Elements of Surgery

by Robert Liston

DISEASES OF THE EYEBALL

Diseases of the eyeball are numerous, and various in their nature. Some are acute, others chronic; and their attack is either sudden, or slow and insidious. Most of them are attended with pain and other annoying symptoms, and some cause loss of vision. Some are cured by internal means; others require surgical operations; and the cure is either complete and permanent, or palliative and temporary. Some destroy the organ, and others, still more malignant, cause extinction of life. All require much attention and care.

Of Ophthalmia, or Inflammation of the Eye.—The symptoms and appearances of ophthalmia vary much according to the particular texture or textures affected. They require to be minutely attended to, that the treatment may be varied in such a way as to obviate any bad consequences which may be threatened. The great importance of the organ, and the danger to its structure and functions which is likely to occur from any other termination of the affection than resolution, must never be lost sight of.

We shall first treat of inflammation of the more external parts of the ball, an affection generally less dangerous than inflammation of the interior, but at the same time of more frequent occurrence, and produced by slighter causes.

Inflammation of the conjunctiva occurs in many individuals during very warm and sunny weather. At such a period, the eye is often excited by reflection of intense light from the surface of the earth; and is irritated by sudden exposure to a degree of light to which it has not been previously accustomed. Different directions of the sun’s rays, and different kinds of light, seem to exert different influences on the organ. The rays are most hurtful when they do not fall in a perpendicular direction on the eye, but slopingly or horizontally. Strong light from the moon, and light reflected from scarlet, are also particularly injurious. Undue exertion of the eye weakens it, and renders it prone to become inflamed. The eyes of infants are often violently inflamed, in consequence of imprudent exposure to light before they have been gradually accustomed to its stimulus. Again, inflammation is caused by imprudent exposure of the eye directly to cold, or by exposure of other parts causing suppression of their discharges, whether natural or not. Inflammation of the conjunctiva often follows suppression, however occasioned, of the menstrual or hemorrhoidal discharges, as also suppression of discharges from the urethra, from the Schneiderian membrane, or from behind the ears. Irritations in the neighbouring parts, as in the mouth during dentition, may also excite the disease. Immediate irritations, however, are the most frequent cause, as the lodgement of extraneous bodies on the surface of the organ—particles of sand, dust, snuff, pepper, or gunpowder, minute insects, loose or inverted eyelashes. By the presence of such substances, the eye is often kept in a very irritated state for a long period. The most violent conjunctival inflammation is sometimes produced by contact of gonorrhœal matter through carelessness. Occasionally metastasis of inflammation takes place from one eye to another; so that a person may be seen one day with severe inflammation of the right, and on the following day with a similar affection of the left, and the right entirely free from disease. Another cause, sometimes met with, of inflammatory action in the conjunctiva, is the lodgement of large foreign bodies in the orbit, with or without destruction of the eye; as splinters of wood, straws, rusty iron nails, sharp portions of stone, &c., penetrating the globe of the eye, or parts in the immediate neighbourhood. Upon removal of the cause, the redness, discharge of tears, pain, &c., sometimes subside without inflammation having been established, the vessels of the part regaining their contractility; but if the cause is continued for any considerable time the effects do not rapidly abate. Wounds and other injuries of the organ are generally followed by inflammation. But a simple clean wound or puncture made with a fine instrument, as in many operations, and in a favourable constitution, frequently produces little or no excitement of the part. The degree of excitement must of course depend upon the nature of the wound, the structure of the parts involved, the lodgement or not of the body by which the wound is inflicted, and many accidental circumstances. The eye may be injured by acids or by lime, and the textures acted upon chemically; again, the membrane may be wounded by pieces of hot metal, and then the destructive action is both chemical and mechanical: in both cases active inflammation of the injured conjunctiva is kindled. The state of the patient’s constitution modifies very much inflammatory action of the eye, however induced; and it has been observed, that dark eyes bear injury or incited action better than those of a light hue. Not unfrequently conjunctivitis is a secondary affection, accompanying eruptile diseases, as measles or small-pox.

In considering the disease, it is necessary to keep in mind the loose connection of the membrane with the subjacent parts, as well as its own texture and functions.

In conjunctival inflammation, the patient first feels a degree of pain and stiffness in moving the organ; and has always a feeling as if a foreign body were present, whether such is the case or not. There is also a degree of itching with a sensation of fulness in the part, and this is followed by redness of the membrane, becoming more and more intense. If the disease gain ground, the colour changes to a darkish red or purple hue. To the redness succeeds heat, with profuse and hot lachrymation. Then swelling supervenes, often to a great extent: the vessels, both veins and arteries, are much gorged, and effusion of serum or blood takes place into the loose cellular tissue which connects the conjunctiva to the sclerotic.

In some cases, the effusion in this situation is very considerable; lymph as well as blood is deposited, and a bulging forwards of the conjunctiva is produced; the stretched membrane becomes thickened, of a raw granulated appearance, and a bright scarlet hue, and the cornea appears sunk in the midst of the swelling, and almost hid by it: this state of matters is termed Inflammatory Chemosis, and only occurs when the excitement is very intense.

Blood is frequently effused beneath the conjunctiva in small quantity, in consequence of a bruise or other injury of the eye,—from violent exertion, as during coughing,—or from a less degree of inflammatory action than in the preceding case; but the swelling thereby occasioned is comparatively trifling, and the effusion is, in general, speedily absorbed. To this affection the term Ecchymosis is attached.

In inflammation of the external parts of the eye, the redness begins from the margins of the organ, and gradually diffuses itself towards the cornea. Such is not the case in inflammation more deeply seated. There is intolerance of light in a slight degree, and the patient is inclined to keep the eyelids shut. At first the discharge from the conjunctiva and meibomian glands is increased and changed, and flows occasionally over the cheek, producing a scalding sensation. When the eyelids are at rest, as during the night, they become glued together by the viscid fluid from the meibomian follicles; but, if the inflammation increases in intensity, the discharge is arrested.

In external inflammation there is more or less constitutional disturbance, proportioned to the violence of the action and the irritability of the system. In most instances the patient complains of headache.

The above symptoms subside along with the inflammation; but, if this has been at all severe or protracted, distension of the vessels to a considerable degree continues, and the ophthalmia becomes chronic. This change from acute to chronic takes place at various periods of the affection, according to the intensity of the action, the nature of the cause, and the irritability of the constitution. And again, the second stage of ophthalmia may revert to the first, acute inflammation being rekindled by fresh irritation of the organ.

Purulent Ophthalmia most frequently occurs in warm climates, and is attended from the first with profuse puriform discharge from the conjunctiva. In the natural state of the organ, the conjunctival discharge is pellucid, and so small in quantity as to be indiscernible; but in this disease it possesses all the external characters of pus, and is secreted in large quantity. The affection commences generally in the under eyelid, with a feeling as if sand or foreign bodies were lodged in the eye. The parts swell very much, and the eyelids become more or less inverted, in consequence of serous effusion into their cellular texture. Frequently the patient experiences an exacerbation of the complaint about three or four hours after each meal. Though the disease usually commences in the conjunctival lining of the eyelids, the external coverings of the ball are often secondarily affected. In some cases the bulb becomes the seat of lancinating pains; its coats give way; the humours are discharged; and the eye sinks, with immediate relief to the patient from the more urgent symptoms, but at the same time with irreparable loss of vision. In other instances the effects are less injurious to the structure of the organ, but equally so to the sense of vision: the cornea becomes dull, and ultimately opaque, or ulcerates, or partially sloughs; the swollen conjunctival surface of the lids is covered with granulations, and secretes a copious puriform discharge, with or without eversion, according to the degree of swelling. At first the lids are more or less inverted, on account of œdematous swelling of the cellular tissue: in the latter stages they are everted by thickening and turgescence of the conjunctiva. This membrane is at first villous and of a dull red colour, relaxed, and its vessels enlarged and loaded; afterwards it becomes hard, almost warty, and continues to discharge puriform fluid. The latter state of the lining of the lid produces disease of the cornea, opacity of a greenish colour, or an ulcer with intolerance of light, and other symptoms of disorganisation proceeding in that tissue. The disease is supposed to be contagious, and was the scourge of the British army for many years after the campaign in Egypt. In that country it seems to be caused by exposure to cold and damp during the night, and the intense rays of light during the day, more especially when these causes act on eyes which have not been accustomed to such vicissitudes. After its invasion, it is communicable to others by contact of the morbid secretion; and in individuals who have been once affected the disease is very apt to recur when they are crowded together in unhealthy situations.

A disease of equal malignity, and resembling in all respects the Egyptian ophthalmia, occurs from the application of gonorrhœal matter to the conjunctiva, or on sudden suppression of the gonorrhœal discharge,—metastasis of the action sometimes takes place from the urethral membrane to the conjunctiva. The eye is seldom saved from the destructive effects of the violent inflammation which follows the contact of the morbid fluid. Of all forms of purulent ophthalmia, the gonorrhœal is the most rapid in its course and destructive in its effects.

Children are not unfrequently the victims of purulent ophthalmia—the ophthalmia neonatorum. Immediately after birth the conjunctival lining of the eyelids seems unusually red and turgid, and a great degree of swelling soon takes place, so as to render separation of the eyelids very difficult. Occasionally eversion of the lids occurs, when the child cries, from sudden and forcible contraction of the strong external fibres of the orbicular muscle. In general, the lids soon relapse into their former situation; but sometimes the eversion remains, if the internally projecting tumour of the conjunctiva is allowed to become still more swelled from strangulation, caused by the outer margin of the reflected lid. The inflammation spreads over the ball; and, in general, the swelling of the conjunctiva, being greatest at the circumference of the eye, bulges out the eyelids, and turns in their margins. Puriform matter is secreted copiously, and is confined, more especially when, from inattention, the margins of the lids are allowed to become glued together. They often adhere so firmly as to require a very considerable force for their separation, and when opened the matter gushes out as if from the cavity of an abscess. From confinement of the matter the inflammation is still more increased, and the cornea involved. Whitish specks form on it, or it ulcerates, and the ulcers make their way into the anterior chamber of the eye; or portions of it slough, causing partial loss of the organ and openings into the chamber, in consequence of which the aqueous humour is discharged, and the cornea sinks and becomes flaccid. In many instances the cornea becomes opaque, changed in texture, and increased in thickness, so as to form a convex projection from betwixt the eyelids, termed Staphyloma; the sclerotic coat also is occasionally affected

in a similar manner. A frequent cause of purulent ophthalmia in children is imprudent exposure of the eyes to strong light, the parent or nurse not remembering that the organ must be gradually accustomed to the stimulus. Exposure to cold may also induce the inflammatory action. The application of leucorrhœal or gonorrhœal matter to the eyes of the child, whilst passing through the vagina of the mother, is perhaps the most common cause of the disease. A very unhealthy state of the constitution accompanies the affection: the scalp and other parts of the surface are frequently covered with eruptions. A singular result sometimes follows the purulent ophthalmia of infants. A small opaque spot is observed on the capsule of the lens, which remains through life a central spurious capsular cataract.

