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Full text of "A synopsis of the diseases of the eye, and their treatment : to which are prefixed, a short anatomical description and a sketch of the physiology of that organ"

YALE 
MEDICAL LIBRARY 




HISTORICAL 
LIBRARY 



EX LIBRIS 
JOHN FARQUHAR FULTON 



Digitized by the Internet Archive 

in 2012 with funding from 

Open Knowledge Commons and Yale University, Cushing/Whitney Medical Library 



http://www.archive.org/details/synopsiiseasOOtrav 



A 

SYNOPSIS 

OF THE 

DISEASES OF THE EYE, 

AND THEIR TREATMENT: 

TO WHICH ARE PREFIXED, 

A SHORT ANATOMICAL DESCRIPTION 

AND 

A SKETCH OF THE PHYSIOLOGY 
OF THAT ORGAN. 



BY BENJAMIN TRAVERS, F.R.S. 

SURGEON TO ST. THOMASES HOSPITAL. 



" Vel me monere hoc, vel percontari puta : 
Rectum est, ego lit faciam ; non, ut deterream." 

TERENCE. 



Itontron: 

Printed for 

LONGMAN, HURST, REES, ORME AND BROWN, 
PATERNOSTER ROW. 

1820. 



8^ot 



G. Woodfall, Printer, Angel Court, Skinner Street, London. 



TO 

JOHN RICHARD FARRE, M.D. 

THE AUTHOR 

DEDICATES 

THIS VOLUME, 

AS A 

MEMORIAL 

OF 

ESTEEM FOR HIS CHARACTER, 
ADMIRATION OF HIS TALENTS, 

AMD 

GRATITUDE FOR HIS FRIENDSHIP. 



a2 



PREFACE. 



The Volume which I now present to the 
Public, is the result of a more ample op- 
portunity of observing the diseases of the 
important organ of which it treats, than 
commonly falls to the lot of Hospital Sur- 
geons. This opportunity, originally de- 
rived from my situation during a period 
of seven years, as Surgeon to the London 
Infirmary for Diseases of the Eye, has 
been considerably augmented by private 
practice in the same branch of the Pro- 
fession, contingent to that appointment. 

I have always thought that the ad- 
vantages obtained by the subdivision of 
professional talent and labor, are infinitely 
overbalanced by those which arise from 
the general and undivided application of 
these instruments of knowledge. No fact 



vi PREFACE. 

more strikingly illustrates the truth of the 
doctrine, that the confinement of any 
branch of the Profession to the hands of 
a few, operates prejudicially to science, 
than the state of information in this 
Country, concerning the Diseases of the 
Eye. Mr. Samuel Cooper has spoken so 
precisely as I think, upon this subject, 
that I cannot do better than quote his 
words. 

" The disorders of the eye and its appen- 
dages are far more numerous and diversi- 
fied than those of any other individual part 
of the body, and some of the requisite ope- 
rations for their relief ought to be done 
with the nicest combination of skill and 
delicacy. These circumstances, strangely 
enough, have had the effect of inducing an 
erroneous supposition, that such cases do 
not properly enter into the department of 
ordinary surgery ; but ought to be con- 
signed to the care of a man, who makes 
them exclusively the object of his atten- 
tion, and disregards disease in every other 
form. The morbid affections of the eye, 
it is true, like all other surgical cases, 
must be studied, in order to be understood. 



PREFACE, Vll 

They have no peculiarity, however, except 
what depends upon their number, and the 
tenderness and functions of the organ af- 
fected. In their nature they are swayed by 
the same laws which influence all common 
diseases, for which the practice of surgery 
is instituted ; and their treatment is regu- 
lated by general principles, which prevail 
throughout the whole of this indispensable 
art. 

" No one, except the thorough surgeon, 
can make the complete oculist ; by which 
last term is not meant any body who can 
merely manage to extract the cataract bet- 
ter than the generality of surgeons, but a 
man whose science leads him to recognise 
the analogy betwixt the diseases of the 
eye and those of other parts, and whose 
knowledge of the latter, while it qualifies 
him in a great measure for the treatment 
of the former, gives him a decided superi- 
ority over the bare oculist." 

" On a cru faussement (says the intelli- 
gent M. Louis, in adverting to the diseases 
of the eye,) que le scavoir necessaire pour 
discerner le caractere de ces di verses af- 



Vlll PREFACE. 

fections contre-nature, ct pour y remedier, 
faisoit en quelque sorte un art particulier. 
Mais quels fruits pourroit porter cette 
branche, etant separee du tronc? II est 
bien prouve, par les faits, que les progres 
de cette partie de la chirurgie ne sont diis 
qu'aux grands Maitres qui ont pratique 
Tart dans toute sa plenitude, et dont Inex- 
perience, relative aux maladies des yeux, 
a ete eclairee par les lumieres que leur 
avoient donnees les principes qui consti- 
tuent indivisiblement la science, sans la- 
quelle on ne peut exercer aucune partie 
avec connoissance de cause/' — First lines 
of the Practice of Surgery, Vol. I. p. 433. 
4th edit. 

In this country, I believe no one before 
myself, who designed to practise general 
surgery, ventured to give more than a 
cursory attention to the diseases of the 
eye. A fear of being disqualified in pub- 
lic opinion, by a reputation acquired in 
these, for the treatment of other diseases, 
was a motive, however groundless, suffi- 
cient to deter surgeons from the culti- 
vation of a large and legitimate field of 
observation and practice. 



F R E F A C E . IX 

It was with a public avowal of the sen- 
timents so well expressed by the writers 
just quoted, that I accepted the situation of 
Surgeon to the Eye Infirmary, in the year 
1810; and from these I have never 
swerved. 

At the commencement of the following 
year, the students of surgery were first in- 
vited to attend the practice of the Infir- 
mary ; an opportunity eagerly embraced, 
and which many hundreds have since en- 
joyed. 

Among the gentlemen who with ardor 
and diligence entered upon this new and 
interesting study, during my connection 
with the Infirmary, I have the pleasure of 
including many of the best educated and 
most rising men in the Profession ; and, if 
they will permit me to say so, some of my 
most estimable friends. 

Upon occasion of electing a second sur- 
geon to that Establishment in 1814, my 
friend, Mr. Lawrence, became my col- 
league. I consider it to be no ordinary 
sanction of my views, that they were thus 



PREFACE. 

seconded by the co-operation of a gentle- 
man, so highly distinguished as the present 
senior surgeon of the Infirmary. 

But whether my example or my services 
have been in any degree instrumental in 
promoting so desirable an object as that 
of recalling to the notice of the Profession 
at large, the neglected subject of these 
diseases, is a matter of no public interest, 
and which I am content to leave to the 
candor of the Profession. 

In offering these observations, I en- 
treat it may be understood, that it is far 
from my meaning to insinuate the slight- 
est derogation from the merits of some 
truly respectable Members of the Pro- 
fession, who confine their attention to this 
class of diseases. We take a different 
view of the subject ; but no man of inge- 
nuous feelings will arrogate to himself that 
he alone walks in the right path. 

In this country, the want of a compre- 
hensive treatise on the diseases of the eye 
has long been felt and acknowledged. The 
work of Professor Scarpa was the only 



PREFACE. XI 

book of reference for English students 
before the publication of Mr. Saunders's 
Treatise, which, from its intrinsic evi- 
dence of a strong and original talent for 
observation, leaves us to regret as a 
national calamity, the premature ter- 
mination of his labors. Mr. Wardrop's 
ingenious Essays on the Morbid Anatomy 
of the Eye, have since contributed to in- 
struct and gratify the Profession. But 
the object is yet unaccomplished, and I 
can only flatter myself with having ad- 
vanced a step or two nearer to its com- 
pletion. 

In Germany a merited share of attention 
has long been devoted to the diseases of 
the eye. The elaborate work of Professor 
Beer of Vienna, who has devoted a life to 
the subject, is said by those of our country- 
men who read the German language, and 
are competent to appreciate its merit, to 
evince a familiarity with these diseases — 
a comprehensiveness of arrangement, a 
depth and minuteness of observation, a 
promptitude and fidelity of diagnosis — un- 
attainedin any other department of Patho- 
logy. Walther of Landshut, Schmidt of 



X1L PREFACE. 

Vienna, Himly and Langenbeck of Got- 
tingen, and others, have distinguished 
themselves in the same field of research. 

I ardently hope that the example of 
German industry may operate as an in- 
centive to our exertions, and should it 
prove so — without meaning to question the 
extent or value of their researches in oph- 
thalmology — I may be permitted to ex- 
press my belief, that they can la} T us under 
no deeper obligation. 

Nations, like individuals, are distin- 
guished by a peculiar character of mind, 
to whatever -auses attributable, evinced 
in their respective modes of observing, 
reflecting and acting; and the sentiment 
of Phredrus is as strictly applicable to the 
one as to the other : 

" Sua cuique quum sit animi cogitatio 
Colorque privus *" 

I should be sorry to see the sober sense 

of my countrymen perverted by a taste 

for fastidious distinctions. Simplicity is 

the characteristic feature of English Sur- 

* Prol. Lib. V. 



PREP ACE. Xlll 

gery, which is neither more nor less than 
the application of the principles of inflam- 
mation, as illustrated by the genius of 
John Hunter. 

I cannot but fear that the condensed 
and compendious plan of this Volume may 
occasion disappointment to persons ad- 
vanced in the study of eye diseases. But 
I must remind them that it makes no pre- 
tension to the character of an elaborate 
systematic treatise, and is designed more 
particularly for the information of sur- 
geons and students of surgery. It is the 
result of personal observation, not a com- 
pilation from the works of others. Neither 
is it in any degree critical. I have not 
time enough at my command to be an 
historian, nor ambition to be a controver- 
sialist. Facts, whether new or old, derive 
a value of authenticity from personal ob- 
servation, which is not enhanced by the 
custom of collating materials from other 
sources. Such a custom is likewise incon- 
sistent with another valuable quality, in 
practical matters especially — I mean con- 
ciseness. 

