No proper vitreous body was
found in this  osseous cavity, but a kind of nerve, that is, a white cylin-
der, which entering through  the  foramen  of  the bony cup, passed
along its axis, and adhered  in  front  to  a confused mass of bone,
which might have been  taken  for  a  degenerated  crystalline.  In this
same mass, the iris, ciliary processes, and cornea,  were firmly consoli-
dated."   (Opera minora, torn, iii. p. 366,  367.)
  Panizza minutely examined an  eye, which contained a large calculous
formation between the choroid and retina; a description and good  de-
lineation of the parts are given  in his work on fungus haematodes of

  * Saggio di Osservazioni e d'Esperienze, Sfc. cap. xx., plate ii., fig. 8.  Treatise, &c. p.
534. The morbid structure  is delineated  in plate ii.  fig. 8. 
ENTOZOA IN THE EYE.
685
the eye.*  The left eye, in which vision had been lost in youth from in-
ternal inflammation, was taken from the body of a farmer, sixty years
of age, who had died of peripneumony.   The cornea was opaque, flat-
tened, and shrunk; the globe generally was rather diminished, and firm
to the touch.  When  the sclerotica and choroid, which were  natural,
had been cut through, a white, stony,  and somewhat rough  substance
was  exposed,  covering the globe  completely within the choroid, and
connected behind, at the entrance of the optic  nerve, by a small white
cord, which was the nerve passing through an opening in the calcareous
substance.   In front, the latter, the iris, cornea, and lens, which was
diminished and stony, were consolidated into one mass.   A  portion of
the calcareous stratum, including part of the opening for the passage of
the retina was broken away to  expose the interior.  It was hard and
brittle externally, about a line in thickness, and disposed in layers, of
which the internal were less firm and at last almost membranous. The
cavity was filled with a whitish  gelatinous substance deposited  in la-
minae.   In the midst of this the retina was found contracted and  folded
together, ending behind in the thin cord  which passed through the cal-
careous shell,  and spreading out in front into a broad attachment, con-
necting it to the ciliary body.  An incision was made into the conical
portion of the  retina, and the edges separated.  The cavity contained
the vitreous humour, shrunk, folded, and reduced into  a small conical
mass.
   A specimen in the museum of St. Bartholomew's hospital resembles
very nearly the two examples of disease last  mentioned.  Within the
sclerotica and choroid, which are healthy, there is a cup-like,  calcareous
deposition, a line in thickness; its exterior surface, which was in con-
tact with the choroid, is a little rough; the interior concavity is smooth.
I do not know what it contained  internally, nor whether it was perfo-
rated by the optic nerve.  It was an old, diseased eye.
   Walther says, " I possess a really stony vitreous humour, which was
still  covered by the retina, when I  took it out of the eye;  the concretion
possesses completely the size and form of the vitreous body,  and  sounds
when struck with a metallic probe."  (Graefe and Walther's Journal,
vol.  i. p. 164.)

SECTION III.--ENTOZOA (INTERNAL  OR PARASITIC  ANIMALS) IN THE EYES OF
                   MAN AND OF OTHER VERTEBRALIA.

   In the next chapter, on affections of the orbit, will be found an exam-
ple of a cyst in that cavity containing a large number of  the  simple
globular hydatid {echino coccus.)
   Filaria in the anterior chamber of the horse s eye.—It has been long
well-known that a species of filaria (thread-worm) is occasionally found
in the anterior chamber of the horse's eye, moving rapidly about in the
aqueous humour.  The  circumstance, though rare in these climates, is
by no  means uncommon in India, where it is only seen during the cold
months, not having been observed before the beginning of October or
later than the end of February, or the commencement of March.  The

  * Sulfungo midollare delV occhio.  Appendice; Pavia, 1826. P. 22, 23, tab. i. fig. 7. 
686
ENTOZOA IN THE EYE.
 heavier the  rains  have  been during the periodical rainy season, and
 particularly towards its close, the more numerous have cases of worm
 in the eye been during  the subsequent cold season.  They occur chiefly
 in low districts, being hardly known in the upper provinces,  where the
 soil and climate are  drier.   Mr. Gibb, surgeon to the East India com-
 pany's stud  at  Poonah,  used  to  see-about  twenty cases  annually.
 Thirty oases occurred in  one season at Poonah among the young stock,
 while in another depot, situated higher (Ghazepoor,) not a single case
 occurred  during the same  time.   Two  worms  have  sometimes, but
 rarely, been seen in the same eye at one time; and a second  worm has
 made its appearance in an eye from which one had been extracted some
 months before.  Similar worms are met with in the stomach and in-
 testines of the horse;  also, according  to some reports, in the cellular
 substance of the loins.   The animal, which has received the name of
filaria papillosa, is about an inch long, equal in size to a sewing-thread,
 white or darker coloured.   It  causes  inflammation of the  eye, with
 uneasiness, watering, and turbidity of the anterior chamber.   Opacity
 of the cornea comes on,  and blindness  ensues.  These results may be
 prevented  by extracting the  animal.   A small incision is made in the
 cornea with a  lancet, and  the worm  comes out with the aqueous
 humour.*
   This worm has been  seen in the horse's eye in Europe,f [and also in
 the United States.J]
   In the work just quoted, Dr. Nordmann, of Odessa, describes the cir-
 cumstances which led him to discover the existence of entozoa in  the
eyes of several vertebralia;  and he gives a  minute account of them,
illustrated  by beautiful figures, representing their form  and internal
structure.   His  researches,  which  were  carried  on during  eighteen
months, from March  1830,  to  September 1831,  enbraced numerous
eyes of horned cattle, sheep,  pigs, frogs, lizards, and fishes, with some
from the  human subject,  and birds.  He found entozoa of the genus
filaria in the human eye, and  in that of the gadus aeglefinus  (hadock,)
of the genus ascaris in the frog, of the genus oxyuris in the perch, of the
genus cysticercus in the pig, and trematoda in great abundance in other
fishes.  The  genera  examined  for this  purpose were muraena, gadus,
perca, gasterosteus, cobitis, silurus, cyprinus, salmo, esox, pleuronectes.
In the fish  he first found entozoa in  the vitreous humour, but he subse-
quently met with them in  the crystalline, between  the lens and the cap-
sule, between the laminae  of  the cornea, in the iris and retina, in  the
choroid gland, between  the sclerotica and retina, and in  the aqueous
humour.   (Lib. cit. p. 1—6.)   In the crystalline lens of some fish they

   * On the Worm found within the Eye of the Horse, by P. Breton, Esq.  Observations on
the Filaria or Threadworm found in the Eyes of Horses in India, by W. Twining,  Esq.
In Transactions of the Medical and  Physical Society of Calcutta, vol. i.  A  short state-
ment of Mr. Twining's observations will  be found in the Edinburgh Medical and Surgical
Journal, vol. xxv. p. 240, 241.
  t Nordmann, Mikrographische Beitrage zur Natur geschichte der Wirbellosen Thiere;
Erstes Heft, p. 11—13.  A delineation of the worm is given by Gurlt, in his pathologi-
cal anatomy of the horse.
  Leuckart has collected all that is known respecting this^iaria of the horse's eye in his
Persuch einer naturgemassen Eintheilung der Helminthen, Heidelberg und Leipzic, 1827,
p. 28, 29.
  [t See Trans. Am. Philos. Soc. 1st  series, vol. 2.  And Am. Journ. Sc. and art.-vol. 39.] 
ENTOZOA IN THE EYE.
687
are so numerous as to render it more or less opaque, and thus to impair
or injure sight.   (Lib. cit. p. 19, 20.)
  Filaria  under the conjunctiva  in the human  subject.—A species of
filaria {filaria medinensis ?) has been seen under the conjunctiva oculi
in the West Indies.  Schon has quoted some facts of this kind.   A case
was related to him by Dr. Gaertner, who had resided long in the West
Indies.  A blackish thread-like streak, which moved, was  seen in the
conjunctiva of a negro girl.  In a little time it had disappeared, and  a
slender bluish line  was observed in the upper eye-lid.  It appeared  like
a small cutaneous vein, and moved in various directions.  Dr.  Gaert-
ner considered it to be the  guinea-worm : he  made an incision,  and ex-
tracted the animal.*
   Filaria  in the crystalline lens.—Dr. Nordmann examined two lenti-
cular cataracts taken from  an elderly man, half an hour after they had
been extracted by  Professor Von Graefe.  In one of these, which was
still partially surrounded  by the capsule, he observed in the Morgagnian
fluid two  very small and delicate  rings, which  he clearly recognised
under the  microscope as convoluted filariae.  One of the two had been
injured in  the  middle, probably by the cataract needle, so that the in-
testines  had come out of the body, and were  visible as slender threads.
The other was uninjured, of  uniform thickness, three quarters of a line
long,  and extremely narrow.   It was spirally convoluted  and com-
pletely dead.  A simple intestinal canal, a mouth without visible  papillae,
an uterus, and a prominent anal  aperture, could be distinguished.  In
the other  lens, which, as  is  usual, was completely free from the capsule,
nothing similar could be discovered.  Dr. Nordmann calls this entozoon
filaria oculi humani.   He  adds, that  he had since examined several
cataracts, and human  eyes under various circumstances, without dis-
covering  any entozoa.   (Lib. cit. p. 7, 8.)
   Filaria and monostomata in the lens.—In a second  part of the same
work, the author recites  two additional  instances of entozoa  found in
the opaque lens.   He says, "In the month of May, 1832, I was  pre-
sent at two operations of extraction performed  on old women by pro-
fessor Juengken.   I found  a living  filaria, five lines and a half long, in
the act  of casting  its skin (in der hautung begriffene,) in one lens of the
first patient, a case of green lenticular cataract.  No extraneous living
body  was discovered in  the other lens.  The second case was more
interesting, as it presented  the first example of microscopical  entozoa
possessing suckers (Trematoda, Rudolphi,) being found  in  the human
eye;  eight individuals of the genus monostoma  were found in  the sub-
stance of the  lens.  These minute beings were situated in the upper
strata of  the crystalline; they were one-tenth of a line long, and moved
sluggishly when placed in  warm water.  The examination took place
immediately after  the  operation.  In both  cases the opacity  was not
yet complete, and the lenticular substance was soft. (Lib. cit.  Zweites
Heft; Vorwert, p. 9.)               ,    •  ,              ,   .. ,    ,
   Von  Ammon found a filaria in  a lenticular cataract, of  which  the
nucleus was firm, the exterior pulpy.   The cataract  was extracted.
He has figured the animal, of its natural size, and magnified.   (Klinis-
che Darsteliungen, pt. i. pi. xii. fig. 22 and 23.)

    * Handbuch der pathologischen Anatomie des menschlichen Auges, p. 226, 227. 
688
entozoa in the eye.
   Dr. Gescheidt  and professor  Von  Ammon found, in the crystalline
 lens, four entozoa of the genus distoma, in  a case of  congenital cata-
 ract.  (Zeitschrift fur die Ophthalmologic, vol. iii. p.  75, 76.   Also
 Klin. Darstell. pi. xii. fig. 24 and 25.)
   Cysticercus celluloses in the anterior chamber of the human eye.—
 This hydatid, consisting of a small  globular vesicle, with a slender
 neck, of which the end  is a little  enlarged, so as to  form  a kind of
 head, which is found all over the body of the  domestic pig under cer-
 tain circumstances,* occurs also in the eye of the animal, where it has
 been seen both in the anterior and posterior chamber.   It  has  been
 twice observed in the anterior chamber of the human eye, floating in
 the aqueous humour.  Dr. W. Soemmering communicated  the first in-
 stance to the  assembly of German  naturalists at  Heidelberg, in the
 year 1829: it was published in the Isis, 1830, p. 717, from which Dr.
 Nordmann has taken the following  account.
   "A living cysticercus, of the size of a vetch, was found  in  the ante-
 rior chamber of the left eye of a girl eighteen years old, and otherwise
 healthy.   It was said to have shown itself after an acute inflammation
 of the organ.   I saw, and delineated  it, two months afterwards, when
 no trace of inflammation  remained,  excepting a  slight blush of  red
 round the cornea, on excitement of the organ.  It caused no pain, or
 merely a transient uneasiness when it moved considerably; and inter-
 fered with sight only when it  came  before the pupil.  Usually it lay
 at the bottom of the anterior  chamber, like  an imperfectly  dissolved
 lens, where it appeared as a partially  transparent sphere, from which,
 there was, at one point, a milk-white opaque prominence.  In this situa-
 tion the  thick  wrinkled portion of the neck occasionally projected,
 sometimes spontaneously, sometimes in  consequence of gently rubbing
 the upper eye-lid.   Then slowly came out the thinner thread-like half,
 ending in a head with four suckers  and a double circle  of hooks.  (The
 latter circumstances, however, were  not distinguished till the animal,
 after extraction, had been examined with the microscope.)   The body
 of the animal changed its  figure, more or less quickly,  from the ordi-
 nary globular to an  oval or pyriform shape.   It generally lay half a
 line from the margin  of  the cornea, on account of the narrow interval
 between the two parts at their circumference.   The neck  hung down-
 wards like a leaden plummet;  it was not attached, but  moved freely,
 and changed its position according to the movements of the head, always
 passing downwards.   In  the  course  of seven months it had become
 twice as  large as when first observed,  and  had attained the magnitude
of a pea, when it was extracted  alive  by Dr. Schott, through a small
 incision of the cornea.  It was put  in  lukewarm water,  and continued
to move more than half an hour; it then became gradually opaque and
 white, and we  could plainly distinguish with  the  microscope the four
prominent suckers with their  orifices, and the double circle  of hooks
in the middle of them.   As it  corresponded  in all respects, not only

  * The pigs, in whom these hydatids or cysticerci are found, are said to be measled; and
 their flesh is called measly pork.  The French term the affection ladrerie; while the Ger.
mans call these parasitic creatures Finnen.  Hence Blumenbach has derived the name of
hydatis Jinna, under which he has described this hydatid, in his Abbildungen Naturhis-
lorischer Gegenstande, No. 39, with an engraving of the creature, both of the natural size,
and in an enlarged view. 
ENTOZOA OF THE EYE.
689
with the delineations of Goze and Bremser, but with other similar
specimens from the  human body, which I compared with it, I could
have no hesitation in  considering it as a cysticercus cellulosce, which, so
far as I know, has never been observed in the human eye, although,
according to Van der Hoeven, it  is found in  that of the pig."   (Lib.
cit. Erstes Heft, p. 8, 9.)
  The case of another patient, in  whose eye there is a living cysticer-
cus, has been recently published, by Mr. Logan of New Lanark, in a
pamphlet which I have not  seen.  A description of the appearances, il-
lustrated by two wood-cuts, has been sent to the London  Medical Ga'
zette, (Vol. xii. p. 1 ] 0—112,) by Mr. Mackenzie of Glasgow.   The dis-
ease exists in a lively and  otherwise healthy girl  seven years of age.
From the month of August, 1832, to the following January, there had
been repeated  attacks of inflammation in the left eye, which had ren-
dered the cornea nebulous,  and  still continued so  severe as to threaten
loss of sight: the inflammatory symptoms, however, subsided, leaving a
slight opacity of the  cornea.   " After a week the  child was again
brought to Mr. Logan, who, on examining  the  eye, discovered, to  his
great surprise, a semi-transparent body, of about two lines in diameter,
floating unattached in the anterior  chamber.  This body appeared al-
most perfectly spherical, except that there proceeded from its lower
edge a slender process, of  a white  colour, with a slightly bulbous ex-
tremity, not unlike the proboscis of a common house-fly.   This process
Mr. L. observed to be of greater  specific gravity  than the spherical or
cystic portion, so that it always turned into the most depending position.
He also remarked that it was projected or elongated from time to time,
and again retracted,  so as to be  completely hid within the cystic por-
tion, while this, in its turn, also  assumed various changes of form, ex-
plicable only on the supposition of the whole constituting a living hyda-
tid."  Mr. Mackenzie found the cornea slightly nebulous: he adds,
" When the patient kept  her head at rest, as  she  sat before me, in a
moderate light, the animal covered  the two lower thirds of the pupil.
Watching it carefully, its cystic portion was seen to be more or less
spherical, and then to assume a flattened form, while its proboscis I saw
at one moment thrust suddenly down to the bottom of the anterior

               Fig. 58.                       Fig. 59.
chamber, [see fig. 58,] and at the next drawn up so completely as scarce-
ly to be visible.   [See fig. 59.]   Mr. Meikle  turned  the child's head
gently back, and  instantly the  hydatid  revolved through the  aqueous
      87 
690
INJURIES of the orbit.
humour so that the proboscis fell to the upper edge of the cornea, now
become the more depending part.  On ihe child again leaning forward,
it settled like a little balloon in  its former position, preventing the pa-
tient from seeing objects directly before  her, or below the level of the
eye, but permitting the vision of such as  were placed above."  As the
child was healthy,  and the eye free  from inflammation,  it had not
been thought advisable to  institute any treatment in reference to this
parasitical inhabitant of the anterior chamber.
  In a few weeks after the preceding  account had  been drawn up, it
was thought proper to  make an  incision in the  cornea  for the purpose
of removing the hydatid, which had become larger, and caused vascu-
lar  disturbance and pain in the  eye.  Violent action  of the muscles en-
sued by which  the  lens was   forced  out  and the   hydatid ruptured.
The remains were removed in  shreds,  being so delicate as scarcely to
bear the slightest touch.  After the eye had recovered, the patient could
merely distinguish the  presence of light.   (Practical Treatise; edit. iii.
p. 912.)
  The cysticercus cellulosce has  also been found in the subconjunctival
cellular tissue, and  under  the integument of the  eye-lid.  Mr. Estlin
removed one in the former  position near the internal canthus in  a girl
six  years old.   The small  tumour caused by its presence had been un-
attended with pain or inconvenience. (London Med. Gazette; vol. xxii.
p. 839.)
  In a boy of fourteen, there was a swelling in the left temple commu-
nicating with an elevation of the mucous  membrane of the mouth.  The
latter was punctured, when several hydatids came out with glairy fluid.
Afterwards  swelling and suppuration of  the upper  eye-lid  took place,
and the part was punctured.   Pus was discharged with six or eight
cysticerci cellulosae, about  the  size of small peas.   (Mr. Mackenzie's
Practical  Treatise; edit. iii. p. 909.)
CHAPTER  XXV.
AFFECTIONS of the orbit.
                       SECTION I.--INJURIES.

  Fractures of the orbit, whether simple or compound, single, commi-
nuted or attended with displacement; gun-shot injuries of the same part,
and diseases of the bone or of its membranous covering, such as enlarge-
ment {hyperostosis,) exostosis, caries,  periostitis whether simple, syphi-
litic, or scrofulous, must he treated according to the general principles
applicable  to  the  management of such  injuries and diseases, which,
however, are more serious here than  in many other situations, from the 
INJURIES OF THE ORBIT.
691
near neighbourhood of the eye-ball and brain.  Diseases originating in
various neighbouring parts, such as the brain, the antrum, the nose and
its sinuses, may make their way into the orbit, and cause displacement
of the globe.  This circumstance must be borne in mind when we are
endeavouring, in a case of obscurity, to ascertain the cause on which
protrusion of the eye-ball depends.
  Penetrating wounds of the orbit.—When wounds occur within the
margin  of  the cavity, their depth is of more consequence than their
extent;  indeed, the smaller are the more dangerous, as a small pointed
instrument is more likely than a larger one  to penetrate into the orbit.
Here the external wound affords no criterion of the internal injury and
danger.   A slender and sharp instrument may easily pierce the bony
roof of the orbit, which  is as thin as paper at some points, and thus
wound the brain.  Some of the muscles or nerves, contained in the
cavity, may be divided or injured, the position of the globe being con-
sequently changed, and  its motions more or less  affected.
  Lastly, the entrance of a foreign body into the orbit  often displaces
the globe, pushing it out between the palpebrae, where it remains in the
state technically termed exophthalmia.  It is thus protruded by pressure
of the thumb at the external angle in the barbarous practice of gouging,
which  is still allowed  in fighting, in some parts of the country.  The
globe itself escapes injury from its spherical figure; it can hardly be
wounded, except on its  anterior surface.
   All penetrating wounds of the orbit are  to be  regarded as serious
cases, when we do not know how far the  injury has extended, and
should be treated accordingly until the period of danger is passed.  The
patient should be kept quiet and should not employ the eye;  the bowels
ought to be emptied and a light diet enjoined, the symptoms being care-
fully watched, so that the earliest indications of danger may be noticed
and properly treated.
   Protrusion of the globe; exophthalmia.—\i the globe should have been
thrust out between the lids, the nerve is rendered  insensible.   We should
ascertain whether any foreign substance remains in the orbit, and if so,
remove it.   The globe  is then to be gently replaced;  it returns  easily
and remains in its situation.   If the latter should not be the case, it must
be retained by a soft, folded, linen rag, dipped  in water and  confined
by a light bandage.   Rest of the eyes, and of the body generally, and
antiphlogistic treatment with spare diet, will be proper.   Vision is soon
restored in these cases, if the globe should have been merely  thrust
between the  lids: such  a displacement involves no considerable stretch-
ing of the nerve.  Beer mentions the case  of a young man, who had
received a blow on the external angle  of the eye by a tobacco-pipe,
violently thrust in his face by a fellow-student.  When Beer came, there
was complete exophthalmia, and the cornea was turned towards the
nose.  He found and  extracted from the orbit a piece of the pipe, nearly
an inch long, when the globe returned of itself into the cavity, the cornea
being still turned inwards, and the patient having a very feeble perception
of  light.   In five weeks vision was perfectly restored, but the eye was
still directed towards  the nose, and could scarcely be moved  in the
opposite direction, probably from injury to the external straight muscle.
(Lehre, vol.  i. § 167.) 
692
INJURIES OF THE ORBIT.
  Penetrating wounds of the orbit, without apparent injury of the globe,
or optic nerve, when neglected, have  sometimes given  rise to violent
inflammation, involving the eye, and ending in loss of vision.
  Cases of exophthalmia from accident are recorded, in which replace-
ment of the globe has not been effected for some days, or even weeks,
but has been accomplished ultimately, with restoration of vision when
there has been simple protrusion without any other  injury.
  If the muscles and nerves should be extensively wounded, the globe
may be loose, and insensible to light;  it will probably slip  out of the
orbit  again, after  being replaced.   It should  be  restored, and gently
confined in  its situation.
SECTION II.--ACUTE INFLAMMATION AND SUPPURATION OF THE ORBITAL CELLU-
                           LAR TEXTURE.

  Phlegmonous inflammation  and abscess  may occur in  the cellular
texture behind and  around the globe.   If, according to some descrip-
tions, the affection should be combined with inflammation of the globe,
the combination must be very rare; for I have not seen an instance of it.
  When we consider the vascular and nervous structures which com-     •
pose the contents of the orbit, their close contiguity with the sensorium;
further, the direct membranous continuation  between the periorbita and
the fibrous sheath of the optic nerve on one side, and the  dura mater
lining the cavity of the cranium on the  other, we shall not be surprised
to find that inflammation of the orbital contents is characterized by the
most violent and agonizing pain deeply seated in  the orbit, extending
over the whole of the head, and accompanied by a sensation of tension
and bursting, as if the contained parts were  too large for the cavity in
which they are lodged,  As  the bony socket cannot .give  way, the
swelling of the parts behind pushes the  globe forwards, distending the
lids, and making them unnaturally  protuberant.   The inflammation
soon extends to the palpebrae,  which become red and swollen by cede-
matous effusion.  The slightest  attempt to move the eye excites acute
pain, and the patient therefore keeps the organ perfectly still.  In con-
junction with the local symptoms, there is violent inflammatory fever;
the patient is delirious at night, and continues so  for several nights in
succession.  As the disease proceeds, all the symptoms are  aggravated
to a pitch which is almost intolerable.   The globe of the eye is thrust
further out, often beyond the palpebrae.   Under such circumstances the
retina  is rendered insensible to light.  The pain intermits a little; throb-
bing and  rigors are felt; suppuration  takes  place, and an abscess is
formed, without, however, any material relief to the patient, since the
bony parietes of the orbit cannot yield.   Ultimately the matter makes
its way to  the  surface, either presenting  at some  part of the orbital
margin,  or under the lid, in  which latter case it pushes forwards the
fold of the conjunctiva passing from the lid to the globe.
  Beer' has described this affection as involving the globe of the eye,

  *  hehre, vol. i. (j 346—353.  He slates that it is one of the most uncommon forms of
ophthalmic inflammation (p. 340,) and that the prognosis, even in  the first period, is never
favourable, at all events very uucertain (p. 344.)  The affection was not of this formidable 
CHRONIC ABSCESS IN THE ORBIT.
693
together with the surrounding soft parts.   Should such a combination
occur, symptoms denoting  inflammation of the external and internal
tunics of the eye will be  added to those  already  described.   The eye
is thrust out, the sclerotica  becomes red, the conjunctiva is inflamed,
the iris changes its colour, and the sufferings of the patient are of course
aggravated.
   Treatment.—If we see the complaint in an early stage, the violent
pain, and the general febrile disturbance, clearly point out the necessity
of vigorous antiphlogistic measures.  When the  presence of fluctua-
tion shows  that matter has  formed,  an opening should  be immediately
made into the collection; by this proceeding we shall relieve the patient,
and limit the extent of the local mischief.   When the symptoms point
out that matter has formed, although we may not feel fluctuation, it is
best to make an opening, by means of a lancet or double-edged  bistoury,
in the situation where the matter appears  to be deposited, taking care
not to injure any part of  consequence.
   Some time ago I saw  two instances of this affection, in which the
local and general symptoms were characterized by a degree of violence
seldom seen in other cases.   One was that of a  young man between
twenty and thirty years of age; he came to  me  accompanied  by his
wife, who told me that he had suffered  much agonizing pain for three
or four preceding  nights, that she feared he would  have gone out of
his mind.   In  this case matter was presenting just under the super-
ciliary ridge; after making a free opening, a large quantity issued out,
and a probe introduced at the puncture went to the bottom of the orbit.
   In the other case, that of a child between three and four years old,
the local and general symptoms were equally severe;  the matter pre-
sented  between the lower lid and the globe, but the quantity discharged
on making an opening  was not considerable.  In  both instances the
globe of the  eye was protruded, but not  actually thrust out between
the palpebrae; and after the matter had been discharged it  receded to
its natural  situation.  In the  child, vision was restored; but in the adult,
the eye, although it had not been inflamed, remained amaurotic.
             SECTION III.--CHRONIC ABSCESS IN THE ORBIT.

  The inflammation is sometimes of more chronic character, with less
severe symptoms:  matter  forms, and  advances  to the surface more
slowly.   I  saw  a  child, two years old, for an affection of the right
eye, which was said to have existed for a  week.   The globe projected
half  an inch further than the left, and was pushed outwards.   The in-
ternal angle, the neighbouring  part of the lids, and the side of the nose,
were red and  swelled.  On careful examination,  I thought that deep-
seated fluctuation  was obscurely perceptible;  the gentleman  who ac-
companied the patient could not feel it.   The child  had  not suffered
much • its rest had  not been interrupted.   Leeches had been applied
twice.' From a consideration of the history and symptoms, I concluded

character in the cases detailed in the text; but it will be observed, that in them the globe
was not involved, 
694
CHRONIC ABSCESS IN THE ORBIT.
that suppuration had taken place in  the  orbit, and  that an  opening
ought  to be  made.   I accordingly punctured with  a lancet, which
entered to the depth of three quarters of an inch, when a dessert spoon-
ful  of thick  well-formed  pus flowed out.   A small bit of lint, spread
with simple cerate, was introduced  to maintain the opening.   At the
end of a  week, the  puncture had closed;  the eye had regained  its
natural position; and  the swelling at  the internal angle had disappeared.
  Mr. Ware has observed, that the suppuration in these cases  is some-
times slow, so that, if the matter be deep-seated, the  eye will be pro-
truded before fluctuation is discovered.  In a child, six years old, thus
affected, he says,  " I  passed a lancet on the side of  the  eye next the
nose a little below the commissure of the eye-lids, at least an inch into
the orbit, before I reached the matter.  On withdrawing the instrument,
its  point  was evidently marked  with  pus.   I  therefore  enlarged  the
puncture with a blunt-pointed bistoury, and discharged a considerable
quantity, which was  thick and putrid.  It was necessary to preserve
the opening by the insertion of a small dossil of lint; on the  removal
of  which, a vent was given daily to new  matter for  a  fortnight.  Its
quantity gradually decreased, together with the prominence of the eye;
and at length it wholly ceased, the wound healed, and the child became
well.   The  motion of the affected  eye, however, was  not  quite free
towards the nose for several months  afterwards."  (Observations on
the Treatment of the Epiphora, &c, &c.   1811. p. 292—293.)
  A case of orbital abscess, singularly slow in its progress, is  related by
Mr. Mackenzie.
  A lady received a severe blow over the right eye-brow, by coming suddenly in con-
tact with a lamp-post.  Four years after, one of her relations observed a difference in
the  appearance of her eyes, but she herself noticed no change for another period of
four years, when she observed that the right eye-ball protruded.   The protrusion gra-
dually increased, and was attended with  photopsia, double vision, dimness  of sight, and
sense of tension.  At the end of twelve years from the accident, there was a tumour
with obscure fluctuation at the upper and inner part of the orbit: no pain had been
felt  in it:  the eye-ball was pushed  downwards and outwards. The eye-lids, particu-
larly the upper, were distended, but not discoloured.  Rigors had never been expe-
rienced.   A large quantity of pus, first flaky, then healthy, was let out by puncturing
the  tumour.  Discharge of matter continued for six months.  The eye-ball ultimately
regained nearly its natural position, and vision was  perfect.  (Practical Treatise, edit.
3, p. 299.)
  Propagation of inflammation from the orbit to the contents of the cra-
nium.—Inflammation in the  orbit may involve the fibrous  membrane
lining the bone, and affect the bone itself; it may then extend to the dura
mater, and even to the brain: thus serious  and fatal disease may be ex-
cited  within the cranium.   The possibility of such an occurrence ren-
ders it imperatively necessary to  use active antiphlogistic means in the
first instance, and to evacuate matter as  soon as we  can satisfy our-
selves of its existence.   The following case mentioned by Borsieri illus-
trates these points.
  Case.—Abscess in the orbit, with suppuration of the anterior lobe of the brain.—
A lady, twenty-five years of age, was seized with acute pain in the left side of the
head, which lasted fifteen days.  At length the left eye became red and swollen, and,
in a few days, the eye-lids and neighbouring parts formed a large red swelling, which
was attended with considerable feverish disturbance.  Antiphlogistic measures were
adopted, but suppuration occurred in a few days, and a large quantity of fetid pus came 
chronic abscess in the orbit.
695
out of a spontaneous opening near the external angle of the eye.  The swelling now
subsided, so that the eye could be seen.  The conjunctiva was intensely red, and very
tumid, the cornea transparent, the pupil dilated, and vision destroyed.  On the fourth
day after the rupture of the abscess, general and strong convulsions came on, followed
by paralysis of all the limbs, loss of the senses, languid and stertorous respiration,
small and intermittent pulse, and death.  The space between the globe and the orbit
was filled with fetid  pus, which extended also under the eye-lids and  cheek.  The left
anterior lobe of the brain had suffered by suppuration almost as far as the lateral ven-
tricle.  The optic nerve was surrounded with  pus, but not diseased :  the matter com-
municated with the cavity of the orbit.  (Institut. Medicinae Practical, vol. iii. p. 14—
16, note.)
  An instance  somewhat similar has been recorded by Professor Fischer
of Prague.
  A man twenty-seven years old, had an upper molar tooth of the left jaw extracted.
Severe pain in the part followed.  In a few days, profuse flow of tears took place from
the left eye, and  discharge from the left  nostril with pain in the head.  Soon rigors
came on, with severe pain in the head and intolerance of light; then swelling of the
cheek and  eye-lids, with  fixed  state of the eye-ball, which was somewhat protruded,
and agonizing pain of pulsating character; these symptoms being accompanied by in-
tense fever.  An opening was made at the inner angle, and a considerable quantity of
offensive matter  was discharged.  Considerable relief was experienced, and  copious
flow of matter continued.  In a few days, symptoms occurred denoting affection of the
head; convulsions ensued with  stertorous respiration and insensibility, and the patient
died apoplectic.  The blood vessels of the  dura and pia mater covering  the left ante-
rior lobe of the  brain  were distended, and the membranes themselves discoloured.
There was a large collection of pus in the anterior lobe, communicating with the late-
ral ventricle,  which, as well as the fourth, contained matter.  The suppuration in the
anterior lobe communicated with the abscess of the orbit through an opening in the or-
bital  plate  of the os frontis, which was dark-coloured, and broke down under slight
force.  (Klinischer Unterricht, p. 9.)
  In a case recorded  by Mr. Guthrie, of a bayonet wound, followed
by inflammation of the orbit, and of the eye-ball, the latter " was pro-
truded, the  lid could not be raised  so as to explore the eye,  which was
highly inflamed; chemosis had taken place, vision was indistinct, the iris
was discoloured, the  pupil contracted, the  pain was excruciating, both
in the eye,  which felt as if it were  too large for the orbit, and all over
the forehead and temple of that side; flashes of light, of various colours,
darted through the eye,Jn consequence of the surrounding pressure upon
it; the swelling increased, the patient became delirious, and an abscess
burst in the upper eye-lid  on the fourth day, without  any alleviation of
the symptoms.  He soon after became comatose and died, I have little
doubt, from the formation  of matter within the head.  The eye had pre-
viously been lost by sloughing of the cornea."   (Lectures on the Ope-
rative Surgery of the Eye. p. 146.)
  "I have  known," says  Mr.  Mackenzie, "deep-seated abscess  of the
orbit to prove fatal, the patient having for a day or two  shown  symp-
toms of pressure on the brain, and in fact dying apoplectic."   (Practi-
cal Treatise, p. 34.)



SECTION IV.  PROTRUSION OF  THE GLOBE FROM  CHANGES IN  THE CONTENTS OF
                     THE ORBIT OF OBSCURE NATURE.

  I  have mentioned  displacement of the globe, or  exophthalmia, in
describing the symptoms  of those affections to which  it  is incidental. 
696
PROTRUSION OF THE EYE.
 I shall, therefore now advert  shortly to the cases, in which  the  causes
 producing the protrusion are obscure.
   It sometimes occurs as a  temporary affection, under circumstances
 which lead us to refer it to  inflammatory swelling of the orbital con-
 tents, not sufficiently active  to cause suppuration, or to  effusion into
 the  orbital cellular texture.
   Case I.—Partial protrusion of the left eye-ball, after erysipelas of the face conse-
 quent on fever.—Charles Hutten, a sailor, aged forty-two, was received  into the Lon-
 don Fever Hospital the 10th of July, 1831, labouring under feverish symptoms, which
 had  commenced without any obvious cause,  three weeks before.   On the 3rd of
 August, as he was recovering from the  fever, erysipelas of the face came on.  The
 palpebrse were considerably swollen on  the 6th, although the parts affected with the
 erysipelas  were not much reddened.  The eye became slightly protruded on the 12th,
 the erysipelas having disappeared on the preceding day.   He was admitted into St.
 Bartholomew's Hospital on the 16th, when the projection of the globe had considera-
 bly increased.  The left eye was now more prominent than the right by three quar-
 ters of an inch.  The conjunctiva covering its lower half, considerably distended with
 serous effusion, overlapped the under lid, so as to present, at first, the appearance of
 ectropium.   No  inflammatory symptoms  were present;  the eye and orbit were free
 from pain; vision  was a little impaired. The patient, being weak, was placed on
 broth diet: a rag dipped in cold water was applied over the lids and brow.   A saline
 aperient draught was directed occasionally.  22nd. Twelve leeches near the eye.
 7th September. The eye has regained  its natural position and aspect.  Vision is
 perfect; a  small glandular tumour is seated below the jaw ; six leeches  to the swell-
 ing, and poultice afterwards.  14th. Discharged perfectly well.
  Case II.—Protrusion of the eye-ball, with  impaired vision.—Richard Gilbert,
 a healthy young sailor, thirty years of age, came under my care, at the London Oph-
 thalmic Infirmary, on the 18th of February, 1826, with the complaint above-mentioned.
 The  displacement had come on gradually, and had not existed long; without being
 considerable, it was quite conspicuous, and produced an unpleasant appearance and
 expression.   The health was perfectly good.  Blood was twice abstracted by cupping;
 mercurial alteratives and aperient medicines were  afterwards administered  and con--
 tinued  till  May.  He was then dismissed cured, with vision  perfectly restored, and
 the globe nearly in its natural position.
   I have seen some instances, in females, of  protrusion of the  globes,
 so that the  palpebrae would  not  come  together.   The eyes, unusually
 denuded in front, have had an unpleasant  appearance of enlargement
 and projection.   Surgical treatment has alleviated the symptoms and
 checked the progress of the complaint, without entirely removing it.
   Mr. Middlemore has recorded an instance of the  foregoing descrip-
 tion, in which protrusion of the eyes was  preceded  and  accompanied
 by severe pain  in the head, attended with  something like a  slight epi-
 leptic  attack every five  or six days.   The pain was moderated after
 several months of active treatment by bleeding, and the administration
 of mercury ; but the  protrusion  continued, so that a large part of the
 sclerotica is exposed, and the patient, a young woman, has a remarka-
bly disagreeable staring appearance.   (Treatise vol. ii. p. 504.)
   "In some instances," says  Mr.  Ware, "a  projection of the eye ap-
pears to be occasioned solely by a morbid accumulation of the substance
on  which the eye  rests in  the orbit.   The  repeated application of
leeches on the temple and forehead  has been found of  great use in
subduing  this  morbid tendency.   In one case, that  came  under my
own care, the  projection was speedily diminished  by opening the tem-
poral artery ; and,  after the hemorrhage had ceased, by convertincr the
orifice into an issue, the discharge from which  became soon very consi- 
PROTRUSION OF THE EYE.
697
derable. In another case, in which the protrusion occasioned great pain,
and  nearly destroyed  vision, a perfect cure was accomplished by the
application of a large caustic behind the ear.   The discharge which it
occasioned, when  the  eschar separated, was  profuse; and it was  kept
up nearly  a month, by the insertion of a dozen peas daily/'
  " I have occasionally met," says  Mr. Travers, " with cases of prop-
tosis to such an extent, as  to occasion a morbid change upon the  cor-
nea, with  a varicose state  of the vessels  of the conjunctiva; and with
others in which  although the  cornea remained clear, the vision was ma-
terially deranged, when the cause of the protrusion was altogether ob-
scure, and the progress of the disease  had been so slow as to occupy a
period of several years.   In these cases both eyes are equally affected;
they are attended with a distressingdegree of deformity, obtuse pain in the
forehead, and other occasional  signs of determination of blood to the
head.   It  is probably a  morbid increase of the  adeps contained in the
orbit, obstructing its circulation, as  well as protruding the eye-ball."