Inflammation of the Cornea supervenes on simple conjunctival inflammation, and frequently on the purulent. The vessels of the part, both veins and arteries, previously carrying single and therefore invisible blood corpuscules, become much dilated, are filled with numerous globules, and hence are rendered red and conspicuous to the unassisted eye. Writers on ophthalmic surgery, in their rage for refinement, speak of three kinds of this inflammation—inflammation of the external or conjunctival covering, of the middle tunics or cornea propria, and, lastly, of the third coat, the capsule of the aqueous humour: such distinctions, however, are found to effect no good practical end, and it is unnecessary to follow them. One particular layer of the cornea may be first attacked, but the whole structure soon becomes involved. The inflammation generally commences in the conjunctival covering. Vision is necessarily much obscured from even slight inflammatory affection of the cornea. Part only of the organ may be affected, but frequently the whole is involved. Sometimes only one or two vessels remain dilated; but still they, passing over the centre of the cornea, render vision indistinct. Opacity of the cornea, to a greater or less degree, always attends dilatation of its vessels.

In inflammation of the internal and middle tunics of the cornea, most of the enlarged vessels which traverse it are seen to be continuations of those that ramify in the conjunctival covering; while the anastomotic vessels derived from the sclerotic coat are smaller and less apparent than those of the conjunctiva. The cornea, and the sclerotic immediately surrounding it, frequently appear to be almost entirely covered with meshes of their dilated capillaries. At first the whole cornea has a clouded appearance, but as the disease advances portions become distinctly opaque, and at these points either lymph or pus is effused. Sometimes matter collects between the laminæ, distends them, and, causing ulceration, discharges itself either into the anterior chamber or externally. Inflammation of the cornea arises frequently from lodgement of a foreign body in it: and ulcers of it are often produced by a similar cause. If the extraneous matter is not removed soon after its insertion, nature commences her endeavours to detach it, and the process employed is ulceration. Sometimes, however, a sac is formed around the foreign body as in other parts, and no ulcer is produced.

Ulceration of the cornea also takes place in order to afford an exit to matter formed between its layers deeply or superficially. Deep abscess of the cornea is by no means a rare consequence of violent inflammatory action in the part. A minute opaque spot is at first seen; this extends, assumes a yellow colour, and does not change its situation on the head being moved. The internal lamellæ may ulcerate in consequence of the pressure; but this seldom happens; the matter is discharged externally. Suppuration in this situation is often attended with much pain. Abscess of the surface of the cornea is of more frequent occurrence than one more deeply seated: from its external covering yielding readily to the pressure of the accumulating matter, it generally assumes a pustular form. The fluid in such cases is sometimes absorbed, and no vestige of disease remains in the part; but more frequently the apex of the pustule gives way, and an ulcer is the consequence. A similar result takes place if an artificial opening is made for evacuation of the matter; and it may be considered as a good rule in practice not to interfere with collections in the cornea, as there is a probable chance of the matter being absorbed, and the cornea regaining its transparency; while it is certain that breach of its surface, in such cases, though made by the most delicate instrument, will give rise to ulceration.

Pustular Opthalmia is at some seasons frequently met with: small pustules, sometimes numerous, form on the conjunctiva, whilst that membrane is turgid and its vessels dilated; the sclerotic conjunctiva around the cornea is their most common situation, but sometimes almost the whole conjunctival surface appears studded with them. When the cornea is affected, the pustules frequently give way, and produce ulceration; and when the pustules are numerous, and surrounded by much vascularity, the part becomes opaque as well as ulcerated.

In weak constitutions Ulcers of the Cornea occur from slight causes,—exposure to strong light, intemperance, inverted or irregular ciliæ, a granulated state of the lining of the lids, or from momentary irritation of the part by extraneous matter. The ulcer appears at first circular, but during its progress it often becomes of an irregular form; its surface is depressed and ragged, and can readily be seen by directing the patient to fix the eye, and then looking at the part from one side. The edges are elevated; and the surface, which is of an ash colour, discharges an acrid colourless fluid, as in similar affections of all surfaces that are covered with a delicate, tense, and exquisitely sensible expansion. Sometimes the ulcer is very minute and superficial, and enlarges very slowly, if at all; but in other instances it extends rapidly in depth and size, with great pain and irritability of the organ, and intolerance of light. Occasionally their increase is expedited by partial sloughing. At first, when the ulcer is minute, the part often retains its natural transparency. But as the disease advances, when the sore spreads superficially either by the sloughing or the ulcerative process, or by both, the cornea becomes opaque, often to a considerable extent, around the ulcerated part; and if the ulcer extends deeply, so as to perforate the tunics, the aqueous humour escapes, the iris falls forward, and the pupil becomes distorted: in either case vision is impaired or destroyed. In some cases great relief follows discharge of the humour, and the consequent flaccidity of the cornea, the ulcers seeming to have been prolonged and irritated by the fulness of the chamber. Sometimes an ulcer will penetrate the laminæ of the cornea, even to the aqueous membrane. This latter tissue may resist the ulcerative process, and will then be pushed forward into the opening by the pressure of the aqueous fluid. This is the hernia of the aqueous membrane, so called, instances of which have been known to acquire a considerable size before the bag has given way.

Abrasion of the conjunctival covering of the cornea is produced by accident, or follows incited action of the vessels. The abraded surface either ulcerates, or contracts and heals kindly, with or without opacity of the part. Breach of surface in the cornea,—whether an ulcer, an abrasion, or a raw surface, caused by the giving way of a pustule, or of a small abscess,—is constantly liable to irritation, on account of not being protected by mucous membrane and mucous discharge: even the contact of the tears irritates, and keeps up inflammatory action in the membranes. When the ulcerative process ceases, lymph is effused, and a grayish halo forms around the sore; the ash colour of the surface of the sore disappears, and is succeeded by florid granulations, extremely minute, which fill up the cavity; cicatrisation follows in due time, with subsidence of all the symptoms and appearances of inflammation. There remains, however, an opaque speck of a pearly hue corresponding to the sore, but occupying rather less space. When the cornea is perforated by ulceration, the sore sometimes shows no disposition to heal, becoming a fistulous aperture through which the aqueous humour is from time to time discharged. By this condition of parts vision is much impaired, the cornea being always more or less flaccid. Touching the fistulous opening with the nitrate of silver, reduced by scraping to a very fine point, will often promote a healthy action in the tissue, and effect adhesion of its sides.

The pearly speck which remains after cicatrisation of a corneal sore is termed Leucoma, and is permanent. It is generally of an uniform colour, but occasionally a black speck is perceptible in some part of it. For, when an ulcer lays open the anterior chamber, part or the whole of the aqueous humour is evacuated, and the iris falls forward; a portion of the iris falling into the opening, provided this is not in the centre of the cornea, closes it up, and becomes adherent to that part. If the opening is large, the prolapsus of the iris is considerable; and in some cases this membrane, being pressed on by the humours, is forced through the opening in the form of a small bag. This change of position is termed Hernia of the Iris; and the dark sacculated portion of the iris which projects from the surface of the cornea is called Myocephalon, from its resemblance to the head

of a fly. The myocephalon may remain for a considerable time, or may sphacelate and drop away. The pupil is thus rendered irregular, is perhaps nearly obliterated, or is drawn down behind the opaque part, and thereby rendered totally useless to the patient. The impairment of vision caused by Leucoma depends on the size and situation of the speck. The disease is irremediable, though the thin cloudy opacity, which frequently surrounds the leucoma, may be dissipated. The operation of artificial pupil is sometimes required, in order to afford a degree of vision in this affection of the cornea,—as well as in the speck of a similar appearance occasioned by effusion and organisation of lymph betwixt the deep lamellæ of the cornea, and which is termed Albugo.

Albugo occurs during the intensity of inflammatory attacks. It also is surrounded occasionally by thinner opacity, but not depressed and unequal on the surface, as leucoma sometimes is. Large and tortuous vessels are generally seen passing into albugines, but meshes of dilated vessels are seldom present. When the affection is recent, it sometimes disappears under proper treatment, especially in young subjects; but the albugo is by no means so readily removed as the Nebula, or thin cloudy opacity which is the frequent consequence of obstinate chronic dilatation of the conjunctival vessels. Nebula is superficial, and consists of mere thickening of the conjunctival covering, from lymph having been effused. It impairs vision, but does not destroy it, for the affected part remains semitransparent.

In strumous constitutions specks of the cornea are often accompanied with ulceration of the edges of the palpebræ, and destruction of the ciliæ—the ophthalmia tarsi. The margins of the eyelids are red and slightly tumid, and discharge an acrid fluid; the ciliæ are matted together; pustules form at their roots; the bags which secrete them are laid open and destroyed, and they consequently fall out. The affection is often of long duration, and may be in part prolonged by vitiated secretion from the meibomian glands. During its progress it excites very considerable irritation in the whole eye, and, as has been already stated, opacities of the cornea not unfrequently accompany it. Veins become enlarged, and varicose on the conjunctiva, as also their minute ramifications on the clear part of the ball; small reddish lines appear on the cornea, and around them is “diffused a thin, milky, or albuminous humour,” which destroys its transparency at that part. Such spots may be solitary or numerous, and darken the cornea either partially or entirely. They are always surrounded with a fasciculus of enlarged veins.

In elderly people a dim opaque ring, of a greyish colour, sometimes encircles the margins of the cornea, and is called Arcus Senilis; but this can scarcely be looked upon as a disease.

Sometimes the cornea presents a spotted appearance; and this state of the organ is generally attended by obstinate inflammatory action in the part. The affection, however, is rare. I have seen several instances of it: in one, both corneæ were spotted, and sight was almost destroyed, without much irritability of the organ. The disease yielded to external stimulants, and the internal use of the bichloride of mercury. It is met with in a chronic and very intractable form.

The cornea may sometimes be rendered dim by over-distension, the aqueous humour being unusually copious.

Occasionally sloughing takes place in the cornea from over-action. It is dangerous to the structure and functions of the organ, according to the extent to which it occurs.

Ossification of the cornea is said to take place; but few cases are on record, and these were in very old people.

The cornea sometimes becomes conical to a great degree in persons considerably advanced in life. The cone has its apex in the centre of the organ, seems thick and crystalline when viewed laterally, and when

looked on from the front has a sparkling appearance. In some cases it is opaque in the centre, and occasionally its surface is irregular. Vision of objects at any distance is very indistinct; those placed within an inch or two of the eye are most distinctly seen, especially if looked on through a small aperture. The disease usually affects both eyes, though not always in an equal degree. The patients cannot judge accurately of distance, and see objects multiplied and disfigured.