It was at the suggestion of a friend that 



XIV PREFACE. 

I prefixed the sketches of anatomy and 
physiology, for the purpose of bringing 
the entire subject before the reader in 
the compass of a volume. In these short 
pieces, I have aimed at a simple and 
perspicuous exposition of all that appears 
essential to a right understanding of the 
principal diseases of the organ. For the 
more subtle anatomical points, or rather 
questions, which I have purposely avoided, 
I refer my reader to the Appendix. 

Against an over-weening spirit of anato- 
tomical discovery, the pathologist should 
be jealously upon his guard, if he would ob- 
serve honestly and reason accurately on the 
phenomena of disease. Some ingenious 
disquisitions have occasionally been given 
to the Public on the morbid affections of 
textures, of which the existence is proble- 
matical. I would by no means speak with 
disrespect of the pursuit of minute ana- 
tomy, nor presume to question its utility 
when conducted after the manner of Har- 
vey and Ruysch ; but I must be allowed to 
remark that such points as are too subtle 
to admit of demonstration, are not to be 
cleared by the helps of analogy and con- 
jecture, and indeed are never satisfactorily 



PREFACE. XV 

proved but by the anatomy of disease, 
from which they derive their importance. 

The second part of the work, containing 
the Pathology, was drawn up and intended 
for publication in the last Volume of the 
Surgical Essays, published jointly by Mr. 
Astley Cooper and myself. It is unneces- 
sary to state the reasons of its postpone- 
ment; a principal motive was the belief that 
it would be more useful and acceptable to 
the junior part of the Profession, as it now 
stands, connected with the remaining con- 
tents of this Volume. I am induced 
to mention this circumstance, by way of 
apology, for what might appear to be occa- 
sional infringements upon the plan of con- 
sidering the diseases and their treatment 
distinctly. To a certain extent the blend- 
ing of these subjects is unavoidable, but 
the Pathology having been designed for a 
separate and distinct Essay without any 
direct view to the subject of treatment, the 
latter is introduced more freely in the way 
of illustration, than it would otherwise have 
been ; and consequently, anticipations and 
repetitions are more frequent. 1 do think 
however, that this fault is mainly in the 
plan. I should not therefore a priori have 



XVI PREFACE. 

adopted it, but I was unwilling to disturb 
the arrangement of the piece first written, 
and to some readers it is probable that the 
division may not be unacceptable. 

Some highly important topics, in the 
third division of the Volume, my experience, 
as the reader may conclude, would have 
enabled me to treat much more in detail, 
than the plan of this Work permitted. It 
is difficult to speak in so small a compass 
upon subjects like those of cataract and 
artificial pupil, either of which is sufficient, 
from its extent and importance, to furnish 
materials for a distinct volume. I have 
endeavoured, how successfully I know 
not, to guard against material omissions in 
studying to preserve conciseness. 

As I have made little reference to the 
writings of others, the omission of the sv- 
nonima forming the crabbed vocabulary of 
Ophthalmologists, ancient and modern, will, 
I hope, need no apology. The nomencla- 
turing mania appears to me an evil of in- 
creasing magnitude. 

Nat Broad S 

Oct. -20, 1320. 



CONTENTS. 



PART I. 



Page 

Anatomical Description of the Eye and its Appendages.. 1 
Sketch of the Physiology of the Eye and its Appen- 
dages 45 



PART II. 

CHAPTER I. 
PATHOLOGY OF THE MEMBRANES. 

Section I. Conjunctiva 87 

II. Cornea 106 

III. Sclerotica 126 

IV. Choroid and Iris 131 

V. Retina 137 

CHAPTER II. 
PATHOLOGY OF THE HUMORS. 

Section I. Aqueous Humor 195 

II. Vitreous Humor 198 

III. Crystalline Humor 206 

IV. Diseases affecting the Eyeball 214 

b 



XV111 CONTENTS. 

CHAPTER III. 

PATHOLOGY OF THE APPENDAGES. 

Page 

Section I. Orbitar Appendages 224 

II. Facial Appendages 230 



PART III. 

CHAPTER I. 
TREATMENT OF THE DISEASES OF THE EYE. 

Section I. Simple Inflammation of the Conjunctiva... 246 

II. Inflammation modified by Struma 256 

III. Acute suppurative Inflammation of the 

Conjunctiva 263 

IV. Secondary Diseases of the Conjunctiva 271 

CHAPTER II. 

Section I. Diseases of the Cornea 277 

II. Sclerotitis, Choroiditis, and Iritis 28S 

III. Amaurosis 293 

IV. Diseases affecting the Eyeball 307 

CHAPTER III. 

Section I. On the Operations for the Cataract 312 

II. Of the Operations for artificial Pupil 334 



CONTENTS. XIX 

CHAPTER IV. 

DISEASES OF THE APPENDAGES. 

Page 

Section I. Diseases of the Eyelids 350 

II. Obstruction of the Lacrymal Passages 359 

Appendix S81 

Explanation of the Plates .. 391 



ERRATA. 



Pa^e 6, line 16, for ' section of its,' read ' section of ike frozen humor.* 

43, 15, for ' palbebras,' read 'palpebral.' 

44, 2, for ' of this subject in the foregoing description,' read 

. it subject of the foregoing description.' 

191, S, for ' lacrymal ducts,' read ' ducts of the lacrymal 

— gland.' 

160, note in the margin, for ■ inanimation,' read ' inanition.' 

— — 161, line 9, dele the words 'from constant suffusion.' 

175, 13, for ' prevents,' read'fntemts.' 

, 21, for ' aad, read ' and.' 

216, last line but one, for ' stages,' read ' ; 

231, line 18, for ' margin,' read ' margins.' 

272, 15, for ' sul>-acetatis,' read ' acetatu.* 

329, 13, for ' particle/ read ' partic'.. ■ 



PART I. 

ANATOMICAL DESCRIPTION 

OF 

THE EYE 

AND ITS APPENDAGES. 



The orbits are two funnel-shaped cavities situ- o.bits. 
ated under the arch of the forehead, on either 
side of the root of the nose. The roof of the or- 
bit is formed by the frontal and sphenoid bones; 
the floor is contributed by the superior maxillary 
and malar bones ; the malar and sphenoid bones 
make up the temporal side ; the lacrymal, seth- 
moid, sphenoid, and palate bones compose the 
nasal. The nasal sides are plane, and nearly pa- 
rallel ; the temporal are considerably divergent, 
so that the axis of the orbit is an oblique line. 
A line drawn horizontally across the base of the 
cavity is also oblique ; the nasal being more ad- 
vanced than the temporal angle. This configu- 
ration of the orbits prevents us from command- 
ing the parietes of both cavities in a front view 
of the cranium, and greatly extends the field of 
vision. The globe of the eye is considerably- 
smaller than the receptacle in which it is con- 

B 



2 ANATOMICAL DESCRIPTION OF THE EYE 

tained, to allow of its free motion on all sides. 
The capaciousness of the orbit provides for the 
lodgment of the adipose substance upon which 
the eyeball is cushioned ; the muscles which 
move and adapt it to vision in all directions ; 
the vessels which nourish its membranes and 
secrete its humors j the nerves which supply 
these several parts with energy ; and the gland 
for preparing the lubricating fluid which is es- 
sential to its economy. These being situated 
posterior to that membrane which shuts up the 
cell of the orbit, may be termed, for the conve- 
nience of description, the orbitar appendages, 
in contradistinction to those which the organ 
presents on its facial aspect, viz. the supercilium 
or eyebrow, palpebral or eyelids, and the la- 
crymal passages ; which parts, together with the 
tunica conjunctiva, I shall call the facial appen- 
dages of the globe. 

Their holes The foramina and depressions of the orbit, 

and depres- 
sions, as of all the bony cavities, form a natural intro- 
duction to the anatomy of the parts contained. 
The nasal and superior sides, for example, 
are terminated by the opt,ic hole for the in- 
troduction into the orbit of the optic nerve. 
The temporal and superior sides are bounded 
by an irregular slit or fissure, denominated, 
foramen lacerum orbitale superius ; the temporal 
and inferior are separated by a similar fissure, 
termed, foramen lacerum orbitale inferius vel 
spheno-maxillare, The numerous nerves, the 



AND ITS APPENDAGES. 

optic nerve excepted, and the principal vein 
of the eye and its appendages pass through 
the foramen lacerum. Two minute fora- 
mina left in the suture, connecting the fron- 
tal and asthmoid bones, by which a direct 
vascular and nervous communication is main- 
tained between the nares and the orbit, are 
termed, foramina orbitalia interna, anterius 
et posterius. A small hole in the orbitar por- 
tion of the malar bone establishes a similar 
communication with the cheek. A depression 
in the orbitar plate of the os frontis, next 
its external angular process, receives the lacry- 
mal gland, which is fastened to it by a par- 
ticular ligament. A minute pit behind and 
above the internal angular process of the same 
bone, gives attachment to a ligament and car- 
tilaginous trochlea, in which the tendon of a 
muscle plays in its passage to the globe. A 
notch or foramen is observed in the orbitar 
ridge of the os frontis, which permits vessels 
and nerves to pass from the orbit to the eye- 
brow, glabella, and forehead. The infra-orbital 
canal which opens obliquely at the back of the 
orbital floor, is continued under it to the cheek, 
transmits vessels freely communicating with the 
ophthalmic, and a nerve from which the inferior 
palpebra derives its chief supply. 

The globe or ball of the eye is not exactly Eye-baii. 
spherical, the line forming the visual axis ex- 

b 2 



ANATOMICAL DESCRIPTION OF THE EYE 

ceeding its transverse diameter. This line is 
parallel in the two eyes. 