  Case III.— Protrusion and destruction of the globe, from acute inflammation in
the orbit; subsequently, induration of the adipous and cellular substance, and extir-
pation of the orbital contents.—A  young man of thirty, previously healthy, came un-
der  my care in St.. Bartholomew's Hospital, on the fourth of April, 1827.  He had
travelled from Brighton to London  in an open cart, on one of the coldest days of the
preceding January, and had suffered most  severely.  The left arm and  leg were be-
numbed, so that he could not move them, and he did not recover the use of them for
three or four days.   He also experienced pain in the left eye ; but in a fortnight the
lids swelled and closed, with distracting  pain in the eye and side of the headi  He was
in constant agony night and day, and he  got no rest until he was completely exhausted
by suffering. Cupping on the temple, repeated leechings, shaving and blistering the
head, gave only partial and temporary relief.   When he came to the hospital, the eye-
ball was pushed  forwards  and  upwards,  projecting, by comparison  with the  other,
about three  quarters of an  inch.  The upper lid slightly inflamed and protruded, could
not be elevated by  the patient.  The lower lid was everted by a considerable swelling
of the conjunctiva, which  was red, and loaded with serous effusion.   The globe was
natural; the iris moved freely,  but  vision  was so imperfect, that the largest  letters
could not be seen.   Nothing issued from a deep puncture, made on the supposition of
matter having formed in the orbit; but at the end of three or four days pus was dis-
charged copiously.  The pain now ceased, the swelling of the lids and the protrusion
of the globe lessened, and  sight  improved, so  that the patient could read small  print.
After some time bare  bone could  be felt towards the bottom of the orbit, and  matter
was discharged from the left nostril; on holding the nose and expiring, air came freely
through the puncture.   This subsequently closed, when the pain and protrusion of the
eye returned; the  latter indeed became  more considerable than  before, and vision was
lost.   In August another free incision was made, with temporary relief, and air again
passed through the puncture.  The probe entered deeply, and discovered a large ex-
cavation below the eye.
  Severe pain about the orbit and  side of the head continued ; numbness of the cheek
and  jaw came on,  with increased redness  of the eye and lid?, and greater protrusion,
these symptoms receiving only a temporary alleviation from local bleedings and nar-
cotics.  The protrusion of the globe  was now more than  an inch ; the pupil largely
dilated the  iris motionless, and  vision lost, except the mere power of distinguishing
Iicht from darkness.  In November, the conjunctiva of the globe, which had hitherto
remained nearly natural, became of a deep red, while the cornea lost its transparency,
and then slouched, the humours escaping, and the iris protruding in an irregular dirty-
looking mass?  The inflammatory, sloughing, and ulcerative  process, by which the
cornea had been  destroyed, in  this  case, resembled what Magendie  has described
as the consequpnce of dividing the nerve of the fifth pair in animals:  it was probably
owin<r to an analogous cause, as the morbid growth which caused the protrusion, must
certainly have compressed, or otherwise injured the infra-orbital, and perhaps the oph-
thalmic branch of the  nervus trigeminus.  The evacuation and subsidence of the globe
        88 
698
PROTRUSION OF THE EYE.
did not diminish the patient's sufferings, nor the external swelling, which, on the con-
trary, still increased.  As the complaint had now been progressive for  many months,
in spite of active treatment, both local and general, and as the health, although in other
respects good, was suffering under the constant severe pain, I proposed  to remove the
contents of the orbit, being persuaded that the operation afforded the only remaining
chance of relief: the patient readily assented  to the proposal, and the operation was
performed on the 6th of December.  The palpebrse were freely separated at their ex-
ternal commissure, and  then turned aside, so as  to expose fully the anterior aperture
of the orbit, the entire contents of which were  detached from the cavity, by dissecting
close on the surface of the latter, first below, then above and at the sides, until the
posterior connexion alone was left.  The latter was then divided by a knife curved
on its flat surface, the patient experiencing excruciating but  momentary agony when
the muscles and  nerves were divided.  The mass, which was hard, completely filled
the orbit, so that the dissection  was necessarily carried on close to the bone, and per-
formed slowly.  As the ophthalmic artery bled  profusely, a conical  compress  of lint
was  introduced into the  cavity, and held for 6ome time on the vessel.  This was re-
moved in the evening, without  renewal of hemorrhage.   The divided commissure of
the lids was  united by two  sutures, and  the tumid upper eye-lid closed the front of
the orbit.  He took thirty drops of laudanum at night.  7th. He slept at  intervals,
and passed a comfortable night; bloody fluid had oozed between the lids, but there had
been  no actual bleeding.  The palpebrse are swollen and bright red; the  face is flushed,
and he  has slight headach, thirst, and foul tongue.  (Twelve leeches round the mar-
gin of the orbit; saturnine lotion; a dose of calomel and jalap.)   The  inflammatory
and febrile symptoms had disappeared on the next day, and the pain of the brow, head,
and cheek which had distressed the patient for so many months, was almost gone.
Recovery now proceeded rapidly and uninterruptedly, the surface of the orbit granu.
lating, and producing a vascular substance, which filled up a large part of the cavity;
rest and appetite returned, and the patient soon regained his flesh, strength, and good
looks. He left the hospital perfectly well on the 28th of December.   The right eye,
which had been  sympathetically  affected before the  operation, regained  its full
strength.
   The mass removed from the orbit consisted of the collapsed and shrunk eye-ball in
front, with a hard  and  incompressible substance behind, extending lo the point, at
which the nerves  and  vessels had been  divided.  The recti  muscles, unaltered in
colour or texture, covered this substance, the exterior of which had the usual appear-
ance  of the orbital fat, except that it was more dense.  An incision was carried from
before backwards, directly through the centre of the entire mass.   An apparently
recent coagulum of blood separated the sclerotica from the  choroid coat, the  latter,
with  the retina, being compressed by the coagulum into a thick cord, extending from
the optic nerve to the iris.   There was no trace  of the humours.  The sclerotica was
unchanged:  the morbid growth adhered to it closely behind,  and the optic nerve pro-
ceeded through the centre of the mass.   The latter was a dense compact structure
of scirrhous firmness, resisting the edge of the knife; its exterior consisted of a light
grey  texture, very  much like that of a scirrhous breast, while in the interior this was
intermixed with a light yellow, yet firm substance, resembling what is seen in scrofu-
lous diseases.   I use the term " scirrhous" merely to describe the sensible  characters
of the structure, and not to convey an opinion that it was of carcinomatous  nature.
I did  not entertain the slightest apprehension  that disease would  return:  yet, on re-
viewing the  history of the case, and comparing  with its course the bulk and  texture
of the morbid growth, I could not doubt that the latter would have continued to enlarge,
and the sufferings of the patient to increase, had the disease been left to itself.
   Mr. Mackenzie has  related  a case  in which  the globe  was  occa-
sionally protruded, the cause and nature of  the  affection  being  quite
obscure.
  " The patient was a cooper by trade, and was admitted at the Glasgow Eye Infir-
mary, for  catarrho-rheumatic ophthalmia affecting  chiefly  the  right eye.  After he
had attended for a few days, it  was discovered that if he stooped forwards, although
only for a few minutes, he felt as if something was filling or  pressing above his right
eye, which immediately began  to protrude: on raising  his head, the protrusion was
very striking.  In this state he saw indistinctly with the eye.  It  soon began to  re-
tire, and in a few minutes was  in its natural place.  He had the complete power  of 
TUMOURS IN THE ORBIT.
699
moving the eye, when in its natural situation, and moved it considerably even while it
was displaced.  The iris  moved naturally.  He complained of considerable pain  in
the orbit, which was relieved by venesection, and the use of mercurial purges.  He
stated that the protrusion of the eye commenced about five years before his applica-
tion at the  Eye Infirmary, after carrying a heavy load on his back.  It was difficult to
assign  any satisfactory explanation of  the case." (Practical  Treatise,  edit. 3. p.
280; note.)                                                        F
    SECTION V.--INDURATION OF THE ORBITAL CELLULAR TEXTURE FROM
                         SLOW INFLAMMATION.

  "I  have  repeatedly seen,"  says Mr. Mackenzie, "the cellular sub-
stance near the front of  the orbit become hard  and tuberculated, in
consequence of slow inflammation, occasioned by an injury.  In one
instance a piece of limestone  struck the  outer edge of the orbit, pro-
ducing a lacerated wound of no great extent, and which readily healed.
Some time after, a small hard  swelling formed at the site of the injury,
was extirpated, and was found to contain a minute fragment of lime-
stone.  After some months, another small tumour made its appearance
in the same spot, and in connexion with  it another, attached  so firmly
to the edge of the  orbit, that it was taken for an exostosis.   In a few
weeks, a third  circumscribed  swelling was discovered  running along
the  lower edge of the orbit, more moveable than that last mentioned,
but  firm to the touch as a  piece of cartilage.  The  patient was under
the  care of Mr. Samuel Clarke of this  town,  whom I  assisted at  the
removal of  the  tumours.   The two  which felt so  like exostoses, lay
partly  within  the  orbit, and  adhered firmly to  its periosteum.   On
making a section of them, they presented the white striated texture of
scirrhus.   The extirpation was accomplished after a semilunar incision,
running parallel  to the outer and  lower  edge of the orbit, and every
particle of indurated substance  was carefully removed.   Nearly a
year has elapsed since the operation, and there has been  no return  of
the disease."   (Practical Treatise, p. 265.)
                  SECTION VI.--TUMOURS IN THE ORBIT.

   The cellular texture in the orbit, like that in other parts, may become
 the seat of the various adventitious growths called tumours.   These
 may be sarcomatous, steatomatous, or encysted, the latter  being  met
 with much more frequently than  the two former  kinds.  Sometimes,
 but rarely, tumours in the orbit have been of malignant character.
   The encysted tumours may contain watery fluid, a viscid fluid  like
 white of egg, or various thicker matters, so as to come under the tech-
 nical denominations of meliceris,or atheroma: in two or three recorded
 instances they have contained hydatids.
   From the limited space which  the orbit affords  for their increase,
 these productions  interfere with the  other important contents of the
 cavity, and often seriously injure  the optic nerve or the globe by their
 pressure  They may arise in various parts of the orbit; and  they grow
not unfrequently at some distance from its anterior aperture. As they 
700
TUMOURS IN THE ORBIT.
enlarge, they push the globe forwards, and stretch the optic nerve, at
the same time displacing the former downwards, upwards, outwards,
or inwards, according to the part of the cavity in which they are pro-
duced,  Ultimately they may thrust the eye out of the orbit and between
the lids, so as to cause complete exophthalmia.  According to the de-
gree of pressure or displacement, imperfection or  loss of sight  takes
place.   Sometimes they are attended with pain from the first; in other
cases we do not suspect the disorder until sensible displacement of the
globe, and impaired vision  have occurred.  Finding no other sufficient
cause for these symptoms,  we carefully examine the anterior aperture
of the orbit, when we may be able to discover obscurely the presence
of a swelling.  The enlargement  of  this, with the  aggravation of the
other symptoms, in process of time renders the nature of the affection
unequivocal.
   When the  existence of a tumour in the orbit has been  ascertained,
the most advisable course, indeed the only effectual means of removing
the complaint in the great  majority of instances, is that of extirpation
by a surgical operation.  The sooner this  is accomplished the  better.
The growth  of  the disease, and its consequent pressure on  the  globe
and optic nerve, may not  only thrust  the eye out  of its  socket, with
more or less considerable  deformity, and injury or loss of sight, but
may also cause absorption  of the orbit, at its upper part, and thus affect
the brain.
   The mode of  proceeding in the operation will vary according  to the
position and  size of the tumour.  If it should not be large, nor extend
deeply, an external incision may be made through the integuments near
the edge of the orbit, and parallel to the course of the fibres of the orbi-
cularis.  This incision should be ample, in order to facilitate the expo-
sure and dissection of the tumour.  In some instances, when the swelling
is large, it may be necessary to resort to  the expedient of slitting  up
the external canthus, as in the extirpation of the globe, and to remove
the tumour from the inside of the lid.   We must  then detach it from
its surrounding connexions  by a cautious dissection, keeping the knife
close on the surface of the tumour, that the  neighbouring parts may
not be injured.  As  the wound is deep when we  come to the back of
the tumour, and speedily fills again with blood after sponging, the ope-
ration is conducted by feeling and anatomical knowledge, rather than
by sight.  The  danger and difficulty, however, are  not  considerable
enough to induce  us  to follow the example which some  have  set, of
separating the  part behind by  dragging with the fingers  or  by  the
blunt silver  knife.  We  must proceed slowly,  and  the object may
then  be accomplished with the ordinary scalpel without  risk.   Firm
hold may be  taken of the swelling when it  is exposed, with a  double
hook or a ligature passed  through  it, and thus the detachment will be
facilitated.   If hemorrhage should  continue after the operation has been
concluded, the patient  should go to bed, and  have the lids and  neigh-
bouring parts sponged with cold water until the  blood ceases to flow.
The edges of the  wound  may then  be approximated, either by  means
of sutures or otherwise; and the best dressing will consist  of a soft rag
or doubled piece of lint kept damp with cold water, or a portion of lint
thinly spread with spermaceti  cerate.  To fill such a wound with ex- 
TUMOURS IN THE ORBIT.
701
traneous substances, such as lint or  sponge, is the most likely way to
produce  secondary hemorrhage, or inflammation, and  suppuration; it
cannot answer any useful purpose.   The impropriety of such proceed-
ings in the  treatment of wounds generally has been long recognised;
why should a remnant of the ancient  practice be preserved in wounds
close to the eye-ball, and very near the brain, and its membranes?
  Steatomatous tumours.—Morbid growths removed from the orbit have
sometimes been mentioned under the name of steatoma, but without an
exact description of their composition and nature.  Hence, as that term
is often used loosely, we cannot determine whether these steatomatous
orbital tumours  were properly so called, being encysted and containing
fat, or whether  they were of the sarcomatous kind.
  Dr. Hope removed  from the orbit, in a  girl of eighteen, a tumour
which had been  growing  seven years.   At first it did  not  appear out-
wardly, but it increased gradually, and formed a firm swelling, reaching
from the internal to the external angle, protruding the lower lid, and
thrusting the globe upwards and outwards, so that the  pupil was three
quarters of an inch further from the  nose, than that of the other  eye.
Vision  was imperfect, but not lost.   It was removed by an incision
carried through  the integuments of the lower eye-lid.   It proved to be
a spherical swelling, smooth and even, about the size of  a small pigeon's
egg, extending  nearly to  the back of the orbit, and of " carnous sub-
stance."  The eye gradually receded to  its  natural position, and vision
was completely restored.  (Philosophical Transactions,  No. 474, p. 194.
Phil. Trans, abridged, vol. x. p. 251, fig. 61.)
   Dr. Monteath has shortly mentioned two  cases, in one of which there
was relapse of disease.
  "The first was in a young girl. The  tumour was in the upper and outer side of
the orbit.  In order to get at it, I was obliged to cut across, perpendicularly, the whole
breadth of the upper eye-lid, and dissect back the two flaps. The  tumour was nearly
the size of a plum, and reached as far back as the eye-ball.  It was slightly encysted,
perfectly organized, and of anomalous texture.  The healing of the wound was rapid,
and, contrary to my expectation, the eye-lid united perfectly, and regained very nearly
its natural power and  extent of motion.  The eye-ball did so also, and the vision was
perfect  This girl went to England some months after, and I was concerned to learn
from the surgeon, under whose care  she was, that  the  tumour had begun to  grow
again.
  "The second case was in a young adult woman.   The disease was of two years'
standing before I  was consulted, and had produced  hideous exophthalmos. It was
found impracticable to extirpate the tumour without also removing  the eye-ball, which
was accordingly done.  The tumour exceeded  the  size of the eye-ball, lay directly
behind it, and so completely encircled the optic nerve, that the latter was diminished
one half in thickness by the pressure of the tumour.  The vision had been rapidly de-
clining previously to the operation.  This tumour was exceedingly hard, of anomalous
texture and  surrounded by a layer of condensed cellular substance.  The anterior
aspect of the tumour touched and pressed upon the posterior aspect of the eye-ball, but
had no connexion with it, except through the medium of the optic nerve and of the
cellular substance.  This young woman has continued well for twenty  months, and is
in perfect health."'  (Translation of Weller's Manual of the Diseases of the Eye, vol.
i. p. 195, note.)
   Langenbeck removed from the orbit of a  woman, forty years of age,
a " steatomatous tumour," which was connected to the globe and its
muscles.   The swelling, situated behind  the lower lid, reached from the
inner to'the outer angle, and extended to the upper margin  of the orbit; 
702
TUMOURS IN THE ORBIT.
 it was firm to the feel, and somewhat moveable.   The eye was pushed
 upwards and inwards, but natural in appearance; the iris exhibited its
 usual motions, but vision was lost.   The lids were separated at the ex-
 ternal commissure, and the tumour was then dissected away by cutting
 through the conjunctiva.  The  globe gradually returned to its proper
 position, the deformity caused by its displacement was  completely re-
 moved, and the patient was able to see the smallest objects before she
 left the  hospital.   (Ein Beytrag zu  den abnormen Metamorphosen in
 der Orbita, mit der Erscheinung von Exophthalmos; in the Neue Bibli-
 othek fur die Chirurgie und Ophthalmologic, vol. ii. p. 238—240.   Tab.
 i. fig. 1.)
    Another case of steatomatous swelling, related by Langenbeck, ex-
 emplifies the serious  results which  occasionally follow the operation.
 The patient was a healthy robust man, forty years  of age.   The  ope-
 ration presented no difficulties,  and  after its  performance,  the globe,
 which had been considerably protruded, returned to its natural situation.
 In the  course of the day restlessness, loss of speech, involuntary dis-
 charge of feces and urine took place, and the patient died comatous on
 the following morning, in spite of large bleeding, and cold applications
 to the head.  It was afterwards discovered that he had been intoxicated
 with  spirits the evening before the operation.   No morbid  appearances
 were discovered, except in the anterior lobe of the brain, on the side of
 the operation, and in the corresponding  superior  surface  of the orbit.
 They showed all the traces of inflammation, such as change of colour
 and purulent  exudation.   There was no  communication  between the
 tumour and the cavity of the cranium.  (Lib. cit. p. 241—244.)
    Langenbeck removed from a  lady of thirty, a  steatoma, which had
 caused not only considerable protrusion of the eye, but also a conspicu-
 ous enlargement of the external  side of the orbit.   Violent pain of the
 head  had attended the origin and development of the deformity.   The
 patient recovered favourably from the  operation ;  the headach ceased ;
 the eye  partly returned to its  situation in the orbit, but the unnatural
 prominence of the latter,  in its temporal region, was unaltered.  After
 some months, periodical  pains in the head returned, and became more
 and  more  violent; coma and death ensued.   The body was not exa-
 mined.   (Lib. cit. p. 244.  Tab. i. fig. 3.)
    Medullary tumours  in the orbit.—Case.—T.  Larkin  sixty-five years of age, a
 labourer from the county of Kent, of swarthy complexion, and spare  habit, who had
 generally enjoyed good health, excepting  that he had experienced  two  attacks of
 ague,  which is common in his part of the county, came under my care in St. Bartho-
« lomew's Hospital, on May 10, 1838.  Two years previously he had  observed a swell-
 ing coining forwards from under the upper edge of the left orbit, which, as  it in-
 creased, pushed the eye forwards  and  inwards, causing dimness of sight, and  some-
 times double vision.  A year ago he began to feel  pain in the region of the orbit, par-
 ticularly towards the  inner  canthus:  it was worse at night than in  the day.  The
 eye had not  been dry.   At the time of admission there was a tumour under the upper
 and outer edge of the left orbit, nearly  as  large  as the  last joint of the thumb.
 The eye, still covered by the palpebrse, was pushed forwards and inwards ;  vision
 very imperfect;  objects situated laterally could be seen indistinctly; the lachrymal
 secretion normal.  The tumour was even on the surface, with a sense of fluctuation,
 or, at least, of softness. It obviously passed back  into  the orbit, and  might be pre-
 sumed, from the protrusion of the globe, to occupy the posterior portion of the cavity.
 There was pain at night, sometimes preventing sleep.  We considered that the case
 was either encysted tumour or medullary growth.  A small puncture was made in 
TUMOURS IN THE ORBIT.
703
 the softest part of the swelling on the 12th, when a dessert spoonful of turbid yellow-
 ish fluid was discharged.  A director introduced into the opening passed nearly to the
 back of the cavity.  No hemorrhage ensued :  the apparent bulk of the swelling, and
 the position of the eye were not altered.   The puncture soon healed; and T pro-
 ceeded on May 19th,  to  remove the swelling.   When denuded  by division of the
 skin and orbicularis palpebrarum, it was  found of reddish colour, very vascular, and
 of soft consistence, so  that it  quickly gave way when  I attempted to insulate  it by
 dissection.   The handle of the scalpel  passed with perfect ease through the swelling
 to the  back of the orbit.  I therefore scooped out the soft substance with the  finger
 and  the knife handle, as perfectly as I could, leaving a large excavation between the
 roof of the  cavity and the orbital contents.  There had been profuse bleeding through-
 out the operation, and  blood flowed freely from the surfaces  exposed.   The sides of
 the  external wound were brought together;  the patient  placed  in bed; and cold
 cloths, frequently renewed, were laid on the eye and  forehead.  The oozing of blood
 had ceased before night.   The case went on quite favourably; the  eye did not pass
 back into the orbit, but its projection was lessened, and the patient  represented that
 his vision was improved.  He left the  hospital in the beginning of July.  I saw him
 again more than a year after.   There was a little preternatural fulness in the former
 situation of the swelling, but no distinct morbid production.   He promised to come to
 me immediately  if there should be any ground of alarm ; but I have not seen him
 since.
   The morbid growth in this case was so soft, that it broke down under slight pres-
 sure of  the  finger  or  instrument.  A  director or the handle of  a knife  passed
 through  it almost without the feeling of resistance.   It was rather friable than of
 brain-like consistence.  The  colour was reddish  grey; the vessels numerous  and
 large, and  blood issued from  all  points as if from  a  sponge.   In colour, consistence,
 and vascularity, it closely resembled some soft malignant growths, which came under
 my observation about the same  time in other parts of the body ;  particularly one in
 the thigh and another in the fore-arm,  both of which ended fatally after operation.
   In the  following  two cases, fungus hgematodes, or a  disease equally
 malignant, occurred in the  orbit as a separate tumour,  which affected
 the  eye-ball merely by pressure.
   Case I.—Large medullary tumour in front of the orbit, extirpated; relapse of
 disease in  the neck, and death.—A man, thirty years of age, of good  constitution and
 health, was received into the surgical clinic of  Heidelberg, in February, 1831, had
 a  large tumour occupying the  front of the right orbit, which had begun  to grow nine
 years before.  He had at this time an inflammatory affection of both eyes, with impaired
 vision.  The left recovered;  but the sight of the right became  worse and worse,
 and was at  last entirely lost.   At the same time a small excrescence appeared between
 the eye and the lower lid, and gradually increased.  It was as large as two fists when
 the patient came under the care of professor Chelius at Heidelberg.   It was of a deep
 red,  ulcerated at various points, and bleeding freely, even when slightly touched.
 The mass was extirpated in February, 1831.   Its structure was  medullary or cere-
 briform, firmer at  one  part, softer, to  the consistence  of jelly, in  another;  it was
 partly dark coloured, partly lighter.  The eye-ball, entire, but diminished in size,
 was  found  at the upper and  anterior part of  the  tumour.   The  sclerotica was not
 perforated at any point, but it  had become thick and hard at the entrance of the optic
 nerve.   The cornea could be still distinguished, and a portion of the  iris.  The crys-
 talline was shrunk  and  ossified, the ciliary processes  still distinguishable, as well
 as remains  of the pigmentum and  retina.   The optic nerve was  considerably elon-
 gated and reduced in size, but healthy in  structure.   The healing  process went on
 favourably, and the patient was allowed to leave the clinic in April.  In September
 of the same year he was seen in excellent health, without any return of disease.   Intel-
 ligence wae  afterwards received that  this  patient died from a swelling, which ap-
 peared in the lower part of the neck, and extended in front of the chest*
   CASe II.__Medullary tumour in front of the orbit, extirpated; relapse of disease.—
 A  Hebrew  girl, seven years old, struck  the right side of the head against the ground

   * Disertation sur le Fongus medullaire de fCEil; these presentee a la Faculte de Medecine,
&c. par. F.  Bauer, Paris, 4to. 1830, p. 41—44.  The external appearance of the swelling
is represented in plate 2, fig. 1. 
704
TUMOURS IN THE ORBIT.
in a fall, receiving no other injury than a slight graze of the skin, near the external
angle of the eye.  Three weeks after, a small swelling, not differing in colour from
the  rest of the skin, appeared on the middle of the right  upper eye-lid.  This in-
creased rapidly, and  soon became reddish, instead of white, which it had been origi-
nally.   It was twice punctured without any other effect than  the escape of some
clear blood.   When  the patient entered the surgical clinic at  Heidelberg, eighteen
weeks after  the fall, the  swelling  was as large as a  goose egg, deep red, with a
shining surface, which exhibited numerous vascular anastomoses.  It  was  moveable,
and soft.  It covered the eye completely, but there was no reason to suppose that the
organ  was involved,  as the patient had been able to see a little fifteen days  before.
The tumour was removed, together  with the eye-ball, on the 13th of October, 1820.
It was solid, of sarcomatous and medullary composition, in  some parts even  cartila-
ginous; it contained  numerous vessels.  In three weeks the cicatrization was nearly
completed, but in the fourth  week a small tumour showed itself near the internal
angle of the eye, and increased so rapidly, that it was again removed  on the 27th of
December.  It was  now discovered that  the  tumour extended through  the orbital
parietes towards the  nose.   In a few days  the growth  reappeared ;  but the termina-
tion of the disease was not known.  (Lib. cit. p. 45—48, plate 2, fig. 2.)
  Encysted tumours.—Encysted tumours are  much  more frequent in
the orbit, than those of the sarcomatous kind.   In the greater number
of cases, the cyst  is thin, and its contents are an aqueous or glairy fluid :*
under such circumstances, the nature of the disease  may be indicated
by  the  characters of softness  and  fluctuation  in  the swelling.   If the
cyst should  be thick, and the  contents of greater consistence, the case
cannot be  distinguished  from  that of  a  fleshy  tumour.  Encysted
growths  of the  latter kind  must   be  extirpated.   The serous  cysts,
which  contain watery fluid  or hydatids, may be obliterated  by the in-
flammation  consequent on puncture and exposure of the cavity.  A
knowledge of this circumstance, which will be fully proved  by cases
subsequently related, is of great importance where cysts, in consequence
of  their magnitude, and  close connexion to the  globe and  other sur-
rounding parts, cannot be extirpated without sacrificing the contents of
the orbit generally.   Beer removed the globe with  the  cyst in such a
case.   (Lehre, vol. ii. p. 589, note.)   That this  severe  proceeding is
not necessary, will appear clearly  from  facts to be adduced presently.
   Langenbeck had under his care a young man with a swelling  under
the upper and outer part  of the orbit, which pushed the eye downwards
and inwards.   It projected  externally, and fluctuation  could be felt in
it.   When  an incision had  been made  through  the  integuments, and
the tumour  was  denuded, it proved to  be a shining white transparent
bladder, as  large as a pigeon's  egg, which was  removed entire.  It
contained fluid.   (Lib. cit. p.  241.   Tab. i. fig. 2.)
   An interesting case of orbital encysted tumour is related in the fourth
volume of  the Medico-Chirurgical  Transactions,^ by Mr. Barnes, of
Exeter.  The patient was a healthy youth of seventeen.  " The tumour
was situated beneath  the eye, occupying a very considerable portion
of  the orbit;  the eye in  consequence being pushed into the upper part

  * The encysted tumours which I have found between  the globe and the  orbit, have
always been of the aqueous kind (hygroma,) and have appeared, either as a  swelling of
the lachrymal sac (dacryops,) or as an hydatid of the lachrymal gland."  Beer, hehre, vol.
ii. p. 589. He mentions, however, in  a note,  that he had met, in one instance, with a large
watery cyst external  to the lachrymal gland.
  t Case of a double  encysted Tumour, the posterior cyst of which, situated deeply between
the eye-ball and the floor of the orbit, was attached to, and partly contained a tooth, p. 316—
321.  Plate 1, figs. 1  and 2. 
TUMOURS IN THE OREIT.
705
of that cavity, so as to be almost wholly hidden behind the upper lid.
On turning it backwards, it appeared to extend to a very considerable
depth ; and it projected so much in front, as to constitute a very striking
deformity."—" The ciliary edge of  the  lower  tarsus, with a few scat-
tered hairs  in  it, crossed the front of the tumour, rather above its
middle;  the conjunctiva, drawn forwards from  the eye-ball, greatly
stretched, but  not apparently much altered in structure, investing it
above; and a thin skin of a deep red, loaded with purple vessels, covering
it below;  but neither of them closely adherent to iL  The portion of
the tumour  in  front was soft, and  could be moulded into  different
shapes by the fingers;  the posterior division felt more elas'ic."  He
could not elevate the upper lid, but when it was lifted, so as to expose
the pupil partially, objects could  be  imperfectly distinguished.  There
was scarcely any power of moving  the  eye to different points.  " The
swelling was first observed in early  infancy, and was  at that time not
much larger than a pea.  It increased but slowly, until  about four or
five years since, when it began evidently to enlarge, and for some time
it grew rapidly.  Latterly it  had not advanced  much.  The sac ad-
hered firmly to  the  outer angle and part of  the lower  edge of the
orbit;  elsewhere its connexions  were loose.  It was found to extend
almost to the bottom of the orbit, and  to  occupy more of  the cavity
than the eye itself did.   The  contents were evacuated by a puncture,
in order to get room.   On the inner  side, and about an inch  from the
edge of  the orbit, the  sac seemed to embrace a sharp bony process
arising from the surface of  the cavity, but slightly  moveable,  as  if
attached to the periosteum only.   This body was removed without dif-
ficulty, together with the connected  portion of the cyst;  it turned out
to be a tooth.   The tumour was made up of two cysts, separated by
a deep groove all round, but indissolubly united in the centre.  The in-
terior of the  front cyst  was rough, with a little chalky matter  adhering
to it.   The contents were a compact lardaceous substance.  The inner
surface of the  posterior sac  was smooth, excepting a part near the
tooth, where it  had much the appearance of coarse skin with many
pores in it.   The contents  were partly  a whey-coloured fluid, and
partly a yellow curdy substance.  The eye gradually sunk to its natural
situation,"so  that, within a fortnight,  it was nearly on  a level  with the
other.  The  vision of  this eye was perfect, but its motions were very
limited.
  Dr. Bushe published  in the  lancet,  " a case where the right eye, and
a large encysted tumour, were successfully removed^  In November,
1826, J. Albatt seven  years of age, was, without any known  cause,
affected with protrusion of the right eye, which  gradually increased.
In April, 1829, there was considerable exophthalmia, with total loss of
vision, and a great tendency  to torpor.  A tumour could be felt above
the globe, which was pushed  downwards and forwards. Some of those
who saw'the case supposed, from the situation of the swelling, its rapid
growth, and the accompanying cerebral symptoms, that it  was a fun-
gus from the anterior lobe of the brain.   As there was no affection of
the brain in the commencement, Dr. Bushe considered that the alarming
symptoms arose from the pressure of the tumour on the brain, and pro-
posed extirpation, to which the parents consented when the progress of
       89 
706
TUMOURS IN THE ORBIT.
 the disease  had  caused more serious symptoms, viz. coma, partial pa-
 ralysis of the left side of the face and upper extremity, with a dilated
 and immoveable condition of the pupil.   The commissure  of the lids
 was divided, and the tumour partially separated from the orbit: it was
 found so closely  connected to the globe, that it could  not be removed
 without the latter.  " I, therefore," says Dr. Bushe, " drew the contents
 of  the orbit downwards and forwards, by inserting a curved  needle,
 armed with a strong  ligature, through  the  edge of  the  tumour and
 globe of the eye; I now cautiously proceeded to detach the tumour at
 its  posterior part; but, before I  had proceeded  far, I was  not  a little
 surprised to find, that what I had anticipated was correct, viz. that the
 tumour pressed on the anterior lobe of the brain, the posterior and su-
 perior part of the roof of the orbit being absorbed; however, I cautiously
 pursued the separation of  parts  to the  foramen  opticum, and finally
 divided the optic nerve and recti muscles with a curved scissors.  Slight
 hemorrhage followed the operation, but was easily restrained by a por-
 tion of sponge.   In ten  days the wound had nearly healed, and the little
 patient was walking about without any inconvenience." (Lancet, 1827-8.
 vol. ii. p. 430.)   No  description  is given of the extirpated parts;  an
 omission  which  detracts greally  from  the value and  interest of the
 case.
   Case.—Immense cyst in the orbit, containing serous fluid, treated by incision and
 obliterated by subsequent inflammation and granulation.—The following case, which
 is related by Delpech, in the second volume of his Chirurgie Clinique, (P. 92—98.
 Plate xxxv.) is that of a girl, twenty-four years old, in whom the disease  began at the
 age of three, after a fall, in which the back of the head struck the ground.  The accident
 was  followed by pains in the head, which soon  went away;  but the  right eye began
 to project, and became inflamed ; sight was lost, the globe was thrust out of the orbit
 and between the lids, so as to form the apex of a large tumour.   When this patient
 was received into the hospital Saint Eloi, at Montpellier, a conical tumour, more than
 six inches in height,  seemed to issue from the right orbit.  Its circular basis measured
 nearly twelve inches in circumference, and contained a bony ridge, which was easily
 distinguished as the anterior aperture of the orbit enormously enlarged.   Correspond-
 ing alterations had necessarily occurred in the form and position of the superciliary
 ridge, the temple, cheek, and upper jaw, as well as in the angle of the mouth, which was
 depressed, and in the  nose which was strongly turned towards the left.  The eyebrow
 and the eye-lids, singularly stretched, were seen at the circumference of the swelling.
 A line, scarcely perceptible above and below, marked the ciliary margin of the latter,
 in which there were a few cilia.  The tumour with the exception of its central and
 prominent part, was covered  by the conjunctiva, converted, by exposure to the air for
 twenty-one years, into an artificial cutaneous texture, but still delicate and suscepti-
 ble of occasional  inflammation.  The situation of the cornea was marked iD the apex
 of the cone, by a small surface of a light blue tint. The tumour generally was elastic
 and fluctuating, and the fluctuation  was  more manifest at  the apex, and  in the situa-
 tion of the lower lid. Professor  Delpech concluded from the  good constitution and
 perfect health of the patient, together with the history of the case, and the state of parts
just detailed, that the disease was a cyst developed in the bottom of the orbit; and
 that an attempt to procure its obliteration might be made with a fair prospect of suc-
 cess.  He punctured  the swelling a little behind the situation of the ciliary margin
 of the lower lid, when a limpid or rather slightly yellow serosity escaped.  He then
 enlarged the opening horizontally, to the extent of two inches, and introduced his
 finger into the cavity, which  he  found to be lined throughout by a thick membrane
consolidated with the parts on which it was expanded.  Towards the centre, the pa-
rietes of the swelling were scarcely thicker than elsewhere, so that the globe must
 have been shrunk and nearly effaced.   The swelling subsided considerably after its
evacuation.  The interior of the cyst  was filled with  bundles of charpie tied with
 waxed thread, which  were renewed every six days.  The discharge, at first serous, 
TUMOURS IN THE ORBIT.
707
 became opaque, and  then purulent.   The febrile disturbance concomitant on the sup-
 puration was attended with pain  in  the stomach and bowels,  thirst, and  occasional
 vomiting; and these symptoms lasted, in spite of all remedies, until the introduction of
 foreign substances into the cyst was prevented by its obliteration. For the first month, the
 cavity underwent no diminution.  On the sixtieth day the swelling had shrunk to one-
 half its former size, and the cavity was reduced to  a small sinus.   In three months
 the cicatrization was complete; the swelled parts then shrunk  rapidly, and were re-
 tracted towards the orbit; she left the hospital in good health at the end of four months.
 When she was seen after the lapse of twelve years, the parts had completely retired
 within the orbit, of which the dimensions were greatly reduced ; and she wore a simple
 black patch.
   Case of hydatid in the orbit, with protrusion of the globe, and blindness; removal
 of the hydatid by an operation;  recovery of sight.—A peasant, twenty-five years of
 age, experienced, in the beginning of 1820, sharp pain in the right eye, which he com-
 pared  to that  caused  by a foreign substance under ihe eye-lid.   It disappeared soon.
 In January, 1821, he had a severe pleurisy, with inflammation of the same eye, which
 went off, but left the sight weakened.  It is probable that the protrusion had begun
 then, though the patient had not observed it.  In a short time inflammation of the eye
 returned, with swelling of the lids and pain.  Ultimately sight was lost.  The patient
 came to the hospital  Saint Eloi in November, 1822.  The eye was then considerably
 displaced, distending the lids, which covered it imperfectly.  The iris was motionless,
 the pupil fixed, and vision was gone.  There was a little redness of the conjunctiva.
 The integuments of the palpebrse were raised by a tumour, which  was particularly
 distinguishable towards the external angle, and distended the  upper more than the
 lower  lid.  There was a deep-seated and rather equivocal fluctuation in the swelling,
 from which, together with the other  circumstances  of the case, Monsieur  Delpech
 thought it probable that the swelling was caused by a  serous cyst.  He made a curved
 incision along the outer half of the upper lid, the external angle and one-third of the
 lower  lid.   Alter the orbicularis had been divided, the lachrymal gland came in  view,
 displaced from its fossa, and  enlarged.   The projecting part was removed to give  room.
 A serous cyst was soon discovered, but it could  not be completely denuded until the
 levator palpebrae superioris had been cut through in half its width.  The cyst was now
 punctured, and about three ounces of nearly colourless serous fluid escaped. Imme-
 diately a white membranous mass presented at the opening; when  seized, it readily
 came out, and proved to be a large hydatid (acephalocyste.)  The cyst was found, on
 examination, to be merely a condensation of the cellular membrane.  The eye now
 returned to its situation.  The cavity was gently filled with pieces of agaric, tied with
 waxed thread.  The  pain and fever in the evening required bleeding from  the arm.
 On the fourth day some of the agaric had been pushed out of the wound; the dressings
 were renewed, and were repeated every day till the twelfth, when the wound would
 only admit a small bit of lint.  On elevating the upper lid, which had been swelled
 after the operation, and was  now reduced in size, the patient discovered that he had
 regained his sight; the iris  now moved again, and the pupil exhibited the usual  varia-
 tions in size.   On the fifteenth day the sinus was obliterated, and the patient left the
 hospital, completely cured, in a month after  the operation.  The  eye had regained its
 natural situation, and  its vision was nearly equal to  that  of the other.  (Delpech in
 lib. cit. p. 99—104.)
   I consider the practice followed by Professor  Delpech in these cases,
 of filling the cavity, after  the operation, with charpie or agaric, highly
 objectionable,  as  likely  to excite and  keep  up serious  inflammation.
 That  the objects  we have in view can  be accomplished without  it, is
obvious from a case which I have related elsewhere, (Medico-Chirurgi-
cal Transactions, vol. xvii.  p. 44—46,)  as well  as from  the following
example.
   Case of cyst in the orbit, containing hydatids, and causing protrusion of the globe;
puncture  of the cyst, and  subsequent obliteration.—.« Charles Rowell,  forty-two
years of age, was admitted,  under  my care, into  the London Ophthalmic Infirmary on
the 3d  of January, 1820, with protrusion of the globe from the orbit by a deep-seated
tumour which had been growing  for  seven  years.  He had applied  at the infirmary
in  an earlier period of the affection, when the unnatural  prominence of the eye-ball 
708               ANEURISMAL AFFECTIONS IN THE ORBIT.

was distinctly marked, but vision had not become impaired.  I could then feel ob-
scurely, under the superciliary arch, a small firm protuberance, which seemed to be
part of a deeply-seated swelling, and 1 considered that extirpation of this growth by an
operation afforded the only chance of relief.  The patient was averse to this measure,
which was not strongly recommended, and he discontinued his attendance.   The com-
plaint had slowly increased, its progress having been attended with great pain, which
for some months had been so severe, both day and night, as to cause emaciation and
general weakness.  When this patient was admitted into the infirmary, the  tumour
had advanced so far between the upper and inner portion of the eyeball and the eye-
lid as to have thrust the globe  completely out of the orbit.   The upper  lid, greatly
stretched  and inflamed,  covered  the eye and the tumour; the lower was  completely
everted, and its membranous lining appeared as a thick fleshy mass.  The conjuncti-
val  covering of the globe was thickened  by chronic inflammation, the consequence of
exposure.   The structure of the eye was uninjured: the pupil round, and about in the
middle state ; the iris motionless.  Vision was destroyed.  The tumour was firm, and
apparently fixed to the orbit: it afforded, on pressure, an obscure sense of fluctuation.
To  relieve the distention and pain, and acquire some further insight into the nature
of the disease, a puncture was made into  the most prominent part of the swelling, and
about a  dessert spoonful  of clear watery fluid escaped.  Considerable diminution of
suffering  ensued.  When I examined  the part  two days afterwards, I found a soft
opaque white substance in the puncture,  and proceeded  to remove it with a pair of for-
ceps;  it proved to be an hydatid, and a few others escaped when pressure was made
on  the  swelling.  Some more  came  away on the following day, and I afterwards
cleared  out the whole collection, amounting  to half a tea-cup full, by enlarging the
puncture and injecting water forcibly into the sac.  The hydatids varied in size, from
that of a filbert to that of a small pea; some were entire, others collapsed.   Inflamma-
tion and suppuration of the cyst followed  without much  pain; the discharge then gra-
dually diminished, and the opening closed in about a month.   The eye returned to its
natural  situation, and all uneasiness ceased.  In  March, the  only traces of the com-
plaint were a loose and  wrinkled state of the integuments of the upper  lid, and the
eversion of the lower, which was gradually diminishing by the  application of lunar
caustic to  the thickened  conjunctiva.   A  little motion of the iris and slight perception
of light had returned."  (Lib. cit. p. 48—50.)
            SECTION VII.--ANEURISMAL AFFECTIONS IN THE ORBIT-