Staphyloma has been already alluded to as an occasional consequence of purulent ophthalmia in children. The cornea is thickened, prominent, and opaque; and in most cases vision is either much impaired or entirely lost. The prominence varies in different cases, being sometimes very little elevated beyond the natural state of the part, while in other instances it protrudes from between the eyelids. After having attained a certain size it often becomes stationary; but very frequently it continues to enlarge gradually. When the prominence is large, much inconvenience arises from the eyelids not being allowed to close; and the eye, being thereby deprived of its natural covering, is extremely liable to become inflamed from external irritation. When one eye is affected with staphyloma, the other not unfrequently becomes similarly diseased.

Dropsy of the anterior chamber, or Hydrophthalmia, occasionally takes place in persons of weak constitutions. The aqueous humour is either secreted in greater abundance than it usually is, or absorption is diminished. The cornea gradually accommodates itself to the increase of the fluid behind, and becomes wider and more prominent, but retains its transparency; in looking at the eye, the anterior chamber is seen evidently enlarged, and occasionally the aqueous humour is of a turbid appearance. There is little or no pain in the eyeball, but the patient complains of an annoying sense of fulness and tension in the part. In consequence of the vitreous humour also accumulating, the whole organ is ultimately enlarged considerably, and its motions are thereby much impeded. At first, vision of near objects is impaired, whilst the patient sees very distinctly those placed at a distance; ultimately sight is entirely lost.

Exophthalmia, or protrusion of the eye, attends the preceding disease, and is also a consequence of various other morbid actions in the globe and its neighbourhood, especially from the pressure of tumours in the orbit. The chronic enlargement of the bulb is noticed more fully in the succeeding chapters.

Treatment of External Ophthalmia, and its Consequences.—The exciting cause, if such exist and can be discovered, ought in the first place to be removed. The surface of the organ and of the palpebræ should be carefully examined, either with the naked eye or with a magnifying glass, in order to detect any small extraneous body which may be lodged in the part. In examining the inner surfaces of the palpebræ, it is necessary, to produce complete eversion, to bring the parts completely into view; and the most convenient method of accomplishing this is to lay hold of the ciliæ between the finger and thumb, and reflect the lid over a silver probe placed along its base. This can, by a little practice, be accomplished readily without using a probe, and even by the fingers of one hand only. This is the more necessary, as small particles of foreign matter lodge more frequently on the palpebral conjunctiva than on any other part. If a particle of glass, metal, stone, &c., be discovered, it should be gently removed by the flattened extremity of a silver probe, or by a scoop, a fine needle, or a delicate brush. In some cases washing the surface by means of a small syringe, filled with a bland fluid, is extremely useful; as when an impalpable powder has been thrown into the eye, and can with difficulty be removed, in consequence of spasmodic contraction of the eyelids preventing exposure of the parts. The application of an emollient poultice, with the addition of hyoscyamus, is beneficial when it has been found impossible to remove the whole of a fine powder. When particles of lunar caustic have, by accident, come in contact with the eye, they are to be removed, as soon after insertion as possible, by a fine hair pencil dipped in oil or fresh butter,—not in water. Small loose bodies are generally carried, by the increased lachrymal secretion, along the sulcus formed by the apposition of the eyelids, to the inner canthus, and there discharged. And, in order to favour this natural process for removing extraneous matter, the patient should be directed to keep the eyelids shut, and as quiet as possible, to cover them with his hands, and to blow his nose forcibly: thus the greater number of the extraneous particles will be got rid of. Those which remain lodged in the membranes must be speedily removed by those artificial means which have been already enumerated. If entropion is the cause of the inflammation, the eyelashes are either plucked out, or completely destroyed by removal of their roots. The inflamed organ should be carefully protected from the stimulus of strong light; the patient is to be placed in a darkened room, and the eye protected by a thin green shade. The shade, however, may be worn too long, so as to induce an extremely weak and tender state of the organ.

If there be good grounds for believing that the incited action has been caused by suppression of any discharge, that should be encouraged to return, and the cause of the suppression must be avoided. If a gonorrhœa have been suddenly arrested by the employment of stimulating injections, these must be instantly discontinued; and some have even gone so far, in such cases, as to introduce bougies impregnated with gonorrhœal matter, in order to procure a renewal of the discharge. In cases of suppression of purulent discharge from the ears, or the surrounding parts, followed by external ophthalmia, a blister or sinapism should be applied in the neighbourhood of the part from which the discharge formerly issued. When the menstrual evacuation has been arrested, leeches and fomentations should be applied to the pudenda, or around the anus, and emenagogues administered internally; the patient should be placed in a quiet and well ventilated apartment, and kept free from any emotions of the mind; all noise and other sources of irritation should be studiously avoided.

If the incited action in the eye do not subside, as it often will not, on removal of the exciting cause, recourse must immediately be had to very active means for its subjugation; for in no other organ does inflammatory action proceed more rapidly to an unfavourable termination. By timely use of antiphlogistic means, those consequences of external ophthalmia, which we have already treated of, may be avoided; and, with respect to most of them, it is much better to prevent their occurrence, than combat them after they have been allowed to take place. The eye is more valuable to a great proportion of people than a limb; and the surgeon is very culpable if he be not master of this part of his profession, and able to undertake the management of every disease and accident to which the eye is liable. “In cases of inflammation the general treatment is the same; but each variety requires peculiar attention during the cure, depending on the structure and function of the tissue affected.”

In the first stage of external ophthalmia, active antiphlogistic measures must be put in force. In full habits, and cases of intense action, general bleeding must be employed, even to fainting, from the veins of the arm or of the neck, or from the temporal artery,—and repeated, if necessary, according to circumstances. Blood is sometimes abstracted by cupping from the temples or the nape of the neck; but it is a painful and uncertain mode of emptying the vessels. Local bloodletting, in many cases, suffices to moderate the action; in all it is most beneficial and important, after the employment of general depletion. The application of leeches to the inner canthus is the most effectual method of abstracting blood locally, as at that point the venous return is made from the eye. If placed on the temples, they can produce very little benefit; if on the outer surface of the eyelids, ecchymosis follows, on account of the extreme looseness of the cellular tissue in that situation. Or the angular vein, at the inner canthus, may be opened with a lancet, and a considerable quantity of blood thereby abstracted from the seat of the disease. Leeches applied to the conjunctiva of the lower lid are sometimes advantageous; but leeching and scarification are more useful in the chronic stage: and the latter is injurious in acute ophthalmia. Saline purgatives, and antimonial medicines, a very material part of the antiphlogistic regimen, must not be omitted. Enemata, with occasional pediluvia, are much recommended by some Continental writers. In bilious habits emetics, followed by mercurial purges, will be found very useful. With respect to topical treatment, warm applications are found to afford decided relief in the first stage, and are, in consequence, generally used. By some, however, cold water, or water with vinegar, is applied from the first. Poultices, whether warm or cold, prove annoying from their weight. Warm fomentations, simple or anodyne, are preferable, and may be repeated according to the feelings of the patient; or the eye may be exposed to the steam of water.

When by these means the violence of the symptoms has abated, as usually happens in the course of a very few days, the organ must be gradually accustomed to its natural stimulus, light. The shade must be discontinued, and the room no longer darkened; and now leeching becomes of great service, while the evacuation is to be followed by gently stimulating or astringent applications, so as to produce contraction of the still dilated, though partially emptied, vessels. Various collyria may be employed for this purpose. Solutions of the sulphate of zinc, of muriate of mercury, of sulphate of alum, of acetate of lead, or of the lapis divinus—wine of opium—the citrine ointment, or the unguentum oxydi hydrargyri rubri, &c.—or stimulating vapours of various kinds. Camphor is a good addition to many of the applications. The collyria may be cold, or slightly warmed; and maybe dropped into the outer canthus, flowing over the eye, and escaping by the inner canthus, according to the natural course of the fluids of the eye; or they may be inserted at the inner canthus, the head being immediately afterwards inclined so as to allow the fluid to pass towards the external canthus; or they may be applied by means of an eyeglass. Warm fomentations, and other relaxing remedies, however useful during the first stage, are worse than useless, are hurtful in the highest degree, when the affection has passed into a chronic state; as also are antiphlogistic means, and exclusion of light,—remedies so essentially necessary in the first stage.

In ophthalmia, attended with profuse purulent discharge, the structure of the eye is in great danger of being destroyed, from the intensity of the action, and its liability to extend to the deep parts of the organ; the most active practice is required from the first. Copious general depletion, ad deliquium, must be quickly had recourse to; and the patient must be freely purged, and kept in a state of partial nausea for some time, by exhibition of antimonials. After general bloodletting, the repeated application of leeches to the inner canthus is necessary, in order to empty sufficiently the vessels of the part. Where the chemosis is so extensive as to bury the cornea, as it were, beneath the folds of the swollen conjunctiva, sloughing of the transparent tunic is frequently threatened. In order to arrest this fatal result, much good is often obtained by division of the chemosis. A sharp-pointed bistoury is passed through the swollen membrane, and radiating incisions practised, commencing at the corneal margins, and directing them towards the circumference of the globe. Sometimes four or even five of such divisions are called for, while care is taken not to wound the sclerotic coat beneath. A considerable quantity of blood is sometimes lost by this procedure, and, the chemosis subsiding, the cornea is saved. Infusion of tobacco, solutions of acetate of lead, and nitrate of silver, æther and laudanum, have been used as applications to the eye from the very commencement of the affection; but the propriety of the practice appears very questionable. Blistering the nape of the neck proves highly beneficial, after the employment of the antiphlogistic measures; and in many cases it is necessary to keep up discharge from the blistered surface for some time. On subsidence of the violent symptoms, the swelled conjunctiva is to be attacked with escharotics and stimulants, as the nitras argenti, sulphas cupri, or various collyria: then only can such applications be advantageous; at an earlier period they must do harm. They repress the exuberant granulations which may have formed, or may be forming, on the conjunctiva of the eyelids, promote contraction of the dilated vessels, diminish the relaxation of all the tissues, and stimulate the now dormant action of the part into a healthy state of excitement. Gently stimulating collyria may be injected betwixt the lids, by means of a small syringe. In granulated conjunctiva, it is sometimes necessary to remove a greater or less part of the diseased membrane by escharotics, the knife, or scissors; and after this has been accomplished it is well to encourage bleeding to a slight extent. In removing part of the palpebral conjunctiva, care must be taken to avoid injuring the cartilage of the tarsus; and, in the lower lid, not to take away too large a portion, lest entropion should occur during cicatrisation. In hospital practice, the infected should be separated from the healthy; and promiscuous use of towels and sponges must not be allowed.