The figure of the orbit demonstrates that 
a part only of the ball is contained within it. 
A needle placed upon the temporal angle of 
the orbit, and pushed horizontally across the 
globe, perforates the orbitar plate of the seth- 
moid bone, and measures its greatest transverse 
diameter. 

The difference in the degree of projection of 
the eye in different individuals is determined by 
the relative volume of the ball and its socket ; 
but the figure and the ordinary interspace of the 
eyelids are subject to variations, which convey 
a delusive idea of the magnitude of the globe. 
When a paralysis affects the palpebral muscle of 
one eye, the organ, compared with its fellow, 
has the appearance of being diminished in bulk. 

The eye of the female is commonly smaller 
than that of the male 5 and the fissure of the 
eyelids, which are rounder, broader, and more 
delicate in texture, is generally less. 



Humors The eyeball is composed of the following 

and mem- * ' *■ ° 

branes. parts : 

1. The vitreous humor, * united by their 

2. The crystalline humor.) common tunic. 



AND ITS APPENDAGES. 

3. The aqueous humor. 

4. The retina. 

5. The choroides and its appendages, the 
annulus and processus ciliares. 

6. The iris. 

7. The sclerotica. 

8. The cornea. 

The humors give shape to the eye-ball, and 
support to its tunics. 

The crystalline is set in the vitreous humor, 
and washed in front by the aqueous. 

The retina is the membranous expansion of 
the optic nerve, upon which the images of ex- 
ternal objects are painted. 

The choroid is the bed of the vessels of the 
eye, and the dark screen which confines and 
condenses the rays of light in their passage to 
the retina. Its appendages are auxiliary to this 
purpose, and to other parts of the economy of 
vision. 

The iris is the colored membrane in which 
the aperture termed, the pupil, is formed. 

The sclerotica is the external opaque investi- 
ture of the choroid. 

The cornea is the anterior transparent mem- 
brane which first converges the rays of light. 

Nearly in the order in which these several 
parts have been named, I proceed to describe 
them. 

The vitreous humor is the basis upon which y itr eou» 

x humor. 



6 ANATOMICAL DESCRIPTION OF THE EYE 

the larger tunics are expanded, and fills a space 
somewhat exceeding three quarters of the 
volume of the globe. Upon its anterior surface 
it is somewhat abruptly flattened, and presents 
a central cup-like depression ; the dimensions of 
which exactly correspond to the posterior seg- 
ment of the crystalline humor, which is imbed- 
ded therein. Its substance is a glairy fluid 
heavier than water, perfectly pellucid, and con- 
tained within cells formed by processes of its 
tunic, arranged in horizontal planes. Towards 
the back and sides of the humor these cells are 
larger than in the interior, adjacent to the 
crystalline fossula ; the septa are likewise 
thicker and stronger towards the circumference 
of the humor. After a careful section of its 
frozen humor its substance may be picked 
out in solid wedge-like flakes from the in- 
Tunica terstices of the septa, The continuous co- 

hyaloidea. L 

vering, though of great tenuity and perfect 
transparency, is of much strength, and resists, 
owing to the support it receives from the 
numerous septiform productions of its internal 
surface, a considerable pressure. When lace- 
rated or wounded, the humor of the corres- 
ponding cell or interstice is instantly evacuated; 
but if the wound is superficial, the humor does 
not escape in quantity, while supported by the 
other parts of the globe, or if removed from 
the globe, while suspended in a fluid. But if 
in any way compressed after a wound, a drib- 
bling of the humor goes slowly on, until the 



AND ITS APPENDAGES. 7 

cells, which communicate with each other, are 
emptied. 

The tunica hyaloidea is covered by the re- 
tina in the whole extent of that membrane, 
but is connected with it only at the entrance of 
the optic nerve. The substance of the humor 
is penetrated by a branch of the arteria cen- 
tralis retinae, which contributes a few very deli- 
cate vessels to its containing membrane. In the 
foetus they have been displayed ramifying on 
the capsule of the vitreous, at the back of 
the lens. 

THE CRYSTALLINE HUMOR is a double COn- Crystalline 

humor. 

vex lens, its breadth about four lines, its thick- 
ness about two. The posterior and most convex 
face of the lens is exactly fitted to the cup in 
the fore part of the vitreous humor ; the an- 
terior is opposed to the iris, and the circum- 
ference to the canal of Petit. The axis of the 
lens is that of the pupil, a little to the innet 
side of the axis of the eye. This humor is of 
perfect transparency in its healthy state. In 
the foetus and new-born infant it is spherical, 
semi-fluid, and has a slightly reddish tint. In 
the adult, it is gelatinous in consistency, its ex- 
ternal lamellae easily broken down between the 
fingers, but a nucleus of greater firmness is found 
in the centre, which in some degree resists this 
pressure. In advanced age, the lens becomes 



8 ANATOMICAL DESCRIPTION OF THE EYE 

i 

more close and compact in texture, and the 
nucleus acquires a yellow or topaz color. 

The texture of the lens is lamellated ; the 
lamellae concentric and connected by a 
very delicate fibrous tissue. After maceration, 
the crystalline breaks into triangular pieces 
composed of concentric scales, of which the 
apices meet in the centre. The anterior may 
sometimes be separated from the posterior part 
of the lens, at the line of its circumference, as 
if it were composed of two segments of spheres 
of unequal size, applied face to face. The crys- 
talline discovers no vascular organization. 

canal of The tunic of the vitreous humor, called tu- 

nica hyaloidea, has also upon its exterior surface, 
a process or duplicative, membranula coronae 
ciliaris of Zinn, who considered it a distinct 
texture. It is produced at the distance of 
a line's breadth from the circumference of 
the cup which receives the crystalline humor. 
At the verge of the cup the duplicatures 
coalesce, and thus an annular space is included 
between them, which has been named after its 
describer, canalis Petitianus. Inflation of the 
canal shews that it is not of uniform dimensions j 
like the intestine colon, it is tacked up into cells 
or pouches by short transverse septa, whence the 
name given by Petit, canal gauderonne, or 
godronne. In the grooves corresponding to 



AND ITS APPENDAGES. » 

these septa, the posterior edges of the ciliary 
processes are inserted. The intervening looser 
portions of the membrane correspond to the 
interstices of the processes ; and the black ra- 
diated lines, which appear upon the membrane 
of the canal, are stains left by the pigment 
which fills them. Like the corpus ciliare, the 
canal is broader on the temporal than on the 
nasal side. 

After the condensation of the lamella?, at the Capsuieot- 

the crystal 

margin of the crystalline, the proper tunic is Hue. 
continued over the concave face of the vitreous 
humor, posterior to the crystalline lens, and a 
continuous transparent membrane re-produced 
anteriorly, passes before the crystalline, so as 
to retain it in its place. This portion of the 
membrane covering the crystalline is termed 
capsule of the crystalline, or tunica aranea, 
and is considerably more dense and elastic than 
the proper tunic of the vitreous humor. Inde- 
pendent of the membranous enclosure now de- 
scribed, the existence of a distinct and proper 
capsule of the crystalline is generally assumed ; 
but I have never seen it demonstrated to my 
satisfaction. A small quantity of aqueous fluid, 
contained in the capsule enclosing the crystal- 
line humor, is called after its discoverer, humor 
Morgagnii. 

The retina. The optic nerve having per- Retina - 
forated the sclerotic and choroid coats at the 



10 ANATOMICAL DESCRIPTION OF THE EYE 

internal and posterior part of the globe, termi- 
nates abruptly in a little white conical emi- 
nence or papilla. From the base of this pa- 
pilla proceeds the very delicate membranous 
expansion termed, retina. It encompasses the 
vitreous humor, the front part only excepted. 
Its anterior termination is also abruptly defined, 
and corresponds to that of the choroid tunic 
which lies exterior to it. It is of exceeding deli- 
cacy, and on dissection, resembles, in semi- 
transparency and in color, the ground glass of 
which ornamental lamps are constructed. Du- 
ring life it is of perfect transparency. Without 
caution it cannot be preserved entire in dissec- 
tion, and if, when the sclerotic and choroid are 
divided, the parts of the globe are separated by 
their weight, by its strict adhesion to the other 
coats at its origin, it is drawn off the vitreous 
tunic in the form of a fine medullary rope, 
which expands and reassumes its proper form 
in water. The arteria centralis emerging from 
the axis of the optic nerve, distributes a few 
delicate branches upon it, which do not in the 
healthy adult convey red blood. 

its onhai A minute foramen in the retina is seen on the 
temporal side of the optic nerve, having a yel- 
low border, around which, the arteria and vena 
centralis, after a delicate injection, display a vas- 
cular corona. This appearance first described 
by Soemmering, " foramen centrale cum limbo 
luteo," is seen only in the recent state of the eye. 



AND ITS APPENDAGES. 11 

Its situation corresponds to the extremity of the 
visual axis. The membranous surface of the 
retina is opposed to the tunica hyaloidea, the 
medullary to the choroid. Its attachment, at its 
insertion into the ciliary body, is very slight, 
as it commonly yields at that part, if recent 
and uninjured, rather than tears by the force 
exerted to separate it entire. The retina is 
uniformly expanded over the tunica hyaloidea, 
but has no demonstrable connexion with that 
membrane. 



tunic. 



The tunica choroides extends from the cir- choroid 
cumference of the optic nerve to the margin of 
the exterior or flattened surface of the vitreous 
humor ; there it terminates, together with the 
retina, in a greyish colored substance, termed, 
ganglion or ligamentum ciliare, or better, annu- 
lus ciliaris, and which is the common centre of 
union for the interior membranes of the eye. 