   In the following  two cases the disease  called aneurism by anasto-
mosis, of which  the nature is hitherto imperfectly understood, existed
in the orbit, and  was  remedied by a surgical operation.
  Case I.—Aneurism by anastomosis in the orbit, cured by the ligature of the com-
mon carotid  artery.—"Frances Stoffell, (aged thirty-tour, a  healthy active wo-
man,  of fair  complexion, middle stature, and the  mother of five children,) on the
evening of the 28th of December, 1804, being some months advanced  in pregnancy,
felt a sudden  snap on the left side of the forehead, which was attended with pain, and
followed by copious  effusion of a limpid fluid into the cellular substance of the eye-
lids on the same side.  For some days preceding, she had complained of severe pain
in the head, which was now increased to so great  a degree, that  for the  space of a
week she  was unable to raise it from the pillow.   The cedematous swelling surround-
ing the orbit  was reduced by punctures; an issue was set in the temple for a smart
attack of ophthalmia, which supervened, and leeches and cold washes  were applied.
She now first perceived a protrusion of the globe of the eye, which affected  the sight,
and a circumscribed tumour, elastic to  the  touch, about  as large as a hazelnut, ap-
peared upon  the  infra-orbitary ridge.   Another softer  and more  diffused swelling
arose, at the same time, above the tendon of the orbicularis palpebrarum.  The lower
tumour communicated,  both to the  sight and touch, the pulse of the larger arteries;
the upper gave the sensation of a strong vibratory thrill.   The swellings grew slowly,
and the skin between the eyes and that  of the lower eye-lid became puffed  and thick-
ened.  The globe of the eye was gradually forced  upwards and  outwards, and  its
motions were considerably impeded.  She had a constant noise in her head, which, to 
ANEURISMAL AFFECTIONS IN THE ORBIT.
709
her sensation, exactly resembled the blowing of a pair of bellows.  The pulsatory
motion of the tumours was much increased by agitation of mind, or strong exercise of
body.  But the most distressing of her symptoms was a cold obtuse pain in the crown
of the  head,  occasionally shooting across the forehead  and temples.   Se was com-
pelled to rest the left side of the head  on her hand when in the recumbent  posture,
and found the beating and noise  to increase sensibly  when her head was low and un-
supported.  Mr. Travers found that the thrilling tumour at the inner canthus had a
loose woolly feel, was very compressible, and  when firmly compressed, offered slight
pulsation.  The veins of the superior lid were  distended and varicous, and those on
the sides of the nose were turgid.   "The lower tumour could be  emptied or pressed
back into the orbit,  but the  pulsation  then became violent;  and from  the increased
pressure of the globe upon the roof and side of  the orbit, the pain was insupportable.
Careful compression of the temporal, angular and maxillary arteries produced no effect
on the  aneurism.  Upon applying  my thumb  to the  trunk of the common carotid, I
found the pulsation  cease altogether, and the whiz of the little swelling was rendered
so exceeding faint,  that it was difficult to determine whether it continued  or not."
The common carotid artery was tied on  the 23rd of May, 1809; the pain in the head
was immediately numbed, and the noise in the head entirely ceased ; the small tumour
over the angle of the  eye  still thrilled,  but very obscurely.  The recovery from  the
operation was favourable, and at the end of four months the tumours were  smaller,
and their motion materially diminished;  the eye was less projecting, and the dull pain
but rarely felt.   On the 28th of October, she experienced miscarriage with profuse
hemorrhage.   This  was followed by diminution of the swellings, and entire cessation
of pulsation:  the projection of the  eye  was also lessened.   In  May, 1811, no vestige
of the  disease remained, but a knob of  the size of a  pea, over the inner angle of the
eye.  I saw this patient two or three years after the date  last mentioned; she con-
tinued  perfectly  well.   (Medico-Chirurgical Transactions, vol. ii. p. 1—16. Plate 1.)
  Case II.—'Aneurism by anastomosis  in the left orbit, cured by tying the  common
carotid artery.—-Dinah Fielh, aged forty-four, delicate and sickly, being then preg-
nant with her sixth child,  was seized in the middle of the night with an intense pain
in the  left  eye-ball, accompanied by a whizzing noise in the head, which grievously
distressed her.   The attack  was instantaneous:  hearing a noise as of the cracking of
a whip, and feeling an extraordinary pain in the left eye, she awoke in great pain,
and leaped out  of bed.  Inflammation of the eye and swelling of the  lids came on,
with almost  intolerable anguish in the left eye-brow and at the bottom of the orbit,
and acute pain over the whole side of the head.  The extreme violence of the pain
abated  the following night, but  the swelling of the lids was  rather increased.   No
further change took place in the next seven weeks,  at the end of which she was de-
livered.  Subsequently she lost the power of elevating the upper eye-lid, and became
totally  blind on  the diseased side.  At the end of eight or nine months, there  was
constant and acute  pain, chiefly referred to the bottom  of the orbit: but the great-
est suffering  arose  from  an unceasing noise  in the  head, compared to  the  rip-
pling of  water, and  becoming  insupportable whenever the  head fell below a certain
level.  The left eye-ball was protruded,  so as to distend the upper lid, and immoveable.
The cornea was transparent, the iris motionless, the pupil fixed, and a fawn-coloured
appearance was seen behind the lens.   The  palpebrse were swollen, and  the lower
everted, so as to form a bright red convex swelling.   The tumid  parts were soft and
elastic  to the touch, but contained portions of a firmer  feel, which  communicated  a
vibratory thrill on pressure.   The  integuments of the forehead, above the inner end
of the eyebrow, and  those on the inside of the nose, were elevated into a soft undefined
tumour, giving a faint tremulous motion to a finger placed upon it.  The veins of the
face generally3 were turgid.  Pressure on  the common carotid artery nearly stopped
the pulsation about the eye.  The common carotid artery was tied by Mr. Dai.rymple,
on the 7th of April,  1813.  " The effects of the operation were immediate and decisive.
As soon as the ligatures were  tied, the  pulsatory motions of the tumours on the fore-
head and cheek entirely ceased; but a slight  thrilling was still  perceptible in  the
tumid upper eye-lid.  The red swelling of the lower eye-lid became  paler, and its
surface shrivelled.  A  few minutes after the patient  was placed in bed, she was quite
free from pain and  the noise by which  she had been so  long tormented having now
also ceased she declared that her head  no longer felt like her old head."  At the end
of two  year's from the operation, Mr. Dalrymple says that the cure appears complete,
with the exception of the sight which is irrecoverably lost.   No pulsation can be felt 
710
ANEURISMAL AFFECTIONS IN THE ORBIT.
 in any of the branches of the temporal and fascial arteries on the side of the operation.
 (Medico-Chirurgical Transactions, vol. vi. p. 117—122.)
   Mr.  Guthrie has recorded an example of true aneurism of the oph-
 thalmic artery on both sides, which terminated" fatally.  The globe was
 protruded, but vision was scarcely affected.   Hissing noise in the head
 was distinctly  heard, and attributed to aneurism.   On the death of the
 patient, an aneurism of the ophthalmic artery was discovered on each
 side, of about the size of a large nut.  The ophthalmic vein was greatly
 enlarged and obstructed near where it passes through the foramen lace-
 rum orbitale superius, in  consequence of a great increase of size  the
 four recti muscles had attained, accompanied by an almost  cartilagi-
 nous hardness, which had been as much concerned in the  protrusion of
 the eye as the enlargement of the vessels."   (Lectures on the Operative
 Surgery of the Eye, 2nd edition, p. 168.)
   [My friend Dr. John C. Warren of Boston relates in his valuable work on
 Tumours, a very interesting case of aneurism in the orbit which occurred
 spontaneously in a servant girl  18 years of age, who was admitted  into the
 Massachusetts General Hospital May 4th, 1829.  Little more than a year before,
 she began to experience a strange feeling in the internal angle of the right eye,
 at the anastomosis of the fascial ophthalmic and frontal arteries, which soon ex-
 tended to the head, and was  accompanied with a pain so severe that though
 otherwise in perfect health, she was obliged to give up work.
   At the period of her admission  into  the hospital, " there was a small tumour
 at the internal angle of the right eye, just above the lachrymal sac, as large as
 a hazelnut.  It had an active  pulsation which extended into the surrounding
 arteries.  The pulsations of the fascial were very strong; and by compressing
 it, the vibrations of the tumour were much lessened.   Compression of the tem-
 poral artery produced no change.  The skin over the tumour was slightly
 reddened, and there was a sensible increase of heat, the carotid  artery had an
 increased pulsation, pressure on this artery suspended the pulse of the tumour.
 The stethoscope applied to the carotid and fascial arteries, gave the saw-mill
 sound.
   " Having observed the  case for  a few days, I performed the following opera-
 tion on the llth  of October.  A small  incision was  made  between the tumour
 and the cavity of the orbit, the pulsation of the anastomosing branch of  the
 ophthalmic was discovered, and a  ligature passed round this branch.  Next an
 incision was made across the fascial artery below the tumour, and after allow-
 ing it to bleed  about eighteen  ounces, a compress was applied to include  the
 artery and sac.  On  the division of the  fascial the pulsation ceased, and  the
 patient was relieved from her  bad feelings.  On removing the compression,
 three days after, a slight  pulsation was  perceived.   The  wounds healed  im-
 mediately, and the patient finding  herself very comfortable, was  discharged on
 the 1st of June, although the pulsation had not wholly ceased.  This was done
 at her own request, and I was disposed  to believe that the  cutting off the sup-
 ply from these two vessels, must be followed by a disappearance of the tumour.
 The frontal branch was not divided at this time, because there was no pulsation
 in it.
   " My expectations were disappointed.  In the latter part of October of the
 same year, she entered the hospital again, a very slight pulsation was discerni-
 ble in  the tumour.   The internal angle  of the other eye had a pulsation
 somewhat stronger than that in the right eye.   The  arteries leading into it,
 had  strong pulsations, the carotids on both sides, especially  on the right,
throbbed violently, so  that she sometimes said she felt as if ' the top of her
head was flying off.'   The  upper  part of the face and forehead were red  and 
AFFECTIONS OF THE MUSCLES IN THE ORBIT.
711
 swollen; and on the whole, there was a  great aggravation of disease.   I was
 at a loss how to proceed under these circumstances, as the disease now ap-
 peared equally on the left  and on the right  sides, and extended apparently to
 the whole arterial system of both.  It seemed therefore proper to begin the effect
 of general remedies.  The  patient was ordered to be kept perfectly quiet, to live
 as low as possible; to have blood taken  from  the arm and leeches applied fre-
 quently to the head;  and she also  took  the tincture  of digitalis.  These mea-
 sures were followed by no favourable effect.  I  therefore laid bare  and pene-
 trated the temporal artery  of the right side, allowed it to bleed freely, and then
 divided it.  No permanent mitigation of symptoms followed, the vibrations and
 their distressing consequences remained  unmitigated.  There  seemed but one
 course remaining—that  of tying both carotids,  or rather of tying one, and if
 this did not answer, the other.  On the  2nd of  January 1830,1 tied the right
 carotid.   The pulsations of the right side  were immediately relieved.   Those of
 the  left side continued for a time, then slowly  subsided, and on the 3rd of
 March, she was discharged perfectly well.
   " There are two important pathological facts brought into view by this case.
 The first is the sympathy of the arterial system of one side of the head with that
 of the other.  The vibratory action  of the vessels  of the right side, produced
 corresponding vibrations in those of the left.  Hence arose some embarrassment
 in the treatment of the case; since it seemed  probable that the cure of the origi-
 nal affection would leave behind  it  a disease equal in amount to itself;  and it
 never could be determined  whether  this would be the fact, but by actual experi-
 ment.   In the period of disease which succeeded the operations on the fascial,
 ophthalmic,  and temporal arteries, the phenomena were in truth more conspicu-
 ous on the  left than on the  side originally deranged.   So very striking were
 they, that I was entirely at  a loss whether the ligature of the right or left carotid
 would be most likely to be useful.   The perfect success, from tying the right
 carotid, showed that the affection of the left side was altogether sympathetic;
 yet  certainly it is  remarkable that  two great  arteries like the carotids, should
 seem to be so much under  the influence of the nerves, as to take on this sym-
 pathetic action; unless  we deny the doctrine that the pulsations of the great
 arteries  are dependent  principally on the action of the heart, and allow that
 they act from their own power."  (pp. 400—4.)
   Dr.  Warren briefly alludes also to another similar case, in which there was a
 pulsating tumour  at the inner angle of the right eye following a blow on the
 part.  This  tumour affected the vision of that eye;  and extended into the orbit
 so that he could not  reach  the  ophthalmic branch within the tumour, he there-
 fore tied  the  carotid artery, but without any alleviation of the disease.  He
 would then have attempted the angular arteries;  but the patient refused, left the
 hospital and he lost sight of her.   (Op. cit. p. 407.)
   My friend, Dr. Isaac Parrish, has also  recorded an interesting case of aneu-
 rism in the  orbit, in a boy, resulting from a blow.—See American  Journal of
 the Medical Sciences for Oct.  1841.]

         section viii.—AFFECTIONS of the muscles in the orbit.

   Injuries.__The muscles  may be injured  in penetrating  wounds of the
 orbit; and  hence the movements of the  globe  may  be subsequently im-
 paired, or it  tnay be turned in some unnatural direction.   An example
 is  afforded  in a case quoted from Beer in the first section of the present

 C Paralytic affections.—Paralysis of the levator  palpebras superioris has
been already considered  under the head of  Ptosis, in Chapter II.  § IV.

p.  133. 
 712            affections of the muscles in the orbit.

   I have mentioned  incidentally paralysis  of the muscles supplied by
 the nerve of the third pair.  See p. 73.  In this affection the upper eye-
 lid falls, and cannot  be raised by voluntary effort.  The eye cannot be
 moved upwards, downwards, or inwards;  it is drawn outwards by the
 unopposed action of the external straight muscle.  As the ciliary nerves,
 of which the source  is derived  principally  from the nerve of  the third
 pair  are involved in  the paralytic  affection, the iris is motionless, and
 the pupil dilated.   This state of the pupil causes imperfection of vision,
 more or less serious; if, however, the  disease is  confined  to  the third
 nerve, the patient will be  able  to  see well by looking through a small
 aperture in a card.   The optic  nerve is sometimes involved, with con-
 siderable  and alarming injury of sight.
   Under  the circumstances  now mentioned, the eye-ball is nearly mo-
 tionless ;  and as it cannot move in accordance with the  sound eye,
 squinting  exists.
   If the pupil should not be largely dilated and the retina should be unaf-
 fected, sight may not be materially impaired, but there  will probably be
 double vision.
   If  the external straight  muscle should be  paralyzed as well as the
 others, the globe will be quite fixed.  Sometimes, but  rarely, this mus-
 cle is paralyzed alone ; the eye will then be turned inwards by the action
 of the adductor.
   Loss of power  in  the muscles of the eye, like other paralysis, is ge-
 nerally caused by sensorial disorder, either  of apoplectic character or
 of milder nature; and it is then frequently combined with other paralytic
 affections.   It may arise from organic disease, such as change of struc-
 ture in the brain, tumours or other diseases  affecting the nerves at their
 origin, or in their course to the orbit.   If it ever  depends on slight ex-
 ternal causes, such as exposure to cold, the occurrence is  rare.
   When all the muscles of the orbit are paralyzed, the globe is no longer
 supported and maintained  in a proper position;  it falls forwards, push-
 ing out the lids, and  might possibly bulge between them.  This state,
 which is very rarely seen,  is  called ophthalmoptosis; probably it might
 also be produced by division  of the muscles from  external injury.
  As paralysis of the muscles of the globe, considered pathologically,
 is analogous to  other paralytic  affections, the treatment  must  be con-
 ducted on the same principles.   Our  attention will be directed  in the
 first instance to  the state  of  the sensorium; and  any disorder in that
 quarter must be rectified.   Should the failure  of the means adopted for
 that purpose, or other indications  lead to the belief that organic mis-
 chief has  occurred, the prognosis will  be  very unfavourable.   If  the
 complaint should owe its origin  to any  obvious  external  agency, or to
 disorder in any other  quarter not seriously involving the head, we shall
 probably be able to remove or at least to relieve the affection.
  Irregular motions.—An irregular movement of the eyes from side to
 side, of involuntary character, is seen in those born blind, or who have
 lost their sight at an early age.  This  is a  consequence  of blindness;
the habit of fixing the eyes either  has  not  been acquired, or has been
lost.   Unsteady  and involuntary movements of the eyes are sometimes
seen where vision has been lost at a later period.  Such motions, either
oscillatory or of irregular  character, may occur  in conjunction with 
SQUINTING.
713
 sensorial or other nervous affections, or may be symptomatic of irrita-
 tion in remote organs;  they have been  designated  by the term nys-
 tagmus.*
   Spasm of the orbital muscles, with more or less severe pain, (tetanus
 oculi) is a very  rare  affection: it would probably not be idiopathic,
 but symptomatic of disorder  in some other quarter.   The  treatment,
 depending on the cause would be the same as that of other spasmodic
 diseases.
   The  harmony  of motion between the two eyes may be disturbed in
 so sliuht a degree as to be perceptible only in its effect on sight.  Thus
 double  vision {diplopia)  may arise without  that  conspicuous want of
 correspondence between  the eyes, which constitutes squinting.  We are
 generally able to discover, on  close inspection, that  the two eyes do
 not move accurately together.
   Patients sometimes  see well with one eye, but experience confusion
 when both are open.   This state which  has been called monoblepsis,f
 and the preceding condition of  diplopia, are merely symptoms of sen-
 sorial or retinal disorder, not distinct diseases.
   Squinting ; strabismus.—If the want of  harmony between  the two
 eyes proceed  to such an extent, that one of them does not move with
 the other, but is turned away involuntarily; the case is termed squinting,
 or a cast  in  the eye, technically, strabismus.   (The  term is  Greek,
 <rTe»fitTft,es; from crTecc/Ztfy  to squint.)
   The  affected eye may be turned to the inner  angle, in which case
 the cornea is  directed towards the nose, or to the outer angle when the
 cornea  has the opposite direction: these states are called respectively
 strabismus convergens and divergens.   The  former is  by far the most
 frequent; of the latter  there will probably  not be more than one or two
 cases in a hundred.
   Mr.  Lucas  says, that  in some hundreds  of cases of squinting, sub-
 mitted to his  observation, there was only one of the  divergent kind.
 (Practical  Treatise  on the cure of Strabismus;  p. 47.)  Mr. Duffin
 had seen only three out of upwards of four hundred  cases.   (London
 Medical Gazette; vol. xxvii. p. 48.)   He makes, however, a different
 statement in  another  passage; (Ibid, p. 79,) viz., "out of upwards of
 four hundred cases that I have examined, 1 have  only met with fifteen
 examples"  (of divergent  squint.)
   [Of 100 cases reported by Mr. Estlin of Bristol, 92 were affected with conver-
 gent and 8 with  divergent strabismus.  (Provincial Medical Journal July
 23d, 1842.)  Of 200 cases operated on by Mr. C. R. Hall of Manchester,
 148 had convergent, and 32 divergent squint.  (London Med. Gaz. Jan. 1841,
 p.  642.)  Of 72 cases operated on by Dr. F. A. Ammon of Dresden, 63 had con-
 vergent  and 9 divergent strabismus.  Of about 40 cases observed by ourselves
 one only was of divergent strabismus.]
   The greater frequency of the converging squint may in some degree
 be accounted for  by the circumstances that  the internal  rectus is

 * The meaning of  this word, which is derived from  vi/<tt*£» to wink, is rather vague.
Blancard defines it " vel palpebrarum, vel bulbi oculi, imo iridis, seu uveas, alternus mo-
tus rapidus et continuus, vel oculorum instabilitas.  hexicon Medicum, a Kuhn.
 t From *ovo; single, and ,3x4" s'gnt-  7 he Ialter  word' wh,ch seems reSular^ de"vcd
from Sxww to see, has been  coined for the occasion: it is not in the dictionaries.
       90 
714
SQUINTING.
stronger than the outer recti, that its insertion  advances  nearer  to the
margin of the cornea, [see p. 83,] and that in our habitual employment
of the  eyes they are turned inwards much more frequently than in any
other direction.
  The eye may be directed a little upwards or downwards in con-
verging strabismus.
  Deviation of the globe upwards or  downwards is extremely rare;
the former has occurred  after the  operation of dividing the  internal
straight muscle.  (London Med. Gaz. vol. xxvi. p. 977.)
  If the sound eye be closed, the squinting ceases; the affected  organ
resumes its proper direction, and  can be moved freely in obedience to
the will.  When the sound eye is re-opened,  the squint  is immediately
reproduced by an involuntary movement of the globe.
  There are instances in which the eye is fixed  in the abnormal posi-
tion, and remains  unmoved  even when  the sound one is closed: this
state has been called luscitas.   Sometimes the motions of the squinting
eye are  limited, even when the other is closed;  for instance, in the
converging squint, the patient  may be able to bring the eye into the
centre of the orbit, but not to move it outwards.
  The vision of the squinting eye is generally more or less defective;
but this is not invariably the case.  Speaking of the cases in which  he
had operated, Dr. Franz says, " In all the affected eyes, weakness  of
sight existed to a greater  or less extent;  many of them were perfectly
myopic.  Muscae volitantes, photopsia, nystaxis or nictitatio palpebra-
rum, occurred in a few cases.  Where the eye was much inverted, the
pupil was observed to  be dilated when  the eye was in this  state."
(Medical Gazette; vol. xxvii. p. 41.)
  [Of the 200 cases observed by Mr. C. R. Hall, in all but two the power of
vision of the squinting eye was more or less impaired; and in all the cases of per-
manent strabismus we have  met with, there was a difference in the power of
vision of the two eyes, with  one exception only.]
  Inequality of power in  the two eyes is said  to be the cause of squint-
ing, in the  numerous instances  of young persons  more  especially,
where it cannot be traced to  any other obvious influence.  It is said
that the stronger of the two eyes is used  in vision, the impression  on
the weaker organ  being neglected;  hence the latter is turned aside, so
that it does not interfere with  the correct sight of the other.  The va-
lidity of this explanation is  at  least  doubtful.   In young persons, who
are the most frequent subjects of  the complaint, it is difficult to ascer-
tain satisfactorily the comparative  powers of  the  two  eyes.   In the
numerous cases of  amaurosis confined to one eye, we have the oppor-
tunity  of seeing defective vision in  all  its  degrees; generally, without
squinting.  In the exceptional instances, the wrong direction of the eye
may be referable to sensorial  affection, and not to the  state of sight.
Disparity of power in the two eyes is common;  and one is often con-
siderably weaker than the other; yet strabismus does not occur.
  The  imperfection of visual power  is probably in most cases  the
effect,  and not  the cause  of strabismus.   The  squinting eye becomes
weakened by want of employment.  Hence we account for the im-
provement of sight represented as a frequent  result of the operation by
which  the proper direction of the eye is restored.  If the eyes should 
SQUINTING.
715
ave
 have been previously unequal  in power, and the squinting should h„,
 been caused by such disparity, no benefit to vision  can  be  expected
 from that operation.
   Another cause of imperfect vision in squinting is that the rays of
 light do  not strike on the most sensible  part of the retina, viz. that
 which  corresponds  to the visual axis: they come in contact with  the
 membrane  towards its circumference.  An operation  which restores
 the eye to its natural position,  improves sight by remedying this  source
 of imperfection.
   A person  who squints,  seems to  be near-sighted, because he  cannot
 see an  object in the most  distinct manner, that is, with both eyes at
 once, unless he  brings it near to his face.  When farther off,  it  is seen
 with the sound  eye only.  This kind  of near-sightedness  ceases after
 the operation.
   Double vision generally attends squinting on its first  occurrence: it
 goes off in a few days.
   The  degree of squinting differs in different instances.   The eye may
 be a little turned inwards, so that the deviation escapes  notice without
 close observation: the inner edge of the  cornea may correspond to  the
 internal canthus; a part or nearly the  whole of the cornea may be
 buried in the internal angle.
   The  abnormal direction of the eye may be constant, except when  the
 sound organ is closed.  In other and  numerous cases, it is only occa-
 sional, being observed under certain circumstances, especially when  the
 patient  looks attentively at objects, or under various states of mental
 excitement;  at other times the  appearance and movements of the eyes
 are natural, and we can see no defect.
   Squinting  is  generally  confined to  one eye.   The  motions of both
 may be irregular, so that  sometimes  one squints, sometimes the other.
 Occasionally, there is a general want of  control over the ocular  move-
 ments, so that we are puzzled to determine which eye squints, and  on
 which an operation  should  be  performed.  When, by binding up the
 sound eye, the defective organ  has been brought into exercise, and has
 regained its natural  power  of  motion, squinting has  sometimes  taken
 place on the other  side:  under the like circumstances, the complaint
 may again change sides.
   Squinting may occur in both eyes, which are in such cases defective,
 usually  near-sighted, and limited in  their  mode and extent of exertion.
   Squinting  is  sometimes a temporary  defect,  owing  its origin  to
 causes of short duration, and disappearing when they  cease to operate.
 The double vision of drunkenness is probably caused by slight strabis-
 mus. More frequently it is permanent, even though it should have
 originated in temporary causes.  It is often aggravated by occasional
 circumstances,  such  as  mental affections, disorders of the digestive
 organs,  and determination of blood to  the head.
   Causes.—Preternatural contraction  of one of the recti may be brought
 on by disorder in the sensorium; which may be vascular conjestion,  as
 in  impending apoplexy, acute or chronic inflammation, as in the various
 forms of  hydrocephalus,  organic change,  such  as softening,  the de-
 velopment of various new growths in the  form of tumours or tubercles,
irritation or pressure from disease of membrane, bone, or other contigu- 
716
SQUINTING.
ous structures.   Strabismus with double vision is a frequent premoni-
tory sign of apoplexy.  It  sometimes occurs in the beginning,  some-
times at a later period of hydrocephalus ; or it may be seen occasionally
in conjunction with heat and pain  of the head, and other evidences of
vascular fulness, as a forerunner of active  mischief, and an indication
for the employment of preventive measures, in children who have shown
a disposition to hydrocephalus.
   The origin of the disease is frequently dated from an attack of con-
vulsions  at  an  early age;  or from some other circumstance involving
determination of blood to  the head, such as violent coughing, particu-
larly in the  hooping cough.  It has sometimes followed serious injuries
of the head  or the orbit.
   Mental emotions  are considered  to have  brought it on in some in-
stances; and they cause temporary aggravation of the affection  where
it exists already.
   In young children it is seen not unfrequently in conjunction with in-
disposition caused by teething: here the muscles of the eye are probably
affected through the medium of the sensorium.  In such cases it some-
times disappears  with the cessation of the  cause.  Disorder  of the
stomach or of the intestinal canal  is a frequent source of the complaint,
particularly in children, causing temporary strabismus, which becomes
permanent  if neglected.   The irritation of worms and an  overloaded
stomach will act in this way, also costiveness, with the general  imper-
fection in the digestive and assimilative process, which that implies.
These disorders of the digestive organs may disturb the head, and thus
influence the muscles of the eyes: but they may also act directly on the
latter; at least, we  see squinting  produced when the alimentary canal
is out of order, without any evidence of cerebral disturbance.
   Squinting may be induced by  causes acting  directly on the eyes,
 such as injuries of the globe, chronic inflammatory complaints, particu-
 larly strumous ophthalmia,  and the inflammations consequent  on  the
 exanthemata.  Dieffenbach says  that in most of his cases " the strabis-
 mus had commenced in very early childhood after ophthalmia  neona-
 torum, scrofulous inflammation of the eyes with ulcers of the cornea,
 or after acute exanthemata, &c.  In many there were cicatrices on the
 cornea or  cataracta  centralis."*   It may be brought on by affections
 of the cornea and pupil, either singly or combined.  Such corneal opa-
 cities as leave  an access for light  on one side only will cause the eye to
 be so turned, that light may pass through the transparent portion of the
 membrane.  Displacement of the pupil  from accident or disease, its
 partial obstruction by opacity of the lens  or  capsule, or the formation
 of an artificial pupil, will have a  similar effect.  In  these cases the
 patient sees imperfectly, or not  at all, so long as the eye is directed
 normally: the squint improves or  restores vision.
   Squinting occasionally attends the commencement of amaurosis, when
 it is seated  in one eye. Perhaps the disparity between the two organs,
 when suddenly produced, may cause  the want of  harmony in their
 motions.  It is accompanied with double vision;  the latter being a

   * Casper's  Wochenschrift, July, 1840, quoted in the British and Foreign Medical Review,
 vol.  xx. p. 570. 
SQUINTING.
717
temporary inconvenience, and going off after a time, even although the
cause continues.  Squinting may coexist with confirmed amaurosis.
  The habit of turning the eye  inwards, to see an object on the nose,
such as a wart, pimple, or nsevus, has appeared  to produce squinting
in some instances ; and tumours  or other diseases on  the  edges of the
lids have had a similar effect.
  Causes of more doubtful agency have  sometimes been  assigned for
the  occurrence of the complaint; for example, imitation by children of
a squinting associate;  covering one eye for a long  time with bandage
or shade; such a position of the child's bed that the light comes on one
side or falls obliquely.   If the danger of imitation be a real one, it may
be obviated by avoiding the society of those who squint:  this is a safe
and advisable  precaution.
  The affection is sometimes  apparently spontaneous; it begins imper-
ceptibly and increases gradually in healthy children,  in  whom we  can
neither discover disturbance in the sensorium or the alimentary canal,
nor trace the action  of any injurious influence on the  eye.
  [Mr. C. Radclyffe Hall (loc. cit.) in an interesting analysis of 200 cases of
strabismus  enumerates the following, as the causes assigned and  believed by
the patients themselves, or  their parents, without vouching for the correctness
of the testimony, except where physical conditions yet remained to  substan-
tiate the opinions given.
  " 1. Convulsions during infancy, in nine cases; falls on the head, in seven; se-
vere concussion of the  brain, in one; difficult dentition, in three; hooping cough,
in two; intestinal worms, in three ; epilepsy, in two; a severe thrashing, in one;
excessive fright, in one.
  " 2. Ophthalmia which had left no opacities, in fourteen; opacity of the cornea,
in five; opacity said to have existed formerly, in one; wound of  the cornea, by
a stocking  needle, in two; by a fork, in one; by a thorn in two;  blow on the
eye, in five; burn of the eye from a piece of metal flying into it, in one; a habit
of looking at the sun,  in two ; crush from a cart-wheel going over the orbit, in
two;  amaurosis, in two; imperfect cataract, in three; exposure  during infancy
to the light and heat of  a  blazing fire, in three.
   " 3. Imitation of a squinting person, in thirty-nine ; watching the motion of a
shuttle, in one;  voluntarily trying to squint, in one; a habit of looking at a scar
on  the eye-brow, in one; at a scar on the nose, in two; at a scar on the cheek,
in two; at a small encysted tumour at the inner canthus, in one; at a small nae-
vus in the same situation, in one; at a mole on the nose, in one; a habit of suck-
 ing the thumb,  and looking steadfastly at it at  the same  time, in one; holding
the head sideways whilst knitting, in three.
   " 4. Measles,in four; small-pox, in six.
   " 5. Severe burns of the abdomen, in two.
   " In four instances, I was assured that the squint was congenital.  In the re-
maining cases of the two hundred, no causes were assigned."
  Mr Hall makes the  following judicious remarks on the manner in which these
different classes of cases produce strabismus.            „ r  u. .
   "Under the first set of the above,  are included cases m all of which, probably,
the strabismus occurred consecutively to some affection of the brain.   From the
anatomical relations of the vessels and nerves within the cranium, Mr. Lucas has
well  remarked we may account for many of those cases of strabismus which
Mow determinations of the blood  to the brain.  The  nervus abducens  is
more esoecially in close contiguity to several important blood-vessels.  During
the long-continued paroxysms of hooping-cough, and in the convulsive struggles 
718
SQUINTING.
of epilepsy, the cerebral circulation must be obstructed, and we cannot feel sur-
prise, that as one of the effects of congestion, strabismus should occasionally re-
sult, it may also happen in these cases, that the retina of the affected eye has it-
self suffered from the disordered circulation, and thus a difference of visual
power in the two  organs has arisen.   Compression of the sixth nerve in  any
part of its course, or at its origin, as in apoplexy, haemorrhage from fracture of
the skull, &c, so long  as it affects no part of the third nerve, will of course, by
inducing paralysis, occasion  convergent strabismus.   In cases of cerebral  hae-
morrhage, there is often  a temporary squint, which disappears as soon as the
origin of the nerve supplying the antagonist muscles has become  affected by the
effusion.
   " When strabismus depends on  irritation of some distant part, as where it is
caused by constipation, worms in  the intestinal canal, irritation of the fifth pair
of nerves in dentition,  or, as  it is stated, by severe burns of the abdomen,—the
whole nervous system becomes morbidly  sensible, and more or less diseased
action is often set up  in the brain, as proved by the occasional occurrence of
effusion in such cases, if neglected.  We can do little  more than surmise whe-
ther the  over-action of the at/ducting muscle arises in the first instance from
spasmodic contraction, or from impaired  contractile power of the adductor.
But, it is certain that, in the  majority of cases, after  some  years have elapsed,
the overpowered  muscle  is  only  weaker than its  antagonist, not  completely
paralyzed, though the degree of deficiency varies very  considerably.  The
habit of  squinting once formed, interstitial changes of the muscles engaged re-
sult, the over-acting one being not unfrequently hypertrophied, whilst it is rather
assumed than demonstrated that the other is in an opposite condition.
   " Causes residing in the eye itself must act in different ways in  the production
of strabismus.   When a mechanical impediment obstructs the passage of light
through  the pupil, except in  a certain  position of the eye-ball, any variety of
squint may result  from the instinctive effort of the individual to accommodate
his eye to the rays of  light:  e. g.  dense opacities of the  cornea, capsular cata-
ract where a portion has been removed, detachment of the ciliary border of the
iris with obliteration of  the  natural  pupil from  injury,  a partially depressed
opaque lens half blocking up the pupil, &c.   When the strabismus is occasioned
by ophthalmic inflammations, it may arise  from the cornea of the affected eye
being directed upwards and inwards so as to exclude the light as much as pos-
sible, and at the same  time, as Dr. Mackenzie observes, to  lessen friction from
motion of the eye-lids.  I have seen four cases of double convergent strabismus,
where the patient attributed the defect to having had sore eyes"  for a consider-
able time during childhood; the disease, from general marks of scrofula, having
been, I presume, strumous  ophthalmia.  In many instances of strabismus, the
central part of the cornea has appeared slightly nebulous;  here the obliquity
must certainly be ascribed to other effects of inflammation than the slight hazi-
ness it has left.   When one eye is inflamed for a length of time, its  retina  be-
comes morbidly sensitive, partly from sympathy  with  the  tissues more espe-
cially the seat of disease, and partly from the prolonged  exclusion of light, so
that, when once more  exposed, the natural stimulus proves too powerful, and
the eye is habitually inverted; just as, when the power of the retina is suddenly
impaired, as by looking at the sun, the other eye being closed, by amaurosis of
one eye occurring rapidly, or by one of the eyes of an infant being exposed to
a bright fire, it is turned out of the proper axis, to prevent the impression made
upon it from confusing that conveyed to the sensorium by the more perfect
organ.  I have not seen a case of divergent  strabismus  from any of these
causes.
  " Blows on the eye may lead to  strabismus either by the inflammation they
occasion, or by injury to  the  retina from the mere concussion of the eye-ball. 
SQUINTING.
719
Muscles habitually called into action gradually obtain an increase of power at
the expense of their antagonists.  The tendency to copy abnormal muscular
actions, so strong in children, is manifest in chorea,  epilepsy, and hysteria, and
we can scarcely hesitate to admit imitation as  an occasional cause of squint.
hi one family, where the mother squinted, each  of her five children presented a
similar defect; in another, where  the father,  who was much from home, was
the subject of strabismus, not one of his seven children acquired it.   In many
instances, several children in  the same family have  had squints, which, if we
credit the testimony of the  parents, the younger ' learnt' from the elder child.
I was unable to ascertain any other cause than the one assigned in every case
enumerated as  occasioned by imitation.
  " I have not seen an instance of divergent strabismus produced by the habit of
directing the eye towards some personal mark in the immediate vicinity.
  " In measles and small-pox, the conjunctiva participates more or less, and stra-
bismus may occur from one eye having suffered a higher degree of inflamma-
tion than the other; or, in variola, from a pustule having left a corneal opacity.
But without any dense  opacity of the cornea, there is, occasionally, after small-
pox, a more or less opaque condition of the capsule of the lens; or, without this,
considerable impairment of vision; so that, in  some cases, it is probable that in-
 flammation implicates  the deeper-seated structures, and by injuring vision of
one eye more than of the other, may give rise  to strabismus.  In three instances,
where the eyes appeared perfectly healthy in structure, the squint was attributed
to a habit of constantly looking at a deep pit left on the side of the tip of the
nose."]
  State of the affected muscles.—Hitherto we know little  respecting the
 pathological  condition of the  muscles in  squinting eyes.  Sometimes
paralysis exists, but these are  exceptional  cases.   As the affected eye
 comes into its proper  position, and can be moved freely outwards, when
 the other is  closed, the abductor  muscle  possesses its normal power
 in the ordinary cases of convergent  squint.  I have seen no instance
 of this  affection caused by paralysis of  the abductor.  In  most of the
 cases under my own  observation, external  squint has depended on want
 of power in the abductor muscle, the parts supplied by the motor nerve
 havino- been generally paralyzed.  Mr.  Duffin (Medical Gazette,  vol.
 xxvii.°p. 18,)  mentions a  case  of paralysis  " in  which the eyes are both
 turned outwards, the left  completely, although the  loss of  muscular
 power in the limbs is on the right  side of  the  body.  The affection of
 the eyes occurred  at the  moment of  paralytic seizure, and  singularly
 enough, is limited to the abductor muscles."  When this muscle is para-
 lyzed  the faultv direction of the eye does not cease on closing the sound
 one- 'the deviation is permanent, and comes under the denomination of
 luscitas   In  other  cases the  divergent  squint is analogous to the con-
 vergent  the power of the abductor being  unimpaired, so that the right
position'is resumed when the sound eye  is closed.
  It can hardly be  doubted that convergent  strabismus is Caused  by
abnormal  contraction of the  internal straight muscle, which,  having
been  spasmodically  affected in   the first instance  by some temporary
cause  remains permanently in a state of  morbid contraction.   Although
  his  rnuscT^:  s Jommonly spoke" of as being « contracted " or « short-
ened " no actual shortening has been ascertained by direct examination;
and  the power, which still exists, of moving the eye outwards when the
other is  closed, shows that  the  muscle  can be elongated to the natural
extent    Generally  speaking, the internal  rectus is not increased in 
720
SQUINTING.
 bulk;  nor is the external deficient in power, for  it draws the eye out-
 wards, and retains it in a proper position when the other is closed.
   When the complaint has lasted for a long time, hypertrophy of the
 abductor, and shrinking or atrophy of the abductor might be expected
 as consequences  of the affection.  If the latter should exist  in  any
 marked degree, the power of drawing the eye outwards would be im-
 paired  or lost.   Mr. Middlemore had  the opportunity of examining,
 after death, a child who had been affected  with divergent squint.   The
 external rectus of the diseased eye was much larger  than  it ought to
 have been, larger in proportion  to the other muscles of the  same eye,
 and larger than the corresponding muscle of the opposite side.  (Prac-
 tical Treatise, vol.  ii. p. 561.)   Mr. Lucas  has frequently found the
 inner rectus preternaturally large in convergent strabismus: in one case
 he considered it to be twice the  usual size; it was also red and power-
 fully contracted, so as to have  a rounded appearance,  (p. 30.)   In
 another case of convergent strabismus, which had existed five years in
 a child eight years old, with very slight power of everting the eye, the
 internal rectus " consisted of three times the natural quantity of muscu-
 lar and tendinous structure."   (p. 58.)   This hypertrophy, which seems
 analogous to the increase of bulk produced in other muscles by con-
 stant exertion, must be the effect and  not the  cause  of the  disease.
 Squinting  occurs suddenly;  muscular hypertrophy comes on  very
 slowly.   If one rectus were in a state of atrophy, squinting would pro-
 bably be produced by the unopposed action of its antagonist, and the
 eye  would not be brought into the proper position when the other was
 closed.   Such a morbid condition has never been ascertained by direct
 observation.   Actual injury of  a muscle  by a  penetrating wound of
 the orbit may cause squinting: it is a fixed squint, for the injured mus-
 cle is incapacitated.   See the case of wound in the orbit at p. 691.
   The  numerous instances,  in which squinting is merely occasional,
 the eye having at other times its normal direction and power  of mo-
 tion, and the cases of double squinting, in which the normal and abnor-
 mal  position and movements alternate on the two sides, are sufficient
 to show that there cannot be any permanent change in  the condition of
 the  muscles.   Nor do we see any such change so far as the  muscle
 comes under our view in the  operation.  It must be remembered that
 visible changes of structure are extremely rare in the voluntary mus-
 cles, and  thus that we could not expect to meet  with such alterations
 in the present instance;  the disorder, which seems to be purely func-
 tional, must be produced in the first  instance through  the medium of
 the nervous system.
   It  is represented by Mr.  Duffin that the cellular texture around the
 affected muscle is frequently found condensed and unyielding, so as to
 hold  the eye in its faulty  position, even after the tendon has been divided.
 He states that thickening and contraction  of this tissue may come on
 gradually as an accommodation  to  the  shortened state of the  muscle
 and  its tendon, and to the new position of the  eye-ball; while a more
considerable  change  is  produced if inflammatory affections  of  the
 membranes of the eye should supervene during the existence  of  squint-
 ing.  The cellular texture under the conjunctiva and between the mus-
cles  of the globe loses its softness and pliancy, and becomes condensed. 
SQUINTING.                         721
It is subsequently elongated by the motions of the eye into bands of ad-
hesion between the sclerotica and the tendon of the adductor.   " It is
these bands of fibro-cellular connexion  passing  between  the sclerotic
tunic and the under surface of the muscle and its sheath, that  in such
numerous instances retain the eye in an abnormal  position after the
tendon has been  divided, and render  so  many  cases only partially suc-
cessful.  I have  met with these bands very far back, even beyond the
greatest diameter of the globe of the  eye; and  in two cases found them
almost cartilaginous,  and so unyielding that the patients were wholly
unable to move the pupil out of the inner canthus."—" When either of
these morbid  alterations  of structure is  fairly established,  we tnay rely
on it that nothing short  of their  complete  separation  will  effectually
liberate the eye from bondage."   (London Medical Gazette, vol. xxvii.
p. 48, 49.)
  Mr. Duffin observes further, that when the eyes during childhood
have been  repeatedly affected with  strumous or  other  inflammation,
the whole of  the muscles and investing cellular tissue of  the eye may
be found in a morbid  condition, condensed, and extremely adherent to
the sclerotica.   (Ibid.  p. 16.)
  Squinting is an acquired, not a congenital defect.  If it is ever seen
at all in the latter shape, the  occurrence  is extremely rare.  " I have
not," says Mr. Duffin, " met with a single case of congenital  strabis-
mus, though, in  many  instances, the  deformity  is reported  to have
supervened a few days after  birth."   (Ibid. p. 48.)  Mr.  Lucas  (Ibid.
p. 46,) states that he  has only met with one case; we must regret
that he has furnished no details of so rare a fact.  He  says that it sel-
dom appears  until two or three years after birth.  He mentions a lady
who squinted : she gave birth to  two children with perfectly  straight
eyes; one of them began to squint at the age of three, the other at five.
  [We have several times seen strabismus in infants a few days after birth, but
we do not know that in any of them  the defect was permanent.  Within the
past year we have met with one case in which an infant a day or two after birth
was observed by  us to  have a decided  squint.  This continued until the child
was nearly two months old when it began to diminish and at the same time the
irides which were of a pale blue, commenced to change to hazel.
  When the child was four months old the  squint had  entirely ceased, and at
the age of six months the irides had become very dark hazel—almost  black.]
   Treatment.—In a  disease, which may be produced  by causes  so
numerous and  various, the treatment cannot  be  uniform.  Before we
determine on remedial measures, the history of the affection  must  be
closelv investigated, in order to discover the particular cause.    When
this has been accomplished, the proper treatment will be obvious.  The
strabismus  and  double  vision, which  sometimes attend  the com-
mencement of amaurotic or apoplectic  affections will disappear, if we
succeed in removing the primary disorder.   The same  remark is ap-
plicable, where  the disease is brought on by teething, by  vascular con-
gestion 'inflammation, or other irritation of  the  sensorium, by disor-
dered stomach,  costive bowels or worms.
  Where squinting  has been induced by injury of the  head or eye, or
by some morbid affection of the latter, such as conjunctival inflamma-
       91 
722
OPERATION FOR THE CURE OF SQUINTING.
tion or speck of the cornea, it will probably cease, if we can succeed
in remedying the cause.
  [We have had under our care two very interesting  cases of strabismus, one
resulting from some affection of the brain, the precise nature of which could not
be satisfactorily determined; the other occasioned by a fall on the head.   In both
cases vision was perfect with either eye  separately, but when the patients at-
tempted to look with both eyes,  it occasioned  such a  sense of confusion, that
they were compelled to cover one eye, to enable them to find their way about
   Both patients were cured by repeated  cupping to the head and back of the
neck, purging, stimulating pedeluviae, and irritation to  the back of neck.
   The subject of the first case after continuing well some months, had an attack
of hemiplegia.  The second patient has continued well up  to the present mo-
ment,  and the cure is doubtless permanent.]
   In the numerous cases, which arise spontaneously in young persons,
we are at a loss on the subject of treatment, because  we do not detect
the cause of the mischief.   As the  affection is often excited sympathe-
tically by  disorder in the  abdomen, we try  the  effect  at first of an
active purgative or two, and then employ such mild aperients or other
remedies as circumstances may require,  with a careful  regulation of
diet, and the general  management most  favourable to health.
   When the squint remains after cessation or removal of the cause, and
after  attention to  the several  circumstances just pointed out, we should
endeavour to strengthen  by exercise the muscle of which the action is
deficient; and we shall be particularly encouraged to  persevere in such
efforts when the vision of the affected eye is  good, and when it can be
readily brought into the proper direction  by shutting that of the oppo-
site side.   We may close the  sound eye by tying a light  handkerchief
over it during a part of the day, so  that the  patient may be obliged to
exercise the squinting eye.   At first  this  may be done for a quarter of
an hour at a time, two, three, or four times in  the day  ; and the period of
exercise may be gradually lengthened to an hour or more.  Sometimes,
when  the diseased eye has ceased  to squint under this treatment, the
other has become affected.
   Another mode  of exercise  may be adopted by older patients.  The
sound eye being closed, the other is fixed  on  some object, at which the
patient looks attentively.   He then  slowly opens the  sound eye, endea-
vouring to keep the other fixed.   This kind of trial fails at first, but the
point may be accomplished by perseverance.
   I have seen  no advantage  from  the use of goggles, black patches on
the nose, or other similar contrivances.
   Operation for the  cure of squinting  by dividing one or other of the
recti muscles.—When, according to the nature of the case, the several
means already specified have been employed, for the  removal of squint-
 ing, without success, and the disease may thus be regarded as confirmed,
 the eye may be brought  back to its normal direction  by dividing the in-
 ternal or external rectus, according as  the strabismus is convergent or
 divergent.   This  operation, of which the  idea was suggested  and the
 practicability asserted by Dr. Stromeyer of  Hanover, (In his Beitrage
 zur Operativen Orthopadik; Hanover,  1838,) was first performed  to-
 wards the end of last year (1839) by Professor Dieffenbach* of Berlin,
   * See the  Berlin Medicinische  Zeitung, No. 46, November, 1839, and February, 1840.
 The subject is mentioned, with a notice of these cases, in the British and Foreign Medical 
OPERATION FOR THE CURE OF SQUINTING.
723
who has since employed it in some hundreds of cases.  In the spring of
the present year it was introduced into practice in this country, and has
now been performed in great numbers of instances.*
   Cases proper for the operation.—The operation is applicable to cases
of confirmed squinting only.   If the disease be of occasional and tempo-
rary character, and accompanied by other irregular movements or  con-
tractions, such as those of chorea; if it be induced by causes still in ac-
tion, such as disease or injury of the orbit or its contents, disorder of the
sensorium, nervous excitement, derangement of the digestive organs;  or
if it is of recent origin, and there is a reasonable prospect  of removing
it by  the means already specified;  division of the muscle is neither ne-
cessary nor advisable.
   Nor would it be proper in strabismus from corneal opacity or changes
in the pupil.   The misdirection of the eye in these cases renders it avail-
able for  vision ;  this advantage is lost, if the squint is removed.  Since
the operation is submitted to as a remedy for deformity, it is hardly ap-
plicable  where the cornea is opaque, as that opacity will still cause  an
unpleasant appearance even if the normal direction of the eye is restored.
The removal of the  squint  in  such a case might however improve the
appearance of the eye: hence the operation might be performed, if it
should be  found that  the eye could be brought into its normal position
without injury to vision.
   Where  the squint is slight in  degree, the  effect on  personal appear-
ance  is inconsiderable, and the  operation consequently not necessary.
We must remember, too, that although the squint may be removed, the
operation not unfrequently causes changes in the appearance of the eye
quite as  conspicuous  as a slight squint;  also, that consequences rather
serious have sometimes ensued  from the operation itself;  for example,
acute inflammation of the conjunctiva  with chemosis, inflammation and
abscess in the orbit, suppuration of the globe, and bleeding to so dange-
rous an extent as to render transfusion necessary.   [This has occurred
in a single case only, and that was in  a boy of hsGtnorrhagic diathesis,
whose life had previously been  in danger several  times  from haemor-
rhage after slight injuries.]
   If  the squinting eye does not resume its  proper  position when the