In Purulent Ophthalmia of Children, antiphlogistic means must be pursued, if the patient is seen during the first stage of the disease; but children do not bear depletion well. After the discharge is established, the surface of the eye must be kept free of matter, by frequent injection of a bland, tepid fluid; and stimulating or astringent collyria should be applied three or four times a-day.

When Inflammation of the Cornea is established, it is exceedingly difficult to procure contraction of the vessels. Active antiphlogistic measures must be employed in the acute stage; and in the chronic, stimulant applications are to be had recourse to. As, however, corneitis is frequently kept up in its chronic form, from deficient constitutional power in strumous habits, strict attention must be paid to the diet and secretions of the patient. Mild mercurial alteratives, diaphoretics, and tonics combined, will often effect a cure, where all local treatment has been tried in vain. When a large plexus of vessels remain dilated on the part, the most effectual method of removal is to divide them, as they ramify on the sclerotic, by means of scissors, or a fine knife, and afterwards to employ stimulating applications.

The irritability of ulcers on the cornea is diminished by the application of nitrate of silver, in solution or substance. If in solution, the application is used in the proportion of three to ten grains of the salt to the ounce of distilled water; if in substance, a portion, finely pointed, is gently applied to the sore, which may be afterwards besmeared with a little oil or simple ointment, in order to confine the action of the nitrate to the ulcerated part. It is not necessary, but, on the contrary, hurtful, to rub the caustic freely on the sore; a very slight application is sufficient to coagulate the secretions on the part, and form a covering for protection of the surface. In two or three days afterwards, when the temporary covering has become detached, and when the irritability of the sore has in consequence returned, it will be necessary to repeat the application, but not till then. On each application, and few are in general required, the sore is found reduced in size considerably. The collyrium nitratis argenti is very useful in many obstinate cases of affections of the eye and eyelids, the strength of the solution being varied, according to circumstances.

In Albugo and Leucoma, proposals have been made for excising, scraping, or perforating the opaque part; but the cure by such means is worse than the disease, as a raw surface is left larger than the previous opacity, and the cicatrix which must inevitably form also occupies a larger space, and is equally opaque. Leucoma and Albugo are incurable diseases, though the opacities may become somewhat thinner, by natural processes, after the lapse of a long period. Nebulæ, however, are often removable. During the treatment of them, or, rather, before beginning to treat them, it is of the utmost importance to attend to the state of the surface of the eye, and of the lids and eyelashes. Stimulating substances may be applied in cases where the opacities are thin: powders of calomel, aloes, sugar, &c., have been blown into the eye; stimulating lotions or ointments are preferable; one containing the nitrate of silver, with the addition of a proportion of the liq. sub-acet. plumbi, is sometimes used with advantage. These, however, are often of no avail, unless the dilated vessels, when such exist, are divided, or a portion dissected out; afterwards stimulants will be efficacious, and must be used assiduously. The vessels may require to be divided again and again.

In Ophthalmia tarsi, gently stimulating ointments or lotions are to be used, and in obstinate cases much advantage will result from the application of blisters behind the ears and to the nape of the neck, or from the insertion of a seton in the latter situation. In children it is necessary to correct the state of the bowels, scarify teeth, and remove other irritating causes to which that tender age is liable.

Sloughing of the Cornea should, of course, be prevented, if possible, by subduing the incited action before it has attained such intensity as to overcome the power of the part. The slough is slow in separating when the constitution has been much weakened; and sometimes tonics and stimulants, both external and internal, are required to hasten the process of separation. When the surface has at length become clean, the same treatment is required as to an ulcer of the part.

Conical Cornea.—This deformity can scarcely be cured, nor can any optical contrivance effectually remedy the disturbance of vision. When the apex of the cone is opaque, the removal of the pupil to the circumference by operation affords the best chance of assisting the sight of the patient.

When staphyloma is small, neither impeding the motions of the eye, nor preventing its being protected by the lids, no surgical interference is called for, as the loss or impairment of vision cannot be remedied, and as no other inconvenience than blindness is produced by the change of form in the part. But when the diseased cornea projects from between the eyelids the prominence must be diminished, on account of the deformity which it occasions, and in consequence of the eye being deprived of its natural protection of the lids, and being thereby exposed to constant irritation. In such cases it is necessary to take away a portion of the cornea, that the eye may be so diminished in bulk as to retract within the eyelids; the size of the part removed must be proportioned to the degree of protrusion. A cornea-knife is passed into the prominence, and carried forwards so as to transfix the part, in a direction from the external to the inner canthus; and by the knife being carried on, with its cutting edge looking downwards, a flap of the cornea is made. This flap is then laid hold of by means of forceps, and removed either with the knife or with scissors. The aqueous humour immediately escapes, and in most cases the crystalline lens and vitreous humour are also discharged. The eye consequently shrinks, and retracts within the palpebræ. The cut margins of the cornea soon assume a reddish appearance—they form granulations, the wound contracts gradually, and ultimately closes; but the eye is necessarily much shrunk, and totally useless as an organ of vision. Generally suppuration takes place, causing complete disorganisation of the parts; and the preceding inflammatory action may be so intense, and attended with so much constitutional disturbance, as to require active measures for its moderation. Deformity may be in a great measure removed by adapting an artificial eye to the shrivelled remains of the natural one. When it is necessary to remove only a small part of the cornea, the aqueous humour alone escapes, and during the cure of the wound the patient not unfrequently enjoys a tolerable degree of vision; but after the wound has completely closed, vision is again lost completely.

Hydrophthalmia, also, is a disease in which little hope can be entertained of materially benefiting the patient. In the slighter cases, in which no very annoying symptoms accompany the affection, vision may be improved by the use of optical instruments; mercurial preparations may be employed in moderation, with the view of promoting absorption of the superabundant fluid. When the disease has made considerable progress, temporary relief may be obtained from puncturing the cornea at its lower part, so as to discharge the accumulated aqueous humour; but a cure can scarcely be expected from such a practice, however often the paracentesis may be repeated. In the worst cases the pain is so excruciating, and the system so much disturbed by the local affection, as almost to warrant the destruction of the organ, in order to relieve the patient; but, after all, even such severe measures will most probably prove unavailing.

In Exophthalmos the treatment must vary according to the circumstances which cause the protrusion of the eyeball.

Of Internal Ophthalmia.—Inflammation of the internal parts of the eyeball sometimes supervenes on conjunctival inflammation, and then the distinctive characters of the two affections are not perceptible. When inflammatory action attacks the deep parts primarily, the external ciliary vessels ramifying on the sclerotic coat are seen, enlarged, shining through the conjunctiva; and, as they advance towards the clearer part of the eye, they form a zone of a pink colour, whose vessels run in a straight direction towards the margin of the cornea; but between the zone and the cornea a distinct white line is often interposed. Then large arborescent and reticulated vessels soon appear on the white part of the eye; and from their being more superficial than the first, and of a brighter hue, it is obvious that they belong to the conjunctiva. They also approach the clear part of the eye, and, if numerous, obscure the former vessels—as also the red zone and white line—for they pass over them, and reach the corneal margins, and often go beyond it, in continuous ramifications. The sclerotic, in consequence, assumes a pink-red colour, and the cornea becomes dim.

The iris may be primarily and principally affected, and, if so, the disease is termed Iritis; but in most cases all the other internal parts suffer more or less. The iris changes its appearance, becomes of a dusky hue, either in part or throughout, and red vessels are sometimes distinctly seen in it; from grey or blue it changes to a greenish colour, and when formerly black or brown it becomes reddish. The size of the pupil diminishes, and the contraction is often irregular, when the inflammatory action is intense. The iris swells perceptibly, and the pupil loses its dark colour, or is almost entirely closed, either from effusion of lymph, or from inflammation and consequent opacity of the crystalline lens and its capsule. The iris projects forwards, and diminishes the capacity of the anterior chamber; the pupil is irregular, and often assumes an angular appearance; and the irregularity becomes permanent from adhesion of the pupillary margin of the iris to the capsule of the lens, lymph being effused and organised, and forming a firm uniting medium between the parts. Occasionally adhesions form at the middle of the iris, and cause so great contraction as to give the pupil an appearance of being double. Of course irregularities of the pupil are most distinct when the part is dilated, either spontaneously or by the application of belladonna. Tubercles sometimes form on the iris, and not unfrequently it presents a granulated appearance. From the commencement of the inflammatory attack the patient feels great pain in the organ and in the forehead, and there is great intolerance of light. There is a feeling of tension of the eyeball, followed by deep throbbing pain increasing every instant. As the disease advances, the cornea is rendered opaque by the fulness of the chambers, and the aqueous humour becomes turbid and of a milky appearance; or lymph is effused into the anterior chamber, and floats about in flaky portions. Occasionally the vessels of the iris are so distended as to give way, causing effusion of blood into the chamber, often in considerable quantity.

More frequently, however, puriform fluid is deposited, occasioning the appearance termed Hypopium. The pus is either fluid or of a thick curdy consistence: when fluid and thin, it mixes with the aqueous humour, rendering it white and opaque; if of firmer consistence, it lodges in the lower part of the chamber, but changes its position, and mixes partially with the humour, on the head being moved; when dense and curdy, it remains separate from the humour, and its position is not altered by motions of the head.

During the progress of the inflammatory action, all the symptoms increase; the pain shoots to the top of the head, and is much aggravated by pressure on the eyeball. Of course vision is materially impaired. Constitutional disturbance always accompanies the affection, and exists in a greater or less degree according to the extent of the disease. The iris may be primarily affected, but the other textures, both external and more deeply seated, too often become involved; and in aggravated cases the whole eyeball suffers. When the most internal parts, as the choroid coat, the retina, and the vitreous humour, are affected, sudden and bright flashes of light disturb the patient, whilst vision is rapidly lost, and for ever. Occasionally the intense over-action terminates in suppuration of all the affected textures, and the eyeball soon becomes completely disorganised.

In Rheumatic Ophthalmia the appearances of the diseased eye are similar to those in ophthalmia produced by any other cause. But the affection is accompanied with, and seems to arise from rheumatic diathesis. There is pain in many of the joints, and frequently in the scalp and portions of the face, increased on hanging the head, and by pressing the parts. The pains are remittent, supervene at night, and subside in the morning. In general the ophthalmia is external; but in severe cases the internal parts become affected, and the eye is sometimes lost by giving way of the cornea.

Internal ophthalmia is often occasioned by wounds inflicted either accidentally or by operation. Laceration of the iris in the extraction of cataract, or an improper performance of the operation for cataract with a needle, is by no means an unfrequent cause of the affection. Iritis often occurs during the exhibition of mercury in undue quantities, and is said also to be a symptom of syphilitic taint. It is, in many cases, preceded by cutaneous eruption, and seems to be the consequence of the eruption being repelled, or interfered with in its progress.