The choroid is of a dusky brown color in 
the adult, reddish in infants, and adhering by 
an abundant and lax cellular tissue, which maybe 
readily inflated, to the sclerotic coat, and by the 
numerous ciliary vessels and nerves, which per- 
forate the latter, to take their course upon the 
choroid. This cellular substance is more plen- 
tiful in the infant than in the adult, and is most 
abundant in the track of the principal vessels 
and nerves. The vessels terminating upon it 
are exceedingly numerous, and secrete a dark 

7 



12 ANATOMICAL DESCRIPTION OF THE EYE 



its pig- pigment, or varnish, which stains the contigu- 

meat. 

ous adhering surface of the sclerotic ; it like- 
wise communicates its stain to the finger, or a 
piece of white paper, but the texture of the 
membrane is permanently dark, and is not 
bleached by maceration. 

The interior surface of the choroid is also 
covered with a black varnish, thicker and 
deeper colored in the infant, than in the adult ; 
but having no connexion by texture with the re- 
tina, its stain is not communicated to this tunic. 
Around the insertion of the optic nerve, the 
choroid is destitute of this dye. Residence for 
some time in alcohol discovers a fine white 
flocculent substance coating the interior of the 
choroid, formerly described by Ruysch as a 
distinct tunic, (tunica Ruyschiana,) but not 
regarded in this light by modern anatomists. 
The pigment, there can be no doubt, is secreted 
into a fine cellulous tissue, flakes of which are 
detached, in some diseased states of the organ, 
from the ciliary processes and back of the iris, 
forming to all appearance a real membrana nigra. 

its nerves The ciliary nerves run in parallel lines, at 

and vessels. ^ L 

equal distances,upon the choroid ; and from their 
size and whiteness are particularly conspicuous. 
The long ciliary arteries appear, one on either 
side of the globe, in their course to the annulus 
ciliaris. Beneath these the membrane pre- 
sents, on its opposite sides, vessels arranged in 



AND ITS APPENDAGES. ]3 

form of trees with weeping branches, or the 
figure of a jet d'eau ; these which have been 
named, vasa vorticosa, are veins returning 
the blood distributed to the ciliary processes, 
and are collected into three or four distinct 
venous trunks. The short posterior ciliary 
arteries pass under the ciliary veins, in the 
intervals of the trunks, to the interior of the 
choroid, and uniting with the anterior at the 
fore part of the globe, their extremities form 
a very intricate and beautiful net-work upon 
its interior surface. The adhesion of the 
choroid to the sclerotic is most strict, adjoining 
the optic nerve behind, and the ciliary ring be- 
fore, owing to the introduction of the ciliary- 
vessels at these parts. 

The annulus ciliaris is an elastic ring Ciliar y 

ring. 

composed of a short and dense pulpy texture, 
closely adherent to the inner border of the scle- 
rotic, at the distance of a line and a half from 
the external circumference of the cornea. It 
is of greater breadth on the temporal than on 
the nasal side. The choroid and retina adjoin 
its greater, the cornea and iris its lesser circum- 
ference. Anteriorly it adheres firmly to the scle- 
rotic, as before observed, and the ciliary pro- 
cesses are attached to its posterior surface, so 
that it forms a common centre of union for 
these tunics. Its color is observed to corres- 
pond to that of the iris. 



14 ANATOMICAL DESCRIPTION OF THE EYE 

ciliary The processus ciliares. On the internal 

plaits or 

processes, surface of the choroid, at the root of the annu- 
lus ciliaris, the plica? or processus ciliares 
arise in delicate striae and advancing a little 
anterior to the circumference of the crystalline 
lens, terminate in a circle of fine grey points 
at the base of the iris. They appear to be ra- 
diated folds of the choroid tunic, from sixty to 
seventy in number, long and short alternately, 
and gathered at their origin like the plaits of a 
shirt at the wristband. Viewed collectively 
through the vitreous humor they have some 
resemblance to a radiated flower ; a small 
white circle appears within a large dark one. 
The white lines represent the edges of the 
plica?. The black, their, interstices coated 
with pigment. These edges of the plicae are en- 
grooved in the duplicative of the vitreous cap- 
sule, which assists in forming the canal of Petit. 

The extremities of the processes projecting 
from the interior border of the annulus ciliaris 
interdigitate with the radical fibres of the iris. 
To obtain a view of them, let the cornea be ac- 
curately removed at its junction with the scle- 
rotic, and the iris be torn away, entire, from its 
ciliary attachment. The points of the pro- 
Cesses will then appear,' projecting like the teeth 
of a comb from behind the annulus ciliaris, and 
the ciliary border of the iris, upon floating it in 
water, will be found to present a corresponding 
arrangement. 



AND ITS APPENDAGES. 15 

The processes having their edges thus inlaid 
in the tunica hyaloidea at the margin of the 
crystalline fossula, and their points or anterior 
extremities interlaced with the radical fibres of 
the iris, form a posterior iris, the aperture of 
which is exactly occupied by the crystalline 
lens and its capsule. From their origin to 
their insertion, they are supported exteriorly by 
the annulus ciliaris, with which substance they 
are in fact incorporated. The figure of each 
plica ciliaris is triangular, the internal obtuse 
angle being opposed to the circumference of 
the crystalline lens ; the posterior, elongated, 
loses itself in the choroid ; the anterior is in- 
serted into the iris. The anterior edge is at- 
tached to the annulus ciliaris and root of the 
iris, the posterior to the tunica hyaloidea, and 
the internal and shorter of the three measures 
the space between the verge of the crystal- 
line lens and the basis of the iris ; or in other 
words, forms the outer boundary of the pos- 
terior chamber. 

The iris. This is the colored membrane ins. 
which presents a plane surface traversing the 
globe horizontally, and dividing the corneal 
from the sclerotic segment. It is rendered im- 
perfect as a septum by the pupilla or round 
hole in its centre. The pupil is not, how- 
ever, quite central in relation to the iris, the 
breadth of the iris being always somewhat less 
on the nasal than on the temporal side. It is 



16 ANATOMICAL DESCRIPTION OF THE EYE 

divided into a ciliary and a pupillary portion. 
Its attachment is, as already observed, by in- 
denture with the extremities of the plicae cho- 
roideae, at the inner margin of the annulus ci- 
liaris from which it originates. The ciliary 
portion of the iris is the larger one, and is 
composed of a delicate fibrous and vascular 
tissue, in which grey serpentine lines or stria? 
are seen proceeding like radii from the annu- 
lus ciliaris : from this the smaller pupillary por- 
tion is distinguished by a darker shade of color, 
and a gently elevated circular line, most con- 
spicuous on the posterior surface of the mem- 
brane. The fibres of this portion have a similar 
tortuous direction, and are convergent to- 
wards the pupillar aperture. The pupillary 
margin is thin and defined, and presents the 
appearance of a dark circular line when placed 
upon a white ground, as e. g. the opaque cap- 
sule of the crystalline lens. The iris diminishes 
in thickness from its base to the margin of the 
pupil. Its anterior surface is richly colored of 
different hues in different individuals. It is 
thickly coated on its posterior surface by the 
pigmentum nigrum. 

its vessels The ciliary vessels entering the anterior part 

and nerves. • 

of the globe, unite with the other detachments, 
and form arches at the basis of the iris and 
processes. From the zone thus produced (zona 
major) the branches run in straight lines upon 
the iris. In the dilated state of the pupil these 



AND ITS APPENDAGES. 17 

radiated vessels are tortuous ; by its contraction 
they become straight. At the distance of ra- 
ther less than half its diameter from the pupil, 
another zone is formed by their anastomosis, 
from which branches are detached to the margin 
of the pupil. The zona minor gives the ap- 
pearance of the undulating circular line, distin- 
guishing the pupillary from the ciliary portion 
of the membrane. The two long ciliary arte- 
ries chiefly contribute to the formation of these 
zones and the supply of the iris. The short 
ciliaries, seen upon the interior of the choroid, 
decach numerous fasciculi to each ciliary pro- 
cess, which pursue a serpentine course along 
the fixed edge of the fold, and are inverted to 
form concentric arches upon its opposite free 
margin. 



The membrana pupillaris, a delicate mem 
brane ■occupying the pupil of the foetus, and p^ 
which is supplied by the vessels of the iris, 
disappears before birth. 

Of the proper structure of the corpus ciliare, 
nothing is with certainty known. The notion 
that it is wholly constituted of vascular and 
nervous tissue, having no proper fibrous texture 
for its base, which has also been conceived of 
the iris, is absurdly contrary to observation 
and analogy. The annulus appears to be a 
ffangliform or bulbous termination of the cho- 
roid coat, and the processes resemble plaits or 

c 



Membrnne 
of the pu- 



18 ANATOMICAL DESCRIPTION OF THE EYE 

doublings of this membrane laid back to back, to 
accommodate it to the area of the posterior cham- 
ber. Similar uncertainty prevails as to the struc- 
ture of the ins, the different opinions of its texture 
being founded rather upon inferencefrom its func- 
tions than upon demonstration. If the former 
species of evidence be regarded, it is in part 
unquestionably a muscular texture ; the pheno- 
mena of its action can be best explained upon 
the supposition that it is both muscular and 
elastic, and that these forces act alternately. 

sclerotic The tunica sclerotica is the external co- 

tunic. . 

venng of the ball, with the exception of one- 
fifth part, bearing a proportion to the cornea 
somewhat similar to that which the vitreous bears 
to the aqueous humor. It is a dense compact 
fibrous membrane, of a blueish white color ; its 
fibres appear reticulated on maceration. It has 
few nutrient vessels and no traceable nerves ; 
its texture is both extensile and elastic. In the 
foetus and infant it admits of separation into two 
plates, but these are inseparably connected in 
the adult. For the entrance of the optic nerve, 
with the sheath of which it is intimately con- 
nected, it is cribrated or perforated with many 
small holes, by which the fibres of the nerve 
enter and terminate in the conical protuberance 
before described. The choroid and retina adhere 
firmly to the margin of this cribriform plate. 
In other parts the connection between the scle- 
rotic and choroid is by the medium of blood- 



AND ITS APPENDAGES. 19 

vessels and cellular tissue. The sclerotic around 
the entrance of the nerve, and likewise around the 
margin of the cornea, has many small oblique 
passages, of which the apertures on its internal 
surface are conspicuous, when separated from the 
choroid, for the entrance and exit of the ciliary 
vessels and nerves. Adjoining the cornea, the 
choroid and conjunctival vessels communicate 
through the foraminula of the sclerotic, at this 
part. On its inner surface it has furrows in 
right lines, in which the long ciliary vessels 
and nerves are lodged. The sclerotic is of 
greatest density in the vicinity of the nerve ; 
it gradually diminishes in thickness towards the 
middle of the globe, where it is fortified by the 
tendons of the several muscles. The opening in 
front of the sclerotic is nearly circular, having its 
inner edge sloped for the broad insertion of the 
cornea between its anterior and posterior margins. 