Review, vol. ix. p. 558.  A short description of the operation by Dieffenbach himself will
be found in'the hondon Medical Gazette, vol. xxvi. p. 109.  He has given a more detailed
statement, with the results of his  experience, in Casper's Wochenschrift, July 4th, 1840.
There is an account of this paper in the British and Foreign Review, vol. x. p. 570.
  * The Medical Gazette and the Lancet of the present year (1840) contain several com-
munications on this subject, detailing cases in which the operation has been performed in
various parts of England, and describing modifications in  the instruments employed, and
in the mode of proceeding.   Those of Dr. Franz, Mr. Lucas and Mr. Duffin may be parti-
cularly mentioned.  In a series of papers entitled An Inquiry into some of the Consequences
and Causes of the Failure of the new Operation for the Cure of Strabismus or Squinting,
the eentleman la«t named has examined scientifically the  principal physiological and pa-
tholouical points relating to the disease and the operation; he has given judicious directions
for the latter, and has pointed out the more frequent causes of failure.
  The onlv express publications on the subject are the following two :—On the Cure of
o  • ,„„  /« th* Dimiion of one of the straight Muscles of the Eye; by C. W. G. Guthrie;
wilTa pfattf  Sv^London, 1840.   A Practical Treatiseon the Cure If Strabismus, $c. by
P  R  I ocas-with plates.  8vo. London, 1840.
  r\ number of publications on the subject have since appeared in France, Germany,  and
England, the titles of which it is unnecessary to give.] 
YZA
OPERATION FOR THE CURE OF SQUINTING.
other is closed, the operation is contra-indicated.   The unnatural direc-
tion of the eye  here depends on paralysis, or on other changes, which
the operation will not remedy.  The divergent squint connected with
paralysis of the parts supplied by the motor nerve  is a case of this kind.
  If the eye, in convergent squint, can be brought only into the centre
of the orbit, but not turned outwards, the operation  will not be completely
successful, that is, it will not give perfect freedom of motion; it may
produce partial improvement.   [We have seen exceptions to this rule.]
  The propriety of performing the operation is doubtful when the cellu-
lar texture under the conjunctiva and around the muscles has been con-
densed and indurated by repeated inflammations, as mentioned at p.
720.  These  parts, says Mr. Duffin, may be " so extremely adherent
to the sclerotica, that it would  be imprudent to detach them to the ex-
tent  necessary to liberate the globe in a sufficient  degree to admit of its
assuming the proper  position, even were the rectus, and  membranous
attachments on  the exterior of the organ to have escaped the  ravages
of the disease, but which, under such circumstances, seldom happens.
When then we find the motions of the eye very limited, and that the pa-
tient is incapable of bringing the pupil by an effort  of his  will to the cen-
tre of the orbit, having previously suffered  inflammation, either during
childhood, from accident or other causes, we  should consider well the
probable degree of success  before we operate."   In a  case, where both
eyes were operated  on, " the whole of the  investing  structures of the
inner periphery of the eye were found to  be  thickened, contracted, and
infiltrated  to such a degree, that  they cut like cartilage, and  required
both extensive and careful dissection from the sclerotica.  Fortunately
the mischief was confined to the inner portion of  the sclerotic surface,
so that when the eye was liberated at this part, the external muscle had
power to draw  the pupil into its proper situation, and the case did well.
This man had two small specks on one eye, and a nebulous opacity  on
the other. Notwithstanding this disadvantage, his  vision was  much
improved by the operation, as his eyes were previously buried in an un-
usual manner in the nasal canthus, from which position  he could move
them but in a very slight degree, being only able to bring the pupils, by
the greatest effort of the will, to a point scarcely  mid-way between the
inner canthus and the centre of the orbit."   In other analogous cases
operated on by Mr. Duffin, the abductor muscle has not been able to
draw the pupil  into the centre of  the orbit at the  time;  it has regained
the power gradually in the course of some days.  (Medical  Gazette,
Vol. xxvii. p. 16, 17.)
  The operation.—If the patient is  adult, or younger, but not unruly,
the best position is  sitting on a chair  with  a back, against which the
head is gently reclined:  the  recumbent  position  on a couch,  with the
head resting against the higher  end, is equally convenient.  A  younger
patient who cannot be depended on for steadiness, must  be placed on a
narrow table, and confined by a sheet passed over the body and  limbs;
the head  being  rested on a pillow, and well secured, as well as the body,
by a sufficient number of assistants; or the arms may  be strapped to
the body by a broad  belt, and  the patient held by a strong man, who
secures the lower limbs between his thighs, allowing the head to rest on
his shoulder or chest. 
OPERATION FOR THE CURE OF SQUINTING.            725
  The following are the steps of the operation: separation of the eye-
lids, which must be held apart so as to denude the globe on its inner or
nasal aspect; drawing the globe  outwards, to  bring  the  situation of
the internal rectus  within the view and reach of the operator; incision
of the conjunctiva; division of the muscle.  There are differences, more
or less important, in the mode of executing each of these steps, and in
the instruments employed.  The upper lid  may be raised and fixed by
the finger of an assistant, or a small silver wire speculum may be used,
either passed under the lid, or applied on  its external surface.  The
lower lid is managed with the finger, by  an assistant  or by the opera-
tor, or it is depressed and kept out of the way by a speculum.  A simple
but ingenious contrivance for this purpose is represented by Mr. Lucas.
(PI. 3, fig. 3.)  It  is a  bowed speculum, with a curved steel  spring,
fixed to the speculum at one end, and having a small pad at the other.
When the speculum is placed on the eye-lid, the pad comes under the
edge of the lower jaw, and the action of the spring keeps the instrument
in place without the help of an assistant.    Some use a  large spring ar-
tery forceps, seizing the conjunctiva in the fold between the lid and globe,
towards the  internal angle, and then letting the forceps hang by the
membrane on the cheek : thus the lower lid  is effectually kept out of the
way.   The conjunctiva may  be divided with the knife  or scissors; the
latter is generally  found the  most convenient instrument for this pur-
pose.   The  rectus muscle may be cut through with  either instrument.
The  latter is generally raised by a small curved director, or by a
slender blunt hook  before it is divided.  Hooks, directors, and knives, of
very  various shapes,  have been  used  by  different  operators.
   In Mr. C. Guthrie's mode of proceeding,  an assistant raises the upper
lid with a silver elevator or speculum, holding it with one hand nearly
perpendicularly to the forehead, and confining the  lid gently  against
the edge of the orbit, so that it may not slip, nor allow the upper con-
junctival fold to bulge  out below it.  He  then fixes  a  strong double
hook with the  other hand  into the tunica  albuginea, through the con-
junctiva at a little  distance from the cornea, in the  middle line  of the
eye.   The operator, having depressed the under eye-lid with the fore or
second  finger of the left hand, directs the  assistant  to draw the eye-
ball gently outwards with the hook, until the semilunar fold of the con-
junctiva begins to yield to the traction, when  it  should be held per-
fectly  steady on the  middle  line,  the centre of  the  pupil  being  di-
rectly under  the shaft of the  hook.   He then makes  an incision nearly
equidistant from the hook  and the edge of the semilunar fold, through
the conjunctiva and the  cellular  membrane, which may intervene be-
tween it and the tendon of the rectus muscle, directly  upwards and in-
wards towards the orbit.  Some surgeons use a small straight knife for
this purpose, some a pair of scissors, in which case the membrane is raised
by a  pair of eye-forceps at the semilunar valve, and the fold thus formed
between it and the hook divided ; but Mr. G. generally cuts through the
conjunctiva at once with a small curved  knife, which is introduced un-
der  the membrane from  below the line of the hook, the  point being
brought out upwards; or with scissors curved on the  lower edge, and
cutting sharply up to the points, which are blunt.   The  incision is to 
726
OPERATION FOR THE CURE OF SQUINTING.
be enlarged upwards and downwards, if necessary, to  at least three-
eighths of an inch, which exposes the tendon of the rectus.   This  may
be made  more distinct by the point of the knife or  scissors, whichever
is  used,  or  by the blunt  end of the small flat, curved, and slightly
grooved  director, for which the knife is to be exchanged.  The director
is now to be introduced by a gentle steady  motion  beneath the tendon,
carrying it inwards rather deeply through  the cellular membrane and
fat, so as to  be passed under the muscular as well as the tendinous part,
which causes the eye to roll a little inwards:  this should not be  pre-
vented by holding  the hook too firmly.  The point is then to be raised
by depressing the handle, when it will  appear at the upper part of the
incision,  having the muscle  on its grooved surface: this  elevation of
the tendinous attachment turns the eye-ball  outwards, so that the hook
is no longer necessary, and may be dispensed with after the first  inci-
sion is made through the conjunctiva, while in very determined persons
it need not be used at all.   The director being now held in the left hand
over the  lower  eye-lid, the curved knife is  to be run along the slightly
marked groove so  as to divide the tendon.  The operation may be done
throughout with the same pair of blunt ended curved scissors with which
it was begun, the lower convex limb being gradually introduced under
the muscle in the same manner and with the same precautions as the
director.  The eye-lid now falls,  and  the eye should  be  sponged clean.
If, when the patient opens the eye, he  is unable to turn it inwards, the
operation is completed; but, if he can do it in  the slightest degree, the
muscle, or its lateral cellular or tendinous  attachments, have not  been
entirely divided.   The scissors or director  must be again used, and the
undivided part  sought for  and incised.   A  very small portion of undi-
vided attachment, either on the under or upper part, will give the power
of turning the  eye inwards.   This effect may  be  produced  from con-
nexion either with the  rectus superior above, or the inferior  below.
In five of the cases performed the eyes would not at first turn outwards,
although the sclerotic coat was rendered distinct to all present for nearly
three-eighths of an inch every way, which indeed  ought always to be
done to ensure  success in  doubtful cases; and it was only by dividing
the additional band of membrane  or tendinous expansion I have alluded
to, in three cases upwards, and in two downwards, that the operations
were perfectly  completed.  The posterior  cut  end of the muscle is to
be pushed backward by the director away  from the other  portion, and
from the ball of the eye, so that it may unite indirectly to the posterior
part of the  globe,  and not to  its  side, and the  edges of the  incision in
the conjunctival meinbrane are to be  adjusted by the same instrument.
(On the cure of squinting, &c. p.  12—14.)
  If the method with the  scissors is  preferred, it will  be most conve-
nient to use a rather long  pair with strong blades, cutting sharply to the
ends, which are just  blunted.   The conjunctiva, raised by common for-
ceps, is divided  with these in the  inner side of  the globe, and the scle-
rotica is then dissected clear  for  the space of a finger-nail,  care being
taken to  divide every fibre and even cellular  attachment upwards and
downwards.
  Mr. Lucas recommends  that the operation should be performed with- 
OPERATION FOR THE CURE OF SQUINTING.
727
out the elevator under the upper lid, or the  double hook fixed into the
globe.  When the sound eye is closed, the patient can evert the affected
organ voluntarily.   Mr. L. therefore binds up the former with a pad of
lint, and  a silk handkerchief,  trusting to the  voluntary eversion  of the
eye for procuring a sufficient exposure of the globe on  its inner  side.
He places the patient on a chair with a back sufficiently high to allow
of the head  being moderately  reclined.  An  assistant, placed behind the
patient, raises the upper  lid and fixes it against, the edge  of  ihe orbit,
and gently depresses and draws outward the lower lid, taking care not
to cause eversion of the tarsus.  A sharp-pointed hook and a common
sharp-pointed pair of scissors are used for dividing the conjunctiva.  " By
having the hook  fixed in a cedar handle, a great degree of lightness is
given to  the instrument, so that if the patient should start suddenly,  or in
any other way struggle, so  as to  interfere with the operation, the  ope-
rator may let go  the instrument, while it is still fixed in the conjunctiva,
without doing injury to this membrane, endangering the  eye itself, or
losing its hold.                  <
   " The operator takes the hook in his right  hand, and inserts it into the
tunica conjunctiva about two  lines  or two lines and a half distant  from
the cornea, and in a line corresponding to its transverse axis.   He  then
transfers the hook to his left hand, and taking in his right hand  the sharp-
pointed scissors, he first  gently draws forward the conjunctiva, and
makes  a semicircular incision of  this  membrane  from below up-
wards,  on the outer  side of  the hook,  to   an extent  varying  from
four to  six  lines.  It may sometimes even  be desirable  to  make the
incision longer.
   " When the required section of  the conjunctiva is made, the fine
sharp-pointed hook should be  withdrawn, the eye-lids be  permitted to
meet, and the further  progress of the operation be suspended  for a few
moments; during which time, if there be any hemorrhage, the sponge and
tepid water are to be used; indeed,  whether there be hemorrhage  or
not, the application  of tepid water is always agreeable to the patient.
The eye-lids are  next to  be carefully wiped dry with  a handkerchief,
and the assistant is to secure  them as before, when the lips of the  inci-
sion of the conjunctiva will be found more or less separated from  each
other.  The  operator then takes the blunt hook in his right hand, and, in-
serting it between the edges of the divided conjunctiva,  he  insinuates
it  from  below upwards, between  the tendon  of  the muscle and the
sclerotica.   This being effected, either  totally or  partially, the  eye-
ball and  the muscle are at the complete command of the operator.*

  * In operating on  either of the recti, the exact situation of the  tendinous insertion
should be borne in mind.  Mr. Lucas makes the following  statement on this  point,  which
he has taken the trouble to ascertain.
  " In the well-proportioned eye of an adult, the centre of the tendon of  the  superior rec-
tus, and that of the inferior rectus, are at an equal distance from the cornea, viz. four lines;
the inner edges of each are about the same distance, whilst the outer edges are considera-
bly more removed, being distant seven lines.  In consequence  of this arrangement, both
muscles will fairly antagonize each other in their alternate actions of  raising the eye up-
wards and  downwards ; but in consequence of the close proximity of the  internal fibres of
their tendons to the cornea, in comparison with the distance of their external fibres from this
point, the former have much greater  power in directing the eye inwards than the latter
have in directing it outwards.
  "The centre  of the tendon of the internal rectus muscle is distant from  the  cornea about 
728
OPERATION FOR THE CURE OF SQUINTING.
  " The cellular tissue immediately behind the conjunctiva, and the sub-
conjunctival and submuscular fascia;, often afford resistance  to the pas-
sage of the blunt hook.   The former can  be easily separated  by the
point of the instrument, and  the  fascia also, but with  more difficulty.
The blunt  hook being inserted beneath the muscle, the operator trans-
fers it to his left hand, and having brought the tendon into view, he di-
vides it with a sharp-pointed pair of scissors held  in  his right hand,
as close to its insertion  as is compatible with the safety  of  the sclero-
tica.
  "If the eye be  not immediately everted, or  if the  patient has  the
power of turning  it  so  far  inwards as to conceal any  portion of the
cornea, or to hide completely the white of the eye between  the cornea
and the inner canthus, in all probability some of the  tendinous fibres
of the muscle  have not been  divided.  To ascertain if this be the case,
I have found the blunt hook the besNinstrument; it should again be in-
serted between the edges of the incision of the conjunctiva,  and by di-
recting its point upwards and downwards, keeping  it at the  same time
close to the sclerotica, the most minute tendinous filament, if undivided,
can be detected, and  its  section accomplished."   Should the eye be
still inverted, it must  be  from condensation of the subconjunctival and
submuscular fasciae, with which  there is usually combined  an unnatu-
ral firmness of the conjunctiva, and  of the cellular stratum under it.
Any condensed cellular tissue or fascia, which still draws  the eye in-
wards, must be freely divided with the forceps and  scissors.
  Mr. Lucas says, " that he  has  found no necessity for instruments to
fix the eye, provided  the patient can evert his eye when the other is
closed ; and, except in the most extreme cases of convergent strabis-
mus, he can do so : this is all that is necessary ; he can keep it so suffi-
ciently long to allow the slowest  operator  to  insert the sharp  hook
into  the conjunctiva, and when once this is  accomplished, its  sec-
tion  is  easy.   Occasionally the  eye will at this time turn  in, but this
is of no consequence, the operator has only to wait a moment or two,
and with the assistance of the hook and the patient, the eye  can be
readily turned sufficiently out to enable him to make the necessary sec-
tion of the conjunctiva.  This  being effected the blunt  hook can be
readily passed under  the muscle, and then the eye  and the  muscle are
under our perfect control."
  In a few cases,  where the inversion was very great, and  the patient
could not evert  the eye  to a sufficient degree, the simple sharp hook
was quite sufficient.
  Mr.  Duffin performs  the operation  recommended  by Mr. Lucas,
considering it to be decidedly the best in every respect.   He has never
found it necessary to  depress the lower lid by means of artery forceps,
nor to use sharp hooks for fixing the globe.   For separating and fixing
the lids, he recommends the  silver wire specula proposed by Mr. J. N.
Thompson of Nottingham.  (They are figured in  the Medical Gazette,
vol. xxvii. p. 51.)   These are  applied on the external surface  of the

three lines, its superior edge is distant four lines, and its inferior edge five lines. Contrast-
ed with the tendon of this  muscle, that of the external rectus is distant at its centre from
the cornea nearly five lines, and its superior and inferior edges are distant nearly six lines."
P. 20. [For full details  of the anatomical relation of the muscles of the eye, seep. 83, et seq.] 
OPERATION FOR THE CURE OF SQUINTING.
729
lids, and thus cause no pain; and they are fixed in handles, so that the
hands of the assistant, by whom they are held, are removed to a dis-
tance, and the region of the eye is thus left free for the operator.  " The
patient is desired to direct his eye outwards; the conjunctiva is then to
be pinched up by means of a fine forceps, and cut across with a pair
of strong scissors, nearly midway between the edge of the cornea,
and the semilunar fold of the membrane.   This opening should be made
freely, and care taken in making it to completely divide the subconjuncti-
val loose cellular tissue, so as to fairly expose the tendon from its upper
to its lower margin.   The blunt hook is then to be inserted under it, so
that when raised and  drawn to the external opening, a small portion,
may be snipped out of  it.   Should the pupil, when this  is  done, be
found not to occupy its proper situation, the hook should be introduced
again, and  any bands of fibro-cellular tissue that still fix the eye-ball
should be brought to the external opening  in  the same manner as the
tendon has  been divided; this being  repeated till the eye is perfectly
liberated.   The only point in the  operation  that requires more precise
instructions is the direction in which  the  blunt hook  should be intro-
duced, and the manner in which it should  be  made to  gently sweep
the sclerotica in search of adhesions.   This is the grand step in which
most surgeons in their  early operations fail.   They generally introduce
the hook by holding it  at a right angle with the eye, its concavity look-
ing upwards,  and thus  almost invariably miss  inserting  it under the
tendon; whereas if introduced by holding  it almost parallel with the
eye, the point  being  directed downwards, until it  reach the inferior
margin of the tendon,  and then the handle be turned carefully upon its
axis, and the hook next swept gently over that portion of the sclerotica
which it is necessary to clear, no difficulty will ever  be experienced in
passing it under the tendon, or  any thing else it may be  necessary to
divide.  After its point is turned upwards, all that requires attention is
to keep the flat side of the instrument towards the eye-ball, and its ex-
tremity in gentle contact with the  sclerotica, taking care  to make it
emerge through the external wound, by keeping the handle  well de-
pressed, and  causing  it  to obliquely cross  the  nose.  I  have seen a
great many  operators at first thrust the extremity of the hook against
the globe of the eye ;  and some, I am informed, have actually pushed
it through the sclerotic  coat, and allowed the  humours to  escape;
whilst almost  every one, from want of attention  to the last direction,
that of making the handle obliquely to cross the nose, catches its ex-
tremity under the superior tarsal cartilage, from whence only after nume-
rous ineffectual efforts, they finally  disentangle it."  (Medical  Gazette,
vol. xxvii. p. 51, 52.)
   The maxim of avoiding  all  unnecessary roughness and violence,
which ought to be observed in operations generally, is more especially
imperative in  those performed on  the  eyes.  Experience has  shown
that the adductor muscle can be easily divided without the painful ap-
plication of specula under  the lids, without fixing a spring forceps in
the conjunctiva to depress the lower lid, and without inserting hooks
into the globe of the eye.  The latter are said to  be fixed into the con-
junctiva, or  into the tunica albuginea: the latter expression is obscure;
however, if the hooks are  to be  effective  in everting and fixing the
       92 
730
OPERATION FOR THE CURE OF SQUINTING.
 globe, they must penetrate the sclerotica, and I cannot doubt that they
 pierce the choroid and  retina also.  If the patient possesses moderate
 steadiness and control over the  movements of the eye, the hooks are
 unnecessary; they are dangerous  in the case of such unruliness as to
 require that he  should be  overpowered by main force.   In general,
 however, no unpleasant results have followed the use of the hooks.
   A fold of conjunctiva may be seized and held by the spring artery
 forceps:  in this way the eye can be drawn outwards  and fixed, suffi-
 ciently for the purpose  of the operation in  many cases.  Dr. Franz
 employs  a simple  sharp hook like that used  in dissection: a  small
 sheath  for its point  is connected with  the  handle, so  that  it can  be
 moved up or down.   When the  hook has been passed under the con-
 junctiva, so  as to  take up  a portion  of the membrane, the  sheath is
 pushed down, covers the  point of the  hook, and thus gives a secure
 hold on the membrane.
   The best proceeding, in my opinion, is to separate  and fix the pal-
 pebrae, by means of the specula employed  by Messrs. Thompson and
 Duffin, and to elevate the tendon, as well as  any cellular  connexions
 that may require to be divided, by the blunt  hook devised by Mr. Lucas.
 The latter is made as thin as it can be to preserve a blunt edge, and is
 flattened on the sides.
   On the exterior aspect of the globe we can denude a larger surface,
 and with greater facility than on the nasal side.  Hence the division of
 the external rectus is easier than that of the internal.   Diverging squint
 is caused most frequently by paralysis of the adductor, and cannot then
 be benefited by the operation.  This may explain in part the unfavoura-
 ble statement made by Mr. Duffin, respecting the result of such cases
 when submitted to operation.  He says, " I have only met with fifteen
 examples; and of  the  operations  performed upon them, not one has
 been, strictly speaking  successful, although they have  been all im-
 proved in a trifling degree."   (Medical Gazette, vol. xxvii. p. 59.)
   Double1 convergent strabismus.—When  this affection exists in both
 eyes, it will be found more  strongly marked  in the one than  in the
 other.   The obliquity in the  eye least  affected  is secondary, and  af-
 fords evidence of the harmony or co-operation between the two organs
 in the exercise of vision.  If the operation  be  performed on the most
 defective eye, the other will afterwards gradually come right.  This
 however  is not always  the case.  Possibly both eyes may be affected
 in equal degree from the beginning; or  the  disease in the second eye,
 although owing its origin  to the influence of the other, may have be-
 come fully established.  Here it  is  necessary to operate on both eyes,
 but an unpleasant result has ensued in  some cases; " when the second
 eye is thoroughly relieved, the external  recti  are apt to  assume an as-
 cendency of power; and when the patient  looks at all  outwards,  to
 draw  the eye so much to the external  angle as to produce a very un-
 pleasant leer, and at the same time to render vision double."  (Mr.
 Duffin in the Medical Gazette, vol. xxvii. p. 47.)  This happened  to
 a lady in whom the operation was  performed  in the left or worst eye
 with satisfactory result.   As the  defect in the right eye continued very
 marked,  the tendon was divided on this  side three weeks  after the first
operation.  The external rectus of  the left eye now turned the pupil  so 
OPERATION FOR THE CURE OF SQUINTING.
731
  much outwards that vision became  double, and a very unpleasant leer
  supplanted the original squint.   Both  eyes were  directed  properly in
  looking at an  object directly before the patient; but if the object were
  removed  only a few inches to either side, and she looked at it without
  turning  the head, the  external rectus  of the side to which it had been
  moved, immediately drew the  pupil  to the  external angle, causing
  double vision, and a most ungainly cast.   This  defect is  now confined
  to the left eye, and not so marked as at first, so that a hope of its  ulti-
  mate  removal may be  entertained.    (Medical Gazette, vol. xxvi. p.
  978.)  Mr.  Duffin considers that  this  unpleasant  result may  be ob-
  viated by leaving  undivided, in the  second  operation, a portion  of the
  restraint that confines  the eye, in order to control the action of the op-
  posite abductor.   (Ibid. vol. xxvii. p. 47.)
    [The method of operating which we adopt for convergent strabismus is the
  following:—
    The patient is seated facing the light, on a chair without a back or on a stool,
  of such a height that his or her head will rest upon the breast of an assistant seated
  on an ordinary chair behind.   The eye not to be operated on is to be bound
  up with a compress and bandage.  The surgeon is to be seated on a common
  chair facing the patient.
   The first step of the operation consists in the separation of the eye-lids.  This
  may be effected by the assistant if he is a skilful one.  For this purpose, if the
  left eye is to be operated on, he should raise the upper lid with the fore finger
  of his right hand, and depress the lower lid with  the fore finger of his left hand.
  When the right eye is to be operated on, the upper lid is to be raised with the
 fore finger of the left hand and the lower one depressed with the fore finger of the
 right hand.  When the assistant cannot be depended on, the lids may be sepa-
 rated by a speculum; and the best for this purpose, we have seen, is the elastic
 steel  wire speculum, represented in the accompanying figure, [fig. 60.]  The
 two branches  are to be pressed
 together, one end introduced un-         ^_^^    Fig. 60.
 der the upper  and  the other un-       //""^::::::^>^
 der the lower lid; the force of       J       ^"""^v^.
 the spring then separates the lids.      //                nx
 An instrument, which also an-      //                    ^v^\
 swers extremely well, has been      [                         >ix
 devised by Drs. P. B. Goddard,      1 V^TT^n                   '^X\
 and W. W. Ruschenberger.  It   ((3\iOj                       ^^
 is made of silver wire,  some-                               /^"^s^N
 what similar in form to that just                               If      yf\
 figured, but it is constructed in                              (I        VI
 two separate  pieces, to one of                               VN——<^//
 which is attached a cylinder, and                                 -----yj
 to the other a rod which slides           ^^^                       //
 in the former.  When this in-      fP^xT)                    //
 strument is  applied,  and  the   ^L^^f/                   Xr
 branches separated, the friction      Ir-                     XS
 of the rod against the cylinder      \\                  ^^r
 will effectually resist any effort      \\             ^^^
 of the patient to close the lids.         \\     ^^^^^
   The second step is the divi-        ^^-^Z^^
 sion of the  conjunctiva.   The
patient being directed to turn the eye outward, the surgeon takes the small for- 
?32             OPERATION FOR THE CURE OF SQUINTING.

ceps, (fig. 61,) and  seizes the conjunctiva, about midway between the edge of
the cornea and  the caruncula lachrymalis, or  rather a  little nearer  to  the

                                  Fig. 61.
latter,  so  as to  make a horizontal fold, which is then  snipped  across  with
                Fig. 62.                   the scissors, (fig. 62,)  close to the
                                         forceps, and between them and the
                                         cornea.  When the left eye is ope-
                                         rated on, the forceps should be held
                                         in the left hand; and the scissors in
                                         the right, with the probe-pointed
                                         blade upwards.  When the right
                                         eye  is operated on, the forceps are
                                         to be held in the right  and the scis-
                                         sors in the  left hand.   If the first
                                         incision is not sufficiently large it
                                         may be extended above and below.
                                         A very good method of dividing the
                                         conjunctiva  is  with the small iris
                                         knife, (fig. 24 d, p. 429.) If the point
                                         of this be thrust through the fold of
                                         conjunctiva  from  below upwards,
                                         with a single cut a sufficiently ex-
                                         tensive incision  may  always be
                                         made.  The conjunctiva being di-
                                         vided, the surgeon  still holding the
                                         inner  flap  with the  forceps and
                                         drawing it forwards is to separate
                                         it to a sufficient extent from the scle-
                                         rotica, either by dissection with the
                                         scissors, or what is more convenient,
                                         with  one of  the small knives re-
                                         presented at p. 592, fig. 42 and 43.
                                         Some surgeons object to this dis-
                                         section under  the belief that it sub-
                                         jects the patient to protrusion of the
                                         globe.  We have never found this
                                         to result in  any of our operations,
                                         and the dissection Ave  recommend,
                                         much facilitates the subsequent steps
                                         of the operation. If blood now flows
                                         so  as to obscure  the  parts, which
                                         does not often happen, it is to be
carefully wiped away with a small sponge, attached to the end of  a probe, and
tepid water.
  The third step in the operation consists in the introduction of the blunt hook
tinder the muscle.   This sometimes presents  difficulties to the inexperienced
operator, which  may be obviated by the use of a hook such as is represented
 
                  OPERATION FOR THE CURE OF SQUINTING.              733

in fig. 63.   It is formed of silver wire, as small as is consistent with the necessary
strength, set in a bone handle, and is bent at the end so as to accommodate
itself exactly to the curvature of the eye-ball, and flattened
at the point on its convex  surface.  The globe of the eye       F'g- 63.
being a sphere of -|-gths of an inch in diameter, the proper
curve  may be given to the  hook  by bending  it on a
cylinder of that diameter.  The surgeon  takes this blunt
hook in his right hand when operating  on the left eye, and
in his left hand when operating upon  the  right eye, and
applying its concave surface to the eye, he inserts the point
beneath the conjunctiva, the handle being elevated,  and
pushes it backwards and downwards until the point is be-
low the muscle and behind its insertion.  He then rotates
the instrument so as to turn the point  backwards and up-
wards, and at the same time depressing the handle, the point
glides  under the  muscle and  appears at  its upper edge
covered with the fascia which has been pushed before the
instrument: some surgeons  recommend  that  the fascia
should now be cut so as to  bring the point of the hook en-
tirely out;  but this is  not necessary.   The muscle is now
secure and the surgeon gently draws the eye outwards.
  The last step in the operation consists in the division of
the muscle. Incomparably the safest and best instrument
for this purpose is the  scissors represented in fig. 62.   The
surgeon takes  this instrument in the hand which is disen-
gaged, so that  the probe-pointed blade is towaids the eye,
passes that blade  beneath the muscle close to the  convex
surface of the hook; and with a single cut divides the mus-
cle.  The patient may now be  allowed to close  the  eye,
and to rest awhile.  After the  lapse of a  minute or two
the lids should be separated and the condition of the eye
examined.  If the pupil is now in the  centre of  the orbit
and the patient cannot turn the eye horizontally inwards,
the operation may be  considered  as complete.  If the pa-
tient can, however, rotate the cornea into  the inner can-
thus, it will be  found that a  portion of the muscle  or some
tendinous fibres  remain to be  divided.  These are to be
sought for with the blunt  hook, and being raised on  it,
divided with the  scissors.  This is the part of the  opera-
tion which  requires most judgment and tact.  If the fascia
is too extensively divided the eye will  become too  promi-
nent or an external  squint may result;  both of  which
are more disagreeable deformities than  internal strabismus.
On the contrary,  if the muscle is not completely divided
with any adventitious fibrous bands which may exist,—
the squint will be but partially corrected, or when the mus-
cle reunites may be reproduced.   The  muscle and fascia
should be simply cut across, and all dissection and separa-
tion of these parts from the globe of the eye  avoided, except where the defect
has resulted from repeated attacks  of inflammation which have consolidated the
cellular tissue, fascia; and muscles,  giving rise to adventitious bands, &c.
  No dressing is required to the eye operated on.   On the contrary we recom-
mend the patient to use it exclusively for a few days, and to turn it outwards
as far as possible, many times during that period, the other eye being kept bound
up   Afterwards we desire him to look with both eyes at distant objects, so as to
 