Choroiditis.—The choroid membrane is sometimes primarily affected: but more frequently the inflammation of this tunic is the consequence of sclerotitis, or the disease last described. When the result of the former cause, it generally takes on the rheumatic type. The early symptoms are zonular redness of the sclerotic, accompanied by a general impairment of vision, so that the patient expresses himself as if looking through gauze or some dark network. Presently the sight becomes more and more impaired, until a complete amaurosis results. The pupil is generally in a semi-dilated state, and, instead of presenting the intense black hue of the healthy eye, it reflects a greenish-grey colour, dependent upon the effusion of a turbid fluid between the choroid and retina. The nervous structures, becoming thus pressed upon, lose their sensibility to light, and are paralysed. This form of inflammation is generally chronic, and imperceptibly advances to the iris anteriorly, and to the retina within; the ultimate termination being complete glaucoma. Various dull and heavy pains accompany this affection; and, in the latter stages, acute circum-orbitar neuralgia is the most distressing concomitant. By long-continued chronic inflammation the sclerotic coat appears to lose its powers of resistance—the accumulating fluid pushes before it the weakened tunic, and Staphyloma Scleroticæ is produced. This protrusion of the external tunic sometimes takes place in various parts, and to a considerable extent, so that the figure of the globe is entirely lost. The thinning of the sclerotic at these points allows the dark hue of the choroid to shine through, and this, together with the bunched-like appearance of the protruded portions, has entailed upon it the name of Staphyloma Racemosum.

Treatment.—In the first stage of internal ophthalmia, active treatment, properly conducted, should be successful in averting the progress of the disease; in the latter stages, there is every chance of vision being entirely lost. The treatment must be actively antiphlogistic, consisting of general and local bleeding, the internal use of purgatives and antimonial medicines, and strict abstinence. A free use of mercury internally is said to check the disease, and, in its advanced stages, to procure absorption of effused lymph. But the inflammation can be subdued without the aid of that mineral, though its effects are often powerful; and a recollection of the bad effects which are so apt to follow its employment renders a prudent surgeon cautious in having recourse to it. Mercurial ointment, with opium, rubbed on the forehead, immediately above the affected eye, gives great relief. The same relief follows friction with oil, in which the muriate or other salts of morphia is dissolved. When the incited action declines, the extracts of belladonna, hyoscyamus, or stramonium, rubbed on the eyelids and brow, procure dilatation of the pupil, and thereby tend to prevent its further contraction; but whilst acute inflammation exists, the pupil is not dilatable; and it is consequently an encouraging symptom when the pupil begins to yield to the influence of these medicines. In hypopium it is sometimes necessary to evacuate the pus when effused in large quantity, in order to prevent the injurious effects that its pressure might occasion; but, if the quantity be small, there is a good chance of its being removed by absorption. In suppuration of the eyeball, whilst the other eye remains sound, it may be prudent to open the cornea, and allow a free exit for the matter, in order to prevent the healthy eye from becoming affected. In the staphyloma of the sclerotic coat, when the eye, as it were, is affected by a sort of chronic dropsy, (and this disease is met with at various periods of life,) the tension and bulk of the organ may be diminished by occasional puncture. The opening may be kept pervious by the introduction of a conical probe from time to time. I have more than once introduced a silk thread through the most dependent and prominent part of the globe with good effect. The organ ultimately shrinks.

Amaurosis implies an impairment of vision more or less complete, arising from disease in the brain, in the optic nerve, or in the retina, whether consisting of change or destruction of structure, or derangement of function. Vision may be diminished or lost by organic disease in the coats or humours of the eye, or by morbid formations in the orbit; but to such the term Amaurosis does not strictly apply. But, after establishment of the disease, other textures of the eye may, and often do, become affected. Usually one eye at first is amaurotic; but the other soon participates, and ultimately vision is impaired or entirely lost in both. The disease may occur idiopathically, or be symptomatic of other affections.

The general symptoms of amaurosis are the following. Headache is felt for some time, either constant, or, as is most commonly the case, occasional, and most severe in the forehead: in many cases the pain is at times most excruciating. The eyesight gradually becomes weak; distant objects are unusually obscure, or not at all observed; and those which are near cannot be accurately discerned. For a short time vision may seem to be restored, but soon it diminishes more and more, all objects seem to be enshrouded in a mist, at first thin and shadowy, but gradually becoming opaque and impenetrable; or a feeling is communicated of a dark network obstructing the view. Unnatural impressions are made on the retina; flashes of strong light, or luminous sparks, appear to dart across the eyes; darkened spots are seen where none exist; gnats, flies, or other minute bodies, various in colour and brilliancy, seem to flutter before the face; or a single dark speck intercepts the vision. Usually the pupil is dilated and the iris insensible to the stimulus of light; and the former has not its natural translucent aspect, but is dull and cloudy. But the state of the pupil cannot be accurately determined in amaurosis, for not unfrequently it is much contracted, and in many cases the iris retains both its natural appearance and the full exercise of its functions. The disease either advances to complete blindness, or stops in its destructive progress, leaving the patient with vision impaired to a greater or less degree. When the disease is established, pain in the head and eyes usually either ceases quickly and entirely, or gradually abates.

Amaurosis is sometimes temporary, occurring at regular intervals; and, during its accession, it often varies in intensity. With some patients strong light is intolerable, and vision is best in the twilight; others court sunshine, finding their eyesight thereby much improved; accordingly the former are said to labour under nyctalopia, the latter under hemeralopia. Some can discern the shape of objects, but either have no perception of the colours, or mistake the individual colours; others not only see all objects indistinctively, but conceive them distorted, double, or extensively multiplied: in some one-half of the object looked upon is obscured—and frequently there is strabismus, in consequence of the paralysis being only partial.

Organic amaurosis (that depending on organic disease) may arise from the change of structure consequent on inflammatory action in the retina, whether chronic or acute—from atrophy of that membrane and of the optic nerve—from extravasation into the substance of the nerve, or compression of it by morbid formations—from softening or suppuration of the nerve and its connexions—or from various diseases of the encephalon. Functional amaurosis may proceed from temporary plethora about the optic nerve and retina—from intense and long continued use of the organ—from derangement of the digestive apparatus—from general debility, however induced—from excessive influence on the system of poisons or powerful medicines—from concussion of the nervous and cerebral substance, or from long continued irritation in the neighbourhood of the eye. Amaurosis may also follow injuries of various kinds.

In the treatment of organic amaurosis but little can be done, and that little is unsatisfactory. In the functional form, however, vision may be improved, if not wholly restored, by removal of the exciting cause, and the carefully avoiding of such circumstances as seem to predispose to the affection. After due constitutional treatment, considerable benefit is often derived from counter-irritation; and I have in many cases witnessed the good effects of blistering the temples and besprinkling the raw surface with the powder of strychnine,—a practice very far from nugatory. On removing the blister, the cuticle and lymphatic effusion beneath are carefully scraped away, and from one-eighth to one-half of a grain of the powder dusted over the exposed cutis. The sprinkling is repeated daily, and the dose gradually increased. When the surface dries, a fresh blister is applied, and the use of the powder resumed. It may be employed, when gradually increased, to the extent of two grains on each temple; but, if spasmodic twitchings and constitutional disturbance begin to show themselves, it must be immediately abandoned, and not resumed till after some days, and even then in diminished doses. In not a few cases, both of complete amaurosis, and of vision impaired to such an extent that the patient could merely distinguish light from darkness, I have by this practice succeeded in restoring the sight completely; in others, vision has been very much improved. Still, by far the greater number of amaurotic patients are incurable; and even those who have derived benefit from strychnine are, I am strongly inclined to suspect, exceedingly liable to relapse.

In the treatment of functional amaurosis, it will be necessary to investigate minutely the causes on which the defective vision may depend. Thus we may find a congestive state of the retina or brain, arising from suppressed natural discharges, as the menstrual flux, or the sudden suppression of habitual but morbid discharges, as the healing of an old ulcer, &c.

Again, amaurosis maybe the result of irritation in some portion of the alimentary canal, as from the presence of worms. Patients who have long laboured under imperfect amaurosis have occasionally been suddenly relieved by the discharge of a tape-worm. Difficult and painful dentition in children not unfrequently gives rise to this disease. Hence the treatment of functional amaurosis will necessarily vary with the cause; and no general rule can, with any propriety, be laid down as to our selection of remedial measures.

Glaucoma, or green cataract, is a disease of the hyaloid membrane and vitreous humour, probably depending on a varicose state of the bloodvessels. The pupil is usually dilated, irregularly oblong, the iris being narrowed towards the upper and inner side. There is a dull shining appearance at the bottom of the eye, not fixed as in cataract, but varying according to the position of the light. The lens becomes opaque and greenish as the disease advances, vision gradually diminishes, and the iris is immovable. After sight is lost, the patient has a perception of a luminous appearance in the organ when pressed upon. Both eyes are generally affected, one after the other; headache, often violent, attends the disease; many remedies, both external and internal, may be tried on recommendation, though without effect: the disease seldom, if ever, admits of cure.

Of Cataract, or opacity of the crystalline lens and its capsule, attended with partial loss of vision.—The disease is, in general, gradual in its progress: but sometimes it advances rapidly, as when occasioned by a blow or wound. When slow, the opacity commences in the centre of the lens, and extends gradually towards the circumference. Before any change can be perceived in the organ, the patient sees objects as if covered with a mist or veil; and, as the opacity becomes distinct, vision is gradually impaired. During the day, vision is very indistinct, as the pupil is contracted, and the rays of light reach the retina only through the opaque centre of the cataract. But during twilight vision improves, as then the pupil becomes dilated, and admits of transmission of light through a portion of the transparent vitreous humour, as well as through the semi-opaque margins of the crystalline lens: for a similar reason, it is also more distinct after the application of belladonna or hyoscyamus either to the eye or to its neighbourhood. In the ordinary state of the parts, a clear black ring is often visible around the opacity, either from the margins of the lens being unaffected, or from the posterior surface of the pupillary portion of the iris being pushed forwards by enlargement of the lens. Patients, having become aware of the great improvement of vision caused by dilatation of the pupil, are often contented to use narcotic remedies externally, so long as they retain their dilating influence—and, strange to say, they do not soon lose it—instead of submitting to any operation. As cataract advances, even luminous bodies cannot be accurately distinguished, though the situation from which the light proceeds is perceived; thus the patient in a clear light may have an indistinct perception of a candle or window, and in some cases even of the bars of the window. The motions of the iris are not affected, unless, in rare cases, when the cataract is large and compresses the iris; or when the functions of the third pair of nerves have been in any way impaired; or when the iris has been the seat of acute inflammation.