The cornea is of a horny texture, less ex- comea. 
tensile than the sclerotic, and perfectly transpa- 
rent. It is, onion-like, composed of concentric 
lamellae or pellicles, connected by a delicate 
cellular tissue containing a transparent fluid, in 
which exhalant and absorbent vessels are abun- 
dantly distributed. This tissue is more lax or 
copious between the anterior than between the 
posterior lamellae. The transparent conjunctiva 
upon the cornea gives a polish and brilliancy to 
the surface, which the lamellae of the cornea do 
not possess, and which is lost in, or rather at 

c 2 



20 ANATOMICAL DESCRIPTION OF THE EYE 

the approach of death, by the transudation of 
the aqueous humor. They are scabrous from 
the adhesion of the cellular membrane con- 
necting them, and void of lustre. The cornea 
is externally rather elliptical than circular, being 
of greater length in the transverse than the 
vertical diameter. 

The cornea is of greater thickness than the 
sclerotic, in infants especially, in whom its pos- 
terior surface is contiguous to the iris. The 
internal surface is likewise half a line broader 
than the outer, the margin being obliquely 
extended from without inwards, to correspond 
with the sloped edge of the sclerotic. After 
maceration it may be detached from the scle- 
rotic, to which it is connected by cellular sub- 
stance : this separation is most readily effected by 
plunging the macerated eye into boiling water. 
A fine transparent humor is secreted by colorless 
exhalantvessels in the areolae of the cellularmem- 
brane between the lamella? of the cornea. The 
interstitial substance of the cornea receives no 
colored vessels. Numerous lines have been ob- 
served to form figures of many sides between the 
plates of the cornea in the eye of the negro, and 
supposed, from a reddish tinge, to be bloodves- 
sels. The existence of nerves has never been 
demonstrated, and it is much to be doubted if it 
possess any. On its interior surface the cornea 
is smooth, and washed by the aqueous humor. 

Membrane . ,. , ...,., 

of u.e According to modern anatomists, it is lined 



AND ITS APPENDAGES. 21 

by a tunic proper to this humor, which is re- aqueous 
fleeted from it upon the face of the iris, and 
advances even to the margin of the pupil. 
Its tenuity, if it exist, is such as very rarely 
to admit of demonstration, at least in the human 
eye. The convexity of the cornea is greater 
than that of the sclerotic, being the segment 
of a sphere seven lines and a half in diameter. 

The aqueous humor. The name of an- Aqueous 

... . humor, 

tenor chamber is given to that space com- andci.am- 
prised between the cornea and the iris, or- eye. 
dinarily about one line and a half in depth. 
The posterior chamber is that between the 
iris and the crystalline lens, not exceeding a 
quarter of a line ; they communicate by the 
aperture of the pupil, and both are occupied 
by the aqueous humor. This is a transparent 
fluid, evaporates on exposure to heat, and is 
uncoagulable by heat 9 acids, or alkalies; it is 
in quantity about five grains ; in quality, viscous 
and slightly saline. It gives figure and tension 
to the cornea, keeps the pupil properly dilated, 
and supports the parts forming the parietes of 
both chambers. When discharged by the punc- 
ture of the cornea the pupil contracts, and 
the chambers are obliterated by the collapse of 
their parietes : it is however reproduced in a 
few hours. The aqueous humor in foetuses and 
new born infants is turbid, and sometimes of a 
reddish tint. 

7 



22 ANATOMICAL DESCRIPTION OF THE EYE 

wins of The ciliary veins and vasa vorticosa of the 

the globe. 

choroid jointly return the blood distributed by 
the ciliary arteries. 

They perforate in like manner the sclerotic 
coat, and terminate in the infra-orbital branch 
and trunk of the ophthalmic vein, which also 
receives the vena centralis retina?. 

ORBITAR APPENDAGES. 

Periosteum The PERIOSTEUM AND ADEPS OF THE ORBIT. 

The dura mater, which is the internal perios- 
teum of the cranium, lines the orbit, and is con- 
tinuous at all its openings with the periosteum 
of the head and face ; hence the extensive sym- 
pathetic pains in the inflammatory affections of 
the bones of the face and cranium, and their 
common membrane. Hence also probably, the 
suppurative inflammation of the dura mater after 
extensive fractures and injuries of the orbit. 

The fat, which in health is secreted abun- 
dantly in the orbit, surrounds the optic nerve, 
and invests the posterior surface and sides of the 
globe, forming for it a soft bed, and defending 
the vessels and nerves from compression in its 
motions. In emaciating diseases its diminution 
by absorption produces that characteristic sink- 
ing of the globe in its socket, and loss of con- 
vexity in the eyelid, which is familiarly ex- 
pressed by the term " hollow eyed." On the 



AND ITS APPENDAGES. 23 

other hand, its secretion in excess, as in mor- 
bid obesity, protrudes, compresses, and thus in- 
duces congestion in the vessels of the eye. 

I proceed to describe the muscles, vessels, 
and nerves contained in the orbit. 

The muscles are seven in number ; viz. the Muscles. 
levator palpebral ; the rectus superior, inferior, 
internus, and externus ; obliquus superior and 
inferior. 

The levator palpebral has an acute origin from Elevator of 

i m the upper 

the periosteum above the foramen opticum ; eyelid, 
its fibres spread in their course, giving it a fan- 
like shape, and they are inserted by a broad 
aponeurosis in a condensed cellular substance, 
which connects the upper tarsus to the orbitar 
ridge, between the conjunctiva and the fibres of 
the orbicularis palpebrarum. From the nature 
and extent of its connection with the eyelid 
it results that the partial division of the tarsal 
ligament, or even the removal of the cartilage 
does not take away the power of elevating the 
lid as the paralysis of this muscle does ; the 
elevation however, under these circumstances, 
is imperfectly performed. 



The rectus superior lies beneath this muscle, superior 

• • n iii r 1 r ' straight 

arising from the border or the foramen opticum, muscle. 
and the partition between it and the foramen 
lacerum. 



24 ANATOMICAL DESCRIPTION OF THE EYE 

internal The rectus internus and rectus inferior arise in 

and infc- .... 

rior. common from a ligament which in part sur- 

rounds the optic foramen, and fills up the fora- 
men lacerum. 



External. The rectus externus arises by two distinct 
heads : the inferior having a common origin 
with the last named muscles, from the ligament 
which occupies the inferior angle of the fo- 
ramen lacerum ; the superior from an arch of 
ligament crossing the foramen above. It is 
important to note this bicipital origin of the 
rectus externus, as some of the nerves of the 
orbit pass through the interspace between its 
heads, and others through the top of the fora- 
men. The ligament of the foramen spheno-max- 
illare forks into three intermuscular slips which 
give origin and support to the external, inferior, 
and internal recti muscles, in the manner of the 
intermuscular ligaments of the extremities. The 
four recti muscles varying in length and direc- 
tion as the sides of the orbit to which they are 
adjacent, pass over the great circumference of 
the bulb, between which and the cornea they 
are inserted, at equal distances, by straight ten- 
dinous fibres, into the substance of the sclerotic 
coat. 



superior The superior oblique muscle rising from the 

oblique. . r -it • 

periosteum between, and a little anterior to the 
origins of the superior and internal recti, passes 
its slender rope of tendon through a half ring of 



AND ITS APPENDAGES. 25 

cartilage which is affixed by a ligament to the 
os frontis, a little above and behind its internal 
angular process. The trochlea is provided with 
a sacculus mucosus, and the tendon emerging 
from it is inclosed in a ligamentous sheath to 
its insertion in the sclerotic coat, at the posterior 
and upper surface of the globe, beneath the su- 
perior rectus muscle. 



The inferior oblique rises from the orbitar inferior 

oblique. 

plate of the superior maxillary bone, behind 
the lacrymal fossa, and takes an oblique direc- 
tion between the globe and rectus inferior, to 
its posterior and outer surface, where it is like- 
wise inserted into the sclerotic. 

The single actions of the recti are expressed Their ac- 
hy the terms, levator, depressor, adductor, and 
abductor. Their co-operation retracts the globe 
in its socket. The oblique muscles, acting 
singly, roll or rotate the eye in contrary direc- 
tions. Their co-operation antagonises that of 
the recti, which power is demonstrated by the 
course of the superior oblique, the origin of the 
inferior, and their posterior insertions. 

The arteries of the eye are principally de- Arteries* 
rived from the ophthalmic artery, which has a 
short but sharp curve at its origin from the 
internal carotid, before it enters the orbit. This 
it does through the foramen opticum, upon the 
temporal side of the nerve. 



26 ANATOMICAL DESCRIPTION OF THE EYE 

The arteria centralis retina? which runs in the 
centre of the optic nerve, and the long ciliary 
arteries which pass upon either side of it are its 
first branches ; next the lacrymal artery, which 
contributes a ciliary branch, a branch to the 
rectus externus, and another which runs beneath 
the globe to the obliquus inferior muscle, and 
reaches the inferior palpebra. The lacrymal 
branch then divides into two: one, a branch of 
communication with the deep temporal branch 
of the internal maxillary artery at the outer 
margin of the orbit; another, which is dispersed 
in the substance of the lacrymal gland and su- 
perior palpebra. 