734
OPERATION FOR THE CURE OF SQUINTING.
 acquire parallelism of the eyes.  This may be aided by holding a large book
 against the nose, and directing both eyes to some remote object.
    We have never found any inflammation follow the operation requiring treat-
 ment ;  but as a  matter of precaution advise the patient to keep in a darkened
 room, to abstain from stimulating articles  of food for two or three days, and
 to take a dose of salts the night after the operation.
    This mode of operating causes very little pain, is perfectly simple, and three
 instruments,  a pair of forceps (fig.  61,)  a pair  of scissors  (fig. 62,)  and a
 blunt-pointed probe (fig. 63,) are all that are absolutely required.  The hooks
 employed by surgeons to evert  the eye, always  give pain, sometimes inflict
 injury, and are never necessary in cases suitable for the operation.
    This method  is of course  not applicable to young children, but  such, we
 conceive, to be very improper subjects for  the operation.   The deformity is of
 little consequence  to them, and it is sufficiently early to  attempt its  removal
 when they have  arrived at an age to  appreciate the importance of the opera-
 tion, and have acquired sufficient  firmness to offer no resistance.]
    Treatment after the operation.—The eye  should be  managed after
 the operation, as  it would be in the case of accidental injury affecting
 the same parts.   It should be kept at rest, and covered  lightly with a
 piece of wetted lint or folded linen.   Patients have sometimes returned
 to their usual occupations  the next  day: this must be considered im-
 prudent, as  incurring the  risk of inflammation, of  which  the effects
 might be serious.   Suppuration in  the orbit, inflammation and suppura-
 tion of the globe, inflammation of  the  conjunctiva with  chemosis, are
 among the effects which the operation has caused in some instances.
   Mr. Duffin mentions that the division of the tendon is  often attended
 with pain in the  forehead, similar  in degree  and kind to what would
 be produced by pressing the finger very firmly on the part.   This pain
 sometimes lasts  for several hours, and is best relieved  by warm fo-
 mentations.   In a few instances he has seen vomiting induced and last
 for twelve hours.    Temporary confusion or giddiness  of a few hours
 duration has occurred not unfrequently.  He recommends that the pa-
 tient should  be  kept quiet in a dark room.   Effervescing saline medi-
 cines have not been of service, and opiates have  been injurious. (Ibid.
 vol. xvii. p. 52,  53.)
   The  dragging of the muscle by the hook, previously to its being se-
 vered, and the injury of the ciliary  nerves when the sclerotica is exten-
 sively swept with the hook, in order to  discover and  raise cellular ad-
 hesions for the purpose of dividing them, are the probable causes of the
 symptoms first mentioned.
   The  edges of the wound  in  the  conjunctiva remain a little  apart;
 they become red, and  slightly swelled, and cicatrization takes place
 in about three weeks.  Frequently  there is more or  less ecchymosis,
 particularly  on  the under  part of the  eye.   A  fungous granulation
 sometimes  rises  from the  wound, and protracts  healing: it  maybe
 snipped off with curved scissors.
   [When scissors are employed for the removal of this fungous granulation, it
 cannot be completely extirpated,  and  it soon  shoots up  again.  It  may be
 wholly excised by raising it with the forceps (fig. 61,) and cutting it off with the
 small knife (fig. 42 or 43.)   It may aJso be removed by the application to it of
 nitrate of silver or sulphate of copper.  In some cases, after a time, it disappears
spontaneously.]
   It is said that  relapse of the affection is sometimes  produced by  con- 
OPERATION FOR THE CURE OF SQUINTING.
735
traction of the cicatrix at the internal  canthus: and that the evil can
be remedied by a free division and detachment of the contracted parts.
  Effects of the operation for dividing  the  adductor muscle.—The
immediate effect of operation is to bring the eye into its proper position
in the centre of the orbit.  The patient cannot turn it horizontally in-
wards, but he is able to carry  it further outwards  than  in the natural
state.  The eye sometimes is more or less evented; this eversion goes off
in a few days. The detached muscle becomes reunited to the sclerotica
behind its original insertion in about a fortnight, and its natural action
is then restored.
  If the success of  the  operation  is complete, the patient should not
have the power of turning the eye inwards either directly or diagonally;
and  this will take place when the defect is confined to one  eye.   It is
stated  by Mr.  Duffin  that, where both eyes  are implicated,  that
which  has   been operated  on  still  turns  a  little  inwards, when
both eyes  are  directed to  an object  immediately  in  front.   He
refers  this action,  which is probably effected by the inner fibres
of the  superior  and inferior rectus to the  sympathy  existing   be-
tween the two eyes; and he says  that it will cease in  a day or two,
if no permanent obliquity exists in the other eye :  if, however, there is
a confirmed squint in the other eye, it should  be operated on, and  both
will  become straight.  (Medical  Gazette,  vol. xxvii. p. 46.)
   If the position and motions of the eye should not be satisfactory after
the effectual performance of the  operation, the other may be bound up
occasionally, so as to bring into exercise that which has been diseased
and  enfeebled.
   Mr. Duffin states that some  time is necessary  in certain cases, for
the external rectus to recover its contractile  power, which has proba-
bly  been  weakened  by  long continued extension.  The weakness of
the muscle was indicated in three cases by inability to bring the pupil
to the centre of the orbit before the operation.  (Ibid. p. 17.)
   The effect of the  operation  on the  position and movements of the
eye, as observed  in fifty-three  cases, is thus stated  by Dr. Franz.
" The pupil  occupied its normal position in most cases immediately
after the operation :  in some it was first  directed  a little outwards, or
was not on  a' level with the pupil of the other eye, but in both instances
righted itself within  the first four or eight days.   In a few cases where
the pupil occupied its proper position immediately  after  the  operation,
it became slightly inverted  a week afterwards, but regained its nor-
mal  position in a space of from  four to six weeks, by proper exercise
of the eye.   In  three cases the pupil of the operated eye is yet slightly
inverted but even then only when the persons look at objects near them.
This may be attributed  to the squinting, which  was  very  marked,
having been of  sixteen,  twenty-three,  and forty-four years  standing in
these respective  cases, besides  being  complicated with  a considerable
degree of amblyopy, short-sightedness, and weakness of the  external
rectus   Neo-lect of proper exercise of the eye in the one case, in the
other a catarrhal inflammation, which attacked the eye a week after
the  oneration greatly contributed  to  this result, that may yet in time
be remedied by judicious exercise of the eye  and the treatment of the
wpXess of the external rectus which is still continued.  In the third
case the use of  caustic,  which was three times employed to destroy a 
736
OPERATION FOR THE CURE OF SQUINTING.
tumescence of the conjunctiva, seems to have contracted this mem-
brane, and have caused the slight cast  yet  to be observed.  A case,
where the inversion had  originated in hydrocephalus, presents  also
some peculiarities.  After the division  of the shortened muscles, the
squinting yet remained in the same degree  as  before the operation.
By a proper exercise of the eye, by treatment of the almost paralytic
state of the abductors, and by a second division of the adductor in the
one eye, I however succeeded in bringing both eyes  into a perfect nor-
mal condition."   (Medical Gazette,  vol. xxvii. p. 41.)
   In  reference to the effects of the operation on vision, Mr. Lucas says,
" in no case was the sight of the eye injured.   In many, the vision re-
mained as imperfect as before; in  some  it steadily but gradually im-
proved as the organ was exercised,  and in all  these cases where double
vision, inability to adapt the eye to distance, or any other disagreeable
consequence followed the operation,  it disappeared in a  few days."
   Of the  patients  operated  on by  Dr. Franz, " many saw  objects
situated towards the temporal side of the operated eye  more distinctly
than those in other situations.  In all, double  vision  of objects situated
towards  the nasal  side was remarked: in some  this occurred imme-
diately after the operation, in others  after the lapse of a week or more.
Some few saw objects double only when placed in a particular position.
This distinctness of vision towards the temporal side, and double vision
towards  the  nasal, remained in some cases only a  few days; in  the
most, however, several weeks."   (Medical Gazette, vol. xxvii. p. 42.)
   In a few instances, great improvement of sight has followed immedi-
ately on  the operation.  Mr. Duffin says  of a patient, who had under-
gone  the operation on both sides, for bad convergent strabismus, " she
was almost entirely amaurotic before the operation, and recovered her
vision, so as to distinguish  small  objects, wiihin  an  hour afterwards."
(Ibid, p.  17.)   In reference to such cases,  Mr. Duffin inquires whether
the optic  nerve  may not suffer inconvenience from being slightly bent
on itself;  partial amaurosis being a frequent attendant on squinting.
   Dieffenbach represents that " all  those  who had strabismus of only
one eye,  saw more weakly with it than with the other."  " The opera-
tion completely cured  the weakness  of  sight;  some who had actually
amaurotic amblyopia, could see clearly directly after it was performed."
(British and Foreign Review, vol. x. p. 570.)
   Mr. C. Guthrie mentions instances in which the operation was fol-
lowed by great improvement of vision.   (P. 3.)
   Dr. Franz says, that  where  slight  weakness of sight had existed,
full power of vision was recovered in a few weeks;  but where ambly-
opia was present in a greater degree, this improvement did not take
place till after a  longer  time.   Where muscae volitantes, photopsia,
nystaxis, or nictitatio palpebrarum  existed, these affections decreased
in proportion as the centre of the posterior  hemisphere increased  in
acuteness of sensation.   (Medical Gazette, vol. xxvii. p. 42.)
  [In all the cases in which we have operated, with one exception, and in that
the defect had not impaired sight, vision was improved. In one case, a young
lady, who with her left eye had not been able to read long primer, read fluently,
a few minutes after the division of the internal rectus a sentence in diamond
type.  This improvement was permanent.   In another case a gentleman who 
OPERATION FOR THE CURE OF SQUINTING.
737
 was presbyopic, requiring for vision with his left eye a magnifying glass No. 14,
 had this defect so far lessened by the operation as to require a glass No. 11.
   In all the cases also, the fatigue and uneasiness which was experienced from
 using the eye, ceased after the operation.]
   The results of the operation, as generally reported, would seem  to
 be uniformly and  completely successful.  It is performed in hundreds
 of cases, and, as  it is alleged,  without any failure.  If,  by complete
 success, we are to understand  that the eyes, whether one or both be
 operated  on, recover their  normal direction, freedom of motion, and
 harmony of  action, without  exhibiting any unusual  appearance  that
 could  attract  attention, I believe that, of the  entire mass of cases, a
 large proportion do not come up to this mark.  Mr.  Duffin, who has
 had great experience  on the subject,  and who writes  with  perfect
 candour, commences his "inquiry into some of the consequences and
 causes of failure  of the new operation for the  cure  of strabismus or
 squinting, with the following judicious observations :
   " The few cases thus far reported have all  been so  highly coloured,
 and so remarkable for their complete  success, that were  we to credit
 implicitly their various authors, we should  be led to the happy conclu-
 sion that  failure is next to impossible, even in the hands  of the  most
 unskilful; and that  in no instance will any visual deformily remain
 when once this devoted tendon  is severed  from its attachment  to the
 eye-ball.  That it  is a very scientific, beautiful, and highly satisfactory
 operation, in dexterous hands, no one  can  deny, perhaps the most so
 of any in surgery: but that  cases both of complete and partial failure
 are of daily occurrence, though vaunted as successful, will, I imagine,
 be readily conceded by every candid surgeon whose  field of observa-
 tion has been sufficiently extensive to enable him to arrive  at any really
 accurate, practical, and legitimate conclusions on the subject.  Indeed,
 so far  from  being universally successful, there is too much reason to
 fear the operation  will, ere long, fall  into unmerited disrepute, in con-
 sequence of the imperfect and injudicious manner in  which it is often
 performed, and the  inauspicious  results that  have been  occasionally
 observed to proceed from it.
   "To divide the tendon  of the adductor oculi really well,  and to
 liberate the  eye with  certainty,  and  in an  efficient manner, so  as to
 secure the utmost benefit capable of being conferred, at the smallest
 possible cost of suffering and  inconvenience to the  patient, requires
 much more dexterity, neatness, and address, than is commonly believed.
 At first sight the simplicity of the operation is such, that almost every
 one is  induced  to attempt it, but comparatively few succeed to the full
 extent, in conformity with the principles just inculcated.  To  attain
 this delicacy and  excellence, it is essential that the surgeon  perform
 this operation a vast number of times.  That the first attempts, there-
 fore, of the unpractised almost invariably prove only partially success-
 ful,  cannot  surprise us.   I  have myself operated one  hundred  and
 seventy times, and assisted  others to an almost similar extent, as well
 as had opportunities of examining a variety of cases operated  on by
individuals of every degree  of talent, and  feel  satisfied that the state-
ments  I make will  be found correct by every impartial inquirer. Many
of my own  earlv cases  were only partially successful, and some of
       93 
738
operation for the cure of squinting.
 them were decided failures.  The original obliquity of vision, it is true,
 may be  removed;  but if,  in its  stead, there be substituted  a  staring
 vacant projecting  eye, of apparently  disproportionate size,  or  a dis-
 agreeable  leer, or if  a mere alteration only in the nature  of the ob-
 liquity be  effected, it  is very questionable  how far  the  expression of
 the eye is benefited by the change."  (Med. Gaz. vol. xxvi. p. 940,941.)
   Mr. Duffin considers  that  partial  failure  of the operation  arises
 frequently  from the tendon not being completely divided, or from pre-
 ternatural  adhesions  by condensed  and indurated cellular membrane
 being left  unsevered.  To obviate this occurrence, the surface of the
 sclerotica must be carefully swept by the blunt hook, so  that any such
 adhesions  may  be discovered,  drawn forwards,  and  divided.  The
 operation must not be concluded until this has been satisfactorily ac-
 complished.
   The power of turning the eye inwards and upwards, or inwards and
 downwards, after  the tendon of the adductor has been severed, has
 been ascribed to the inner fibres of the superior or  inferior rectus; and
 a partial or complete  division  of one  or other of these muscles has
 been resorted  to as  a remedy.  Mr. Duffin  has never pursued this plan,
 having found  it sufficient  to remove all tendinous and  cellular attach-
 ments in the inner aspect of the globe.
   The eye  has sometimes  been unduly everted after division of the ad-
 ductor muscle.  The  circumstance  has  been mentioned at p. 713.  I
 saw one case in which divergent strabismus had been produced in this
 way to such an extent that it had been thought necessary to divide the
 external rectus a fortnight  after the first operation.  (Dr. Franz, Med.
 Gaz. vol. xxvii. p. 41.)  Mr. C. Guthrie performed the same operation
 for external squint consequent on division of the adductor.   (P. 16.)
   Mr. Duffin operated on a patient, in whom the eye was turned up-
 wards and  inwards, so  much  that,  when it was at rest, one-fourth of
 the cornea was concealed  from  view.  When  the eye had  been com-
 pletely liberated on its inner aspect,  it  immediately darted directly up-
 wards, so that one-third of the cornea was concealed under the superior
 palpebra; it remained  fixed, and the  patient could not look downwards
 sufficiently to obviate double vision.  The tendon of the superior rec-
 tus was divided on the third day after the operation: the pupil assumed
 its proper central position  in the orbit, vision  became  single, and the
 cure proceeded favourably in all respects. (Med. Gaz. vol. xxvi. p. 977.)
   A very frequent result of the  operation is to render the globe more
 prominent;  the palpebrae^ are more widely  separated, and thus the eye
 appears  larger than the other.   This  change occurs in a  greater or
 less degree in most  cases of operation  on one eye, so  that we  can
 generally determine, by attention to this  point, which  eye has  been
 operated on.  According  to our present experience, this  change seems
 to be permanent.   I saw a female, in October, who had  been operated
 on in April: the eye was so much larger than  the other  as  to cause a
 conspicuous deformity quite equal to  that of a slight  squint.   In  a
 gentleman who had undergone the operation about  three months before,
the apparent difference of size  in the two eyes was such as to attract
notice immediately.
  The position of  the  eye  in the orbit  is determined by the combined 
OPERATION FOR THE CURE OF SQUINTING.
739
action of antagonist powers; the recti drawing it back, the obliqui  pul-
ling it forwards.   The division of the adductor lessens the former of these
forces, and thus comparatively increases the latter.  If this explanation
be well-founded, it would constitute a strong objection to dividing a se-
cond rectus in the same eye.
  Mr. Duffin speaks of the projection of the eye as trifling, but vary-
ing in extent according to the manner in which the division  of the  ten-
don has been accomplished.   " When the operation has been  performed
without injuring  the  conjunctival and other coverings more  than is ab-
solutely essential, the increased  prominence  of  the eye that results  is
scarcely appreciable, and, in some instances, cannot be at all detected.
If, on the  contrary, the eye has been liberated by submitting the scle-
rotic to a clean dissection by means of the forceps and scissors, and the
investing membranes have been removed to an unnecessary  extent, the
globe is much more liable to start forward than  when attention is paid
to preserve the appendages and unoffending textures entire."   (Medical
Gazette, vol. xxvi. p. 977.)
  If the faulty eye should be already smaller than the  other, the in-
creased projection of the globe will bring the two eyes to the  same size;
if, however, it should be larger, a conspicuous deformity may result.
  Mr. Lucas mentions the same circumstance, stating that the increased
prominence sometimes disappears in  two or three weeks, while in other
instances it is permanent.  In the latter case, he recommends that the
adductor of the sound eye should be divided in order to make it equally
prominent with the other; and he relates a case, in which this was done
with a perfectly  satisfactory result.  (P. 52.)
  When the eye is still turned a little inwards, either in the  straight or
diagonal direction, after the adductor has been divided, it has been re-
commended that the inner fibres of the superior or inferior rectus should
be divided  also.   Mr.  Duffin recommends in preference that the ad-
ductor of the opposite eye should be cut, if, as is most likely, there should
be a slight cast  in  it.  He  says, that by the former proceeding "the
eye would  be  very prone to start forward, and impart an  ungainly ap-
pearance to the  individual;  whereas, by operating on the other organ,
we not  only obviate the risk of this occurrence, but completely rectify
both eyes;  and should the eye first liberated be a little enlarged by the
operation, we  have it in our power to make both  correspond  in this  par-
ticular."  (Medical Gazette, vol. xxvii.  p. 46.)
  If this increased  prominence should  be found to occur  frequently,
causing such deformity as to render a subsequent operation on the sound
eye advisable, it  will probably be deemed a serious objection  to the  ope-
ration.  Many might be willing to have the adductor muscle divided,
in order to set  straight a squinting  eye, who would hesitate  if they
feared that so much deformity might still remain as to require that the
perfect eye should be submitted afterwards to the same process.
  The time that  has elapsed since the introduction of this operation  is
so short that we are as yet unable to appreciate it fully: its ultimate
influence on the  motions and position of the eye is not yet ascertained.
I have seen some cases in which the result, up  to the present time, is
perfectly successful, and several others which have succeeded partially.
I have  heard  it  stated that in some cases, among those first operated
    where the  effect had appeared completely successful, there has been
on 
740
OPERATION FOR THE CURE OF SQUINTING.
relapse of the squinting.   From the number of cases, in which the ope-
ration has now been performed, we shall be able, in the course of a few
months, to ascertain its final effects, and thus to determine its real value.
In the mean  time, as the reasons for submitting to it are not very urgent,
I should be inclined, if I were the subject of this defect, to wait for the
further and conclusive evidence which the lapse of time will soon pro-
duce.
   [Since the  above paragraph was  written, numerous publications have ap-
peared, professing to  give the results of the operations of their respective au-
thors for strabismus but no small portion of these statements seem little entitled
to credit, being manifestly put forth  to obtain notoriety and  assert  claims to
extraordinary success.
   The operations  of  those who have written most candidly on the subject do
not fully realize the hopes at first raised.
   Mr.  Estlin  (Provincial Med. Journal,  23d July,  1842,)  gives the following
general statement of the results of 100 cases of strabismus at  a period of time
varying from  6 to 14  months after the  operation:—
   In 91 patients with internal  squint, the recovery  was—
 Perfect or very satisfactory in            .       .      .       .44 cases
 Satisfactory   .       .       .        .       .       .       .      21 "
 Very satisfactory a week or two after, but no later report .       .     9  "
 Improved, but requiring an operation on the other eye         .        7  "
 Squint returned, requiring an operation on the other eye .            4  "
 Improved, but the cases unfavourable  .       .       .        .        5  "
 Some degree of external  strabismus  following the operation for in-
   ternal           •       •       •      •       •       •       .   1  "
   In 8 cases of external squint, the result was—
 Perfect in      .......       1 case
 Much improved    .       .       .      .       .       .       .   3  "
 Slightly improved    .       .       .       .       .        .       2  "
 Not improved     .       .        .       .        .      .       .   2  "
   M. Velpeau states  that in about 300 cases in which he has operated, in one
 half the result has been perfectly satisfactory.  Of the other half, in one third the
 cure has been incomplete; and in the  remaining two thirds the operation was
 entirely unsuccessful, either the eye being drawn, in an opposite direction to that
 caused by the original defect, or in some other unnatural direction; or being
 immoveable,  or too  prominent, &c.   (Du Strabisme.   Paris, 1842, p.  116.)
   These results are doubtless, the most favourable which the facts will warrant;
 and infinitely more so than would be  presented, could  the true statistics of all
 the operations performed be ascertained.   The correctness of this inference will
 be  at once assented to, when it is considered, that such a mania has prevailed
 among some  surgeons for operating  that they have seized  upon every case
 suitable or not, and that almost every  where, the greater number of cases have
 fallen  under  the knife of unprincipled  operators, attracted to them  by false
 statements of success widely circulated in the public papers, with the certificates
 of cures given to them by those whom they had duped.
   If the cases, however, be judiciously selected and the operation skilfully per-
 formed, with the  lights we at present possess, much greater success will doubt-
 less be attained.
   M. Velpeau observes, and  the remark  is equally applicable here; that " after
 having enjoyed unprecedented repute, this operation has become in Paris, as
 elsewhere, the subject of serious distrust.  In fact the public having seen daily
 in the newspapers, that the cure of squinting was  simple, easy, exempt from all
 inconvenience, and  invariably  successful, gave full credence, and rushed in 
OPERATION FOR THE CURE OF SQUINTING.
741
crowds to be operated on.   These statements being unfounded, the truth did
not fail in time to manifest itself.   Then the public learned that  they had  been
duped—that a large number of those who squinted were not cured by the ope-
ration, or had only their original deformity changed for another.  Passing quickly
from unbounded confidence to extreme  distrust,  they no longer believe even
in the actual benefits of the operation ; and now many persons who squint and
might be  cured have abandoned all hope of relief from their deformity."
   Another circumstance which has tended to discredit this operation, especially
in France and Germany, is the return of the deformity in some cases at first sup-
posed to be cured.  M. Velpeau  observed the  defect to return in some of the
cases operated on by himself,  after a lapse of eight, fifteen, twenty, and  thirty
days, (op. cit.  p. 104,) and M.  Cunier, has  seen the same  occur at  the end of
one, two, three and four weeks, and after two, three, four and even five months.
A lady of high rank, Madame  A.,  who had been operated on by Dieffenbach at
Berlin,  and had  been announced  to be cured,  six months afterwards squinted
as badly as ever.  (Ibid.)
   If the deformity does not however reappear when the muscle reunites, the
cure is generally permanent.    More than two' years have now elapsed since
our first  operation, and we believe  the first in this  country,  was  performed
(23d of August, 1840,) and the cure has continued permanent up to the present
moment.
   Mr.  Estlin remarks on this subject " whatever may be  the opinion  of those
who have not had the opportunity, or taken the trouble, to  watch cases in which
the muscle has been divided, for the cure  of strabismus, as to the liability of the
defect to  recur, I have only to  say that, as far as my observation has gone, the
tendency is to improve. I  do  not remember a case in which any change for the
worse has taken place after a month had elapsed from the  operation.   In many
cases where I expected it would be necessary to divide the muscle of the second
eye, so regular an improvement has gone on during the course of some months,
as to indispose me to recommend the measure.  In two of the preceding cases
reported  as unfinished, the squint in  both eyes was so bad that I attempted to
operate on the second eye  a week or two after the first had  been done; but
the patients, little girls, were  so  unsteady, that I was obliged to desist; and
now, after an interval of eight months in one case,  and  of ten in the other,
the eyes are  so much more  parallel that I think it  questionable whether the
children  or their parents  will ever desire to have  any thing more done."
(Provincial  Med. J. 23d July, 1842, p. 305.)
   When the  inversion of one eye, after  having  been for a time rectified, re-
turns, the defect may be generally remedied by dividing the internal rectus of
the other eye, as recommended by Mr. Elliot of Carlysle.  (Edinburgh Med. and
Surg. Journal, April,  1841, p.  376.)  M. C. Radclyffe Hall  states that in 29 in-
stances in  which the inversion,  though  completely removed  for the  time re-
turned, he adopted this practice and in every one with  complete success. (Lond.
Med. Gaz. Jan. 1841, p. 647.)]
   Luscilas.__The eye may be distorted and  fixed in its  unnatural posi-
tion by  injuries or paralytic affection of one  or more of its muscles, by
tumours in  the orbit, or  other changes  near the globe.  This state,
which resembles squinting in the wrong  direction of the eye-ball, but
differs from  it in the wantof  power to move the affected eye when the
other  is closed, was called, by Beer, luscitas.  I have seen it caused by
paralysis of the muscles supplied by the nerve of the third pair; in which
case the external straight muscle kept the globe permanently in the state
of diverging squint.  The  mode of treatment will be determined by the
nature of  the cause. 
(  472  )
CHAPTER XXVI.
AFFECTIONS OF THE LACHRYMAL ORGANS. *
          SECTION I.--INJURIES OF THE LACHRYMAL APPARATUS.

  The lachrymal canals and sac are so small, so protected by their
situation in  the corner of the eye, and by the surrounding bone, that
they seldom suffer from external  violence.   If they should be injured,
we can do  nothing more than close the wound accurately, keep the
parts at rest, and employ the means most likely to avert inflammation.
I have seen one of the lachrymal canals, and its correspondent punctum,
obliterated by accidental injury without  any observable defect in the
absorption of the tears.  Even where this has happened  to the lower
canal,  and the nasal  half  of the eye-lid has been  at the same time
drawn down and partially  everted, the person had suffered no incon-
venience from watering of the eye.
  I have seen three or four instances of  the lachrymal sac being  burst
by a blow, with escape of  air into the cellular texture of the lids; the
emphysematous swelling, which  has been  considerable,  but not ex-
tending beyond  the palpebrse, has disappeared spontaneously in a few
days.
  Foreign substances  in the puncta lachrymalia.—I have not seen cilia
in these openings, though the occurrence should seem from the follow-
ing quotation not to be uncommon.  Dr.  Monteath saw inflammation
of the  semi-lunar membrane and caruncula lachrymalis caused  by a
loose eye-lash, of which the thick end had  entered the upper punctum
and  lachrymal  canal:  the  opposite  extremity,  pointing downwards
constantly irritated  the caruncula.  (Welter's "Manual, vol. i. p.  191.)
" This  little accident," says Mr. Mackenzie, " I  have met  with in a
number of instances, in some of  which the  eye-lash was in the lower
punctum,  and in others in  the  upper."   (Practical Treatise, ed. 3rd,
p. 240.)
            SECTION II.--DISEASES OF THE LACHRYMAL GLAND.

  The lachrymal, like the other conglomerate glands, is rarely diseased.
Schmidt  states that acute inflammation of  this gland, with  inflam-
matory swelling of the upper eye-lid, is not  uncommon;  and that he

  * J. A. Schmidt; Ueber die Krankheiten des Thranenorgans.  Wien. 1803.
  VV. Mackenzie; Essay on the Diseases of the excreting parts of the hachrymal Organs.
London, 18111.
  C. H.Todd, on Diseases of the hachrymal Gland; in Dublin Hospital Reports, vol. iii.
p. 407. 
DISEASES OF THE LACHRYMAL GLAND.
743
had often treated such cases.   (Lib. cit. p. 134.)   Beer represents that
the disease is very uncommon;  that he had seen  it only a few times in
the course of  twenty-seven years; and that, when it occurs, it is very
seldom an idiopathic affection.  (Lehre, vol. i. p. 349.)  He describes,
however, acute inflammation of the gland, as sometimes proceeding to
suppuration, and occasionally leaving  behind, under  the  superciliary
ridge, a capillary fistulous opening, from  which  clear lachrymal fluid
is discharged; he calls this a  true fistula-lachrymalis.*  According to
the representation of  Mr. Todd, acute and chronic inflammation, and
suppuration of the lachrymal gland, are common occurrences.  I do not
remember having seen either of these affections;  if, therefore, the pre-
ceding  representations are correct, I must either  have  overlooked
diseases  of this  organ, which have been noticed by others,  or have
mistaken them for other affections.  In twelve of the annual reports of
diseases, treated at the London Ophthalmic Infirmary, which I am able
to refer to as I am writing, embracing an amount  of about 40,000 cases,
the lachrymal gland is not even mentioned in the list of diseases.
   I have met with some recorded cases in  which inflammation and
suppuration  of the lachrymal gland are said to  have occurred.   The
mischief began in these instances with a blow.  I believe them to have
been merely abscesses of  the eye-lid ; at least I see no circumstances to
prove that the lachrymal  gland was involved in the affection.
   Enlargement and induration of the lachrymal, gland.—A change of
structure in  this  part, accompanied with increase of size and hardness,
has been denominated scirrhus by some writers,  who have represented
the affection as cancerous. I doubt the correctness of the latter opinion,
never having  seen any evidences  of malignity  in  such cases.   The
gland is converted into a  knotted swelling, of firm consistence, with an
obscurely lobulated appearance on a section.  It has not the incom-
pressible  hardness  and compact  cartilaginous   texture of  scirrhus,
although nearly resembling it  in colour and  general  appearance.   It
does not become adherent, like scirrhus, to the  surrounding  parts; it
does not contaminate the  absorbent glands; nor does it return after ex-
tirpation.  The texture of the diseased mass is  similar, in consistence
and colour, to that of the knotty swellings, which are formed in  the
neighbourhood of the  parotid gland.  (Medico-Chirurgical Transac-
tions, vol. xvii. p. 19.)
  Beer represents that a  fully developed scirrhus, affecting  the lachry-
mal gland only,  is one of the  very rarest effects  consequent on inflam-
mation of the eye; and that,  in most cases, where this part is the seat
of true  scirrhus, other surrounding textures, and the globe itself, are
usually involved in the  affection.  In describing  the  symptoms, where
the gland alone is affected, he mentions, in addition to the displacement
of the globe by the swelling, and to the absence of pain, dryness of the
eye, opacity of the cornea, and a shrivelled state of the conjunctiva,
making the eye look like that  of a half decayed corpse.   He says that

  * Lib cit vol. i. p. 356 ;  and vol. ii. p. 184.  In the latter  place, Beer says that this
minute ' and sometimes scarcely visible opening, from which a clear lachrymal fluid
escapes through the  day, is one  of the rarest consequences of ophthalmic inflammation.
He recommends rubbing  the fistulous track with lunar caustic, brought to a fine point;
and he once introduced into the  opening; a knitting needle, made red hot, with success. 
744
DISEASES OF THE LACHRYMAL GLAND.
 he never saw cancerous ulceration confined to the lachrymal gland.  He
 advises that no attempt at extirpation should be made, because the ex-
 tent of mischief cannot be ascertained previously to an operation, and
 because the periosteum or the bone may be affected.  He adds, that he
 has seen many cases, in which the complaint, having been left to itself,
 under  favourable circumstances, has remained for several  years with-
 out disturbing the health or comfort of the patient.  (Lehre, vol. ii. p.
 243—246.)   The  foregoing  statements respecting  the  symptoms and
 treatment  of the affection, are  quite  at variance with my  experience,
 as will appear from  the cases subsequently relaled.
   Using the  term scirrhus, in its strict sense, and not including  under
 it  enlargement and  induration  consequent  on  inflammation, Schmidt
 says that he had never seen it as an affection confined to the lachrymal
 gland.   (Lib. cit. p.  130.)
   Mr.  Travers represents that cancer is peculiar, in  the organ of vision,
 to  the  lachrymal gland, conjunctiva, and eye-lids.   (Synopsis, p. 216.)
 He says, " I removed the lachrymal  gland, greatly enlarged and in a
 state of true scirrhus, from the orbit of a middle-aged man, a merchant's
 clerk in this city.  The vision of that eye had  suffered  considerably
 during the  growth of the tumour; in other respects, he continued quite
 well when  I  last saw him, after  an interval of some years."   (Lib. cit.
 p. 228.)
   Mr.  Todd mentions the affection of the lachrymal gland as scirrhous
 or  carcinomatous, and relates two instances  of successful extirpation.
  Case  I.—A woman, seventy years of age, who had received a hlow on  the eye seven
 years  before, and had been subject since that time  to frequent discharges of tears,
 perceived a tumour under the eye-brow a year before she came under the care of Mr.
 Todd.   Pain and headach soon came on, and became very severe.  The tumour, which
 was knotty, projected more than half an inch beyond the superciliary ridge:  it was
 hard, and slightly moveable in the  transverse direction.   The eye-ball was pushed
 downwards, so that the cornea was  nearly on a level with the  ala nasi; and the lower
 lid  was  everted.   The cornea  was slightly obscured; and  vision was  lost.   Severe
 lancinating pains extended from the tumour to the globe, accompanied with a sense of
 heat, and frequent discharge of hot  scalding tears.   The diseased gland was removed
 by Mr. Todd, on the 30th of August,  1831, in the Richmond Hospital. It was so
 firmly wedged into the orbit, that the handle of the scalpel was with difficulty intro-
 duced between  it and the superciliary ridge, to detach the mass from the roof of the
 orbit.  Its surface towards the eye was irregularly lobulated, and the lobes  had in-
 sinuated themselves amongst the muscles and other contents of the orbit, so as to
 render their disentanglement embarrassing and hazardous.  "The diseased gland was
 found, on examination, much larger than a walnut; it presented, on the surface which
 had been turned towards the eye, three considerable eminences or lobes, with deep
 fissures between them: it was almost as firm as, but more elastic than, cartilage.  A
 section of the gland exposed several small  cartilaginous  cysts, which contained a
 glairy fluid, and the interspaces consisted of a firm fatty substance, traversed by a few
 membranous  bands."   The patient recovered from the operation, and was discharged
 from the hospital on the 10th of September.  The eye appeared sound, and had nearly
 regained its  natural position;  vision was extinct.   The patient continued perfectly
 well in the following December.  (Lib. cit. p. 419—426.)
  Case  II.—A strong  and athletic  man, twenty-two years of  age,  was received into
the  Charitable  Infirmary, Dublin, by Mr. O'Beirne, on the  21st of December, 1830.
 The globe of the right eye projected more by its semi-diameter than the opposite, yet
 was covered  by the upper lid  hanging  loosely over it.  The  pupil was dilated and
 fixed, the cornea turned towards the  nose.  A tumour, with indistinct outline, occupied
 the  upper and outer part  of the orbit.  There was considerable pain in the side of the
 head and face, with watering and uneasiness of the eye from external excitement.  He 
DISEASES OF THE LACHRYMAL ORGANS.
745
saw double, and vision was in other respects so imperfect that he could not work as a
labourer.   Two years previously he had first perceived, occasionally, sparks and mists
before the eyes, with pains in the side of the head and face.  In about a year, slight
prominence and inversion of the globe were observed.  The tumour, of which the real
nature bad not been suspected, was removed on the 23rd, and turned out to be an en-
larged and indurated  lachrymal gland.   "The surface was granular, and of a pink
colour.   When cut into, it presented a  hard  membranous, or rather cartilaginous
centre, from which septa passed to the circumference.  No sanies could be perceived.
The gland was enlarged  to at least six times its natural size."  The  wound was healed
on the 14th day after  the operation, when the eye had returned to its natural position,
the iris had regained  its power of motion, vision was perfect, and all uneasiness was
gone."   (Lib. cit. p. 426—429.)
   In the two following instances of successful extirpation, the lachrymal
gland, in respect of its  hardness, might  have  been called  scirrhous; I
saw no reason for  suspecting the disease to be malignant.   In  both these
cases, as well as in those quoted from other authors where extirpation
was practised, the  gland  was greatly  enlarged.   The  female  breast,
when  affected with  scirrhus, is not usually augmented  in bulk;  some-
times, on the contrary,  it is  diminished.
   Case I.—Enlarged and  indurated lachrymal gland  successfully extirpated in a
young  man.—John Clifton, twenty-four years of age, from Market Street, Hertford-
shire, came under my care at the London Ophthalmic Infirmary, on the 14th of March,
1826.  Seven years  ago he was struck violently on the left  upper  lid, by an apple
thrown at him; swelling followed, and gradually subsided.  Two months afterwards
 the lid swelled again, with  considerable  pain, which having lasted a month, went off
entirely.   With the swelling the eye began to water, and there was a constant copi-
ous lachrymal discharge, rendered still more abundant by exposure to the air.  The
swelling  of the lid and the lachrymation continued, and  the globe was gradually pro-
truded from the orbit, with  loss of all useful vision.  A fortnight before admission, in-
flammation of the eye took place, with  considerable  pain.  There is now a general
fulness of the upper  lid, which is more particularly swelled and increased in  breadth
near the  external angle.  The eye-ball and lower lid, pushed downwards and inwards,
reached about half way between the orbit and nose; but though the former is out of
its socket, the lids are so extended, as to cover it completely.  The external tunics  are
considerably  inflamed;  there is a broad red zone in the sclerotica  round the cornea,
 with general dulness, and small ulcer of the latter.  A hard unyielding tumour, with
tuberculated surface,  projects a little beyond the margin  of the orbit, at its upper and
outer part.  This seems to admit of being moved a little, from side to side,  upon  the
bone; but the point is rather doubtful.   Blood was abstracted by cupping and leeches,
and^opening medicine was administered.  The tumour  was removed on the 25th of
March, the external  incisions being ample, as it obviously filled a large portion of the
cavity.   The longest, of about three inches, extended from the root of the nose, along
the fold of the upper  lid, to the temple; a second, of about two inches, passed perpen-
dicularly over the forehead and  upper and outer part of  the orbit, to meet the other at
riwht angles:  it was  necessary  to make a third cut from the first incision towards  the
anterior part of the zygoma.  When the flaps made by this crucial incision were turned
aside, the seat of the tumour was completely exposed.   No other difficulty was expe-
rienced except that  inseparable  from the size and hardness of the swelling, its deep
extent backwards, and close contact with the orbit and  its contents:  the surrounding
connexions were, however, merely cellular.  The tumour was found to be the  lachry-
mal o-land, increased  to the size of a large walnut, and of compact homogeneous texture.
It had a li'o-ht yellow colour, with an appearance of radiated fibres at one point; it ap-
proached in firmness  to cartilage, and altogether bore a near resemblance to the firmest
part of a scirrhous  mammary gland.   A large quantity of blood was lost during the
operation-  as it filled the deep cavity left by removing the tumour, so that its source
could not'be readily  discovered, the patient was left quiet in bed, with the wound open,
in the  hope that the  bleeding would cease; it went on  freely for  more than half an
hour  rendering the  patient very faint; an artery was then tied.   The  edges  of the
wound were now approximated by five small silk ligatures, and three narrow slips of
adhesive plaster, and the parts were covered with a wet rag dipped out of cold water,
         94 
746
DISEASES OF THE LACHRYMAL ORGANS.
and occasionally renewed.  26. The wounds had united by adhesion; the sutures and
adhesive plasters were removed, the  lids thoroughly cleansed, and the parts  then
covered with a wetted rag.  The eye  had receded to its natural position, and the in-
flammation of the sclerotica had ceased.  The patient, having  been  quite well for
some days, left the Infirmary on the 9th of April.  The wound united completely by
adhesion ; no suppuration occurred.  The globe had regained its natural position and
moved freely, its surface, and that of the lids, being as moist as usual.  The external
inflammation had ceased; the cornea had nearly recovered its transparency, and vision
was  much improved.  I saw  this  patient again in 1839, when a hard swelling had
formed about the middle of the cicatrix, under  the superciliary ridge.  As he felt no
inconvenience from it, he declined my proposal  of coming into the hospital.
  Case II.—Enlarged and hardened lachrymal gland successfully extirpated.—A
gentleman, twenty-seven years of age, came  under my care in the summer of 1828,
for a tumour in the orbit, which had caused displacement of the eye and loss of vision.
The complaint had begun five years previously, with considerable headach, slight pain
about the eye, which did not last long, and almost continual flow of tears, which was
increased on exposure to the air.  At  the end of a year and a half the globe began to
be protruded, so that a sensible difference of position was observed between the two
eyes. In three years, with increasing displacement of the globe, sight became im-
paired.  When I saw this gentleman, the left eye projected about an inch beyond the
level of the  right, and was at the same time thrust downwards.  The upper eye-lid
was swelled;  it covered the eye,  and  still  retained  its power  of motion.   A hard
tumour could be felt in the situation  of the lachrymal gland, projecting under the edge
of the orbit, close to the bone, and  hardly moveable.  The largest print could not be
distinguished with the left eye.  I removed the  tumour in June, making a long incision
from the nose to the temple, and  a shorter one  over the forehead,  meeting the former
at right angles.  The diseased gland  was equal in size to a large  walnut, slightly tu-
berculated on the  surface, of a light yellowish  brown  colour, firm, and nearly homo-
geneous in texture, but not so hard  as scirrhus, connected by loose cellular tissue to
the  surrounding parts, and by a short close texture to the bone.   Free bleeding took
place during the operation, but no vessels were tied.  The wound was united by
sutures, and covered with a rag dipped  in cold water.   It united throughout by the
first intention, and the patient was  able to go out  and attend to his affairs in a week,
at which time the globe had receded into its place. At the end of November the po-
sition of the eye was nearly natural,  and the  patient could read with it the leading
article of a  newspaper.  It was not deficient in moisture; but no tears came from it
in weeping.  When I saw this gentleman, between one and two  years after the ope-
ration, he continued perfectly well: as he resides in London, I should, no doubt, have
seen him, if there had been any return of disease.
   Mr. Mackenzie  has recorded  two  cases, in which the lachrymal
gland was enlarged and altered in structure.   In one of these the globe
had been pushed  out  of the  orbit and had  burst many years  before
death.  A tumour was found after death, as large as  a man's fist, oc-
cupying a much expanded  orbit, and  passing down  into  the spheno-
 maxillary fissure.  The roof  of the  orbit  had been  destroyed  by ab-
 sorption, and even the dura mater was gone  at  some points, so that
 the tumour and brain  were in contact.   The anterior and  middle lobes
 of the  cerebral hemisphere had been  pressed on and  altered in figure
 by  the  swelling, which  had  also  obliterated  the nostril.  From the
 size and progress of this  swelling, we  should  have  supposed it rather
 a new formation than a disorganization of the  lachrymal  gland.  Mr.
 Mackenzie, however,  states that it was white and  granular, the grains
 being evidently the  enlarged  acini of the gland.
    The  other case was that of  a  child eight years old, in whom pro-
 trusion of both globes with  ulceration and sloughing of the cornea, had
 occurred a few weeks before death.   The lachrymal  gland on  each
 side was  converted into  an  oval  lobulated tumour of greenish colour
 and firm  homogeneous  consistence, two  and  a half inches  long, and 
DISEASES OF THE LACHRYMAL ORGANS.
747
one and three quarters thick.  Several small growths of similar colour
proceeded from the dura mater, and had caused partial  absorption of
the cranium."  (Practical Treatise ; edit. iii. p. 391.)
   Hydatid of the lachrymal gland, {hydatis glandules lachrymalis ;
glandula lachrymalis hydatoidea,)  Schmidt, and after him Beer, have
described the formation of true hydatids as occasionally occurring in
the lachrymal gland.   It  must be' difficult, if not impossible, to deter-
mine the exact nature and original seat of such a disease, or of a sim-
ple watery cyst developed in the gland.  Nor  is the diagnosis impor-
tant ;  as the symptoms  and  treatment  will be essentially  the same,
whether these diseases have begun  in the gland  or in  the  neighbour-
hood.  When the swelling, by its increase, causes  displacement of the
eye and imperfect vision, it must  be treated on the same principles as
other orbital tumours.
               SECTION III.--EPIPHORA, OR WATERY EYE.

  The quantity of lachrymal  fluid may be greater than is  necessary
for  moistening or clearing the surface of the organ:  the eye  is over-
filled, and  the  redundant tears,  which sometimes partially  obscure
vision, flow over the lower lid, and run down the cheek, especially on
exposure to cold wind.   This  state is called a watery eye, or techni-
cally epiphora.   The latter  term, however, is properly applied to the
redundancy from increased secretion ; while the dripping consequent
on defective excretion is  more appropriately termed stillicidium lach-
rymarum.
  The secretion of the lachrymal gland is increased whenever the ex-
ternal surface of the eye is  irritated, as by cold wind, acrid  powders
or  fumes, and various  extraneous matters, whether of mechanical or
chemical operation.  Inflammation of the  eye, whether external or in-
ternal, or that of the lids, will have the same effect.  Epiphora is often
kept up  for a long time by chronic external inflammation ; and it may
occur, in scrofulous patients, to a high degree, without any visible signs
of inflammation.  Under these various  circumstances, there is an ob-
vious cause for the  watering state of the eye; viz. irritation affecting
the  surface of the organ: this is the stimulus  which naturally calls forth
the  secretion of the gland.   On  removing such  causes, the effect
ceases;  the epiphora goes off in proportion as the eye  regains its natu-

  We sometimes see an increased lachrymal secretion, which cannot
be traced to any of the causes just enumerated.   The  eye waters, es-
pecially when exerted  or exposed to the air; there is no external red-
ness, nor any discoverable exciting  cause.   In  such  cases, fatiguing
exertion of the organ must be avoided  and attention should be paid to
the  state of the hlalth.   The eyes  and the  head generally  should be
washed  with cold water  in the morning.   Astringent collyna, such as
  1  !• \ ^f clnhate of zinc or of copper in rose-water, may be used
ttee°or four'mefdaily, the liquid bejng allowed.to pass between the
ids  so as to  come  in  contact with  the conjunctiva.   If these means
are  unsuccessful, the  nitrate of silver in solution  may  be  employed
are  u"su     The citrine 0jntment may be applied to the edges of the
once a u**y • 
748
DISEASES OF THE LACHRYMAL ORGANS.
lids, more especially if there should be any alteration of the  Meibo-
mian secretion.
  Mr. Middlemore cured an obstinate and troublesome epiphora of one
eye by applying three leeches above the eyebrow every  week for about
two months, and  subsequently a narrow blister on the  highest part of
the forehead.  (Treatise; vol. ii. p.. 636.)
  Stillicidium lachrymarum, as distinguished from epiphora, may be pro-
duced  by any causes which interfere with the regular excretion of the
tears.
  The puncta  lachrymalia may be contracted \ and I have seen this af-
fection proceeding to such an extent, that it was difficult to discern the
situation of the openings.  Under such circumstances, the puncta must
first be enlarged with the point of a  pin; we shall then be able to intro-
duce the slender gold probes of Anel [fig, 64,] and to restore the natural
size of the apertures.
                              Fig. 64.
  In introducing these probes, for the purpose either of opening the
contracted puncta, or of examining the lachrymal canals, we must bear
in mind the exact direction of the tubes, which do not pass in a straight
line from the puncta to the  sac, but first proceed perpendicularly, then
make a sharp bend or elbow, and afterwards run horizontally, or nearly
so, to the sac.  [See fig. 2, p. 36.]  The probe, therefore, must be entered
perpendicularly downwards in the lower^upwards in the upper lid; it must
then be turned and directed almost horizontally to the  sac.
  Injuries of the lachrymal canals are mentioned as causes of stillicidium
lachrymarum.  My experience leads me to doubt the correctness of the
statement.  In a case of carcinomatous ulceration  affecting  the lower
lid, related at page  132, I removed the inferior lachrymal canal.  No
watering of the eye ensued.   I saw a gentleman with ectropium of the
lower lid consequent on a lacerated wound.   It appeared from his own
account, and that of the surgeon who had attended him, that the lid had
been quite detached at the inner angle, and had experienced great con-
tusion, followed  by partial  sloughing.  The cicatrix had become fixed
to the bone, and thus  the lid was drawn downwards,  particularly
towards the nose.   The inner extremity of the tarsus was about twice
its proper distance from the nose, and drawn towards the cheek, so as
to evert the inner third of the lid.   The inferior punctum, on first view,
seemed obliterated;  but  on close  search it was found, so reduced in
size, as to be barely visible: from this circumstance, together with the
ectropium, it was obviously incapable of absorption.  There was not
the slightest stillicidium.
   Graefe has mentioned that the two puncta and  canals were  taken
away in an operation performed for the removal of cancerous disease.
There, was no subsequent watering of the eye.   (Graefe and Walther's
Journal; vol. iv. p.  585.)
   I have never seen any obstruction of the lachrymal canals except as a
consequence of injury, operation, or the pressure of tumours.  The use
of Anel's probes, therefore, in reference to these canals, is unnecessary,
except in the contracted condition of the puncta. 
DISEASES OF THE LACHRYMAL ORGANS.
749
  The most common cause of stillicidium is obstruction of the nasal
duct, which may be produced by thickening of its membrane, by stric-
ture, by partial or general obliteration, or by pressure from various dis-
eases in neighbouring parts.
   SECTION IV.--DISEASES OF THE SEMILUNAR MEMBRANE AND CARUNCULA
                           LACHRYMALIS.

  These  parts are involved, when the conjunctiva is inflamed.   Con-
junctivitis- may commence and be more active in this  quarter, which
might be the seat of a somewhat limited inflammatory disturbance under
the excitement of a local cause, such as a  foreign body of mechanical
or chemical  action.  Under these or similar circumstances, there would
be nothing peculiar in the inflammatory disturbance or its treatment.
   Warts, polypi, or other excrescences, may grow here as on other
parts of the  conjunctiva.
  Encanthis.—Enlargement of the caruncula lachrymalis has been de-
scribed under this name.   Two forms  of the affection are mentioned ;
the innocent and the malignant.  The  former, which is  represented as
simple enlargement usually consequent  on inflammation,  is described at
length in treatises on diseases of  the eye,  and directions are given for
its treatment by applications and operation.  Having never seen an en-
larged caruncula requiring excision, or any other surgical treatment,  I
conclude that the  case must be rare.   I have never seen a malignant
encanthis ; and speaking from my own experience, I should say that the
part is not  liable  to affections of that  character.  If an inflammation
seated in  the internal angle of the eye,, were too diligently treated by
local means, especially by the stimuli which have been so liberally em-
ployed in many  cases of ophthalmic inflammation, aggravation  of mis-
chief might  ensue, with swelling, and  an  unfavourable  appearance of
parts that might be mistaken for malignant.
    SECTION. V.--AFFECTIONS OF THE LACHRYMAL SAC AND NASAL DUCT.

