Elements of Surgery

by Robert Liston

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.