Cataract may be confounded with other diseases of the eye, as with amaurosis. But, in amaurosis, opacity, when it exists, is deep, concave, greenish, or of a metallic appearance; whereas, in cataract, it is of a more or less white colour, convex, and situated immediately behind the pupil.

Cataract may be lenticular only, the lens being opaque whilst its capsule remains transparent. In such a case the disease is slow in its progress, and the opacity uniformly commences in the centre of the lens, and gradually extends to the circumference. The degree of opacity varies in different cases, from cloudy dimness to complete whiteness. In general the predominant hue is white or greyish, but not unfrequently the opacity is of several colours, and occasionally of a mottled appearance. The consistence also of lenticular cataract varies, being sometimes fluid, occasionally extremely dense and almost osseous, but most frequently of caseous consistence. When fluid, the cataract is of larger size than the healthy lens; when caseous, the part usually retains its former dimensions; and when dense, the lens is often considerably diminished in size. The motions of the pupil are seldom, if ever, affected.

Cataract may be entirely capsular, the capsule being opaque, whilst the lens either remains free of disease, or has been removed by natural or artificial processes. The opacity in this case does not always commence in the centre, but frequently begins at the margin, and is of a spotted or mottled appearance, and in general not uniformly opaque. No black ring around the opacity is observed, though the pupil be dilated; and the motions of the iris are sometimes slow. The opaque spots are said sometimes to move when the position of the head is changed. The anterior portion of the capsule, the posterior, or the whole, may be affected; but the anterior is the part which most commonly becomes opaque in the first instance.

In many cases both lens and capsule are affected; and then the cataract is termed capsulo-lenticular. Occasionally the diseased lens, in such circumstances, is of fluid consistence; and in many cases is spotted.

Portions of lymph, organised or not, lodged in the posterior chamber, have by some been termed spurious or adventitious cataract; since, when the pupil is shut by such effusion, the appearances presented are somewhat similar to those caused by opacity of the lens, or of its capsule. Such deposits, however, can readily be distinguished from true cataract, being in general of a yellowish colour, in close contact with the posterior surface of the iris, and, when organised, often streaked with red vessels. Generally, too, the pupil is irregular from adhesions between the lymph and the pupillary margin of the iris.

Cataract would, in some cases, appear to be hereditary,[27] and frequently it is a congenital affection. In very young children it may be caused by imprudent exposure to strong light. In adults it often seems to be produced by the action of strong reflected light, as by exposure to intense fires in forges, glasshouses, &c., or by a dependent position of the head, accompanied with exposure to light. People advanced in life are most subject to the disease.[29] It is not an unfrequent consequence of internal ophthalmia, and almost invariably follows the slightest wound or most delicate puncture of the lens: it often occurs after slight injury of the lens or its capsule, inflicted during attempts to form an artificial pupil. Cataract may occur rapidly from extensive dilatation of the lenticular vessels; or from such an injury of the eye as causes laceration of the vessels supplying the capsule and lens, detaches them from their other connexions, and consequently leaves them without a nutritive source.

Cataract sometimes, though rarely, disappears spontaneously, being absorbed; but most frequently an operation is required to remove the opaque body from the axis of vision, though no hurry is necessary in having recourse to it. The chance of success from operation must depend very much on the state of the different parts of the eye, on the kind of cataract, and on the state of the constitution. Many remedies, external and internal, and mercury amongst the rest, have been employed with the view of dissipating cataracts; but all are of no use. An operation, of one kind or another, only can be relied on. And still, even in favourable cases, and in the best hands, the contingencies attending operation are so great, that success cannot be absolutely promised or expected. The mode of operating, and the kind of operation, must be varied according to circumstances; and great experience is required to determine the proper course of procedure in each case. Steadiness is absolutely necessary both in the patient and the operator, in order that the proceedings may be carried to a happy conclusion. The operator must have a good eye; a steady, light, and skilful hand; a fine touch; courage and caution—qualifications necessary in all surgical operations, and in none more so than in those on the eye.

When cataract is spontaneous, and vision not altogether lost, the patient being able to distinguish bright objects, though unable to direct his steps or follow his avocation—when the pupil is quite sensible to the application or abstraction of light, or to the use of belladonna, &c.,—when all the external parts are sound, the cornea clear, the chambers of the proper size, and no reason to suspect that the retina is affected—the prognosis in regard to the effects of operation is good. When, on the contrary, the organ or the constitution is not sound—when the patient is irritable in habit or temper, or subject to gouty, rheumatic, or catarrhal complaints—when headache has preceded the opacity, and vision is gone, or nearly so, with flashes of light seeming to pass before the eyes—the prognosis is very unfavourable. But even total blindness must not always be considered as an indication of operation proving useless, for sometimes the retina recovers its sensibility after removal of the cataract, and thus sight has been restored in very hopeless cases. There is no objection against operating, though one eye only is affected. By some, operation is recommended as prudent, with a view of preventing the opposite eye from suffering by sympathy; whilst others consider it more safe to refrain from operating, lest violent inflammatory action should follow, and, by extending to the other eye, cause disease there. However, when the cataractous eye does not present such appearances as forbid operation, I conceive it both prudent and safe to remove the obstruction to vision, provided after-treatment is carefully attended to, and all untoward symptoms actively combated as soon as they appear. There is still a considerable difference of opinion on the subject; but the patient, being anxious to get rid of an inconvenience and deformity, often decides for the surgeon. When both eyes are cataractous, a question arises as to operating on both eyes at once. From my own experience I should say, that both eyes ought not to be operated on at one time: if they are, there is great risk of violent inflammation being established, and of the operation failing to restore vision. Immediately after one eye has been operated on, the other becomes very unsteady, and is altogether in an unfavourable state for operation; and, if interfered with, the chance of a happy result is but slight. But by operating on each eye at different times, much less risk is incurred, and the chance of success is doubled.[30] Cataract may be operated upon at all ages, excepting infancy and the period of dentition. In congenital cataract, the eyes acquire an uncontrollable rolling motion, and, if operation be delayed till the patient has attained a considerable age, such motion cannot be afterwards prevented. In such cases, therefore, the disease should be attacked as soon as dentition is completed, for then an operation can be undertaken with as little risk of injury to the organ as at a more advanced age; and a child of twenty months or two years is unconscious of what is intended, and can be more readily secured than at any after period; besides the best period for education is lost if an operation be not done early.[31]

Cataract is not remediable but by surgical operation. It may be removed altogether by incision of the tunics of the eye, and extraction of the opaque body; or by the introduction of a needle, it may be displaced from the axis of vision, or so disturbed as to be acted on and removed by the absorbents.

Operation with the needle is more generally applicable than that with the knife, and is more easily performed. But much mischief may be done with a needle, if the operator be not both cautious and dexterous; by unskilful use of it many eyes have been lost.

In operations for cataract on the adult, the patient, having the eye which is not the subject of operation covered, may be seated on a low chair, opposite and near to a north window, in order that clear light may be obtained. His head is supported on the breast of an intelligent assistant standing behind. The upper eyelid is raised by the assistant’s fore and middle fingers of the left or right hand, applied so as to stretch the lid over the bulb; and the other hand is placed under the patient’s chin, to steady the head. The eye may be very well fixed by the fingers of the right or left hand of the operator himself. He is, in that case, more conveniently placed behind or above the patient’s head. The use of a speculum, for elevating the lid or fixing the ball, is seldom admissible; and, if the eye be so unsteady or sunk as to require it, the surgeon ought not to attempt extraction. No one method can be exclusively followed; by a man of judgment, experience, and skill, the operation will be varied according to circumstances.

The operation may be performed with the needle. The cataract is either depressed or reclined, and is then said to be couched. Depression is preferred by many good authorities in surgery. The needle is introduced at a line—or a line and a half, so as to avoid the ciliary processes—from the junction of the cornea with the sclerotic, towards the external canthus, and below the transverse diameter of the eye; and the opaque lens, if solid, is entangled with the point of the instrument, and pushed into the lower part of the ball. Thus the opaque body is removed from the axis of vision, so as not to obstruct the passage of rays of light to the retina; and, in successful cases, it is highly probable that the lens, after being detached and displaced, is altogether removed by the absorbents. Violent inflammation occasionally takes place after the operation, followed with destruction of the eye from suppuration; or the iris becomes paralytic; or the pupil closes, and sight is gradually lost; or the cornea becomes flaccid, with congestion of the vessels and turbidity of the humours. The needle should be of a conical form, thickest towards the handle, so as to prevent the humours from escaping during its introduction. It should also be straight, excepting a short curvature of its point, rather slim than otherwise, and not longer than from an inch to an inch and a quarter. The extracts of belladonna or stramonium should be used in all cases, previously to determining upon operations, in order to ascertain the state of the humours, the size of the cataract, and whether adhesion of the iris to the capsule of the lens exist or not. Dilatation so produced is allowed to disappear almost entirely before the operation is proceeded in. It is sometimes necessary to steady the eye by means of a speculum, and the wire one of Pellier is the best. By pushing the needle, held like a writing pen, gently forwards, and towards the inner canthus, in a direction almost parallel with the iris, its point is seen in the posterior chamber, opposite the pupil. The instrument is then fixed in the opaque lens, and the cataract is depressed obliquely downwards; the needle is disentangled by a gentle twisting motion, and then withdrawn in the same direction as it was entered. Before depressing, it is necessary to lacerate the capsule of the lens, and this is accomplished by giving the needle a rotatory motion, and moving its point in different directions; the anterior portion of the vitreous humour is at the same time disturbed. Laceration of the capsule may be too great, and allow the lens to escape entire into the anterior chamber; inflammatory action is in consequence excited, and subsides only when an opening has been made in the cornea, and the offending body extracted. If the cataract rise to its original situation on withdrawing the needle, it should be again depressed, and kept down by the instrument for a short time; and when the needle is then removed, its point should be very carefully disentangled. The lens is said frequently to regain its usual situation, a considerable time after the operation; but in many such cases, the opacity in the pupil is not occasioned by the lens, but by the capsule having become opaque. It is said to have arisen, when very solid, twenty or thirty years after depression; and that in many cases no absorption of it occurs. When the vitreous humour has become disorganised, the lens often floats about, rising and falling with the motions of the head.

In reclination, the point of the needle is placed on the upper and anterior surface of the lens; and by raising the handle, and pushing the point slightly forward towards the inner part of the eye, the lens is removed from the axis of vision, placed inferior to it, and has the relative situation of its surfaces changed—its anterior surface becoming the upper, and the posterior the under; the superior, posterior; and the inferior, anterior.

Solid cataracts only can be depressed or reclined. When a cataract is fluid, it is sufficient to puncture, or lacerate slightly, the anterior part of the capsule; as then the opaque contents will be diffused through the aqueous humour, and soon removed by the absorbents. Should the capsule become opaque, after the removal of its contents, the needle must be at a future period introduced; the capsule is to be lacerated and reduced to minute shreds, so that it may escape into the anterior chamber. In the soft or caseous cataract, displacement is not easily effected; and the surgeon must rest satisfied with exposing a part or the whole of it to the action of the aqueous humour.