  Capillary aperture in the anterior part of the sac; congenital ?—I
have seen such an aperture in one instance, that of a boy at school, in
whom it seemed to be a natural peculiarity, as no inflammation, nor any
other affection of the part had been noticed.   A small drop of clear fluid
appeared frequently on the surface of the skin, just below the tendon of
the  orbicularis.   It  caused no inconvenience, except the occasional ap-
plication  of the pocket  handkerchief.  My advice was that it should be
left  alone.
  Inflammation of the internal angle of the eye.—This part may be the
seat of erysipelatous inflammation ; and  the attendant swelling, being
over the lachrymal  sac, may lead to the erroneous supposition that the
sack itself is involved in the mischief.   In a mild case the  inflammation
may subside without any unpleasant result; sometimes, however, it ex
tends to the lids, which become red, swelled, and painful; it may reach
the  lachrymal ducts and  sac, and cause  increased mucous secretion, 
750
DISEASES OF THE LACHRYMAL ORGANS.
with temporary obstruction to the absorption and excretion of the tears.
If it proceeds to  suppuration, the matter should be evacuated early, to
prevent increase of the collection, and thus diminish the risk of subse-
quent deformity.
   The old writers give the name anchylops (or ancylops) to inflamma-
tory swellings of the inner angle, whether caused by disease of the
lachrymal sac, or of the parts exterior to it; and that of cegilops to the
same disorder in its ulcerated  state.   There has been much discussion
respecting the exact sense and proper application of these unmeaning
terms, which have now become nearly obsolete.  Beer, however, calls
the inflammation just described, anchylops erysipelatosa idiopathica;
(Lehre, vol. i. p. 331,) in the ulcerative stage he names \t,aegilops sim-
plex.  (Lib. cit. p. 334.)
   Acute inflammation of the sac.  {Dacryocystitis.)—The lachrymal
sac and duct are susceptible of inflammation in various degrees. The acute
idiopathic form of the affection, as Beer has observed, is comparatively
rare.  The local  suffering and the constitutional disturbance are  much
more considerable than might have been  expected  from  the small ex-
tent of membrane which is the seat of disorder.  The explanation of
the peculiarity is  afforded by the vascularity of the  membrane, and its
inclosure in an unyielding bony receptacle. A dull pain  is felt in the
corner of the eye, shooting to the nose, and to the eye-ball, and at the
same time the lachrymal sac forms a hard, clearly defined, and very
sensitive swelling, about the size of a horse-bean.   This  swelling gra-
dually becomes of a  bright red, and will'not then bear the slightest touch.
The pain is now of  the most  acute kind, with  throbbing and sense of
tension, extending  from the internal angle to all the surrounding parts of
the orbit and head. The internal angle and the palpebrae become swollen
by serous effusion, and the latter are tumefied as in erysipelas; but the
enlargement is firmer.   The swelling sometimes extends to the whole
side of the face and  temple.   In this general tumefaction, the circum-
scribed enlargement of the sac can still be felt, and is usually pointed
out by greater prominence and redness.   The swelling of  the inflamed
membrane closes  the nasal canal, and  prevents the passage of tears into
the nostril; hence dryness of the latter, and watering of the eye.  So
violent an inflammation seated in the head, and near the  eye, may be
expected to cause serious febrile disturbance:  the  general symptoms
are of an inflammatory description, sometimes proceeding to delirium
at night.
   After a certain time increased secretion takes place from the inflamed
membrane, but without bringing the relief that might be expected, because
the effused matters are prevented from escaping by  the unyielding na-
ture of the surrounding parts.  Coagulating lymph may be poured out,
and cause obliteration  of the nasal canal.   Suppuration of the lachry-
mal sac may occur, with  increase  of the swelling at  the  internal
angle, and fluctuation; the integuments become prominent, and the
swelling  bursts if  not previously opened.  I have seen the skin so
distended before  the bursting of the abscess,  that mortification has
ensued.  This  took place  in  a female of full habit, in  whom the
local and general symptoms were most severe.  She would not submit
to a puncture of the abscess, and the skin sloughed to the size of a shil- 
DISEASES OF THE LACHRYMAL ORGANS.
751
   3' u }  l  abs,c^ss burst' or  be  °pened surgically, pus escapes, with
 which lachrymal fluid may be  mixed; or pus may be discharged alone
 at first, mucus and tears being gradually mingled with it as the inflam-
 mation subsides.  When the latter has  ceased, the discharge consists
 merely of lachrymal  fluid  with mucus, the latter  being  either trans-
 parent or opaque;  in  the  latter case it  is yellowish, or partially clear
 with opaque streaks.  The opening communicating with  the sac,  and
 sometimes where  the  collection has been left to burst, being at a little
 distance from it, is a fistula lachrymalis, or more properly a fistula of
 the lachrymal sac.  There may  be more than one external opening. More
 frequently the case does not  proceed  to suppuration and fistulous aper-
 ture.  The natural secretion  of the mucous membrane is increased  and
 altered  in  appearance, becoming thick and yellow, so as to resemble
 pus.  In this state, it either escapes spontaneously through the puncta
 lachrymalia, or issues from  them  copiously when pressure is made on
 the distended sac.   As the inflammation subsides, the secretion becomes
 less thick and yellow; it then appears semi-transparent, with whitish or
 yellowish streaks,  and at last is a clear mucus.  These  changes indi-
 cate the abatement  of inflammatory congestion and  tumefaction,  and
 the return of the membrane to  its natural state.  The sac  and duct re-
 cover their proper caliber, the passage into the nose is restored, and the
 complaint is at an end.  If the nasal duct should have become  perma-
 nently obstructed during the  acute  period, its  surface and that of the
 sac pass into a state of chronic inflammation,  attended with increased
 mucous secretion,  which, with  the lachrymal fluid, accumulates in,  and
 distends the sac, forming a tumour in the corner of  the eye.  Pressure
 on this swelling occasions  the escape  through  the puncta lachry-
 malia of the mingled tears and  mucus, under  various appearances, ac-
 cording to the  degree of inflammation  in the membrane.  A  watery
 state of the eye, with dryness of the nostril, and flow of tears over
 the under lid, are consequences of such  obstruction in the nasal duct.
    Treatment.—The severe local and general symptoms attendant on
 acute inflammation of the lachrymal sac in a robust subject of full habit,
 require  active antiphlogistic means.  According to the urgency of the
 case, blood must be taken by  venesection, cupping on the temple, or
 leeches.   The latter, applied over  the sac, and its neighbourhood, will
 generally  answer the purpose.   The loss of blood  must  be  repeated,
 until the inflammation is reduced.   Fomentations and poultices are the
 best local applications.  The internal treatment and diet  must  be  the
 same as in other inflammations.
   As soon as the existence of fluctuation indicates that suppuration  has
 occurred, an early and free  opening  is advisable, as  a means  of  im-
 mediate relief from acute  suffering;  and in  order  to limit  the extent
 of  mischief, we persist in the employment of  measures calculated to
 reduce  inflammation.  The  swelling of the membrane subsides;  the
 discharge  undergoes the successive  changes  already described;  the
 natural  course of  the  tears is re-established, and the  opening into  the
 sac closes; or the latter may  remain open, if the  nasal  duct  should
 continue impermeable.  We  should be contented, in  these cases, with
opening the sac, and not introduce probes, or attempt to  force a pas-
sage into  the nose.   The  mechanical irritation of such  proceedings 
752
DISEASES OF THE LACHRYMAL ORGANS.
cannot but aggravate  the already acute inflammation of the mucous
membrane.  If we pursue a soothing plan, the course of the tears will
be re-established, as  the inflammatory tumefaction subsides; or, if the
intervention of art should be necessary for clearing an obstructed nasal
duct, it may be resorted to more advantageously when  the general in-
flammatory disturbance has been removed.
   Chronic inflammation of the lachrymal sac.—In this affection, as in
the more acute disorder, there is swelling of the  inflamed membrane,
and consequent  interruption to the passage of  the tears;  hence arise
the following symptoms.  Swelling of the internal  canthus, in the situa-
tion of the lachrymal sac; watering of the eye, so  that it is full of tears,
which  occasionally run over the lower lid and down the cheek,  (stilli-
cidium lachrymarum?)  dryness of the nostril on the affected side, from
the absence of the lachrymal fluid.  The tumour may be colourless,
or more or less red, these differences depending on the degree  of in-
flammation: from the same cause it may be either indolent or painful.
In size, it may be equal to a pea, a horse-bean, or a nut: these varieties
depend partly on the duration of the affection; however, the sac  some-
times enlarges  considerably without any apparently adequate  cause.
Pressure on the tumour causes the contents of the sac to escape through
the puncta,or through the nasal duct; the latter  event is comparatively
rare.   Sometimes the contents cannot be forced out in either direction.
The fluid thus pressed out varies in appearance, according to the state
of the membrane; it may be thick and yellow like pus, or a viscid, opaque,
and streaked mucus, or a clear mucous fluid: tears may be mingled with
these in various proportions.  When the secretion is copious, and the parts
free from active inflammation, it may escape  from the  puncta sponta-
neously, or in consequence of the slight pressure caused by contraction
of the orbicularis palpebrarum.  From  this  increased discharge, the
affection has sometimes been called  blennorrhea sacci lachrymalis.
If the sac be emptied by pressure, it will fill once, twice, or oftener, in
twenty-four hours.   Patients sometimes content  themselves  with this
simple mode of  relief in preference to a surgical operation.
   When disease of the sac has been kept up for some time by obstruc-
tion of the nasal duct,  the affection  generally extends to the palpebrae,
of which the mucous lining is found red  and villous, with some mucous
discharge,  and  more or less  affection  of the  Meibomian  glands, the
lids being in  some instances  agglutinated during the  night.  The in-
flammatory disturbance may extend to the surface of the eye generally;
but the condition of the latter varies considerably in different instances,
and in the same individual  at different  times.  If the atmosphere  is
mild or warm, and the  eye not excited by exertion, there is no watering
nor any inconvenience.  Exposure to cold air, and especially to sharp
winds, causes increased secretion  of  tears,  which  occasion serious
annoyance by irritating the eye, and flowing abundantly over the cheek.
In some cases the eye is  permanently irritable,  and  becomes inflamed
from slight occasional causes, such as employment  in  reading, or
writing, or other modes of exertion.  The lachrymal sac, too, is liable
to attacks of more considerable inflammation, in which the eye is often
involved.  In the course of such attacks, the sac may become distended 
DISEASES OF THE LACHRYMAL ORGANS.
753
inflame and ulcerate; an  external opening or fistula will  thus be pro-
duced.
  The  circumstances more particularly deserving our  attention in
these cases, is the degree of inflammation ; the affection being originally
inflammatory, and the obstruction being kept up by the inflammation.
The increased secretion, or blennorrhoea, proceeds from the inflamed
mucous membrane, and the obstruction is from the same cause, which
produces tumefaction of the membranous lining, and consequently di-
minished caliber or closure of the duct.  The writers on surgical ope-
rations  have not, in general,  taken a  proper view of  the subject;
having directed  their attention merely to the obstruction, and the me-
chanical means of removing it.   The disorder is considered under the
head of fistula lachrymalis, which, instead of being an essential cir-
cumstance, is merely an occasional concomitant.
  In his work on diseases of the  eye, Scarpa appropriates one chapter
to this affection,  of  which he takes what appears to me an  erroneous
view.  He says, that " the curdy viscid humour mixed with the tears,
which in the first instance  flows back again through the puncta lachry-
malia, is not formed by the  sac, as is  commonly believed; but is for
the most part transmitted  to it from the eye-lids  by the puncta lachry-
malia, from it regurgitates upon  the eye whenever the sac, which is
gradually filled  with it, is pressed  upon.   This puriform humour is
principally furnished by the internal  membrane of the  palpebrae, and
comes more particularly from  the lower eye-lid along the tarsus, and
from the glands  of Meibomius :  the sebaceous matter peculiar to those
glands, being not only secreted in larger quantity, but also  acquiring
an acrid and irritating quality, according to the general  state of  the
habits,  with which they participate."   He  states, "that  the lach-
rymal sac has no other share in the disease than that of receiving and
retaining, together with the tears, the puriform humour which is trans-
mitted to it from the affected palpebrae."  He considers that the pal-
pebral mucus is so tenacious, and  the Meibomian secretion so thick,
that they lodge in the sac  and duct, and thus produce obstruction.  In
conformity with  these notions, he calls the disease puriform flux of the
eye-lids, {flusso palpebrale puriforme;) and he shapes his practice  ac-
cordingly, employing astringent washes  to  the  palpebral  linings, and
stimulating ointments to the ciliary  margins to correct these vitiated
secretions0  Although these means may be employed with advantage,
in some cases, and  after  other measures, I consider the  pathological
views, on which they rest, to  be entirely unfounded, being convinced
that the lachrymal sac and nasal  duct  are  the  original and essential
seat of disease, while the  palpebral  affection, when it exists, is only

^islt probable  that fluids, which can  pass  through the small lachry-
mal puncta  and  canals, will  stick in, and block  up, the much  larger
nasal duct f  In  many affections of the  lids, such as inflammation and
ulceration of their  margins, catarrhal, purulent  and gonorrhoeal oph-
thalmia there is increased secretion, often  very abundant, and gene-
rallv viscid; but the lachrymal  passages do not become obstructed.
Ao-ain  in lippitudo  and psorophthalmia, where the Meibomian secre-
tion is'much altered, no disease of the sac or duct takes place.   On
      95 
751
DISEASES OF THE LACHRYMAL ORGANS.
 the other hand, the palpebrae may be perfectly healthy when the nasal
 duct is obstructed.
    Treatment.—Our first  object, the removal of inflammation,  may
 be accomplished by the application of leeches over the sac, and other
 corresponding measures.   We shall  thus prevent the enlargement of
 the sac, suppuration, ulceration, and fistula, as well as the extension of
 disorder to the eye.  Under these means the swelling of the membrane
 often subsides, the increased secretion ceases, and the passage of the
 tears into the nose  is restored.   If obstruction of the  duct, and conse-
 quent distention of  the sac should continue after inflammation has  been
 removed, the patient should empty it occasionally by gentle pressure in
 the corner of  the eye.  The treatment recommended by Scarpa may
 be advantageously pursued under  such circumstances; that is, we
 may use astringent lotions, and stimulating ointments to the lids.   So-
 lutions of the sulphate of zinc,  sulphate of copper, or nitrate of silver,
 answer the former purpose: they may be employed at first in the strength
 of two grains  to the ounce of distilled water.  The sac having  been
 previously emptied  by pressure, and the mucus removed by a  soft hand-
 kerchief or rag, two or three drops of the astringent  collyrium should
 be placed in the  corner of the eye,  from which it will be absorbed by
 the puncta, and conveyed  into the sac.   It is unnecessary to impel it
 directly into the latter; indeed the use of Anel's syringe, the point
 of which is sufficiently small to enter the puncta, often aggravates the
 mischief by its mechanical  irritation.   The citrine ointment, that of
 red precipitate, or the ointment  of Janin (see page 119) may be applied
 occasionally to the edges of the  lids.  By such  management we  may
 remove the unpleasant effects of the complaint, although obstruction of
 the duct may continue, with occasional flow of tears over the cheek, and
 may  require pressure on the sac from time to time to prevent its disten-
 tion.
   The  lachrymal sac is sometimes distended without permanent ob-
 struction  of the duct.  In an  elderly woman, of spare habit, the left
 sac formed a conspicuous  tumour in the corner of the eye, without
 redness or pain, so  large, that  the receptacle must have been  three or
 four times the  natural  size.  On moderate  pressure  the contents de-
 scended into the nostril, and flowed out of the nose if the head were
 held forward.  The fluid  thus  evacuated consisted at first  of mucus
 with  yellow streaks; after surgical treatment, it was  a  clear  mucous
 fluid.   The complaint had  existed seven or eight years, and caused but
 little  inconvenience.
   Permanent obstruction of the nasal duct.—This may take place as a
 consequence either  of acute or chronic inflammation ; or it may be pro-
 duced by extension  of disease from the nose.  It occurs occasionally
 in the latter way, in  strumous  children:  inflammation  begins in the
 Schneiderian membrane, and then creeps on to the lining  of the  sac.
 The general management, and the internal remedies recommended for
 strumous  ophthalmia, particularly the sulphate of quinine, may be ad-
 vantageously employed in strumous  inflammation  of the lachrymal
 sac.
  Inflammation of the sac  and  obstruction of the nasal duct  are occa-
sional consequences of small-pox in children.
  If permanent obstruction  of the duct should cause repeated inflamma- 
DISEASES OF THE LACHRYMAL ORGANS.
755
tions of the sac and of the eye, and if these inconveniences cannot be
prevented or removed by the means already pointed out, we must resort
to further measures for restoring the passage of the tears into the nose.
Much  mischief may ensue from neglect.   The sac  may ulcerate, so as
to form a fistulous aperture, giving issue to mucous discharge and tears;
this may be either a simple opening, or complicated with thickening of
the surrounding cellular tissue, redness of the integuments, or  an un-
sightly growth of fungous  granulations.   Continued distention of the
sac may lead to slow enlargement, in which it forms a swelling in the
corner of the eye, as large as a  bean or a nut, without change of colour
in the  skin.  The swelling is soft,  and  yields to the  pressure of the
finger, under which its contents, consisting of tears mixed with trans-
parent, or yellowish streaked mucus, escape through the puncta or the
nasal duct.   To this  state of the organ Beer (Lehre, vol. i. § 367 and
588; vol.  ii. p. 151—183,) has given the inappropriate  name of rupture
of the sac (hernia sacci lachrymalis;) it  has  been also  called mu-
cocele.
   If the swelled sac feels firm and resisting, without fluctuation, or with
only a very obscure sense of it,  and if it cannot be emptied by pressure,
Beer calls the case dropsy of the sac (hydrops sacci  lachrymalis.*)
This and the former  affection are  both  comprehended by Schmidt/];
under the common name of varix of the lachrymal sac.   Beer says
that in the dropsical affection the sac continues to  enlarge, and that it
may reach the size of a  pigeon's egg; that, as soon as the swelling has
attained the magnitude of a  bean, the integuments become of a livid
red, the colour growing  deeper  as the swelling enlarges; that it is quite
indolent, and resists pressure; and that the cavity is filled with a secre-
tion like  thick glue.   Such a state  of the sac,  in  respect to size and
contents, has not come under my observation.
  Although caries of the os unguis  is spoken of as a  frequent occur-
rence in observations on fistula  lachrymalis, I do not remember to have
seen it as a consequence of disease commencing in  the sac.
   Treatment.—Numerous and various means have  been proposed for
removing obstruction of the nasal duct: they are usually mentioned as
operations for fistula lachrymalis, although in the great majority of in-
stances, there is no fistulous opening.  A description and consideration
of all these proceedings  would fill a moderate volume;  but it may be
well omitted, as the greater part are obsolete.;};
  Before performing  any such operation we  should  ascertain that there
is a permanent obstruction, which cannot be removed by other means.
If the  inflammation of the sac  be treated on the principles already ex-
plained, the cases  requiring  operation will  be very few.   We should

  * Lop cit  In the 41st number of the Chirurgische Kupfertafeln, there is a plate (pi.
208^ bv Professor Von Ammon, of Dresden, with coloured figures in which it is attempted
to show the eXnal characters of the swellings in the corner of the eye caused by various
affections of the lachrymal sac.
  \ ?l ^^t^les^S!^^^ torn. i. p. 327-404.  J. D Mj™,
clrliZZi **H£M' £ffi£^
TTwtSil   DiTonnaire  de Medecine et  de Chirurgie pratiques, art. IWw, torn.
 ■'•179—214.  Juengken, die hehre von den Augenoperahonen,  Kap. jtsu.: Operatm
Fil'tuice  lachrymalis, p. 406—490. 
756
DISEASES OF THE LACHRYMAL ORGANS.
avoid it  as long  as we can, because it is a temporary and imperfect
remedy.   If  we  merely clear away the obstruction, it will probably
soon recur.   To avoid this the patient must submit to the inconvenience
of wearing a foreign body in the duct, to maintain it in a pervious state.
   Anel, a French  surgeon, who  invented the  small  probes for the
puncta, devised  a syringe with a fine point for injecting fluid into the
lachrymal sac, and  thus forcing the obstruction of the duct.*   When
the latter is  so slight that it gives way  to the pressure of the finger on
the distended sac, and allows the contents to pass into the nose, it might
also yield to the syringe.   But the  force exerted  by the latter is altoge-
ther insufficient to overcome the ordinary permanent obstruction of the
nasal  duct.   Indeed, the fluid thrown in at one punctum escapes  by the
other: we can prevent this by compressing the other lachrymal canal;
but the inadequacy of the power to the intended  effect remains.
   The small probes, introduced through  the puncta, have been employed
to clear the obstructed nasal duct.   When the  probe  has  entered the
sac through the superior canal, it should be raised from the horizontal
to the perpendicular position, which the looseness of the lid  allows, and
then carried  through the nasal duct into the nose.  The extremities of
these probes are, however, so small, that they easily  become entangled
in the irregularities of the  membrane, so that we cannot readily judge
whether  the  instrument is stopped by that cause, or by an obstruction
in the duct.   By  pushing  it, in the former case, we wound the mem-
brane, and drive the instrument between it and the bone.   Even if we
conduct it safely  to the obstruction, in which object  failure may often
be expected, from the  necessary  change in the direction of an instru-
ment going first through the lachrymal  canal, then through the sac and
duct, it is badly calculated in size and strength for forcing the obstructed
part.   The small opening  effected by  it is inadequate to the transmis-
sion of the tears, and will  soon close again.  I  therefore  consider the
employment of Anel's probes in this way  more likely to do harm than
good.  He himself acknowledges that the method is  applicable to mild
cases only.
   [Our experience with this method of treatment has led us to a very different
conclusion as to its value.  We are indeed persuaded that it is  applicable to
most cases of obstruction of the nasal duct, and that  it is the safest, most ra-
tional, and least painful method of treatment.  At the end of this section we
shall expose our views more fully.]
   It has been  proposed to fill  the lachrymal sac with quicksilver, by
means of a glass tube, with a steel stopcock, terminated by a steel tube
sufficiently minute to enter the puncta and  lachrymal canals.f   It has
been expected that the weight of the metal thus conveyed into the sac,
would cause the obstruction to give way.  As the cavity of the sac
does not exceed the size of a garden-pea,  the force thus applied would
certainly cure no obstructions which would not have got well of them-
selves.   A more considerable power,  corresponding in degree to the
height of the column, may be applied in the act of injecting the sac, if

  » Nouvelle Methode de guerir les Fistules hachrymalea; et Recueil de differentes Pieces
pour et conlre la Methode. Turin, 1713.  Dissertation sur la nouvelle Decouverte del'Hy-
dropisie du Conduit hacrimal.  Paris, 1716.
  t A new Method of treating the Fistula hachrymalis by Mr. (afterwards Sir William)
Blizard, in the Philosophical Transactions, vol. lxx. p. 239. 
DISEASES OF THE LACHRYMAL ORGANS.
757
the escape of the mercury through the other punctum be prevented by
compressing the corresponding canal.  If the obstruction does not yield
to this  power, we  cannot expect it  to give way to the weight  of the
small globule contained in the sac.
   As the nasal duct, after having been cleared and enlarged, will con-
tract again, it has been proposed, in order to prevent such relapse, and
to maintain a permanent  passage for the tears, to introduce, through
an opening in the lachrymal sac, a gold  or  silver  tube, and to leave it
there.  In length and size the tube must be accommodated to the nasal
duct and the adjoining portion of the sac.   Its upper end,  which is a
little expanded, rests in the lower portion of the lachrymal sac, while the
lower extremity, terminating in an aperture cut obliquely, should clear
the opening of the nasal duct.*  In order to introduce it, the lachrymal
sac must be laid open.  The tendon  of the  orbicularis palpebrarum is
the guide for this incision.  The distended sac must be punctured below
the tendon with a double edged pointed knife, the point of  which is
directed towards the cavity  of the sac.   If the mere puncture does not
make a sufficiently ample opening,  the  knife may be  carried  down-
wards and outwards  in a direction  parallel to the edge of the orbit.
The escape of mucus and tears shows that the  sac has been opened.  A
silver probe is carried through the opening  thus made in the sac, and
into the nasal duct, not perpendicularly downwards, but a  little back-
wards and inwards;  the  inclination  backwards being  just such as the
projection of the eye-brow would give to a probe passed into the nasal
duct from above.   We shall meet with resistance  at the point of ob-
struction, and we must employ a  gradually increased pressure to over-
come it;  the probe then  goes on  into the nose, from which, on  using a
handkerchief, a little blood escapes.  If we cannot force the  obstruction
with the blunt end of the probe, we  must have recourse to the sharp
point.  The resistance may be so great, as  to render it advisable to
desist, and repeat the attempt after an interval of two or  three days.
The tube is placed in the nasal duct  by means of a steel  stilet, bent at
a right angle, of which the portion beyond the bend corresponds to the
cavity  of the tube.  The latter must be fairly lodged in the duct, with
its upper or extended portion occupying the  lower part of the sac. The
skin heals over, the tube  provides an artificial passage for the tears, and
the immediate result of the operation appears very favourable.   Unfor-
tunately, the future history  of these cases  is not equally satisfactory.
We could hardly expect ii priori that a metallic tube would permanently
answer the purpose of the natural duct.  We  find  accordingly,  that the
artificial  substitute, after  the lapse of some months, gets out of its place,
rising  too high, or sinking  too low, or that it becomes obstructed.   It
causes inflammation in some instances, and  in others, pain more or less

   * The employment of the tube, proposed in France  by Pellier de Quengsy, in his
Receuilde Memoires et tfObservations sur les Malaaies  de t(Eil, Montpelher, 1783, was
strongly recommended in  this country by Mr. Wathen,  in " A new and easy Method of
avvluins a  Tube for the Cure of Fistula hachrymahs."  4to. London, 1781; second ed.t.on,
8vo  17U2.  In this work, the tubes  and the other means connected with their employment,

^t^X'™^"^"** b? BAR0N D™™»™. whose method, with the
 forms and dimensions of the tube and subsidiary apparatus, are detailed  in  Ihe two works
 iorni& dim     „„_„„,„ n  711  The instruments employed by Dopuytren are delineated
u^^^^^r^^ No-xxx-pl 147< 
758
DISEASES OF THE LACHRYMAL ORGANS.
severe, an intolerable aching in the corner of the eye and cheek, which
cannot be remedied without removing the tube.  I have seen all the
inconveniences now enumerated resulting from this practice, and  have
found it necessary, on  account  of them, to  remove tubes which had
been introduced by others, a proceeding often attended with considerable
pain.   That the necessity for such removal  is not a very rare occur-
rence, may be inferred from the circumstance of the Baron Dupuytren
having devised an instrument expressly  calculated for the extraction of
the tubes.*  In one case, after removing the  tube, I found it filled with
a slender production of the mucous membrane exactly like a mucous
polypus, entering  above, and extending  nearly to the lower end of the
tube.   That the method, although  strongly recommended by Mr.  Wa-
then, was not permanently successful, may be inferred from the circum-
stance that his partner, Mr. Ware, subsequently proposed and advised
another mode of proceeding.
   Velpeau says, that it  is often necessary to withdraw the canula in
consequence of its rising under the integuments; that M. Darcet relates
twenty-seven cases, in which its extraction  had been required; that it
sometimes sinks into the nasal fossa, and hence the operation  fails.   M.
Delpech had seen a case, in which it had gone through the roof of the
mouth.  (Noveaux Elemens de  Medecine Operatoire,  vol.  i. p. 647.)
Professor Jaeger of Vienna informed  me  that an instance of the latter
kind had  come under his own observation.
   Beer recommends the employment  of catgut to  enlarge the  con-
stricted duct.  The sac must be opened, and the obstruction  of the duct
removed in the manner already described.  A piece of catgut is then to
be introduced into the sac, and passed through the duct into the nose,
when it will either present itself at  the nostril, so that it may be drawn
out with  forceps, or it must be  forced  out by the  patient blowing his
nose.   The extremity of the catgut, thus brought out  at the anterior
aperture of the nostril, is to be fixed by sticking plaster in a convenient
position near the ala nasi; and the  rest of the string may be fastened in
a coil to a cap, or may be fixed on  the brow by a turn or two of a  nar-
row roller.   Every day a fresh  portion  of the  catgut is drawn down
through the duct, and that which  had been there the previous day is
cut off, the extremity being fastened as  before.  After thus consuming
a piece of catgut of the ordinary length  and size of the  fiddle-string E,
Beer commences with a similar length of the string A, and  then  with
the string D.  When this has been passed through, he considers the  cure
completed, and allows the opening into the sac to heal.f
  The  method, proposed by Laforest,J of examining the nasal duct,
and removing obstructions in it by  means  of instruments introduced  at
the inferior orifice, which seems  hardly to have been employed, except

  * This instrument, which has received the name of tire-canule, is described and figured
in Graefe und Walther's Journal; vol. viii. p. 153, tab. 1. fig. 12.  The surgeon, who
contributes this account, says that he saw several Canute extracted while he was in Paris;
and that, in the case of a young girl; the tube had  sunk so low that it could  not be  with-
drawn from above, so that Dopuytren was  obliged to extract it from the  nose with forceps,
which was only accomplished with considerable trouble.
  t  Lehre, vol. ii. in the chapter on the hernia sacci lachrymalis, and hydrops sacci lachry-
malis, p.  151—183.
  t Nouvelle Methode de trailer les Maladies du Sac Lachrymal; Mem de VAcad, de Chi-
rurgie, torn. ii. p. 175.  Thr instruments are represented in plate xiii. 
DISEASES OF THE LACHRYMAL ORGAN*.
759
by the inventor, has again been brought into notice by Mons. Gensoul,
of Lyons, whose mode of proceeding is thus mentioned in the Diction-
naire de Medecine et de  Chirurgie pratiques*  " M. Gensoul employs
the escharotic method in most cases of fistula lachrymalis, making his
applications by  the inferior orifice of the nasal canal.  He filled that
canal, in the dead body, with fusible  metal, which, being removed when
cold,  by breaking away  the bone, afforded a model for probes, capable,
as he says, of entering and passing the canal with the greatest facility.
When the application of caustic is  required, the instrument is formed
into a port-caustique analogous to that employed by Ducamp in strictures
of the urethra.  The probe is bent,  nearly at a right angle,  about nine
or ten lines from its extremity; near this curve there is a slight lateral
inflexion, the direction of which  must be  opposite for the two nostrils;
it corresponds to the projection of the nasal process of the superior max-
illary bone.   M. Gensoul represents that his probe passes into the lach-
rymal sac as easily as a catheter into the bladder."
  The mode of  proceeding, which I consider the most eligible, as com-
bining the advantages of efficiency, simplicity and complete safety, is that
introduced by the late Mr. WARE,f of placing in the lachrymal sac Fig. 65.
and duct, what he calls a nail-headed style,  [see fig. 65,] that is, a  Mx
cylindrical piece of silver, about the thickness of an ordinary
probe, long enough to reach from the corner of the eye to the ter-
mination of the nasal duct, with a head like that of a nail placed
obliquely at  its  upper end, which is a little curved, so that the
style  may sit close in the corner of the  eye.   The sac  must be
opened by an external incision below the tendon of the orbicularis
palpebrarum, [see fig. 66,] and the obstruction of the duct must be
cleared by adequate pressure with a probe, as in other modes of
proceeding.  The style may then be introduced, taking care that
its head is secured, so as  to prevent it from sinking into the wound,
as it is intended that its head should rest on the integuments  in the cor-
ner of the  eye,  where, being blackened, it           Fjg 66>
appears as a small  black patch.  Instead
of  introducing  the  style  immediately,  I
prefer placing a portion of bougie in the
duct, turning down its upper  end, so as to
prevent it from  sinking into the sac.  The
small  end  of the  smallest  bougie will an-
swer the purpose; the length should be an
inch  and a half, or rather less.  In one or
two days this should be  removed, and the
passages may be cleared by gently injecting
a little tepid water through the wound by
means of Anel's syringe, on which a blunt
end is screwed when it  is employed for
this purpose.  Another piece of  bougie, of

  * Tom. viii. p. 210           , th  Fisiuia Lachrymalis, 8vo. London,  1798.  These
  t  Ob,er^^^*^^^/wiih *n  Essay on the Epiphora or  Wattry Eye, and
observatmns are reprmted,  S     ina voIume of tracts on the eye, published after the
dtath orie aulhor by his son, Mr. Martin Ware.  Plate ii. of this volume contains fi-
gures representing the styles.
 
760
DISEASES OF THE LACHRYMAL ORGANS.
 the same or a larger size, is then introduced, and this plan is continued,
 with a gradual increase in the size of the bougie, for a week or ten days.
 The external orifice will now be reduced to a small round opening,through
 which a little mucous discharge may escape, and the style may be substi-
 tuted for the bougie.  The patient soon learns to remove and replace the
 style; and he takes it out and cleans it, from time to time. It might be sup-
 posed that the passage of the tears would not be  assisted by introducing a
 solid substance into the duct.   Experience, however, shows us that the
 fluid takes its natural course, when a style is thus kept in the lachrymal pas-
 sages, and the enlargement of the urethra round a catheter  left in  the
 canal affords an explanation  of the circumstance.   The style, indeed,
 becomes so  loose, that  it sometimes  falls  out when  the head is bent
 downwards.   As the presence of the instrument causes neither pain nor
 inconvenience, I  recommend patients to wear it permanently.   Accord-
 ing to my experience, this method maintains the natural course of the
 tears with  the least trouble to the patient.
   If there  should be fistula of the lachrymal sac, some modification of
 the proceeding may be  necessary,  such  as a previous slitting of the
 fistulous track; or this may be done at the same time with the opening
 of the sac.
   Complicated contrivances for  compressing the enlarged lachrymal
 sac, and thus reducing  it to  its proper dimensions, are described and
 delineated  in  surgical works; I  must doubt whether they have been
 employed,  as they seem ill calculated  to  answer the intended purpose.
 Of one thing I  am certain;  that the annoyance of wearing such ma-
 chinery  would be  greater  than  the  inconveniences  incidental to the
 complaint.
   The various proposals for conveying setons into the nasal duct from
 the nose, and for attacking  the constricted portion with escharotics or
 the actual cautery, are  either obsolete or inappropriate, and  therefore
 do not require detailed consideration.
   When inflammation of the sac occurs repeatedly, and the nasal duct
 is obliterated, so  that the foregoing  methods  are inapplicable, it has
 been recommended to expose the cavity completely, and to destroy the
 mucous  membrane  by the actual  cautery, by pure pot-ash, or some
 other escharotic.  Another  method, suggested under similar  circum-
 stances, is that of perforating the  os  unguis, so as to make a direct
 opening  into  the  nostril.  I have seen no  cases requiring such pro-
 ceedings.
   Obstruction of the duct may arise from syphilitic disease of the nose;
 from caries or exostosis of the surrounding bone; from morbid growths
 of various  kinds, originating in the nose or antrum.   Suppuration and
 ulceration of the sac, with fistulous  openings, may ensue in such cases,
 which admit of palliative relief only.
   Fistula lachrymalis has been kept up by the presence of a calculous
 concretion, and has healed on its removal.  (Graefe und Walther's
Journal; vol.  x.  p.  597.)   I  have not seen such  formations in  the
lachrymal passages.
  [The operations described in the preceding pages for the re-establishment of
the passage for the tears to the nose, are, we  believe, rarely required—never
perhaps, except in cases where the inflammation has been so violent as to cause 
DISEASES OF THE LACHRYMAL ORGANS.
761
effusion of lymph and adhesion of the sides of the nasal duct, thus completely
obliterating this passage.   When the obstruction, however complete, is the re-
sult merely of thickening of the mucous membrane lining the nasal canal, form-
ing as it were a stricture, it may be cured by a recourse to proper methods of
dilatation  on  the  same  principle  that strictures elsewhere are treated.  It is
true that the  mucous membrane in this case is confined in a bony canal, which
does not  admit of dilatation, still the principle is applicable, for pressure on  the
thickened mucous membrane by the sound, causes the removal by the absor-
bents of the newly formed parts,—of the lymph deposited in the mucous tissue.
   Mr. Travers' remarks on this, subject are very judicious.  " It can  hardly be
required " he observes, "that I should occupy the time of the reader in showing
that the practice of restoring a passage partially closed, or even establishing an
artificial passage,  as  nearly as possible in the same direction, when the natural
channel is obliterated,  commands a decided superiority over the practice of
making an artificial opening.   This  applies to the treatment of  the urethra, as
well as  of the ductus nasalis, and  it is only in case  of abscess, in which the  dis-
tended  and inflamed integument threatens to  give way by ulceration, that in
either case it  becomes necessary to deviate from it.
   " A set of silver probes, of about five inches long, varying in size, flattened at
one end, and slightly bulbous* at the point, are the instruments I use for the
purpose of restoring  the passage.   The probe is introduced with perfect facility
by one  who is familiarly acquainted  with the anatomy of the part, from either
of the puncta lachrymalia into the corresponding  nostril,  when no obstruction
is offered to its passage.  If the  punctum be constricted, it is readily entered
and dilated by a common pin;  and upon withdrawing it, by one of the smaller
probes; the direction and relative situation of the lachrymal ducts, the sac,  and
the nasal canal, point out the proper course of the instrument.   It is  confirmed
by its advance without the employment of force, and  the sensation  conveyed
by the free and unencumbered motion of its point; until the point is fairly with-
in the  sac, it is  necessary to keep the  eyelid gently stretched  and slightly
everted ;  the upper lid being drawn a little upward toward the zygoma.   The
point carried home to the sac and touching  lightly its nasal side, the lids may
be left at liberty,  while a half circular motion is performed by the instrument;
the surgeon neither  suffering the  point to recede, nor,  on the other hand, allow-
ing it to become entangled in the membrane.
   " The probe now rests in a perpendicular direction upon the eyebrow towards
 its inner angle, and  in this direction it is to be gently depressed until it strikes
upon the floor of the  nostril, where its  presence is readily ascertained  by a
common probe, passed beneath  the inferior turbinated bone.   The probe  of
 smallest dimensions is of sufficient firmness to preserve its figure in its passage
 through the  healthy duct, but it is too flexible  to  oppose any considerable ob-
 struction, without danger of a change of figure: for the stricture of the lachry-
 mal duct's it  is of sufficient strength.
   " Very many cases of recent origin, and in which  the  stricture has no great
 deeree of firmness,  are completely cured by three or four introductions of the
 probe into the nostril, at intervals of one or two days.      ............
   « I have seldom met with  a stricture so firm as not to yield to the full-sized
 nrnhp   I am fully aware of the  objection that immediately presents itself, viz.
 thTa nassase so obtained is not permanent; by several repetitions  of the  ope-
 uidi a pa   e  ^ rendered so; but if the resistance is not altogether removed,
 ration it  is    ^ experiment for some days in succession, I introduce a  style
 alter a tria         head  a litt]e si0ped, through the punctum lachrymale into
 [hTS and leave it for  a period of twenty-four hours in the  duct.  If worn

             [* We prefer a  probe well rounded at the point without a bulb.]
         96 
762
DISEASES OF THE LACHRYMAL ORGANS.
 longer, as for two days, it ulcerates the orifice ;  but I have never seen it injure
 the punctum in the smallest degree, when worn  for the full period first named.
 A day or two should be suffered to elapse before the style is again introduced,
 and it should then be passed through the other lachrymal duct.   The injection
 of tepid water should be made  on the intervening days with  Anel's  syringe.
 The plan requires perseverance, as may be  said of all plans by which so diffi-
 cult an object is  sought to  be effected.  In many cases the resistance, in the
 first instance opposed, is inconsiderable, yet it is sufficient to maintain the dis-
 ease.  The probe passes daily with increasing facility, and after a very few re-
 petitions, with as  much ease as through the  healthy canal; yet the stillicidium,
 and even the mucous discharge do not immediately subside, because, although
 the obstruction is removed  by which these  symptoms were  originally set  up,
 the parts have not yet recovered the loss  of tone which the state of habitual
 obstruction and inaction has induced;  and  here the  use of the probe is un-
 availing, if not injurious, as in all  cases in which the  full-sized probe  passes
 without impediment.  It  is  important that operators should consider this, and
 not lose sight of  the  vital function of the parts, in treating the morbid altera-
 tions of structure which have  interrupted and deranged them.   For this miti-
 gated, but not recovered state, time alone, with attention to prevent distention
 by occasional gentle pressure of the sac if accompanied with mucous discharge,
 is often sufficient; but the injection of a solution of alum, or even of cold spring
 water, and  the use of astringent washes, will assist.   Sniffing a  stimulant va-
 pour, as of vinegar, or diluted  nitric acid, into the nostril, I have also found use-
 ful.  It is of course unnecessary to  pass a probe, when  the fluid injected  by
 the punctum drips in a stream through the nostril or into  the throat, as the
 head of the patient is inclined forwards or backwards;  but this  test of the free-
 dom of the  passage should  be had, before the use of the probe is laid aside."
 [A Synopsis of the Diseases of the Eye and their Treatment. 3rd. ed.pp. 379-383.]
  We have practiced this method of treatment for the last ten years, and with
the most gratifying results.   The introduction of the probe requires it is true,
a perfect knowledge of the anatomy of the parts, much practice and tact; but
all this may be acquired.
  Mr. Morgan recommends  the strictured duct to  be dilated by a curved probe,
(fig. 62.) introduced by the nose upward through  the duct, an operation which

                                 Fig. 67.
 he remarks " although it may require some  little practice to perform it with
 facility is, so far as  my  experience has  gone, most satisfactory in  its result."
 No force must  be used in  introducing the instrument, the point of which
 having  been carefully fixed in the lower  opening of the  duct, after being car-
 ried under the inferior turbinated bone, is to be  gently pushed  upwards into
 the sac through  the stricture  by depressing  the  handle of the probe or sound,
 keeping the convex part  next to the handle upwards, then having established a
 free passage through one canal from below, I generally inject tepid waters from
 day to day, by means of  a small catheter, [similar in form  to the sound] in-
troduced in the same manner as the sound and attached to an Anel's syringe.
By following this plan, suppuration may sometimes be prevented, but at all 
                   DISEASES OF THE LACHRYMAL ORGANS.              763

events a fistulous opening in the face is prevented, if the disease is confined to
the membrane, (although an abscess may have formed  in the sac) in conse-
quence  of the prevention of any accumulation there by frequent injections."
(Lectures on the Diseases of the Eye. p. 219. 220.)
  We have tried this method of treatment and have found it more unpleasant
to the patients than that  advised by Mr. Travers, and not so far as our expe-
rience has gone, more effectual or speedy in accomplishing a cure.
  Congenital absence of the nasal duct.   M.  Berard  has recorded a case in
which the  nasal duct was  congenitally absent, and in which he made an ar-
tificial one.   The subject of this case a man, 21 years of age, was admitted into
hospital  Necker on account  of a congenital fistula lachrymalis.  This fistula
discharged a limpid transparent fluid, and caused continual epiphora.   On press-
ing on the angle of the eye in the morning, a muco-purulent liquid flowed from
the fistulous orifice and from the puncta.  The nostril of the same side was
habitually dry; stimulating powders, such as snuff, becoming dry without ex-
citing the secretion of the pituitary membrane.  A stylet introduced  into the
fistulous orifice in the direction of the nasal duct would  not  pass, nor was it
possible to penetrate its nasal orifice.  No doubt could exist, therefore, of its
congenital absence, and M. Berard made  an artificial nasal duct by piercing
the os unguis after the manner of Woolhouse.
  The inferior border of the internal portion of the tendon of the  orbicularis
being laid bare by incision, M. Berard directed a trocar downwards, backwards,
and inwards, perforating the internal wall of  the  orbit.   The trocar was im-
mediately replaced  by a  silver canula about half an inch  long, enlarged at its
two extremities, and on closing the mouth and nostrils of the patient, the air
passed through the canula, showing that it was well placed.  Three days after
the operation  the small wound had cicatrized; no bad symptoms  followed.
In two months, the patient having  neglected the directions of the surgeon, re-
turned with epiphora, when M. Berard changed the canula, and in two months
the epiphora had completely disappeared, and the patient was quite well  in
February last.—Bull. Ge,n. de Therapeut. July, 1841. 
 