The trunk of the ophthalmic artery then 
crosses obliquely beneath the optic nerve, and 
on the nasal side of the nerve sends branches to 
the superior oblique and levator palpebra?, rec- 
tus superior and inferior muscles, and commonly 
a ciliary artery. The remaining branches of 
the ophthalmic artery, which is here tortuous, 
are the frontal, through the supra-orbitar fora- 
men ; one or two to the rectus interims, the 
nasal branch which passes by the anterior aeth- 
moid foramen into the nose, and the infra~troch- 
lear branch. The ophthalmic artery at length 
emerges upon the inner canthus, furnishing the 
superciliary and palpebral branches, and anasto- 
moses with the nasal branch of the facial artery 
from the external carotid. The muscular 
branches penetrate between the fibres, and run- 



AND ITS APPENDAGES. 27 

ning in the same direction, appear beneath the 
conjunctiva on the sclerotic coat. Here they 
subdivide and ramify upon the conjunctiva ; the 
fasciculi inosculating so as to form a faint cir- 
culus arteriosus around the cornea, when filled 
with coloured blood. Those of the rectus inter- 
nus are most numerous. 

The veins. The ophthalmic and nasal veins, 
branches of the anterior division of the facial 
vein, freely communicate at the inner angle of 
the orbit with the ophthalmic vein; and the an- 
terior and posterior (ethmoidal or nasal, the 
lacrgmal, all the ciliary veins from the globe, 
the vena centralis retinae, the infra-orbital, the se- 
veral muscular, periosteal, and adipose branches 
are all collected into this trunk in its passage 
through the orbit. It takes a serpentine course 
over the optic nerve, through the foramen lace- 
rum, to terminate in the anterior part of the 
cavernous sinus of the dura mater. 

The nerves of the orbit, exclusive of the Nerves. 
optic, are the third pair, or motor es ; the fourth, 
or pathetici ; the first division of the fifth, or tri- 
gemini; and the sixth, or abducentes. 

The third pair enter the orbit between the 
heads of the rectus externus muscle, in com- 
pany with the nasal branch of the fifth and the 
sixth pair. Its lesser and superior branch rising 



28 ANATOMICAL DESCRIPTION OF THE EYE 

before its entry into the orbit, joins a twig of 
the fifth pair, to assist in forming the ophthalmic 
or lenticular ganglion, and then divides to sup- 
ply the rectus superior and levator palpebral 
muscles. Its larger and inferior branch passes 
under the optic nerve towards the nasal side of 
the orbit ; and while covered by that nerve, is 
divided into a branch to the rectus internus, 
a short thick stalk to the ophthalmic ganglion, 
and a long slender filament to the inferior ob- 
lique muscle. 

From the ophthalmic ganglion lying concealed 
in fat, on the temporal side of the optic nerve, 
a superior and inferior fasciculus of ciliary nerves 
arise, and creep along its sides in a serpentine 
direction to the bulb. 

The fourth pair of nerves, with the lacrymal 
and frontal branch of the fifth, pass through the 
upper part of the foramen lacerum. It some- 
times receives a branch of augmentation from 
the fifth pair, and always increases in size to- 
wards its termination in the central fibres of the 
superior oblique muscle. 

The first or ophthalmic division of the fifth 
pair gives ofT, 

1st. The supra-orbitar, which is subdivided 
into the supra and infra trochlear ramuli, and 



AND ITS APPENDAGES. 29 

the proper frontal nerve ; which last running in 
an external and internal branch upon the levator 
palpebras, is distributed upon the forehead. 

2ndly. The lacrymal nerve, which, taking a 
direction to the outer canthus, splits into an 
external and internal branch. The internal 
supplies with filaments the glomera of the lacry- 
mal gland ; twigs from the external likewise 
enter the gland, and together they are dispersed 
upon the superior palpebra. 

3rd. The nasal nerve, which gives a branch 
to unite with the short stalk of the third pair to 
form the ophthalmic ganglion, and contributes 
two long ciliary nerves to the globe, then passes 
obliquely under the superior oblique muscle to 
the sethmoid foramen, by which it enters the 
nose, furnishing an infra-trochlear filament to 
the nasal region of the orbit. 



-o- 



The sixth pair, having parted with the fila- 
ments supposed to be the roots of the great 
sympathetic upon the canalis caroticus, enters 
the orbit with the nasal of the fifth and the 
third pair, to be spent upon the rectus externus 
muscle. 

The lacrymal gland is of the conglomerate L^ymai 

° gland. 

kind, of a flattened oval form, divided by a cleft 
into two lobes, of which the superior and internal 
is the smaller and thinner, the inferior and exter- 



30 ANATOMICAL DESCRIPTION OF THE EYE 

nal the larger extremity of the gland. Its posi- 
tion is oblique ; the inferior and internal surface 
hollowed to suit the convexity of the globe; the 
superior convex to fit the corresponding surface 
of the orbit to which the gland is attached, by 
a ligament passing transversely beneath it. It 
measures, in length, about ten lines; in breadth, 
five or six. The structure of the gland resem- 
bles that of the salivary, its lobules connected 
by a dense cellular tissue, upon which its vessels 
and nerves subdivide, to supply the granules of 
which they are composed. The vessels enter 
the gland at its posterior margin ; and from the 
anterior, its ducts, five or six in number, pass 
out in straight lines and pierce the conjunctiva 
at the orbitar edge of the superior tarsus. 

We have now briefly described the orbitar 
appendages, or those parts situated behind the 
tunica conjunctiva, and proceed to the 

FACIAL APPENDAGES. 

Eyebrows. The supercilium, or eyebrow. The arch 
of the eyebrow corresponds to that of the super- 
ciliary ridge upon which it is planted. It ex- 
tends from the tuberosity of the frontal sinus to 
the external angle of the orbit. It consists of 
a thick row of strong short hairs, which have a 
disposition almost erect at the commencement 
of the brow, and are then arched obliquely out- 
ward, and gradually reduced in number so as to 



AND ITS APPENDAGES. 

terminate the arch acutely. The few erect hairs 
correspond to the fibres of the corrugator super- 
cilii muscle, the crescentic to the fibres of the 
orbicularis palpebrarum. 

The extent and fulness of the brows vary- 
greatly in different persons. In some, espe- 
cially persons of dark complexion and black 
hair, they have little if any interspace at their 
origin, and are long, prominent, and bushy in 
the centre of the arch. Among the ancients 
these were esteemed points of female beauty. 
The fibres of the occipito-frontalis, or epicranial 
muscle, terminate beneath the skin of the su- 
percilium, blending with those of the orbicular 
muscle of the palpebra. The former elevates 
the brow, wrinkling the integument of the fore- 
head horizontally ; the latter depresses it, and 
closes the eyelids, being the sphincter palpebra- 
rum. 

The corrugatores approximate the heads of 
the supercilia, drawing the integuments over 
the root of the nose into deep longitudinal 
rugae : they co-operate with the orbicularis in 
the act of frowning. The action of the subja- 
cent muscles renders the brow an important 
feature in regulating the quantity of light, con- 
tracting the field of vision, and in assisting the 
expression of the sterner passions. It would 
not be a useless ornament if it were insuscep- 
tible of motion, the hair being advantageously 



$1 



32 ANATOMICAL DESCRIPTION OF THE EYE 

placed upon the projecting ridge of the orbit to 
entangle and arrest particles solid and fluid 
which might otherwise fall or trickle upon the 
eye. The habitual depression of the brow is 
usually a concomitant of a weak or morbid 
retina ; it is characteristic of strumous inflam- 
mation, and is observable in all cases where 
light is offensive, and in those central circum- 
scribed opacities of the cornea and lens, in which 
the dilated state of the pupil is necessary to 
vision. 

Eyelids. The palpebra, or eyelids, are those semi- 

oval curtains which cover the great aperture of 
the orbit, and graduate the light falling upon 
the eye by the degree of their separation, or ex- 
clude it by their apposition. The skin covering 
the palpebral is thin, and loosely connected to 
the subjacent parts by a fine lax cellular texture, 
which abounds at the orbitar margins of the 
palpebral. The frequent oedema of the eyelids, 
so disfiguring to the countenance, is owing to 
the abundance of this tissue void of fat, and 
subject therefore to serous infiltration. 

The superior is broader than the inferior pal- 
pebra, covering two thirds of the surface of the 
globe by its descent. It is also more moveable, 
the inferior palpebra being inconsiderably ele- 
vated to meet it in shutting the eye. The su- 
perior palpebra, when drawn up, makes a dou- 
bling or deep crescent-shaped fold in the skin 



AND ITS APPENDAGES. S'3 

under the orbitar arch, which is effaced when 
the palpebra falls. Upon the skin of the lower 
eyelid narrow and gently curved rugae are seen; 
these, which are signs of the unequal contrac- 
tility of the skin and the muscular fibres be- 
neath it, are more strongly marked in persons 
of advanced years, in whom the muscles have 
been longer and more vigorously employed, 
and whose skin is likewise looser, or redun- 
dant from the absorption of the adeps beneath it. 

When the eyelids are forcibly closed by the oscular 

l • r>\ /-» ii muscle of 

sphincter fibres of the orbicularis palpebrarum, the eyelids, 
the tendon of this muscle starts forward, and 
the rugae are extensively radiated from the nasal 
angle over the skin of the cheek. On removing 
the skin and the subjacent cellular tissue of the 
palpebrae, the thinly spread fibres of the orbi- 
cularis muscle are seen. The tendon with 
which these fibres are connected is a little round 
cord, distinctly seen and felt beneath the tegu- 
ment, implanted in the nasal process of the 
maxillary bone, in the great transverse diame- 
ter of the orbit. The fibres which lie upon the 
palpebral are the interior fibres of the muscle, 
the fissure of the lids being the axis of the oval 
formed by it. The inferior external fibres from 
the round tendon and contiguous parts of the 
maxillary bone, take an extensive sweep over 
the orbitar ridge upon the cheek, towards the 
temple, where they become thin and scattered. 