The above operations may be had recourse to when—from diminution of the anterior chamber, adhesions of the iris, a morbid state of the pupil, and the temper of the patient—extraction cannot be attempted. When the cataract is small, it is immaterial how it is displaced; when large and solid, reclination is to be preferred. The operator is obliged to decide as to the mode of finishing the operation, after he has introduced the needle, and thereby ascertained the consistence of the cataract. If it is so soft as to permit the needle to move in all directions, it is impossible to displace it; it must be broken up, and left in situ.

In the mode of operation termed keratonyxis, the needle is introduced through the cornea, about two or three lines from its margin,[32] and the cataract is either depressed or broken up for solution. Depression through the cornea is, however, an operation not to be recommended, as the surgeon has much less command over the motion of his instrument, necessary in this form of procedure, than where it is introduced through the sclerotic coat. The pupil is previously dilated by belladonna, and the dilatation should be continued for some time afterwards. The puncture may be made at any part of the corneal circumference; it soon heals, and leaves no scar. The operation can be performed without much disturbance of the organ, and it is applicable when the cataract is soft or fluid, as in children, or its consistence doubtful. Young subjects should be placed recumbent during the operation, and rolled up in a sheet, so that they can have no command over their limbs.

Extraction, in favourable circumstances, and in dexterous hands, is a beautiful operation, and most satisfactory; but ought not to be undertaken unless the surgeon has perfect confidence in himself. It can be resorted to only in adults, great steadiness on the part of the patient being absolutely necessary. The case, too, must be judiciously chosen. The conjunctiva must be sound, and indeed almost no operation on the eye should be undertaken unless this membrane is in a healthy condition; the cornea should be transparent in every part—the anterior chamber of a proper size—the pupil regular—the iris steady, and not protruded—and the cataract solid; there should be no rolling motion of the eyeball, and no adhesions of the iris. I repeat, the iris should be steady, for a tremulous motion of it indicates disorganisation and fluidity of the vitreous humour; in such a case, the humour can with difficulty be prevented from escaping; or the lens may fall into the bottom of the eye, and all efforts to remove it will then prove abortive. And though such descent of the lens should not occur, still the organ is in a very unfavourable state for operation, being apt to become affected with deep inflammation, followed by complete amaurosis, or by closure of the pupil. The patient is prepared for the operation by moderate living, and attention to the secretions and digestive organs, for some time previously; and after the operation leeching may be necessary either as a precautionary measure, or when inflammation has occurred. Immediately before having recourse to any of the operations for cataract, a small blister may be applied with advantage behind one or both ears, and kept open for some few days, as a precautionary measure against inflammatory action in the organ operated upon.

The operator is usually seated immediately before the patient, and so that his breast may be on the same level with the patient’s head; if not ambidextrous, he may often be obliged to assume very awkward attitudes. The recumbent position, however, is preferred by many operators, and has the great advantage in the superior steadiness of the head of the patient. The hand of the surgeon may also be rested on the back of the couch, as, if ambidextrous, he will invariably take his position behind the patient, in order that he may have the command of the upper eyelid in his own hands. The incision is made either in the lower or upper half of the cornea. The knife should have a very keen edge, and become gradually broader and thicker, from its point backwards: in using a narrow instrument there is danger of the aqueous humour escaping. The best knife is Beer’s, well made. The light must be good, the patient’s head completely steadied, the eye well fixed by the fingers of the assistant, and the other one covered by a bandage. No speculum should be employed, and the pupil should not be dilated by belladonna. The surgeon, supporting his elbow on his knee, or resting his fingers on the cheek of the patient, holds the knife like a writing pen—in the right hand, if the left eye is to be operated on, in the left, if the opposite (that is to say, if he sits before his patient: if, however, he places himself behind, this must be reversed)—and ascertains the steadiness of the organ by touching the cornea gently with the side of the knife. The cornea is punctured about a line from its margin, and near the outer extremity of its transverse diameter, the point of the knife being directed towards the centre of the eye, lest it should enter between the laminæ. The knife is then passed through the anterior chamber, with its side parallel to the iris, and its point is brought out at that part of the cornea exactly opposite to where it entered: transfixion is thus completed, and by pushing the knife steadily forward, without any sawing motion, a semicircular section is effected. As soon as transfixion is accomplished, the operator has complete command of the eye, and all pressure should be taken off—the assistant should now merely keep the eyelid raised. Should the edge of the knife not come easily through the cornea, its passage maybe assisted by pressure with the finger-nail.

After the pupil has been allowed to dilate, by covering the eye for a few seconds with the hand, the capsule must be opened sufficiently for the escape of the lens. The eyelids are gently raised, a fine curved needle, or curette, is introduced through the incision, and by it a crucial wound is made in the capsule. The lens is then either entangled in the point of the needle and withdrawn, or very gentle pressure is made on the globe, so as to force out the lens; and, should it not readily pass through the wound of the cornea, it can be removed from the anterior chamber by a small scoop. After removal, the eye is allowed to rest; then careful examination is made; and, if any opaque substance remain, it is extracted by the needle or scoop. If the capsule is opaque, it must be taken away along with the lens. Before closing the eyelids the corneal flap should be carefully adjusted, and any matter lodged between the divided surfaces removed: loose eyelashes are to be taken away, inverted ones should be previously extracted, and the margin of the lower lid should be so placed as not to disturb the flap.

In transfixion, the point of the knife should not be brought out too low, nor too much towards the centre of the cornea; and care should be taken to avoid entanglement of the iris. When the iris falls forward so as to come under the edge of the knife, and be in danger of division should transfixion be proceeded in, pressure may be made on the cornea, so that the remaining aqueous humour may repress the iris from its untoward situation; or the knife may be withdrawn, and the operation delayed till the eye has become quiet, and the inflammation, if any, has subsided; or the incision may be completed with a blunt-pointed narrow knife, or with probe-pointed scissors. Division of the capsule by the point of the knife during transfixion has been practised; but it is an unsafe, though dexterous, measure. In opening the capsule care should be taken not to separate its attachments, otherwise it will become opaque, and thereby passage of light to the bottom of the eye will be again obstructed. Neither should much pressure be used for extrusion of the lens; for, in the case of a large and firm cataract, the iris may be lacerated, and the humours escape. When any of the vitreous humour has escaped, in consequence of its cells having been broken down, and its tenacity diminished, the eye soon fills again, but good vision is hardly to be expected.

After the operation, applications to the eye should be very light; a rag dipped in cold water, and renewed occasionally, is sufficient. All stimulants of the organ, as light, should be avoided, and antiphlogistic treatment adopted. Should violent pain supervene, bleeding, both local and general, and other means for subduing inflammatory action, must be had recourse to. The eyelids should not be raised or exposed for at least three days, unless in extraordinary circumstances. Belladonna is of use when gradual contraction of the pupil occurs. In very favourable cases, vision is completely restored in the eye; in others, the functions of the two eyes do not correspond, and vision is confused: the patient requires to wear a convex glass before the one which has been operated on.

The operation of making an artificial pupil is far from being uniformly successful, and ought not to be had recourse to unless vision is entirely lost, or so much impaired as to be insufficient for the guidance of the patient’s steps. It is necessary on account of central opacity of the cornea—leucoma with entanglement of the iris—and entire

closure of the pupil, or diminution of it, with concealment of the remainder by corneal opacity. It may be required after badly performed extraction of a cataract, the iris being entangled in the scar of the incision, at a distance from the junction of the cornea with the sclerotic; or on account of closed pupil from inflammation, when, perhaps, the cornea is all clear. The operation is varied according to the size of the anterior chamber, the presence or absence of the crystalline lens, the extent of sound cornea, and the condition of the iris. Interference is useless when disease of the retina is suspected, from the extent of the previous disease—from violent inflammation, with or without discharge of part of the contents of the eyeball. Three distinct methods of operation are pursued.

I. Simple division of the iris, or corotomia, may be practised when the iris is stretched, as after extraction. It is performed by introducing a small knife, like a needle, through the anterior or posterior chamber,—the surgeon being in this regulated by the size of the anterior chamber and the presence or absence of the lens,—pushing

its point through the iris, or cutting that membrane vertically, horizontally, or both, to an extent sufficient for the transmission of light. If the anterior chamber be of its natural size, a small opening may be made in the cornea with a cataract knife, or a double-edged broad and thin one; and through this opening small scissors may be introduced for division of the iris.

II. Corectomia, or cutting out a portion of the iris, so as to make the opening oval, square, or angular. This is performed by introducing, through an aperture in the cornea, scissors and forceps, or hooks, double or single—the latter to lay hold of the iris, the former to divide it. After the escape of the aqueous humour, a portion of the iris may be made to protrude; and, on the projecting portion being cut off, the membrane, with a proper opening in it, regains its natural situation, in consequence of discharge of the humour from behind. This operation is applicable only in few cases; the whole, or the greater part, of the cornea must be clear, and the anterior chamber not diminished in size, so that sufficient room may be afforded for the introduction of instruments between the iris and the concave surface of the cornea.

In those cases where the natural pupil remains along with a still transparent lens, while vision has been destroyed by a central opacity of the cornea, the use of sharp and pointed instruments is forbidden. Sharp hooks or scissors would endanger wound of the crystalline, and the case becoming complicated with traumatic cataract. The blunt hook, as proposed and used by Mr. Tyrrell, is here to be preferred. A small opening is made through the cornea, as the most convenient part, and the hook carefully introduced and entangled in the existing pupil: the iris is then drawn to the corneal wound, and either left entangled in the section, or removed by a pair of curved scissors. A pupil is thus formed opposite to the remaining transparent portion of the cornea.

III. Corodialysis, or separation of the iris from its ciliary attachments, is the method most easily performed, and most generally applicable. The eye is fixed either with the fingers or with a speculum; and a curved needle, perhaps more curved than that usually employed for cataract, is introduced either behind or before the iris, and at the upper, outer, inner, or lower part of the ball, as circumstances may require. An artificial pupil at the lower part is by much the most useful; but, if the lower part of the cornea is opaque, it must be made opposite to the inner or outer clear part. The point of the needle is entangled in the attached margin of the iris, and by raising the hand quickly, and partially withdrawing the instrument, the connexions are separated to a sufficient extent. Effusion of blood into the chamber, and to a considerable extent, follows these proceedings; and it is only after its absorption that it can be ascertained whether benefit is likely to result or not. After all these operations, inflammatory action requires to be kept down by antiphlogistic measures, abstraction of blood, purgatives, antimonials, and, perhaps, mercurial preparations. It is questionable whether belladonna can be useful in preventing closure of an artificial pupil.