INDEX.
ANATOMY  AND  PHYSIOLOGY  OF  THE  EYE  AND  ITS
                           APPENDAGES.
Annulus albidus, 49
        gangliformis, ib.
Anterior chamber, membrane of, 43
Aqua Morgagni, 63
Aqueous humour, 65
                 anterior chamber of, ib.
                 posterior chamber, ib.
                 membrane of, 43
Arachnoidea oculi, 56
Arteries, anterior ciliary, 51
        long ciliary or iridal, 51
        of conjunctiva and cornea, 44
        short or posterior ciliary, 48
Artery, central, of retina, 60
Canal of Petit, 62
        Fontana, 41
Capsule crystalline, 63, 64
Caruncula lachrymalis, 96
Catoptric phenomena, 80
Choroid coat, 45
Cilia, 91
Chiasma of optic nerves, 79
Ciliary arteries, anterior, 51
                long, ib.
                short or posterior, ib.
       body, 49
       ligament, 60
       nerves, 52
       processes, 49
Circulus, venosus iridis, 47
Conjunctiva, 92
            palpebral is, 92
            sclerotica, 93
            semilunar  fold  of, 96
            corneae, 43, 39
            blood vessels of, 44
            Lymphatic vessels of, 4o
             nerves of, ib.
Corpus ciliare, 61
               pars phcata ot, 49
               pars non plicata of, ib.
 Crystalline lens, 62
Crystalline capsule, 63, 64
           how  connected   with  other
             parts, 63
Eye, as an optical instrument,  parts sub-
  sidary to, 68
        a  catoptric instrument, 80
        humours of, 39
        as a catoptric instrument, 79
Eye, pathology of, 96
    anatomy of,  appendages of, 81
    muscles of, 81
    proper fibrous capsule of, 83
Eye-ball, shape of, 38
         dimensions of, ib.
         tunics, ib. 39
         connexions of coats of, 60
         physiology of, 66
Eye-brow, 86
Eye-lids, 87
         appendages, anatomy of, 81
                    muscles, ib.
Eye-ball, anatomy of, 38
         fascia,  83
         component tissues of, 89
         cellular substance of, 90
         ciliary margins of, 91
Foramen  retina? centrale,  59
Fossa hyaloidea, 62
Horizontal section of the eye, 36
           explanation of, 37
Hyaloid membrane, 61
Inverted image  on  retina, 77
Iris, 50
     blood-vessels of, 51
     nerves of, 52
     circular venous sinus of, 52, 42
     its movements, 71, 72, 74
                    causes of, 72
     nerves of, 75
     muscularity, ib.
     active and  passive state of, 74
 Jacob, membrane of, 58 
766
INDEX.
Light, 66
      reflection and refraction of, 67
      action of transparent media of the
         eye on, 68
Lachrymal organs, 94
Lamina cribriformis,  41
Lens, crystalline, 62
Lenses of the eye, ib. 69
Ligament ciliary, xxiii.
Light, nature of, 66
Limbus luteus foraminis centralis, 59
Macula lutea, ib.
Membrana fusca, 56
Membrane pupillary, 55
           of anterior chamber of aqueous
                humour, 43
             Descemet, ib.
             Jacob, 58
             pigment,  47
             posterior chamber of aqueous
                humour, 65
 Muscles of the  eye, 81
               eye-lids, 87
 Nerve, optic, 58, 85
 Nerves, ciliary, 52
        of the appendages of the eye, 85
 Ophthalmic surgery, history of, 30
                    mode of study, 27
 Optic nerve, 58, 85
 Orbit, nerves of, 85
 Ora serrata, 49
Palpebra?, anatomy of, 87
Papilla conica, 58
Petit, canal of, 62
Pigment, membrane of, 47
Pigmentum nigrum, its uses, 45, 46
Posterior chamber, membrane of, 65
Puncta lachrymaliaj 95
Pupil, 39
      size of, 73
Pupillary membrane, 55
Retina, 58
       central artery of, 60
       transparent point of, 59
       fold of, 59
       yellow spot of, xxvii. 59
Retinal picture, 77
Sclerotica, 39
Sebaceous glands, 89
Section, horizontal of eye, 36
Sight, importance of, 25
Sinus circularis iridis, 42, 52
Soemmering, yellow spot of, 59
Tarsi, 89
Tunica Ruyschiana, 47
Tunics of eye-ball, 38
Uvea, 50
Vasa vorticosa, 48
Vitreous body, 61
         humour, 61
 Zinii, zonula, 62
 Zonula ciliaris, vel Zinii, ib. 
INDEX.
DISEASES  OF  THE  EYE.
Abscess  of anterior chamber, 335, 368
           cornea, 334
           iris, 379
           lachrymal sac, 246, 250
           orbit, 692, 693
Absorption, cure of cataract by, 613
          of depressed lens, 611, 615
             orbit from pressure, 700
Acetate of lead precipitated on ulcerated
  conjunctiva, 345
Adams, Sir  W.'s operation for  artificial
  pupil, 429
Aegilops, 750
Albugo, 347, 275
Alopecia, 124
Amaurosis, 474
           apoplectic, 481, 486
           congenital, 495
           hydrocephalic, 480
           from congestion or inflamma-
             tion  of nervous optic  ap-
             paratus, 479, 487, 496, 506
             cerebral hemorrhage, 481
           causes of, 495, 475, 496
           classifications of, 475
           from debility, 524
           definition of, 474
           diagnosis of, 501
           from belladonna, 499
               blows on eye, 174
               cerebral congestion,  478,
                 479
               concussion of retina, 173,
                 174, 485,163
                       spinal cord, 524
                       or other injury of
                          the head, 478
           debility, 524
           depressed lens, 486
           diarrhoea, 524
Amaurosis from disordered  digestive or-
               gans, 497, 523
             dropsy of the eye, 639
             excessive exertion of  the
               organ, 496, 506
             fractured cranium  with de-
               pression, 482
             gout, 498
             haemorrhagy,  524
             hydrocephalus, 480
             inflammation of choroid, 451
                       eye, 455
                       orbital   cellular
                        membrane, 692,
                          694, 695
                       retina, 452, 458,
                          486
             injuries of branches of fifth
               nerve, 529
             intense light, 453
             irritation of branches of fifth
               nerve, 529
             lead, 500
             lightning, 453
             loss of fluids,  524
             masturbation, ib.
             melanosis, 673
             miscarriage, 528
             morbid  changes  afFectiog
               fifth nerve, 529
                        in optic nerves,
                            482, 484_
                     formations  in brain,
                       481
             onanism, 524, 526
             ophthalmitis, 485
             over exercise of sight, 496,
               454
             plethora, 496
             poisons, 499 
768
INDEX.
 Amaurosis, from pregnancy, 528, 526
                 pressure on eye, 346
                 ptyalism, 524
                 retinitis, 485, 488
                 sanguineous extravasation
                   in head, 481
                 spermatorrhoea, 524, 526
                 suckling, 526
                 suppression of accustomed
                   discharges, 497
                            menses, 497
                           perspiration,
                              497
                           purulent dis-
                             charge, ib.
                syphilis, 498
                tobacco, 524
                tumours in orbit, 304
                venery, 526
                worms, 498, 523
                wounds of eye, 174
                wounds  of eye-brow or
                  eye-lids, 108
            general account of, 474
            hereditary, 495
            illustration  of species of, 475,
              477
            lactantium,  526
            origin and progr ess, 494
            prognosis in, 502
            rheumatica,498
            seats of, 477
            stages and degrees of, 491
            symptoms of, 489
            traumatica,  344,346,348
            treatment of, 503
            with debility, 524
                iritis after typhus, 525
Amaurotic cat's eye, 532
Amblyopia, 489
Ammon's operation for  ectropium  and la-
   gophthalmos,  140
Ankyloblepharon, 149
Anchylops, 750
Anel's probes, 748
       syringe, injections with, 750
Aneurism by anastomosis in orbit, 708
                       of  eye-lids,  157
          of ophthalmic artery, 328
Anterior chamber, abscess of, 335, 368
                  osseous deposit in, 578
                  effusion of blood in, 164,
                    373
                  spontaneous passage of
                    lens into, 472
                  extraneous  substances
                    in, 158,159
                  dropsy  of, 375
        operat on for cataract, 617
Antrum, pressure on orbit from, 64
Apoplexy, amaurosis from, 481
          of eve, 373
 Aphthous ophthalmia, 292
 Ariduria bulbi, 639
 Astringents in conjunctivitis, 216
               ophthalmic   inflammation,
                 205
               purulent ophthalmia, 257
               gonorrhosal ophthalmia,280
 Aqueous chambers, diseases of, 359
                   inflammation of, 364
                   abolition of, 571
                   dropsy of, 375
                   evacuation of, 371
                   foreign bodies in, 158
         membrane, inflammation of, 364
 Aquo-capsulitie, 364
 Arcus senilis, 345
 Arthritic inflammation of internal tunics,
   460
 Artificial eye, 356
          dilatation of pupil, 360
          pupil, 417
               by distortion, 447
                 excision, 434
                 incision, 428
                 separation, 438
               general rules  regarding,
                 425
               prognosis, 422
               states of eye requiring, 418
 Atonia palpebrarum, 133
 Atoniaton blepharon,  ib.
 Atresia iridis, 387
 Atrophy of eye, 175, 387, 639, 642

 Bates' camphoratpd water, 227
 Blepharo-blennorrhcea, 231
         conjunctivitis catarrhalis, 213
 Blepharophthalmia ulcerosa, 120
 Blepharo-ptosis,  133
 Blepharoplastic operation  for lagophthal-
   mos and ectropium,  139
 Blepharophthalmitis   glandulosa   idiopa-
   thica,  117
 Beer's cataract knife, 593
 Belladonna in  iritis, 397
           amaurosis from, 499
           uses of, 400, 397
           its action on the pupil, 73
 Blear eyes, 116
 Bleeding in  ophthalmic inflammation, 192
 Blennorrhoea of excreting  lachrymal or-
   gans, 249
 Blepharitis glandulosa, 117
          scrofulosa, 116
 Blepharospasmus, 135
 Blood effused into eye, 164, 373
            in cornea, 350
Blows on eye, 164
Brain,  morbid  formations  in,  producing
   amaurosis, 481
Buphthalmus, 637 
INDEX.
769
Burns of conjunctiva, 177
         cornea, 239
         eyelids, 108
Bursting of eye, from blows, 162, 163
           cornea, 239
Calculus, lachrymal, 107, 277
         Meibomian, 105
Caligo tenebrarum, 538
Calculous concretions in eye, 684
Callosity of eyelids, 123
Cancer of eyeball,  644
         lower eyelids, 127
       soft, of eyeball, 649
Capsule, aqueous, inflammation of, 364
        crystalline, inflamed, 470
                   injuries of, 166
Carbuncle of eyelids, 115
Carcinoma of the eye, 644
Carcinomatous exophthalmia, 646
Caruncula lachrymalis, inflammation of, 749
                      polypus of, 749
           maligna, 647
           warts  of, 749
Cartilaginous formations in conjunctiva, 320
Cataracta arida siliquata, 582, 621
         cum  bursa ichorem continente,
           582
              zonula, 653
         cystica, 343, 653
         dimidiata, 582
         fenestrata, 581
         fluido-dura, 577
         gypsea, 582
         lymphatica, 572
         marmoracea, 581
         pyramidalis, 582
         trabeculars, 582
         tremulans vel  natatilis, 582
         traumatica, 576
         punctata, 581
         stellata, 581
         variegata, 581
Cataract, 572.
         anterior capsular, 581
         black, 475, 577
         bursal, 582
         capsular, 580
         capsulo-lenticular, 581
         causes of, 586
         central, 578
         choice of operation, 590
         classifications of, 576
         complications of, 584
         congenital, 620
         couching of, 608
         cure of, by absorption or dissolu-
           tion, 613, 611
                   operation, 57J
         definition of, 572
         depression of,  608
         diagnosis of, 573
         diagnosis by catoptric test,5<o
         97
Cataract, displacement of, 608, 617
         extraction of, 591
         false, 572
         fibrinous, 627
         firm, 576
         fluid, 578
         genera and species of, 576
         green, 573, 583
         hard, 583
         history of pathology of, 572
         lenticular, 576
         mature and immature, 584
         milky, 578
         Morgagnian, 579
         operations for, 589
         position of patient in operations
           for, 593
         preparation of patient, 589
         prognosis  in, 587
         radiated, 577
         reclination of, 609
         secondary, 623, 627
         season for operating, 591
         siliquose, 582
         soft, 578
         trabecular, 582
         traumatic, 167
         treatment of, without operation,
           586
         questions  regarding  removal of,
           by operation, 588
                   as to  operating on one
                     or both  eyes, 591
         varieties  dependent upon  age,
           ■585
 Cataracts,  spurious, 572
         true, 572
 Catarrhal inflammation of eyelids, 117
         ophthalmia, 211
 Catarrho-rheumatic ophthalmia, 326
 Cat's eye,  532
 Cellular membrane of orbit, induration of,
   699
                           inflammation
                             of, 692
 Ceratocele, 275
 Cerebral  congestion  causing  amaurosis,
   479, 503, 506
 Chalazion, 154
 Chemosis,  221, 234, 272, 283
 Chemical agents, injuries of eye by, 176
 Cheselden's  operation for  artificial pupil,
   428
 Choroid affections of, 449
        ossified, 683
        non-malignant tumours of, 642
        wounds of, 165
 Choroiditis, 449
 Chronic ophthalmia, treatment of, 201
 Chrupsia, 490
 Cicatrices, eversion of lids from, 136
 Cicatrices  of cornea, 349 
770
INDEX.
Cilia?, excision of, 147
     extraction of,  148
Ciliary body, wounds of, 165
            yellow prominences from, 642
            fungous  excrescence  from,
              414
Cisophthalmia, 461
Clavus, 411
Collapse of globe from suppuration, 639
Concave glasses,  560
Coloboma, 410
Coloured vision, 490
Colours,  insensibility to, 347, 547
Concussion of brain, a cause of amaurosis,
  478
Congenital cataract, 620
                    operation for, 622
                    operation  on opaque
                      capsule, 623
                    proper  age for the
                      operation, 626
Conical cornea, 357
Conjunctiva arida, 317
Conjunctivitis.
           wounds of, 156
           ulcers of, 311
           cartilaginous formations in, 320
           discolouration of by nitrate of
              silver, 318
           cuticular, 317
           diseases of, 211
           ecchymosis of, 156
           excrescences of, 319
           foreign  substances adheting to,
              177
                            in folds of,
                              179
           fungus of, 319
           granular, 261,235
           injuries of, 175
           inflammation of, 211
           polypus of, 319
           tumours of, 320
           with hairs, 321
                     encysted, 323
                     cartilaginous, 320
           vascular excrescences, 319
           warts of, 319
           catarrhalis, 211
           contagiosa, 231
           Egyptiaca, 231
           erysipelatbsa, 292
           gonorrhoica, 271, 219
           leucorrhoica, 219
           morbilosa, 310
           phlyctenulosa, 293
           psorica,  120
           puro-mucous, 231
           purulent of infants, 219
           pustulosa, 292
           scarlatinosa, 310
           scrofulosa, 293
           variolosa, 306
 Consumptio purulenta oculi, 640
                       cornese, 640
 Contagious ophthalmia, 231
 Contusion of cornea, 158
             eyebrow  and eyelids, 106
 Corectomia, 434
 Coremorphosis, 417
 Cornea, abscess of, 335
        bursting of, 239
        cicatrices of, 349
        conical, 357
        effusion  of blood between layers
           of,  350
        fistula of, 345
        foreign  substances  adhering to,
           178
                            imbedded in,
                               178
        globular, 376
        gangrene of, 334
        hernia of, 275, 345
        hypertrophy of, 357
        injuries of, 161
        inflammation of, 333
        with  vesication, 342
        partial inflammation of, 340
        metallic particles sticking to, 176
        non-malignant tumours of,  641,
           642
        opacity of, 221, 240, 345, 346
                   congenital, 350
        ossification of, 682
        paracentesis of, 369
        penetrating wounds of,  158, 160
        punctured wounds of, ib.
        sloughing of, 221, 239, 273, 333
        suppuration, 240, 335, 274,158
                    treatment,  339
        specks or opacities of, 345
        ulceration of, 343
        and iris, staphyloma of,  351
        vascularity of, 342, 334
        wounds of, 158
 Corneitis acute, 334
         scrofulosa, 341
 Coretodialysis, 438
 Coretotomia, 428
 Corotomia, 428
 Couching, 608
 Counter-irritation in amaurosis, 505
 Crampton's operation for entropium, 144
 Crystalline capsule ossified, 471
           lens  and capsule, injuries of,
             166
 Crystallino-capsulitis, 470
 Cuticular conjunctiva,  317
 Cysticercus, in anterior chamber, 688
           under conjunctiva, 690
 Cysts in sclerotica, 332
 Dacryocystitis acuta, 750
                chronica, 752
Datura stramonium, its effects on iris, 361
DavieVs 6ci6eors, 508 
INDEX.
771
DavieVa spoon, 592
Day-blindness, 541
Debility, amaurosis with, 524
Depression of cataract, 608
                     through cornea, 625
                              sclerotica,
                                608
Dieffenbach's operation for ectropium, 138
Dichromatism of lens in glaucoma, 467
Digestive organs, amaurosis from  disor-
  dered, 497
Diplopia, 491, 713
Dislocation of lens, 168, 472, 170
Displacement of cataract, 608
Dissolution of vitreous humour, 469
Distichiasis, 147
Distoma in crystalline, 688
Division of cataract, 617
                   through cornea, 625
                          sclerotica, 617
Dropsy of aqueous chambers, 375
         eye, 637
         vitreous humour, 638
       sub-choroid, 639
       sub-sclerotic, 639
Dryness of eye, 317
Duct nasal, congenital absence of, 763
           obliteration of, 454
           obstruction of, 454, 760
Duffin's operation for strabismus, 728
Dysopia tenebrarum, 538
Ecchymosis of eyelids, 113
            under conjunctiva, 156
Ectropium, 135, 241
            operation of Jaeger, 137
                       Graefe, 137
                       Dieffenbach,  138
            and lagophthalmos, 138
                              operations
                                for, 139
          sarcomatosum,
Effusion of blood into eye, 164, 373
Egyptian ophthalmia, 231
Electricity in amaurosis, 514
Emetics in amaurosis, 512
Empyesis oculi, 368
Emphysema of eyelids, 116
Encanthis beuigna, 749
           maligna, 749
Encysted tumours in  orbit, 704
                    eyelids and eyebrows.
                      151
                    subconjunctival, 323
Enlargement of lachrymal gland, 744
Enlargements of eyeball, 351
Entozoa in eye, 685
Entropium, 142, 241
Epicanthus, 150
Epiphora, 747
Eruptions, syphilitic, affecting eyelids, 124
Erysipelas of eyelids, 115
Erysipelatous ophthalmia, 29
Esquimaux spectacles, 163
Evacuation of aqueous humour, 371
Eversion of eyelids, 135
Examination of eye, 222
Excision, artificial pupil by, 434
Excoriation,  eversion  of eyelids  from,
  136
Excrescence of iris, fungous, 414
Exophthalmia, 640, 691, 695, 700, 701
Extirpation of eyeball, 663, 680, 675
             eyelids, 130
             lachrymal gland,
Extraction of cataract, 591
                    instruments for, 592,
                      593
                    by  superior section
                       of cornea, 596
                    by  exterior and in-
                       ferior  section  of
                       cornea, 601
                    by inferior section
                       of cornea, 601
                    without  an  assist-
                       ant, 602
                     treatment after ope-
                       ration, 602
                    cases  suitable  for,
                       606
Eye, adaptation of artificial, 356
     apoplexy of, 373
     blows on, 160
     dropsy of, 637
     effusion  of pus  in, from spontaneous
       internal inflammation, 660
     entozoa in, 685
     gunshot wounds of, 160
     modes of examining, 222
     penetrating wounds of, 660
     sanguineous effusion into, 164, 373
Eye-ball? atrophy of, 639
         bursting of, 162, 163, 239
         calculous concretions in, 684
         cancer of, 644
         extirpation of, 663, 680
         fungus hsematodes of, 649
         horizontal section of, 37
         inflammatory diseases of, 98
         injuries of, 175
         malignant affections of,  641
         melanosis of, 673
         oscillation of, 712
         scirrhus of, 644
         spongoid or medullary tumour of,
           649
 Eye-brow,  injuries of, 108
                    amaurosis from, ib,
           tumours in,  151
           wounds of, 106
Eye-lashes, false, 147
           inversion of,  146
           loss of, 155
 Eye-lid, upper falling down of, 138 
772
INDEX.
Eye-lid, upper, palsy of, 133
Eye-lids, abscess in, 114
         affections of, 106
         aneurism by anastomosis of, 151
         callosity of, 123
         burns and scalds of, 108
         cancer of, 127
         carbuncle of, 115
         catarrhal inflammation of, 117
         contusion and ecchymosis of, 113
         ecchymosis of, 113
         emphysema of, 116
         encysted tumours in, 151
         erysipelatous  inflammation  of,
           115
         eversion of, 135
         extirpation of, 130
         fibrinous tumour of, 154
         half encysted tumours in, 153
         inflammation of edges of, 116
                    with ulceration, 120
                    of cellular  tissue of,
                      114
         injuries of, 106
         inversion of, 142
         malignant pustule of, 107
         milium of, 154
         morbid connexions, 149
         naevus maternus of, 151
         oedema of, 116
         palsy of, 133, 135
         phlegmonous  inflammation  of,
           114
         phlyctenula of, 154
         poisoned wounds of, 107
         porrigo larvalis affecting, 121
         punctured wounds of, 107
         puriform flux of, 753
         scalds of, 108
         schirrhus of, 127
         scrofulous inflammation of, 120
         secondary inflammation of, 123
         spasm of, 135
         syphilitic ulceration of, 125
                 eruptions affecting, 124
         tarsal tumours, 153
         tumours in, 151
         ulceration of, 120
         warts on, 155
         wounds of, 106
False cataracts, 572
Far-sightedness, 563
Fever, inflammation of the eye, consequent
   on, 457
Fifth nerve, injuries of branches  of, 108
           irritation  of producing amau-
              rosis, ib.
           morbid  changes of, producing
              amaurosis, 529
Filaria in  anterior chamber of eye, 685
           crystalline, 687
           medinensis under conjunctiva,
             687
Fistula of cornea, 345
          lachrymal sac, 751
          lachrymal, 755
Foreign bodies in anterior chamber, 158
        substances  adhering to conjunc-
          tiva, 177
                   imbedded  in cornea,
                      178
                   passing between  lids,
                      175
Fractures of the orbit, 690   ,
Fricke's operation for  lagophthalmos and
  ectropium, 139
Fungoid growths, from anterior or part of
  eye, 641
Fungus hsematodes, of brain producing am-
  aurosis, 657
                    eye-ball, 649
                    optic  nerve, 657
                    diagnosis of, 658
                    treatment of, 662
Gerontoxon, 345
Gland,  lachrymal, enlargement  or schir-
  rhus of 734
                  extirpation of, 744
                  inflammation and  sup-
                    puration of, 743
Glasses for, ]ong-6ightedness, 564
           short-sightedness, 560
         periscopic, ib.
Glaucoma, 463, 467
           causes of, 464
           catoptrical  signs of, 468
           dichromatison of lens in, 467
           dissections of eyes in state of,
             465
           its  diagnosis from  cataract,
             466
           symptoms,  463
           to be distinguished from am-
             aurosis, 466
           seat of disease, 464
           treatment of, 466
           with cataract, 464
Globular cornea, 376
Gonorrhoeal ophthalmia, 271
            conjunctivitis, 271
            iritis, 289
Grando, 154
Granular conjunctiva, 261
Gun-powder, injuries of eye-ball from, 161
Gun-shot wounds of eye,  160
Guthrie's nitrate of silver  ointment, 201,
  217
          operation for ectropium, 144
                      strabismus, 725
Gutta serena, 475
rtemophthalmos, 373
Haemophthalmos, from  suppressed  men-
                   struation, 373
Half encysted tumours of lids, 153
Half-vision, 508, 543
Hays' operation for strabismus, 731 
INDEX.
773
Helos, 411
Hemeralopia, 491, 538
             congenital and  hereditary,
               540
Hemiopia, 508, 543
Hernia of iris, 411
          lachrymal sac, 755
Hordeolum, 122
Hyaloid membrane, ossified, 684
Hydrocephalus, amaurosis from, 480
Hydrophthalmia, 637
Hydrops of lachrymal sac, 755
Hygroma, 704
Hyperkeratosis, 357
Hyperostosis of orbit, 44
Hypertrophy of cornea, 357
Hypopyon, 335, 368, 459
Hypolympha, 375
Hypogala, 375
Incision, artificial pupil  by, 428
        through  cornea,  artificial  pupil
           by, 435
             varieties of, 100
Inflammation,  98
             acute and  chronic, ib.
             effects of, 103
             common and specific, 103
             varieties from difference of
               texture, 104
                           other circum-
                            stances, 104
Inflammation of aqueous capsule, 364
              caruncula lachrymalis,749
              choroid, 449
              conjunctiva, 211
              cornea, 470
              crvstalline  lens and cap-
                 sule, 470
              eye-lids,  erysipelatous, 115
                      phlegmonous,  114
              edges of eye-lids,  116
              globe of the eye, 628
              iris, 376
              lachrymal gland, 472
              Meibomian follicles, 117
              orbital cellular membrane,
                 692
              retina, 452
              semilunar membrane, /47
Inflammations of eye from injuries, 180
Injections of lachrymal passages, 756
Injuries of branches of  fifth nerve, 10H
           conjunctiva, 156
           cornea, 158
           crystalline lens and  capsule,
              166
           eye-ball, 156
           eye-brow and eye-lids, lUb
Injuries of iris, 163
Insensibility to certain colours, 04/
Internal inflammation of the eye, doy
Inversion  of eye-lashes 146
            eye-lids. 142
Iris, abscess of, 379
    change of colour of, 411
    detachment from  ciliary  ligament,
       164
    encysted tumour behind, 415
    fungous excrescences of, 414
    hernia, 411
    inflammation of, 376
    injuries of, 163
    malformation of, 409
    non-malignant tumours of, 415
    paralysis of, 416
    preternatural states of, 409
    prolapsus of, 411, 161, 605
    spotted, 411
    staphyloma of, ib.
    tremulous, 416
    tumours from, 415
    wounds of, 163
Iritis, 376
      acute and chronic, 402
      after tvphus fever, 457, 458
      arthritica, 406, 460
      gonorrhoea, 288
      rheumatica, 406
      scrofulosa, 408
      sympathetica, 635
      syphilitica, 404
Irideremia, 409
Iridencleisis, 441
Iridodialysis, 441
Iridotomia, 423
Irregular refraction, 567
Irritation  of fifth  nerve,  amaurosis from,
  529
Jacob's cataract needle, 618
Jaeger's cornea knife, 593
Janin's ointment, 119
       operation for artificial pupil, 431
Keratatis, 334
Kerato-iritis, 364
Keratonyxis, 617
Lachrymal calculus, 760
Lachrymal canals,  injuries of, 472
                  obstruction of, 269
           gland, enlargement or scirrhus
             of, 743
                  extirpation of, 744
                  hydatid of,  747
                  inflammation  and sup-
                    puration of, 472
                  figure of, 36
                  puncta, obstruction of,
                    748
           sac, abscess of, 750
               blennorrhoea of, 752
               fistula of, 751
               hernia of, 755
Lachrymal sac, hydrops of, 755
               inflammation of, 750
               mucocele of, 266
Lactation  a cause of amaurosis, 526
Lagophthalmos, 135 
774
INDEX.
Langenbeck's operation for artificial pupil,
  441
Lapis divinus, 207
Lapideus scyphus in oculo, (584
Lapsus palpebrae superioris, 133         i
Lauro-cerasus, effects on iris, 316
Lens and capsule affections of, 470, 471  ;
                injuries of, 166
                calcareous, 471
     dichromatic in glaucoma, 467
     dislocation of, 168, 472, 170
     entozoa in, 687
     opacity of, 166
     ossified, 471
Lens, whether removed from chambers of
     the eye by absorption or solution, 615
Lentitis, 470
Leucoma, 275
Leucorrhoeal ophthalmia, 224
Light, amaurosis from intense, 453,  182
      intolerance of, 182, 183, 296, 383
Lime, effects of on eye, 177j
Lippitudo, 117
          pruriginosa, 120
          senilis, 118
Lucas's operation for strabismus, 726
Luscitas, 741
Madarosis, 124
Malignant diseases of the eye, 641
Masturbation, a cause of amaurosis, 524
Maunoir's operation for artificial pupil, 431,
  433
         scissors for artificial pupil,  431
Measles, ophthalmia from, 306, 310
Medullary tumour in orbit, 702
                  of eye-ball, 649
Melanosis of eye-ball, 673
Melon, 411
Menses suppressed, a cause of ophthalmia,
  187
                              amaurosis,
                               497
                            hsemophthal-
                              mus,  373
Mercury in  amaurosis, 504
            corneitis, 339
            iritis, 398, 391, 394
            in ophthalmic  inflammation,
              197
Milium, 154
Monostoma  in crystalline, 687
Morbillous ophthalmia, 306, 310
Mucocele of lachrymal sac, 755
Musca? volitantes, 584
                  treatment of, 537
Mydriasis, 416
Myocephalon, 411
Myodesopsia, 490
Myopia, 491,556
Myosis, 415
Narcotics, their effects on  iris, 361
Naevus raaternus of eye-lids, 151
Nasal duct, capillary aperture in, 749
            obstruction of, 754
Near-sightedness, 556
Nebula, 347
Night-blindness, 538
Nitrate of silver, application of, to ulcere of
  cornea, 344
                stains  of conjunctiva by,
                  318,344
                use of, 506, 207, 217
Nyctalopia, 491,541
Nystagmus, 713
Obliteration of pupil, 386
Oculus leporinus, 135
CEdema of eye-lids, 116
Onanism, amaurosis from, 526
Onyx, 335
Opacities of cornea, 221, 240, 345, 346
                   congenital, 350
Opacity of crystalline capsule, 166
          lens, ib.
Opaque capsule, operation for, 623
Operation for ankyloblepharon, 149
             cataract, choice of an, 589
             symblepharon, 149
Operations for artificial pupil, 427
              cataract, preparation of pa-
                tients for, 590
                       general account
                          of, 427
                        position of patient
                          during, 593
                      indicationsandcon-
                          tra-indications
                             for, 587
                        choice of, 590
                 eversion of eye-lids, 136
                 inversion of eye-lashes,
                  147
                            eye-lids, 143
Ophthalmia, exciting causes of, 180
                              disordered
                           functions and
                           deficient  ex-
                           cretion, 187
                          impaired  ner-
                            vous energy,
                            188
                          idiopathic and
                             sympathetic
                               inflamma-
                             tions, 189
                        injuries, 180
                        chemical   irrit-
                          ants, 181
                        contagious  mat-
                          ters, 181
                        excessive  use of
                         eyes, ib.
                        atmospheric cau-
                          ses, 182
                        strong lights, 182 
INDEX.
775
Ophthalmia, remote causes of, 184
                       natural  peculiari-
                         ties oforganiza-
                         tion, 184
                       unhealthy consti-
                         tution, 185
                     >  of plethora, 185
                       constitutional
                         weakness, 187
                       determination  of
                         blood   to   the
                       head, 187
             treatment, 190,201,209
             aphthous,  592
             arthritic, 460
             bellica, 231
             catarrhal, 211
             catarrho-rheumatic, 326
             contagious, 231
             Egyptian, ib.
             epidemic, 229, 231
             erysipelatosa, 292
             following fever, 457
             from absorption of pus, 632
             gonorrhoica, 271
             impetiginous, 297
             interna, 455
             !eucorrhoica,218
             morbillosa, 310
             neonatorum, 219
             of new-born children, ib.
             phlyctenulosa, 293
             porriginosa, 121
             psorica, 120
             purulent, 218
              purulenta gravior, 237
                    mi tor, 234
                    of infants, 219
             pustulosa, 292
             rheumatic, 326
             scarlatinosa, 306,  310
             scrofulous, 293
             sympathetic, 635
             syphilitic, 404
              tarsi, 116
             variolosa, 306
             varicous,  461
 Ophthalmias, classification of, 209
             remedies  for, 190,201
             traumatic, 180
 Ophthalmic inflammation, causes of, 1BU
   r                     treatment of, 19U
             artery, aneurism of, 328
             surgery, history  of, 30
 Ophthalmitis phlebitica, 632
               arthritica, o64
               idiopathica, 628
               puerperal, 634
 Ophthalmitis, externa  idiopathica, !323
   v           following typhus, 1S7
 Ophthalmo-blennorrhoea, 231
            conjunctivitis catarrhalis,  Z16
 Ophthalmoptosis, 640, 712
Optic nerve, atrophy of, 483
Optic nerves, destruction of, 484
            morbid changes in, producing
              amaurosis, 482
            semi-decussation of, 79
Orbicularis palpebrarum, palsy of, 135
Orbiculus ciliaris, inflammation of, 452
Orbit, abscess of, acute, 692, 694, 695
               chronic, 693
      caries of, 690
      diseases of, 690
      exostosis of, 690
      foreign body in, 691
      fractures of, 690
      fungus hsematodes in, 702
      gunshot wounds of, 690
      injuries of, 690
      muscles, affections of, 711
      penetrating wounds of, 691, 695
      periostitis of, 690
      propagation of inflammation from, to
        contents of cranium, 694
      tumours in, 699
Orbital aneurisms, 708
       cellular membrane,  phlegmonous
         inflammation, and abscess of, 692
                         scirrhus of, 699
                         tumours in, 699
Oscillation of eyeball, 712
Ossification of various parts of eye, 682
              choroid, 683
              cornea, 682
              crystalline capsule, 471
              hyaloid membrane, 684
              iris, 683
              lens, 471
              membrane of the aqueous
                 humour, 683
              retina, 487, 683
              sclerotica, 683
              vitreous humour, 684
 Oxyopia, 489
Palpebra ficosa, 120
Palsy of abductor oculi, 279
        levator palpebrse superioris, 133
        orbicularis palpebrarum, 135
        upper eyelid, 133
Pannus, 342
Paracentesis corneae, 369, 371
Paralysis of iris, 440, 712 '
           the  orbicularis  palpebrarum,
             135
      •         muscles of the eye, 711
Pediculi ciliorum, 155
Periscopic glasses, 560
Perspiration, suppressed, causes amaurosis,
  497
Phlebitic ophthalmitis, 632
Phlegmonous inflammation of eyelids, 115
Phlyctenula of eyelids, 154
Phlyctenular ophthalmia, 293 
776
INDEX.
Photophobia in iritis, 383
Photophobia infantum scrofulosa, 296
Photopsia, 490, 489
Phtheiriasis, 155
Phthisis oculi, 640
Pigmentum nigrum, congenitally deficient
  in albino, 292, 773
                   deficient in glaucoma,
                     771, 753
                               old   age,
                                 452
Pladarotes, see granular conjunctiva.
Porriginous ophthalmia, 297
Porrigo larvalis affecting eyelids, 121
Position of patient during operations for
  cataract, 593
Pregnancy as a cause of amaurosis, 528
Presbyopia, 563
Prolapsus of iris, 161, 411, 274
Proptosis, 640, 697
Prussic acid, its effects on iris, 361
Psorophthalmia, 120
Pterygium, 312
            crassum, 314
            fleshy, 314
            pingue, 314, 317
            tenue, 314
Ptosis, 133
Ptilosis, 124
Puerperal ophthalmitis, 634
Puncta lachrymalia, contraction of, 748
                   foreign  substances in,
                     472
Pupil, adventitious membrane in, 386
       deep-seated yellow shining opacity
         in, 659, 661
       artificial,  states of  the  eye  re-
         quiring, 418
               position of, 424
               by excision, 434
                 incision, 428
                 separation,  438
                 detachment and strangu-
                   lation, 441
                distortion, 447
      morbid contraction of, 416
            dilatation of,  ib.
      artificial dilatation of, 360
      adventitious membrane in, 387
      adhesions of, 386
      displacement of, 413
      obliteration of, 387
Purulent ophthalmia, 218
                    in infants, 219
                    causes, 224 •
Purulent ophthalmia, prognosis, 225
                    treatment, 226
                    in  children, 229
                    in  adult, 231
Puro mucous conjunctivitis, 231
Pustular ophthalmia, 292
Pustule, malignant of eye-lids, 107
Quina, Use  of, in scrofulous ophthalmiae,
   301
Reclination of cataract, 609
Reisinger's double hooked forceps for arti-
   ficial pupil, 444
Refraction,  diminished, 563,
            irregular, 567
Retina,  affection  of from excessive em-
   ployment, 520
       calculus transformation of, 684
       concussion, 172
       ossified, 483
       pressure on by depressed lens, 486
       wounds of,  172
Retinitis, 452
Rheumatic  iritis,  406
            ophthalmia 323, 326
            nature of gonorrhoeal ophthal-
              mia, 289
Rhinoraphy, 150
Sanguineous effusion into eye, 164, 373
Sanson's catoptrical examination of eye, 80
Scarlatinous ophthalmia, 306, 310
Scarpa's operation for  artificial pupil, 438
          mode of  depressing cataract, 610
Schmidt's  operations  for  artificial pupil,
   438
Scirrhus of caruncula lachrymalis, 241
            eye-ball, 644
            eye-lids, 127
            lachrymal gland, 89
            orbital  cellular  membrane,
              699
Scirrhous exophthalmia, 646
Sclerotica, cysts and tumours of, 332
          wounds of, 162
Sclerotico-choroiditis, 449
Sclerotitis, 323
            rheumatica, 326
Scodelle, 684
Scrofula affecting  bones of orbit, 33
                 conjunctiva, 293
Scrofulous corneitis, 341
                   treatment, 342
          iritis, 408
          ophthalmia,  293
          tumours of sclerotica, 332
          constitution, 294
Secondary cataract, 623, 627
          variolous ophthalmia, 309
Semilunar membrane, inflammation of, 709
Separation,  artificial pupil by, 43^
Short-sightedness,  550
Shot in the  eye, 159
Sight, over-exercise of, a cause of amau-
   rosis, 520
Sloughing of cornea, 211, 239, 273, 333
Small pox, ophthalmia from, 300
Spasm of eye-lids,  135
Specks of cornea, 345
Spectacles, concave, 560
           convex, 564 
INDEX.
771
Squinting, 713
Staphyloma, 240, 351
             conical, 355, 357
             iridis, 421
             iridis  per corneam, 411
             morbid anatomy of, 351, 352
             of cornea, 351
             operation for, 354
             partial, 352
             pellucideum, 356
             racemosum, 352, 274, 411
             sclerotic, 330
             spherical, 325
             total, ib.
Steatomatous tumours in orbit, 709
Sternutatories  in amaurosis, 515
Stillicidium lachrymarum, 249, 268
Stimuli and tonics in amaurosis, 515
Strabismus, 713
           convergens, 713
            divergens, 713
            causes of, 715
            effects of operation, 735
            operations for, 722,  724, 727,
              731
            cases suitable for,  713
            state  of affected muscles  in,
              719
            treatment, 721
                     after operation, 734
Stillicidium lachrymarum, 747, 748, 752
Stramonium, its effects on iris, 361
Strychnia in amaurosis, 517
Stye, 122
Style, use of lachrymal,  759
Suckling, protracted amaurosis from, 526
Suffusio, 475
Suppuration of cornea, 274
Suppressed menses, amaurosis from, 497
            perspiration,  amaurosis  from,
              487
            purulent discharge,  amaurosis
              from, 492
Sycosis palpebrae, 120
Symblepharon, 149
Symptomatic  and sympathetic amaurosis,
   522
Sympathetic ophthalmia, 635
Synchesis, 468
Synechia anterior, 413
          posterior, 413
Synizesis, 387
Syphilitic iritis, 404
           ulceration of eyelids,  <WO
Tarsal ophthalmia, 117
Tarsal tumours, 153
Tetanus oculi, 713
Tinea palpebrarum, 120
Trochoma, see granular  conjunctiva.
Traumatic ophthalmiae, lbU
           cataract, 167
Tremulous, 416, 469
Trichasis, 146
         98
Trichiosis bulbi, 232
Tube for nasal duct, 757
Tumour, encysted, in eye-lids, 151
         half encysted, in eye-lids, 153
         spongoid or medullary, of eye-ball,
          702
Tumours, conjunctival, 320
         tarsal, 153
         in eye-lids, 151
           brain,  producing  amaurosis,
             481
           orbit,  699
           vascular, of conjunctiva, 319
           cartilaginous, 320
           congenital, 320
           of sclerotica, 332
         non-malignant of iris, 415
         subconjunctival, 323
Turpentine, its use in iritis, 400
           in purulent ophthalmia, 257
Tylosis, 123
Ulcers of cornea,  221, 240, 343, 273
         conjunctiva,  311
         eye-lids, 124
         cancerous, 127
         scrofulous,
         syphilitic, 125
Unguis, 335
Varicositas oculi,  461
Variolous ophthalmia,  306
                     secondary, 309
Varix of lachrymal sac, 755
Vascular cornea, 343
Veratria in amaurosis, 519
Verruese, 155
Venery, a cause of amaurosis, 526
Vinum opii in chronic ophthalmia, 205
                      iritis, 400
Vesication of cornea, 342
Vision, coloured, 492
       defective,  various states of, 489
Visus duplicatus,  391
      dimidiatus,  543
      interruptus, 490
      lucid us, 490
      nebulosus, 490
      reticulatus,  491
Vitreous body, dropsy  of, 468
             ecchymosis of, 468
         humour, dissolution of, 469
                 hypertrophy, 468
                 change  of structure, 469
                 ossification of, 684
                 calculous transformation
                   of, 685
Ware's nail headed style, 789
Warts on eye-lids, 155
Watery eye, 747
Weakness of sight, 520, 521
Wenzel's operation for artificial pupil, 421
Wollaston's case of hemiopia, 543
          on  semidecussation of  optic
            nerves, 543, 544 
778
INDEX.
Worms, amaurosis from, 498
Wounds, gunshot, of the eye, 159, 160
         of the eye, 156,157
               conjunctiva, 156
               iris, 163
               retina, 172
               vitreous hnmour, 170
               of choroid, 170
                 cornea, penetrating, 161
Wounds of the retina punctured, 158
              eye-brows and eye-lids, 106
              iris, 163
              retina, 172
              penetrating orbit, 691
              by percussion caps, 160
                         of eye, 660
Xeroma, conjunctival, 317
Xerophthalmia, conjunctival, 317 
 
 
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                    PEREIRA'S   MATERIA   MEDICA,

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  ELEMENTS OF  MATERIA  MEDICA AND THERAPEUTICS; COMPRE-
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present day, and  a very copious index.  From the Second London Edition, which has been thoroughly
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containing a faithful outline of this Department  of Medicine, which should embrace a concise account
of the most important modern discoveries in Natural History, Chemistry, Physiology, and Therapeutics
in so far as they pertain to Pharmacology, and treat the subjects in the order of their natural historical
relations.
  This great Library or Cyclopedia of Materia Medica has been fully revised, the errors corrected, and
numerous  additions made, by DR. JOSEPH  CARSON, Professor of Materia Medica-and  Pharmacy in
the "College of Pharmacy," and forms Two Volumes, octavo, of near 1600 large and clo.sely-printed
pages; and it may be fully relied upon as a permanent and standard work for the country,—embodying,
as it does, full references  to the U. S. Pharmacopea and an account of the Medicinal Plants  indige-
nous to the United States.