D 



34 ANATOMICAL DESCRIPTION OF THE EYE 

The superior, from the round tendon and con- 
tiguous part of the frontal bone, take the di- 
rection of the superciliary arch ; being at their 
commencement connected with the fibres of 
the corrugator, and in their course blended 
with those of the frontal muscle. The inte- 
gument of the palpebral is adherent to the 
tendon of the orbicularis, which has been de- 
scribed as the ligament of the palpebral or tarsi, 
and the angle of union between them is larger 
in consequence of this adhesion, than the ex- 
ternal. The inner canthus, formed wholly of 
the doubling of the integument, is that notch 
or triangular sinus formed between the tarsi and 
the tendon of the orbicularis. 

Tarsal car- The tarsi are two elliptical cartilages which 
give figure and firmness to the palpebral, and 
afford a basis for the attachment of their 
several parts. The superior is broader than 
the inferior. Their opposite edges are broad 
and sloped from without inward ; their or- 
bital* edges are thin and continuous with a 
condensed cellular membrane, which is liga- 
mentous where it is inserted into the orbitar 
circumference, and especially at the temporal 
side. Their temporal extremities are angu- 
lar, the nasal rounded. The former termi- 
nate the fissure of the palpebral at the tem- 
poral angle j the latter, which are opposed to 
each other, and brought into contact when the 



AND ITS APPENDAGES. 35 

lids are closed, are situated at the distance of 
two lines from the nasal angle, to which they 
are connected by the doublings of integument 
forming the borders of the inner canthus. The 
convex surface of the tarsi is covered by the 
fibres of the orbicularis and the cellular mem- 
brane connecting them with the integument ; 
the concave, which is exactly moulded to the 
face of the globe, is covered by the membrana 
conjunctiva. 

The cilia, or eyelashes. The exterior bor- Eyelashes. 
ders of the sloped edges of the tarsi, which 
are opposed to each other, are furnished with 
cilia or eyelashes, disposed in three or four 
rows : these we may therefore call the ciliary 
borders of the tarsi. The apertures, in which 
their bulbs are contained, are seen in the inte- 
gument when the cilia are extracted : they are 
more numerous and longer upon the centre 
than the extremities of the tarsal arch, and 
fewer and shorter on the lower than the upper 
tarsus. Their direction is curved, those from 
the upper being arched upwards, from the lower 
downwards. The length and fulness of the 
eyelashes vary in different individuals. They are 
commonly of the same colour as the eyebrows. 

The meibomian follicles. Upon the inte- jJjJJJVj^ 
rior border of the tarsus the mouths of a row of 
follicles, seated vertically on the concave sur- 
face of the tarsus, form a slightly eminent line. 
d 2 



3G ANATOMICAL DESCRIPTION OF THE EYE 

These follicles, when magnified by a glass, ap- 
pear to be small knotted tubes, resembling studs 
of the smallest pearls, arranged for the most 
part in parallel lines, and communicating with 
each other at their origin from the orbitar edges 
of the tarsi, but terminating by distinct orifices 
upon their interior borders, which we may dis- 
tinguish from the ciliary as the meibomian 
borders of the tarsi. In their length, con- 
nection, and arrangement, they present con- 
siderable variety. The fluid, which they 
secrete, may be expressed in a condensed 
form in diseased states of the follicles, or after 
death, in the shape of small white worms. It 
is an unctuous fluid lubricating the tarsal edges, 
preventing the effects of attrition from their 
frequent contact, and facilitating their motions 
over the contiguous surface of the globe. 

Lacrymal The PUNCTA LACRYMALIA, SACCULUS, AND 

ductus lacrymalis. The obliquity of the tar- 
sal edges, which are opposed to each other, 
leaves a groove or sulcus between the meibo- 
mian borders and the surface of the globe 
when the ciliary borders are in contact. This 
increases in breadth toward the nasal angles of 
the tarsi, where the puncta or orifices of the 
lacrymal excretories are placed upon two small 
conical eminences accurately opposed, and ter- 
minating the meibomian borders : they are two 
pinholes formed in the cartilaginous substance, 
and thus preserved permanently open. Their 



AND ITS APPENDAGES. 37 

course is at first perpendicular to the tarsi, in 
which direction they form a short cul de sac; then 
they are turned at right angles towards the nose, 
and lie in the doubling of the skin, forming the 
borders of the inner canthus. They are, if we 
except their orifices, purely membranous canals 
leading to the oblong membranous sac situated 
in the lacrymal fossa ; they terminate side by 
side, or more frequently, in a common duct, 
in the upper and anterior part of this sac, 
under the tendon of the orbicularis. 

The position and direction of the lacrymal 
sac correspond to the fossa formed by the ante- 
rior concave portion of the os unguis, and the 
nasal process of the superior maxillary bone, 
upon which it is seated ; it rises a little higher 
than the termination of the lacrymal duct 
or ducts, and the transverse tendon of the 
orbicularis crosses the upper part of it. Below 
it contracts into a duct, which occupies the 
canal formed by the nasal process of the 
maxillary bone, and the spoon-shaped process 
of the os spongiosum applied to it. The 
course of this duct is downward, outward, and 
gently slanting backward ; it opens by an 
oblique fissure under the convex scroll of 
the spongy bone, in the side and near the 
floor of the nostril. A probe, introduced from 
the nostril into the nasal duct, must have a 
sharp curvature to enter it with facility. The 



38 ANATOMICAL DESCRIPTION OF THE EYE 

membrane of the sac and duct is intimately ad- 
herent to the bony parietes. The anterior and 
exposed surface of the sac is defended by a 
fibrous or ligamentous expansion, derived from 
the circumference of the lacrymal fossa. The 
orbitar is distinguished from the nasal portion of 
the duct by a fold or duplicature of its lining 
membrane, and another similar fold some- 
times occurs in the nasal part of the duct. The 
membrane of the lacrymal canals and nasal duct 
is abundantly furnished with mucous follicles or 
lacunae, The fulness of the membrane, where 
it is reflected from the nasal extremity of the 
duct, greatly diminishes the diameter of the bony 
aperture, and gives it a valve-like form. The 
diameter of the lacrymal and nasal canals ex- 
ceeds that of their orifices. The puncta absorb 
the tears, which have been conducted from the 
lacrymal ducts by the tarsi, and convey them 
into the sac to pass off by the nasal duct. 

conjunctive The tunica conjunctiva. The integument 
of the eyelids is inflected at the edges of the tarsi, 
and lines the whole of the concave surfaces or 
the palpebral ; is reflected upon the visible face 
of the globe, enters into the puncta, lines the 
lacrymal sac, and at the nasal extremity of the 
duct is continuous with the common mucous 
membrane of the nostrils, fauces, and alimen- 
tary canal. 



AND ITS APPENDAGES. 39 

The conjunctiva having lined the interior 
surfaces of the tarsi, is connected to the liga- 
ments of the tarsi and palpebral muscles, and 
from thence reflected upon the globe, so as 
to form an oblong sac or pouch. Its attach- 
ment to the sclerotic is such as to prevent its 
forming folds in the motions of the globe, to the 
freedom of which it offers no impediment. As 
it approaches the cornea, its attachment be- 
comes more strict, and at the margin of that 
membrane it is inseparable from it. Its con- 
tinuity is ascertained by dissection, but its 
tenuity and transparency are increased, and 
when held to the light it has a nearer resem- 
blance to a very delicate lamella of the cornea 
than to the conjunctiva of the sclerotic. After 
maceration, the separation is more readily ef- 
fected. 

The character of this membrane is so mate- its continu- 
ity demon- 

rially modified by its several relations with the stratedby 

i i ii disease. 

integument, the tarsi, the sclerotica and the 
cornea, that its continuity alone establishes its 
identity. The fact of continuity is however 
corroborated by some pathological phenomena, 
which so often illustrate problematical points in 
anatomy and physiology. For example, the 
conjunctiva furnishes the matrix for the adven- 
titious vessels, which are created to repair 
breaches of the corneal texture. These ves- 
sels, whether formed by the healing process, or 



40 ANATOMICAL DESCRIPTION OF THE EYE 

opened by long continued diseased action, as in 
chronic ophthalmia, are obviously superficial. 
The circumstances by which they are produced, 
are characterised by different appearances, as I 
shall hereafter point out. Again, when a small 
portion of conjunctiva is abraded by an ex- 
traneous particle, the scabrous surface of the 
cornea is exposed, and ulceration of this sur- 
face ensues. The deficiency of the conjunc- 
tiva is exactly depicted by the margin of the 
abrasure, and the contrast of the surfaces. 
This is very dissimilar to the interstitial ulcer 
of the cornea. The pterygium, a rare dis- 
ease, exhibits the continuity in a very striking 
manner. It has a full broad base next the can- 
thus, where the conjunctiva lies loose, and is 
gradually flattened and drawn to a point, so as 
to have a wedge-like form as it approaches the 
cornea. But although the deposition is beneath 
the conjunctiva, it does not stop at the cornea, 
but slowly travels across it. The strictness of 
the adhesion alters its appearance ; the lymph 
shed between the conjunctiva and cornea, pre- 
senting only a progressive dense opacity, in- 
stead of the fleshy elevation which it exhibits 
upon the sclerotic. The continuity of the super- 
jacent texture is demonstrable. 

Upon the tarsi, the membrane is closely ad- 
herent, and although transparent appears of a 
pale ied tint - } upon the sclerotica and cornea it 



AND ITS APPENDAGES. 41 

is colourless. The sclerotic conjunctiva, how- 
ever destitute of red vessels in the tranquil state 
of the organ, becomes conspicuously vascular 
and acquires a deep red colour by inflammation, 
its minutest capillaries appearing to convey red 
blood, in the vehement acute ophthalmia. 
Those of the corneal conjunctiva are only to 
be seen when, by continued distension, the 
connection is loosened between the conjunctiva 
and cornea. In this case, the cornea exhibits 
red vessels freely inosculating from its opposite 
sides, and anastomosing with each other. The 
increase in number and extent of these ves- 
sels is a gradual process, demonstrable to ob- 
servation, and the inflammatory action which 
precedes this state, is ordinarily of considerable 
duration. The incapacity of the vessels of the 
corneal conjunctiva to receive red blood, seems 
to depend upon the strictness of its adhesion. 