Wounds of the Eyeball and its Neighbourhood.—Wounds near the eye, though unimportant in themselves, require considerable attention, on account of the eye, or its appendages, being likely to suffer in consequence. Thus, transverse wounds of the forehead or eyebrow, if their edges be not approximated accurately and soon, may cause prolapsus of the eyelids; or the eyelids may become swollen and turgid, or erysipelatous, in consequence of inflammatory action attacking the wound. When wounds of the forehead are in a perpendicular direction, their margins are easily preserved in apposition, having little tendency to retract, and there is no risk of the relative situation of the eyelids being altered. If there be considerable loss of substance in the lower part of the forehead, from the nature of the wound, when inflicted, or from its having become the seat of unhealthy suppuration, on cicatrisation of the part the eyelid will be drawn upwards, and perhaps more or less everted. There is reason to believe that a degree of blindness, and even complete amaurosis, has been caused by wound of the eyebrow, the superciliary nerve having been contused, wounded, or otherwise injured; or the functions of the eyeball may be disturbed by concussion from injury. Paralysis, also, of the levator palpebræ superioris, or of several of the muscles belonging to the eyeball, may follow injury of the forehead and neighbouring parts, from either laceration or concussion of the nerves. Wounds of the eyelids, particularly when neglected, may cause much change of relative situation in the parts, and thereby produce both inconvenience and deformity. In some instances, the relative position of the puncta lachrymalia is altered by the cicatrices of the eyelids or tarsal cartilages, when the original wound has been imperfectly adapted: hence results an incurable epiphora.

In wounds, such as those above mentioned, it is of great importance to bring the raw edges into contact, and retain them so; and, in most cases, one or more points of interrupted suture are necessary. Adhesive plaster may be at the same time applied, but of itself is insufficient to effect permanent coaptation.

Wounds of the eyeball, however slight, require much attention, being inflicted on an important and highly sensible organ, and there being always a risk of destructive inflammatory action. If the breach of surface be clean, simple, and superficial, rest of the parts will in general be sufficient to effect a cure. Lacerated wounds, and such as penetrate into the interior of the eyeball, cannot be expected to heal without morbid action having been excited: inflammation must be anxiously looked for, and actively combated as soon as it appears. When a foreign body lodges in the wound, it must be early removed. But in certain cases it is imprudent to attempt extraction of foreign matter; as when a small shot, or other minute substance, has lodged in the interior of the eyeball. In such circumstances we can only adopt such measures as prevent and subdue morbid excitement. The organ may remain little disturbed for a short period, but violent inflammatory action soon occurs, and, though subdued for a time, again breaks forth, and, by its successive attacks, may ultimately destroy the eyeball. Frequently all endeavours to avert untoward results are unavailing, and the functions of the organ are more or less impaired—the cornea may become opaque, the iris may protrude, the pupil may become irregular, contracted, or obliterated—the crystalline lens may lose its transparency, amaurosis may occur from injury of the retina, the humours may be evacuated, and the eye sink in its socket. The entrance of a large foreign body into the orbit may displace the globe, and cause it to protrude between the eyelids: in such a case the body should be removed and the ball gently replaced; vision may be soon regained; but, if the protrusion has been such as to cause much stretching of the optic nerve, blindness more or less complete remains. Fatal effects may follow wound of the eye, on account of the foreign body, as a sharp-pointed instrument, penetrating the thin parietes of the orbit, splintering the bone, and injuring the brain.

Orbital Inflammation.—Inflammation seldom attacks the parts situated between the orbit and the eyeball; but, when it does, the affection is very serious. The action is very acute, and proceeds rapidly to suppuration. The pain is excruciating, extends to the whole head, accompanied with a sensation of extreme tension in the orbit, and is much increased by the slightest motion of the eye: and from the matter accumulating around the ball, and being confined to the unyielding orbit, by the dense fibrous expansion which extends from the margin of the orbit to the interior surface of the eyeball, the globe is pushed forwards, and distends the lids. The palpebræ become erysipelatous, and swollen by serous effusion. Violent inflammatory fever occurs; and, as the disease advances, all the symptoms are aggravated, and become almost intolerable. The globe is farther protruded, and the retina is insensible to light. At length the accumulated matter makes its way to the surface, and is discharged, giving great relief to the patient, and permitting the protruded globe to regain its situation. The inflammation seldom extends to the eyeball.

In the early stage of this affection, the most decidedly antiphlogistic measures are imperiously called for. When fluctuation can be felt, or when the symptoms indicate that suppuration has taken place, whether fluctuation is perceptible or not, an early opening into the affected part should be made through the dense orbital ligament. Thus a free exit is allowed for the matter, the patient is instantaneously relieved, and the extent of the local mischief is limited. It is unsafe to wait for the spontaneous evacuation of the matter: such a process is necessarily tedious, and, before it has been accomplished, the orbital bones may have become diseased; they may have given way at certain points, and the matter may have escaped within the cranium. The artificial opening should always be free, and deep if necessary.

Tumours in the Orbit.—Sarcomatous tumours occasionally form in the cellular tissue of the orbit. They occur at all periods of life, and may, by slow and gradual increase, cause the eyeball to protrude and disturb its functions; or their growth is rapid, and accompanied with great suffering. In some cases, the eye is made to protrude to a great degree, and by the extension of the optic nerve vision is impaired; in others, the patient is totally blind at the commencement of the disease. Yet the eye may be displaced to no small extent without amaurosis following. The optic nerve appears to bear a good deal of extension without disturbance of its functions. The majority of tumours in this situation are of rapid growth, their structure is soft and medullary, they sooner or later furnish a fungus, and, though removed at an early period, are generally reproduced. The exophthalmos is often the first indication of such a growth, and it is sometimes greater in the early part of the disease than afterwards, when the fascia passing down from the edge of the orbit has given way. The malignant tumours are most frequently met with in childhood, though morbid growths of a bad kind form in the eyeball at different periods of life. They often follow the infliction of a blow or wound. The patient’s sight speedily declines, without any known cause; there is pain in the forehead, temple, and eyeball; the ball protrudes, perhaps slightly, and at first is not otherwise changed; but on careful examination a dimness can be perceived deep in the eye. The opaque body approaches the pupil and fills it, and may in this state be mistaken for disease of the crystalline lens; but the tumour soon pushes forward the iris, and fills the anterior chamber. It has an irregular surface covered with flocculi. Blood-vessels are observed ramifying on it, and by this it is distinguished from cataract, should the accompanying symptoms not have previously convinced the surgeon of the nature of the disease. If not interfered with, the cornea ulcerates, a fungus appears, often grows with great rapidity, and may either furnish not a drop of blood, or bleed profusely. The eyelids are œdematous and permeated by large venous branches. Abscesses form around; the lymphatics of the neck are involved; and the patient succumbs. The original tumour may possess the usual structure of medullary sarcoma, may be of a melanotic nature, or may contain a mixture of both; or it is of harder consistence, containing cells filled with bloody, glairy, or other fluid. The whole coats of the eye are seldom involved: part remains sound, but compressed and disfigured by the morbid mass, and the humours are either absorbed or discharged.

Circumscribed tumours, exterior to the ball, and surrounded by a cellular cyst, may be removed by careful and cautious dissection, without injury to the important parts. A free incision is made along the edge of the orbit, in the course of the fibres of the sphincter oculi. The tumour is exposed, laid hold of with a hook or small vulsellum, and separated from its attachments by a knife, the edge of which is directed towards the new growth. A man, aged 26, had laboured under blindness with exophthalmos for eighteen months. A tumour could be felt above the eyeball, which I dissected out, along with the lachrymal gland, to which it adhered. It was of medullo-sarcomatous structure, and of the size of a plum: at one point it contained a mass of coagulated blood. After its removal, the eye resumed its place and functions. The patient remains well; but such favourable cases are rare.

If the affection be more extensive, it may be necessary to remove all the contents of the orbit: but, in disease involving the entire structures, there is little chance of the patient remaining free from it: it almost uniformly returns, as is also the case whenever the disease has commenced in parts of the eyeball. The optic nerve is often affected at an early period: its cut surface is unsound; and from this, again, springs a fungus which grows rapidly. But under many circumstances the surgeon is not only justified in removing the orbital contents, but called upon to do so. The operation, though cruel and painful, need not be tedious. The commissure of the eyelids is divided with the point of a bistoury, and the forepart of the ball laid hold of firmly and deeply with a vulsellum—that is, forceps provided with a double hook at each extremity of the blades. A straight bistoury is then entered at the margin of the orbit, pushed down to the base, as near as possible to the entrance of the optic nerve, and carried round the tumour rapidly, the blade towards the handle being made to move more quickly than the point. The nerve is cut across, and, after the removal of the morbid mass, the cavity is sponged out and examined. The lachrymal gland, and other soft parts, particularly if altered in texture, are raised with a hook, and removed by means of curved scissors. In young subjects, and in adults, when the disease is far advanced, the parietes of the orbit are thin, softened, and attenuated by pressure: the knife should therefore be used cautiously, and it is, perhaps, safer to finish excision with a narrow, curved, and probe-pointed bistoury, after having penetrated to the bottom of the orbit with a sharp-pointed knife: all other curious and crooked knives are useless. Bleeding is restrained by charpie, pressed firmly and quickly into the cavity, and supported by compresses and bandage; but, before introducing the dossils, all coagula and fluid blood should be carefully sponged out. Afterwards, excited vascular action, with pain in the head and wound, may in some subjects require abstraction of blood, the exhibition of purgatives and antimonials, and immediate removal of the dressings, followed by fomentation and poultice. When matters proceed favourably, the charpie is removed gradually as suppuration advances, and the granulations are supported with light dressing, either dry, or moistened with some slightly astringent lotion. The discharge will gradually cease, and the granulated surface cicatrise under the level of the eyelids. In such circumstances the deformity may be remedied, after the parts have become quiet, by the adaptation of an artificial eye of enamel, made so as to resemble exactly the other eye. It is worn without inconvenience, removed at night like artificial teeth or a wig, and cleaned and replaced in the morning. Such a substitute is also useful when the humours have been evacuated, or the organ destroyed, by injury or the effects of inflammation. Too frequently the morbid growth is reproduced, and that rapidly. It may be restrained by escharotics, the red oxide of mercury, potass, acetate of lead, acids, or the actual cautery; but the patient is thereby put to much pain without a chance of ultimate benefit.

It is too true, that the hopes of a cure, after the extirpation of the eyeball for malignant disease, are defeated by the prior existence of a similar affection within the cranium. In the majority of cases, death has occurred from tumours of greater or less extent, along the course of the optic nerve, or their tract: behind the commissure, and extending to the optic lobes and even cerebellum.