 PRINCIPLES AND PRACTICE  OF SURGERY,  WITH  CUTS.

  THE  PRINCIPLES AND  PRACTICE  OF  MODERN  SURGERY, BY RO-
BERT  DRUITT.  From the Second London  Edition, illustrated with  fifty wood en-
gravings, with notes and comments by Joshua B. Flint, M.D., in one volume 8vo., at

a low price.
                         EXTRACT FROM THE AUTHOR'S PREFACE.

  " The arrangement of a work of this kind ought not, as I conceive, to be regarded as a matter of mere
indifference  o? at most of convenience, but it ought to embody in  it something of a principle; and I
believe that'the arrangement of this work may be useful to  the student, by showing him in what order
he mav best prosecute his researches into the principles of his profession.        ..,..,,  •  ■,
  "Of the five parts into which it is divided, the first two are more especially devoted to the principles,
and ihe toothers to the practice of surgery.  The first part treats of the disturbances of the const.tu-
non a large  that may be produced by injury or disease  of a part; beginning with the simple fa.ntness
or ^naD<e that follows a blow, and proceeding to consider the varieties of fever and tetanus.
  "T Tsprnnd nart describes What may be called the  elements of local disease; that is to say, those
morbid ch!,nCes ^f struXe or Ction^ which  are produced either immediately by externa, causes, <*

^W^tr^l^m^^^^^«' beginning with the simplest mechanical inju-
ries Tthen prSingto  the effects of chemical agents, and  lastly, considering the effects of an.mal

P°"The fourth part considers the various tissues, organs, and regions of the body in order, and describes

,h- r^7ah^^^Z^t^'o^on, as were "ot included in the.former parls-&c'    h
  " To theIwholei £^fppended a collection of formula, the number of which is very much increased ,n
this edition 
LEA  &  BLANCHARD'S  PUBLICATIONS.
               FEVERS  OF  THE  UNITED  STATES.
  THE HISTORY,  DIAGNOSIS AND TREATMENT  OF TYPHOID  AND
TYPHUS FEVER  WITH AN ESSAY ON  THE DIAGNOSIS  OF  BILIOUS
REMITTENT  AND OF YELLOW FEVER, BY ELISHA BARTLETT,  M.D.,
Professor of the Theory and Practice of Medicine in the Transylvania University.
In one volume 8vo; a new work.
  Notice has already been given of the appearance of this work : we have become satisfied of its sterling
value, and, therefore, without hesitation, feel justified in again recommending it to the immediate no-
tice of practitioners.—Boston Medical and Surgical Journal.
                MtlLLER'S   PHYSIOLOGY.
  ELEMENTS OF PHYSIOLOGY;  BY J. MULLER, M.D., Professor of Ana-
tomy and Physiology in the  University  of Berlin, &c.  Translated from the German
by William Baly, M.D., Graduate in Medicine of the University of Berlin.  Ar-
ranged from the Second London  Edition by John Bell, M.D., Lecturer on Materia
Medica and Therapeutics, &c, &c.  In One Volume, 8vo.—Just ready.
  In arranging the Volume now offered to American readers, from the materials furnished in Miller's
Elements of Physiology, the Editor has endeavoured to procure reduction in size, of this latter, with-
out any abstraction of its vitality and mind.  With this view he has omitted, for the most part, mere
disquisitions, many details of experiments, matters of physics and natural philosophy, including mechan-
ics under the head of locomotion, acoustics and the theories of music under voice and bearinz. and of
optics under vision,—much of the minulia: of comparative physiology, and metaphysics or metaphvsico-
physiology.  But, while excluding details on collateral topics, the Editor has been particularly careful to
preserve°Physiology Proper, which, resting on the  basis of Histngeny and General  Anatomy, derives
important aid from Organic Chemistry and Microscopical Observations, and in its turn serves to illus-
trate Hygiene, Pathology and Therapeutics.  Thus aided and thus applied, i>i the manner exhibited by
Miiller himself, Physiology will invite the attention of the Student in these pages.
  It will soon be discovered that, although this volume is an abridgement of the large work of Miiller, it
may rightfully claim to be considered a complete system of Physiology, exceeding in copiousness and
comprehensive details, any other work on the same subject which has yet emanated from the London
press.                                -ww-^v^

       ELEMENTS  OF  PHYSICS-WITH WOOD-CUTS.
  ELEMENTS OF PHYSICS,  OR  NATURAL  PHILOSOPHY,  GENERAL
AND  MEDICAL.  A New Edition, complete in One Volume, written for universal
use, in plain and non-technical language, and containing New Disquisitions and Prac-
tical  Suggestions; comprised in Five Parts: 1. Somatology, Statics  and Dynamics.
2. Mechanics.  3.  Pneumatics, Hydraulics  and Acoustics.   4. Heat and  Light.
5. Animal and Medical Physics.  By NEIL ARNOTT, M.D., of the Royal College
of Physicians.  A New Edition, revised and corrected from the last English Edition ;
with additions by Isaac Hays, M.D., and numerous Wood-cuts.
PRACTICAL  MINERALOGY  AND GEOLOGY-WITH CUTS.

  A  TEXT-BOOK  OF GEOLOGY  AND  MINERALOGY, WITH  INSTRUC-
TIONS  FOR  THE  QUALITATIVE  ANALYSIS  OF MINERALS.   BY
JOSHUA TRIMMER,  F.G.S.,  with Two Hundred  and Twelve Wood-cuts.  A
handsome Octavo Voiume, bound in embossed cloth.
  This is a Systematic Introduction to Mineralogy and Geology, admirably calculated  to instruct the
Student in those sciences.  The Organic Remains of the various  Formations are well illustrated by
numerous Figures, which are drawn with great accuracy.

         ELLIS'S  MEDICAL FORMULARY  IMPROVED.
  THE MEDICAL FORMULARY  OF DR.  ELLIS;  being  a' COLLECTION
OF PRESCRIPTIONS, derived from  the Writings and Practice of many of the most
eminent Physicians in  America and Europe.  To which is added an Appendix, con-
taining the usual Dietetic Preparations and Antidotes for Poisons; the whole accom-
panied with a few brief Pharmaceutic and Medical Observations.  By BENJAMIN
ELLIS,  M.D.   The Sixth  Edition, completely revised, with many  Additions and
Modifications, and brought up to the present improved state of the Science; by Samuel
George  Morton, M.D., Professor in the Pennsylvania College of Medicine, &c, &c.
In One Octavo Volume. 
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              PRINCIPLES  OF  MEDICINE.
M nHPI FrIRST  PRINCIPLES  OF  MEDICINE, BY ARCHIBALD  BILLING,
P ,, ' A-M-' Member of the Senate of the University of London, Fellow of the Roval
v   Fur   f hys,C!ans-  &c-> &c.  In One Volume, 8vo.  First American from the
fourth London Edition.
.. ^f,^""fVi°rn0   k whlch ™n,ains within the fame space so much valuable information,
fi,l. „ M^h I   i°°ry' '!r°r ?f ,<lle ''J'Pothesis, but of close, persevering Clinical Observation, ace
fun mucn soundness of judgment, and extraordinary clinical lad."—Medico-Chirurgical lievie
        the result
      accompanied
rgical Review.
  A TREATISE  ON  FEVER.  By Southwood Smith, M.D., Physician to the Lon-
don bever Hospital, fourth American edition.  In one volume octavo.
  COATES'S  POPULAR  MEDICINE, OR FAMILY ADVISER, consisting of
Outlines of Anatomy, Physiology, and Hygiene, with such Hints on  the Practice of
Physic, Surgery, and the Diseases of Women and Children, as may  prove useful in
families when regular Physicians cannot be procured: being a Companion and  Guide
for intelligent Principals of Manufactories, Plantations, and Boarding Schools; Heads
of Families, Masters of Vessels, Missionaries, or Travellers; and a=useful Sketch for
Young men about commencing the Study of Medicine.   By Reynell Coates,  M.D.
  This work is designed to supply the place of Ewella' Medical Companion,  which is
now entirely out of print.
  OUTLINES OF A  COURSE OF LECTURES ON  MEDICAL JURISPRU-
DENCE. By Thomas Stewart Traill, M.D., with notes and additions. A small volume.
  A PRACTICAL  TREATISE  ON  MEDICAL  JURISPRUDENCE,  with so
much of Anatomy, Physiology, Pathology, and ihe Practice of Medicine and Surgery,
as are Essential to be known by Members of the Bar and Private Gentlemen; and all
the Laws relating to Medical Practitioners ; with Explanatory Plates.  By J. Chitty,
Esq., second American edition, with notes and additions adapted to American Works
and Judicial Decisions.   In One Volume Octavo.
  A TREATISE  ON  PULMONARY  CONSUMPTION, comprehending an In-
quiry into the Nature, Causes, Prevention and Treatment  of Tuberculous and Scro-
fulous Diseases in General.  By James Clark, M.D., F.R.S.
  A PRACTICAL TREATISE ON  THE HUMAN TEETH, showing the causes
of their destruction and the means of their preservation, by William Robertson. With
plates.   First American from the second  London Edition.  In one volume octavo.
  ANATOMY, PHYSIOLOGY, AND  DISEASES OF  THE  TEETH.  By
Thomas Bell, F.R.S., F.L.S., &c.  Third American edition. In one  volume octavo,
with numerous plates.
  DISSERTATIONS  ON  NERVOUS DISEASES.   By Drs. James Hope, J. C.
Prichard, John Hughes Bennett, Robert H.  Taylor and Theophilus Thomson.   In one
volume octavo.
  DISSERTATIONS ON DISEASES OF THE ORGANS OF RESPIRATION.
By  Drs. Williams, Theophilus Thomson,  W. B. Carpenter, and W.  Bruce  Joy.   In
one volume octavo.
  DISSERTATIONS  ON  FEVERS, GENERAL PATHOLOGY,  INFLAMMA-
TION, AND DISEASES  OF THE SKIN.  By Drs. Symonds, Allison, Christison,
&c. &c.   In one volume octavo.
  DISSERTATIONS ON DISEASES  OF  THE DIGESTIVE, URINARY AND
UTERINE  ORGANS.  By Drs. Joy, Symonds, Thomson,  Ferguson, &c.  &c.   In
one volume octavo.
  DISSERTATIONS   ON  HAEMORRHAGES,  DROPSY,  RHEUMATISM,
GOUT, SCROFULA, &c. &c.  By Drs.  Burrows, Watson, Shapter, Joy, &c. &c.
In one volume octavo.
  The above five volumes are from the Library of Practical Medicine, edited  by Dr.
Tweedie, with notes by Dr. Gerhard.   Each volume is  complete within itself, and is
for sale separately.
  THE MEDICAL  STUDENT; OR AIDS TO THE STUDY OF MEDICINE.
Including a  Glossary of the Terms of the Science, and  of the Mode  of Prescribing;
Bibliographical  Notices of Medical Works; the Regulations of the different Medical
Colleges of  the Union, &c.  By Robley Dunglison, M.D., &c. &c.  In one  vol. 8vo. 
_______LEA & BLANCHARD'S  PUBLICATIONS._______

  ESSAYS  ON ASTHMA, APHTHA, ASPHYXIA, APOPLEXY, ARSENIC,
ATROPA, AIR, ABORTION, ANGINA PECTORIS, and other subjects, embraced
in the Articles from A to Azote, prepared for the Cyclopaedia of Practical  Medicine
by Dr. Chapman  and others.  Each article is complete within itself, and embraces the
practical experience of its author, and  as they are only to be had in  this collection,
will be found of great value to the profession.  The two volumes are now offered at
a price so low, as to place them within the reach of every practitioner and student.
  OUTLINES OF PHYSIOLOGY; with an Appendix on Phrenology.  By P. M.
Roget, M.D., Professor  of Physiology  in the  Royal  Institute  of Great Britain, &c.
First American edition revised, with numerous Notes.  In one volume octavo.
  GEOLOGY AND MINERALOGY, considered with reference to Natural Theology.
By the Rev.  William Buckland, D.D., Canon of  Christ Church, and  Reader in Geo-
logy and Mineralogy in  the University of Oxford.  With nearly one hundred copper-
plates and large coloured  maps.  A new edition from the  late London edition, with
supplementary notes and additional plates.
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bracing:
  I. The Adaptation of External Nature to the Moral and Intellectual Constitution of Man. By the
Rev. Thomas Chalmers.
  IT. The Adaptation of External Nature to the Physical Condition of Man.  By John Kidd, M.D.F.R.S.
  HI. Astronomy and General Physics,  considered with reference to Natural Theology.  By the Rev.
William Whewell.
  IV. The Hand ; its Mechanism and vital Endowments as evincing Design.  By Sir Charles Bell, K.H.,
F.R.S,  With numerous wood-cuts.
  V. Chernistrv, Meteorology, and the Function of Digestion.  By William Prout, M.D.F.R.S.
  VI. The History, Habits, and Instincts of Animals.  By the Rev. William Kiroy, M.A.F.R.S. Illus-
trated by numerous engravings on copper.
  VII.  Animal and Vegetable Physiology, considered  with reference to Natural Theology.  By Peter
Mark Roset, M.D.  Illustrated with nearly five hundred wood-cuts.
  VIII. Geology and Mineralogy, considered with reference  to Natural Theology.  By the Rev. William
Buckland, D.D. With numerous engravings on copper, and a large coloured map.
  The works of Buckland, Kirby and Roget, may be had separate.
  A POPULAR TREATISE ON VEGETABLE PHYSIOLOGY, by W. P. Car-
penter, Author of Principles of Human Physiology, &c,  published under the auspices
of the Society  for the Promotion  of Popular Instruction.  With numerous wood-cuts,
in one volume  12mo.
  A POPULAR TREATISE  ON AGRICULTURAL  CHEMISTRY; intended
for the use of the practical farmer, by Charles Squarry, Chemist.  In one vol. 12mo.
  ROCET'S  ANIMAL  AND  VEGETABLE PHYSIOLOGY, with nearly five
hundred wood-cuts, in two volumes, second American edition.
  THE HISTORY, HABITS,  AND INSTINCTS  OF ANIMALS, by the Rev.
William Kirby, M.A.F.R.S.  Illustrated by numerous copperplate engravings.
  The Ninth  Bridgewater  Treatise.  A FRAGMENT,  by  Charles Babbage, Esq.
From the second London edition.  In one volume octavo.
  A PRACTICE OF  PHYSIC.  Comprising most of the diseases not treated of in
Diseases jof  Females and Diseases of Children,  second edition.  By W. P. Dewees,
M.D., formerly Adjunct Professor in the  University of Pennsylvania.   In one vol. 8vo.
  ELEMENTS  OF HYGIENE;  on  the Influence  of Atmosphere  and  Locality;
Change of Air and Climate, Seasons, Food, Clothing, Bathinp;, Sleep, Corporeal and
Intellectual Pursuits, &c, on Human Health, constituting Elements of Hygiene.  By
Robley Dunglison, M.D.  In one volume 8vo..
  ABERCROMBIE ON THE STOiMACH. Pathological and Practical Researches
on Diseases of the Stomach, the Intestinal Canal, the Liver, and other Viscera of the
Abdomen.  By John Abercrombie, M.D.  Third American, from the  second London
edition, enlarged.  In one volume 8vo.


              diseasesTFthe  skdt.
                              A  NEW WORK.
  A PRACTICAL AND THEORETICAL  TREATISE ON THE DIAGNOSIS,
PATHOLOGY.  AND  TREATMENT  OF DISEASES OF THE SKIN, arranged
according to a Natural System of Classification, and preceded by an  Outline of the
Anatomy and Physiology of the Skin. By Erasmus Wilson, M. D., author of a System
of Human Anatomy, &c, in 1 vol. 8vo. 
            LEA & BLANCHARD HAVE  JUST  PUBLISHED

                            A   TREATISE
                                        ON

        THE      DENTAL      ART,
                                      FOUNDED

                  ON  ACTUAL  EXPERIENCE.

  ILLUSTRATED  BY TWO HUNDRED AND  FORTY-ONE FIGURES  IN LITHOGRAPHY,
                           AND FIFTY-FOUR WOOD  CUTS.

                               BY F.  MAURY,
                      DENTIST OF THE ROYAL POLYTECHNIC SCHOOL.

                           KranslateU from t&e  jftend),
                    WITH  NOTES AND ADDITIONS,
                               BY J. B. SAVIER,
                            DOCTOR OF DENTAL SURGERY.
                                   One vol. 8vo.
    This work is designed as a Text Book in the Baltimore College of Dental Surgery, and
  commends itself to the Profession from  the great reputation of the author, and as embra-
  cing the latest information on the subject.

                  From the American Journal of the Medical Sciences.
    "The above is the title  of an interesting, highly valuable, and well written treatise on
  Dental Surgery,  embracing a broader and more extended view  of the subject than  is
  usually given by writers on this branch of the  curative art.  The work is  divided  into
  three parts: the first is devoted to the ' Anatomy and  Physiology of the Mouth and its
  Appendages,' as for  example—the tongue,  maxillary bones, muscles,  nerves, arteries,
  veins and glands; the teeth, together with a description of the manner of their formation,
  development, structure, and  eruption of both  the temporary and  permanent sets; also a
  description of the dental pulps and enamel, and the varieties of 'form,' ' number,' ' posi-
  tion,' 'structure,' and the 'consistency of the teeth.'  "
   " In  the second part of  the work, he treats of ' Dental  Hygiene and Therapeutics,'
 embracing a description of the means for the preservation of the teeth and all the other
  parts of the mouth."
   "The third part of the work is devoted to ' Mechanical Dentistry,' or a description ot
 the various methods for the insertion of  artificial teeth; every one of which is illustrated
 by one  or more wood-cut engravings and lithographic plates."
   "The original work, we believe, is held in high estimation  in France by the medical,
 as well  as the dental profession, and that it is one of merit  is proved by the fact that
 it has passed through six or seven editions, and Dr. Savier, the translator, has done him-
 self much credit by the very correct English version he has given of it."
   " The information contained in the first and second parts of the work should be possessed
 not only by every dental, but by every medical practitioner, and more especially by those
 residing in the country and small  villages where the services of scientific and skilful
 dentists can rarely be had."

   L.  & B. would particularly call the attention of the Profession to the series of works
 written  by Professor Dunglison, and published by them.  They are  now extensively
 used as  Text Books throughout the Union, and great  care is taken  by the author that
 each successive edition embodies the improvements and new information  up to its publica-
 tion. Persons who may order these works may rely upon having the last editions. They are
 THE PRACTICE OF MEDICINE; or a TREATISE ON SPECIAL PATHOLOGY
  AND THERAPEUTICS, in 2 vols. 8vo.
GENERAL THERAPEUTICS AND MATERIA MEDICA, in 2 vols. 8vo.
NEW REMEDIES PHARMACEUTICALLY AND THERAPEUTICALLY CON-
  SIDERED, a New Edition, the fourth, is just ready, 1  vol. 8vo.
A NEW DICTIONARY  OF MEDICAL SCIENCE, the third  edition, in 1 vol. 8vc
HUMAN PHYSIOLOGY, with Illustrations, the fourth edition, in 2  vols. 8vo.
  ET See a more detailed description of them on other pages.
                                                                       9 
A  NEW WORK  ON  PRACTICAL  SURGERY,

         WITH OVER TWO HUNDRED AND FIFTY ILLUSTRATIONS,
                     AT  A VERY LOW PRICE.
                          NOW  READY:


A   SYSTEM   OF   PRACTICAL  S URGERY,

                                  BY
              PROFESSOR WILLIAM FERGUSSON,
                        OP KING'S COLLEGE, LONDON.

     ILLUSTRATED BY  OYER TWO  HUNDRED  AND FIFTY SPLENDID CUTS,

           EXE.CUTED BY GILBERT, FROM DESIGNS BY BAGG,

                                  WITH
               NOTES  AND  ADDITIONS

                    By GEORGE W. NORRIS, M. D.,
              ONE OF THE SURGEONS TO THE PENNSYLVANIA HOSPITAL.

                          In One Volume 8vo.

  The objeat and nature of this volume are thus described by the author:—"The present
work has not been produced to compete with any already before the Profession; the ar-
rangement, the manner in which the subjects have been treated, and the illustrations, are
all different  from any of the kind  in the English  language.  It is not intended to  be
placed in comparison with the elementary systems of Cooper,  Burns, Liston, Symes, Li-
zars, and that excellent epitome by Mr. Druitt.  It may with  more propriety be likened
to the Operative Surgery of Sir C.  Bell, and that of Mr. Averill, both  excellent in their
day, or the more modern production of Mr. Hargrave, and the Practical Surgery of Mr.
Liston. There are subjects treated of in this volume, however, which none of these gen.
tlemen have  noticed, and the author is sufficiently sanguine to entertain the idea that this
work may in some degree assume  that relative position in British Surgery which the
classical volumes of Velpeau and Malgaigne occupy on the Continent."
  The publishers commend this work to the attention of the Profession as one combining
cheapness and elegance, with a clear, sound, and practical treatment of every subject in
surgical science.  No pains or expense has been spared to present it in a style equal, if
not superior to the London edition, and to match the edition of " Wilson's Anatomy,"
lately published, and "Churchill's System of Midwifery" and "Carpenter's Human Phy-
siology" now preparing.

  O" A more beautiful volume of the kind  has never been presented in this country to
the Medical Profession, and the price is so low as to bring it within the reach of all.

  It has been introduced as a Text Book in several Colleges, and at the approaching fall
will be added to the list of several others.
  Some specimens of the illustrations and recommendations are annexed.
      10 
Fig. 103.
Fig. 113.
Fig. 107.
Fig. 10G.
. W
mm
rH^fv<r? ^


11 
                  Notices of Fergusson's Practical Surgery.
  " The object of this work, is to present ' a  manual of the details of Practical Surgery,
which shall, in some degree, meet the wishes  and wants of the student, as well  as of the
surgeon already engaged in practice;' and the author has proved that he well knows what
those wants and wishes are, and that he is  fully competent to the task of supplying them.
Indeed, we know of no volume in which the young surgeon will find so clearly and concisely
described, as in the present, the various duties which he is called upon to  execute, and the
simplest and most efficient means of performing them; and. we feel  sure that its publication
will greatly contribute to the advancement of the art of surgery, by rendering  the  student
familiar with  its elements and details.
  " We must not close this notice without stating that, the editor has contributed some valu-
able additions, and that the getting up of the work—the printing, paper,  and illustrations,
which last are very numerous, are superior to any thing of the kind which has issued  from
the medical press of this country."—Amer. Journal of the Medical Sciences.

  " If we were to say that this volume by Mr. Fergusson, is  one  excellently adapted to the
student, and Ihe yet inexperienced practitioner ot  surgery, we should restrict unduly its
range.  It is  of the kind which every medical man ought to have by him for read}' refer-
ence, as a guide  to the prompt treatment of many accidents and injuries, which whilst he
hesitates, may be followed by incurable defects, and deformities of  structure,  if not by
death itself."
  " In drawing to a close our notice  of Mr. Fergusson's Practical Surgery, we cannot re-
frain from again adverting to the numerous and beautiful illustrations by wood-cuts, which
contribute so admirably to elucidate the descriptions in the text.  Dr. Norris has, as usual,
acquitted himself judiciously in his office of annotator.  His additions are strictly practical,
and to the point."—Bulletin of Medical Science.

  "We know not how generally Mr. Fergusson's system  of  Practical Surgery may be
known to practitioners, but those who are strangers to it, ouuht not to  be so any longer,
since it is obvious, that it is destined to work its way into public favour.   George W. Nor-
ris,  M. D., one of the surgeons of the Pennsylvania Hospital, who  has added  notes and
additional illustrations, says, in a short preface, that it ' is so well adapted to the wants of
the American  student and practitioner, that no apology is necessary for  introducing it to
their notice.   The work is at once clear and concise in style, strictly practical in  its con-
tents, and the wood-cuts,  admirably executed by  Mr. Gilbert, are remarkable for their
spirit and accuracy.'   Dr. Norris is good authority; he is not a man to bestow commenda-
tion where it  is not deserved, nor would he hazard  a growing reputation by recommending
to the notice of surgeons anything that would not bear the most critical examination."
  " The two hundred and fifty-fpur engravings are as correct and beautiful as can be found
anywhere.  We bespeak for such a book, the countenance and patronage of a liberal-minded
faculty."—Boston Med. & Surg. Journal.

  "We can only add  our testimony that, in following this course, the author has  fully suc-
ceeded in making an original and strictly practical work, and one which we are confident
will be considered a standard book  for  the surgeon.  In its style it is concise, easy, and
agreeable; the matter it contains is well arranged, and what is  more important, admirably
digested; the  directions for the use of instruments, for the performance of operations, for
the diagnosis of diseased conditions, and for the proper treatment lor their relief, are all
clearly laid down and illustrated by  excellent wood cuts, which  speak  more intelligibly
oculisjiddibus, than would the most laboured explanations."—N. York American.

  " This new  work, just issued from the house of Messrs. Lea & Blanchard, is remarkable
in many respects  for the value of the information it contains, the number of admirable illus-
trations, and,  withal, for the style in which it has been brought out, taking a place, in this
respect, alongside the  'System of Human Anatomy,'recently published by the same en-
terprising house.  The object of the author throughout the whole of the work, has been ' to
produce a manual of the details of practical surgery, which shall, in some degree, meet the
wishes of the student, as well as of the surgeon already engaged in  practice.'  And in this,
every one must admit,  he has fully succeeded.   The American editor, (one of  our best in-
formed surgeons,) has added matter having reference, principally, to the treatment of some
of the more common  surgical affections, or to operations, done  by his own countrymen,
which have been deemed worthy of notice."
  "A friend, who is well acquainted with all that has been done in this department of sci-
ence, is prepared to say, that no surgical work has emanated from the press of this, or any
other country, which is, in  all respects, more  creditable to  the author and editor; and it
appears to him, that every library ought to possess it.   It will be found a faithful guide,
with no obscurity to lead to hesitation, and with illustrations such as to  guard completely
against error."—U. S. Gazette.

  It is with unfeigned satisfaction that we call the attention of the profession in this country
to this excellent work.  It  richly deserves the reputation conceded to it, of being the best
practical surgery extant, at least in the English language.
  The matter added by the American editor, is both interesting and useful, and bears the
impress of his cautious and discriminating mind.—Medical Examiner. 
ELEMENTS  OF  MATERIA  MEDICA  AND  THERAPEUTICS,
                   Wli'ii NEAR 300 ILLUSTRATIONS.
                           ELEMENTS

                                       OF

MATERIA   MEDICA   AND   THERAPEUTICS;

                                 COMPREHENDING
  THE NATURAL  HISTORY,  PREPARATION, PROPERTIES,
           COMPOSITION, EFFECTS, AND USES OF MEDICINES,

                 By JONATHAN  PEREIRA, M.D., F.R.S.,
                ASSISTANT PHYSICIAN TO THE LONDON  HOSPITAL, ETC.
                        With numerous  Illustrations.
                      FROM THE SECOND LONDON EDITION.
      ENLARGED AND IMPROVED, WITH NOTES  AND ADDITIONS,

                       BY JOSEPH CARSON,  M.D.
    PROFESSOR OF MATERIA MEDICA AND PHARMACY IN THE PHILADELPHIA COLLEGE OF
                                 PHARMACY, ETC.

  Part I., contains the General Action and  Classification of Medicines,and the Mineral Ma-
teria Medica.  Part 11., the Vegetable and Animal Kingdoms, and including diagrams ex-
planatory of the  Processes of the Pharmacopoeias, a tabular view of the History of the
Materia Medica, from the earliest times to the present day, and a very copious index. From
the Second London Edition, which has been thoroughly revised, with the Introduction of the
Processes of the  New Edinburgh  Pharmacopoeia, and containing additional articles on
Mental  Remedies, Light,  Heat, Cold, Electricity, Magnetism,  Exercise,  Dietetics, and
Climate, and many additional Wood Cuts, illustrative of Pharmaceutical Operations, Crys-
tallography, Shape and Organization of the Feculas of Commerce, and the Natural History
of the Materia Medica.
  The object of the author has been to supply the Medical Student with a Class Book on
Materia Medica, containing a faithful outline of this Department of Medicine, which should
embrace a concise account of the most important modern discoveries in Natural History,
Chemistry, Physiology, and TJierapeutics,  in so far as they  pertain to Pharmacology, and
treat the subjects in the order of their natural historical relations.

                 PREFACE TO THE AMERICAN EDITION.
  The very great merit of Pereira's Elements of Materia Medica and Therapeutics, having
attracted the attention of the Profession in the United States, it is believed that an important
service is performed in rendering it accessible, by the publication of an American edition.
It is by far the most comprehensive treatise upon the subject  in the English language.  Re-
plete with erudition and at the same time most satisfactory with respect to references; it is
admirably suited to the wants of the advanced student and the practitioner; while from the
distinctness of the facts, their  methodical arrangement, and  the clear philosophical expla-
nations connected with them, it meets the wants of the student who is in  search of the first
lessons in the science.   It may, therefore,  with equal benefit  be employed as a work of re-
ference  or as an elementary text book, in which two-fold character it occupies an unusual

  More  completely to adapt it to the demands of this country, such additions have been made
as are deemed to be essential.  Thus, the portion devoted to pharmaceutical information, is
in the original work too strictly local, as it  is confined almost  exclusively to the peculiarities
of the three British  Colleges; to obviate  this, the nomenclature of the last edition of the
United States Pharmacopoeia has been introduced, by inserting the name of each article
adopted  by that standard, in connexion with those assumed by the authorities uniformly cited
bv the author, or by expressing a correspondence of name with one or more of them by the
svmbols (U. S.) in union with similar symbols used by him to indicate the authority.  The
formula of'the United States Pharmacopoeia have also been set forth with the formula of
th >  tandards previously mentioned, and where a formula has been adopted, or a medicinal
  enaration assumed by our own work, entirely differing from those found in the text, ithas
l^en presented, with all the details necessary for its employment.
  S   i  ct histories of the most important indigenous medicines of the United States, ot
 VM^no account had been  given, have been  introduced in their  appropriate places, as
r    ■   Marilandica,  Chenopodium, Vimicifuga,  Cornus  Florida, Eupatorium, Gillema,
Lansia  .■     (junaiiensis, Podophyllum, Primus-Virginiana, Sanguinaria and Veratrum
Juglans, .s of n)jn01. importance  have also been noticed,  and a sufficient  exposition of
vtriue;  a '      ma(ie for their employment under circumstances that may render them
their  nropeiwta ma*.»*'>            *  .
expedient.                                                              jg 
PEREIRA CONTINUED.
  It forms.Two Volumes, of about 1600 large and well-printed pages, with  near 300 illus-
trations on wood.  Great expense has beeu incurred in getting it up, and the editor has been
most careful in its revision, so that it may be relied upon as a standard and permanent work.
  It will be used asa Text Book in'various sections of the cour.iry. Numerous testimonials
from Journals, Professors, and others, could be given, but the Publishers prefer exhibiting
this explanation of its contents, and submitting an extract from the work.
                    Extract from the Article—Lobelia.

  Chemical Characteristics.—A strong decoction of lobelia dropped into recti-
fied spirit deposits a precipitate {gum).  Acetate, and especially diacetate of lead,
form yellow precipitates with the decoction.  Protonitrate of mercury also forms a
copious precipitate.   (For other chemical characteristics, see above.)
  Physiological  Effkcts.—An accurate account of the effects of this plant on
man and animals is  yet wanting!-.  But from the observations hitherto made its
operation appears to  be very similar to that of tobacco (see p. 317); and from this
circumstance, indeed, it has  been called the  Indian Tobacco.  1 have before re-
marked, that both  in its taste and in  the sensation of acridity which it excites in
the throat, it  resembles common  tobacco.  This analogy between nicotiana and
lobelia, originally  noticed by the American practitioners, is confirmed by Dr. El-
liotson.  {Lancet,  April 15, 1837, p. 144.)
  a.  On Animals generally.—Horses and cattle have been supposed to be killed
by eating; it accidentally.   (Thacher,  American New Dispensatory, p. 2.)  An ex-
traordinary flow of saliva is said to be produced by it on  cattle.  {Lancet, Ma-v 13,
1837, p. 299.)
  [Mr. Procter administered  a  grain of lobelina in solution to a cat. In less than
two  minutes it produced  violent emesis, and  much prostration,  from  which the
animal fully recovered in  three hours.   Again,  one grain of the  substance  in  an
ounce  of water was administered directly into  the stomach of the  animal by an
elastic tube.   Immediate and total prostration was the consequence, which in half
an hour rendered the animal almost motionless;  the pupils of the eyes were much
dilated.  The animal gradually recovered its strength, but the effects of the pros-
tration were evident  for fifteen  hours  afterwards.  No emetic  or cathartic effects
resulted.  {Am. Journ. of Pharm. vol. xiii. p. 10.)—J. C]
  0. On Man.—ax. In small doses it operates as a diaphoretic and expectorant..  Mr.
Andrews, (Lond. Med. Gaz. vol. iii. p. 260,) who speaks from its effects on  him-
self, says, it has "the peculiar soothing quality of exciting expectoration without
the pain of coughing."
  69. In full medicinal doses (as Qj. of the powder) it acts as a powerful, nauseat-
ing  emetic.   Hence  it has been called the emetic weed.  It  catnes  severe  and
speedy vomiting, attended with continued and distressing nausea, sometimes purg-
ing, copious sweating, and great general relaxation.  These symptoms are usually
preceded by giddiness, headache, and general tremors.   The Rev. Dr.  M. Cutler,
(Thacher, op. cit.,) in  his account of the effects on himself, says, that taken during
a severe paroxysm of asthma, it caused sickness and vomiting, and a kind of prickly
sensation through  the whole system, even to the  extremities of the fingers and
toes.   The  urinary  passage  was perceptibly  affected, by  producing  a smarting
sensation in passing urine, which was probably provoked by  stimulus on  the
bladder.  It sometimes, as in  the Rev. Dr. Cutler's case, gives almost instanta-
neous relief in an attack of spasmodic asthma.  Intermittent pulse was caused by
it in a case mentioned by Dr. Elliotson.  Administered by the rectum, it produces
the same distressing sickness of  stomach, profuse  perspiration, and universal re-
laxation, which result from a similar  use of tobacco.
  yy. In excessive  doses, or in full doses too frequently repeated, its effects are those
of a powerful acro-narcoticpoison.   "The melancholy consequences resulting from
the use of Lobelia inflata," says Dr. Thacher, {op. cit.) "as lately administered by
the adventurous hands of a noted empiric, have justly excited considerable interest,
and  furnished alarming examples of its deleterious  properties and fatal effects.
The dose in which he is said usually to prescribe it, and frequently with impunity,
is a common teaspoor.fiil of the powdered seeds or leaves, and often repeated.   If
the medicine does not puke or  evacuate powerfully, it frequently destroys the pa-
% 
PEREIRA CONTINUED.
tient, and sometimes in five or six  hours."   Its effects, according to Dr. Wood,
{Lmled Stales Dispensatory,) are, "extreme prostration, great anxiety and distress,
and ultimately death, preceded by convulsions."   He also tells us that fatal results
(in America) have been experienced from its empirical use.  These are the more
apt to occur when the poison, as is sometimes the case, is not rejected by vomiting.
  Uses—Lobelia is probably applicable to all the purposes for which tobacco has
been  used (see p. 319).  From my own observation  of its effects,  its principal
value is as an antispasmodic.
  1. In asthma (especially the spasmodic kind) and other disorders of the organs of
respiration.—Given in full doses, so as to excite nausea and vomiting, at the com-
mencement of, or shortly before, an attack of spasmodic asthma, it  sometimes suc-
ceeds in cutting short the paroxysm, or in greatly mitigating its violence; at other
times, however, it completely fails.  Occasionally it has proved serviceable in a
few attacks, and, by repetition, has lost its influence over the disease.
  To obtain the beneficial influence  in asthma, it  is  not  necessary, however, to
give it in doses  sufficient to excite vomiting.  Dr. Elliotson {Lancet, April 15,
1837, p. 144,) recommends the  use of small doses at the commencement, and says
that these should  be gradually increased, if neither headache nor vomiting occur;
but immediately when these symptoms come on, the  use of the remedy  is to be
omitted.   Given in  this way, I can testify to its good effects in  spasmodic asthma.
It has also been used in croup, hooping-cough, and catarrhal asthma, but with no
very encooraging effects.
  2. In strangulated hernia, Dr. Eberle,  {Treat,  of the Mat. Med.  Vol. i. p. 48, 2d
ed.)  employed it effectually, instead of tobacco, in the form of enema.
  3. As an emetic, it has been employed by Dr.  Eberle {op. cit.) in croup; but its
operation is too distressing and dangerous for ordinary use.
  Administration.—It may be given inpotvder, infusion, or tincture  (alcoholic or
ethereal.)  Dr.  Reece employed an oxymel.  The dose of the powder as an emetic,
is from grs. x. to  £)j.; as an expectorant, from gr. j. to grs.  v.   It deserves especial
notice that the  effects  of lobelia are very unequal on  different persons, and  that
some are  exceedingly susceptible of its influence.  (Elliotson, Lancet,  June 1832;
and April 15, 1837.)
  1. TINCTURA LOBELLE, E. (U. S.): Tincture of Lobelia.—Lobelia, dried, and
in moderately fine powder, 3 v.;  Proof Spirit, Oij.  This tincture is best prepared
by the process of percolation, as directed for the tincture of capsicum;  but it may
also  be made in  the usual  way by digestion.)—[The U. S.  P.  directs  Lobelia,
four  ounces;  Diluted Alcohol, two pints.  Macerate  for fourteen  days and filter,
or proceed by displacement.]—Dose, as  an  emetic and antispasmodic, from f3j.
to fjij. repeated every two or three hours until vomiting occur; as an expectorant
tt[x.  to T3J.   For children of one or two years old,  the dose is TT[x. T(|xx.
  I TOCTUHA LttBELLE .ETHEREA, E.; Ethereal Tincture  of Lobelia.—(Lo-
belia, dried, and in moderately fine powder, gv.; Spirit of Sulphuric  Ether,  Oij.
This tincture is best prepared by percolation, as  directed for tincture  of capsicum;
but it may be also obtained by  digestion in a well-closed vessel  for seven days.)
This may be used in the same doses as the alcoholic tincture.
  With some persons the ether is apt to disagree, and  for such the alcoholic tinc-
ture  is preferred.   B^hitlaw's ethereal tincture, used by Dr. Elliotson, consisted of
Lobelia, lb. j.; rectified  spirit, Oiv.; spirit of nitric ether, Oiv.; spirit of sulphuric
ether, giv.   Macerate for fourteen days, in a dark  place.   {Lancet, June 3, 1837.)
  [As has been  stated, page  385, heat  injures  the activity of lobelia, when its
active principle is in a free state, and  though combined with  a weak acid in the
plant, boilinf is found  to impair the activity of the decoction, hence  in  making
preparations^hich require  heat, some acid, as the acetic, should be associated
with it.   A Vinegar of Lobelia may be prepared by treating  four ounces  of lobe-
lia by displacement, with two pints of diluted acetic acid.  With vinegar of lobe-
lia  a syrup may be made in the same  manner as syrup of squills.
  By treatincr the powdered seeds with eight parts of diluted  alcohol, containing
1 per cent. oPacetic acid, a preparation is obtained possessing  the activity of lobe-
lia in a concentrated form (Procter).—J. C]
                                                                    15 
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