TlIE VALVULA SEMILUNARIS, AND CARUNCULA Semilunar 
LACRYMALIS. The Conjunctiva is attached tO crymaTca-' 

the canthi of the eyelids, and at the internal runce ' 
canthus, forms a semilunar duplicature in shape 
of a valve. The horns of this crescentic fold 
are lost in the sinus palpebralis, or angular fold 
of the conjunctiva. 

On the fore part of this valve, a small red 
glandular body, caruncula lacrymalis, is seen, 
occupying the hollow of the canthus. The 



42 ANATOMICAL DESCRIPTION OF THE EYE 

caruncula is a granulated substance, of a co- 
nical form and a deep red colour. The base 
of the cone is next the orbit, the apex towards 
the eye. A few fine hairs are scattered over its 
surface. It is made up of a congeries of minute 
follicles, secreting that mucus which accumu- 
lates during sleep in the form of a gummy mat- 
ter, at the inner corner of the eye ; and appears 
to perforin a similar office to that of the meibo- 
mian glands, which are confined to the tarsi. 

From the above description it will be under- 
stood, that the palpebra, the anterior hemi- 
sphere of the eyeball, and the lacrymal passages 
are every where covered by the reflected in- 
tegument, modified in its disposition and quali- 
ties as its economy requires ; and which in- 
vests the organs of sense, the hollow viscera, 
and forms the external covering of the body. 
It is by the continuity of this membrane that 
the sympathy is established between these sur- 
faces, healthy and morbid, remote and con- 
tiguous, and that the diseases with which they 
are affected have for the most part a common 
character. It remains only that I should point 
out the origin and disposition of the superficial 
vessels and nerves, by which the palpebra? are 
supplied. 



Vessels and THE ARTERIES, VEINS, AND NERVES OF THE 

the eyelid*, talpebr^. A superior and inferior blanch, de- 



AND ITS APPENDAGES. 43 

rived from the ophthalmic artery, at its egress 
from the orbit, course along the orbital edges of 
the tarsi, and form, by inosculation at the exter- 
nal angle, a complete arcus palpebralis. A su- 
perciliary arch is also formed by the union of 
the superciliary artery, from the ophthalmic, 
with the temporal. The nasal branch of the 
facial artery assists in forming these arches, and 
freely communicates with the frontal branch of 
the ophthalmic. The superior coronary, trans- 
verse facial, infra orbital and temporal artery 
participate in the supply of the palpebrae. 

The veins, beginning by small radicles from 
the opposite margins of the tarsi, form an in- 
tricate plexus beneath the skin of the palbebrse, 
and are collected into the facial, supra-orbital, 
and deep temporal vein. The arteries pass in 
the direction of the orbicular fibres, the veins 
cross them at right angles ; their direction ac- 
cording to the breadth of the palpebrae. 

The nerves take a direction similar to the 
veins, the frontal branch of the fifth pair sup- 
plies the superciliary and superior palpebral 
branches ; and the infra orbital, or first branch 
of the superior maxillary nerve, gives off three 
principal branches, which turn round the trunk 
of the facial vein to be dispersed upon the lower 
eyelid. 



44? ANATOMICAL DESCRIPTION, &C. 

For the simple and general view which I have 
taken of this subject in the foregoing descrip- 
tion, if any apology be necessary, I know of 
none more appropriate than that contained in 
the following paragraph. 

u The study of anatomy, as it leads to the 
knowledge of nature and the art of healing, 
needs not many descriptions nor minute dissec- 
tions ; what is most worth knowing is soonest 
learned, and least the subject of dispute ; while 
dividing and describing the parts, more than 
the knowledge of their uses requires, perplexes 
the learner, and makes the science tedious, dry, 
and difficult." Cheselden's Preface to his Ana- 
tomy, 



SKETCH 



PHYSIOLOGY OF THE EYE. 

AND ITS APPENDAGES. 



It is not my intention to enter into an abstract 
discourse on the phenomena of vision, a sub- 
ject more allied to philosophy than medicine, 
but the preceding sketch would be incomplete 
without some account of the functions of the 
organ, and the history of its diseases would 
want the illustration which a competent know- 
ledge of its ceconomy conveys. 

I shall suppose the reader acquainted with Prelimi- 
nary posi- 
the prevailing opinions concerning the origin tions. 

and nature of light ; the velocity of its move- 
ment ; the meaning of the terms direct, re- 
flected, and refracted rays ; the equality between 
the angle of reflection and the angle of inci- 
dence j and the facts, that refraction is in- 



4G PHYSIOLOGY OF THE EYE 

creased according to the relative density of bo- 
dies, and that the convergence of rays after re- 
fraction is proportionate to the curvature of the 
surface through which they pass. Further, the 
decomposition of light by the prism into seven 
elementary colors, which differ in their refrangibi- 
lity ; the reflection of all the rays together pro- 
ducing the appearance of white ; while their par- 
tial reflection occasions the various diversities of 
color, and their total absorption the sensation of 
black, which is in fact but the absence of color. 
Lastly, the emission of the rays of light from 
every visible point of the surface of a lumi- 
nous body, and their divergence thence so as 
to form a cone, of which the apex corre- 
sponds to the point from which they emanate, 
and the base to the surface upon which they 
impinge. 



i 



Influence 
of the se- 



The operation of the cornea upon the rays of 
verai te X - lj s ht is to render them convergent towards the 

tuns upon ° " 

the rays of re tina, by reason of the sphericity of its surface, 

light. ' J . * 

and its greater density compared with the at- 
mospheric medium through which they pass. 
The rays which fall within an angle of 48°, 
or thereabouts, measured on the surface of the 
cornea, pass through it and are refracted in their 
passage. Those which are not included within 
this angle are reflected by the verge of the 
cornea and the sclerotic coat. The aqueous 
humor, being of inferior density to the cornea, 



AND ITS APPENDAGES. 47 

diminishes in some degree the convergence of 
the rays which proceed through it, so that the 
total effect is nearly the same as that which would 
result from the refractive power of the aqueous 
humor alone, if the cornea had not existed. The 
rays which lie remote from the visual axis, are 
not transmitted through the pupillar aperture, 
but are reflected by the iris, and in part ab- 
sorbed by the pigment coating its posterior sur- 
face, without which pigment it would be diapha- 
nous, as in the albino. The superior density of 
the crystalline cooperates with its curvature to 
increase the convergence of the rays which are 
admitted within the pupil ; and by their passage 
through its posterior surface, this convergence is 
increased, because they arrive at the vitreous 
humor, which is a medium of inferior density. 
By the operation of all these causes the rays are 
collected into foci upon the retina, and that 
part of the object from which the rays proceed 
is painted upon this membrane. 

The result then, it appears, of a series of re- 
fractions of the rays of light in passing through 
the humors of the eye is their collection into 
foci upon the retina, so as to form a complete 
picture of the external scene. 

From this account it will be perceived that Jf™™* 01 * 
each pencil will consist of a double cone of rays, '^ageon 

*• * ' the retina. 



48 



PHYSIOLOGY OF THE EYE 



the axes of which are right lines, their base3 
meeting in the crystalline and their apices being 
situated in the object and the retina respect- 
ively. The rays from the top of the object are 
deflected to the bottom of the eye, and those 
from the side of the object to the right of 
the observer, are deflected to the left side of 
the eye, and vice versa ; hence the inversion 
of the picture upon the retina. The following 
simple experiment, demonstrating this fact, is 
well known. A portion of the coats being re- 
moved from the back of the eye, and their place 
supplied by a piece of oiled or tracing paper, 
the flame of a candle placed before the cor- 
nea is exhibited of diminished size and inverted. 
We infer that this image excites the perception 
of the object, because distinct vision is en- 
joyed only in such conformations and conditions 
of the eye, as allow of its being accurately 
formed and impressed. 



Correction 
of aberra- 
tion from 
unequal re- 
fraction. 



The necessary effect of the spherical figure of 
the cornea is to occasion an unequal refraction of 
the rays which permeate it, and hence to create 
a degree of aberration which would confuse 
vision. This is corrected in two ways: first, 
by the gradually increasing density of the lens 
from the circumference to the centre, and its 
consequently refracting with less power those 
rays which arrive at it with a considerable 



AND ITS APPENDAGES. 49 

obliquity ; and secondly, by the mobility of the 
iris, which adapting the size of the pupil to the 
circumstances of the case, excludes more or less 
those rays which would produce aberration. 

I have stated that the iris serves to arrest offkeofthe 
those rays which are denied admission through 
the pupil : they would be unequally refracted 
by those points of the lens through which, if 
uninterrupted, they must pass, or would fall so 
obliquely on the cornea as to be subjected to too 
great a refraction. This is its passive func- 
tion ; but by its power of dilatation and con- 
traction, in obedience to the stimulus of light 
upon the retina, it determines the quan- 
tity necessary for the purpose of distinct 
vision. In regulating the quantity of light 
the iris assists materially in accommodating the 
eye to different distances : in viewing a distant 
object the pupil dilates, and in viewing a near 
one it contracts. It is true that viewing the 
sun occasions a contraction of the pupil, and 
the stedfast vision of a near object in de- 
ficient light, its dilatation. These are con- 
firmations of the statement that its motions are 
in obedience to the impression of light upon 
the retina, because the direct emanation of 
light from its source in the one case, and the 
insufficient light in the other, render these ob- 
jects analogous in this respect to the nearest 
and the remotest visible objects. But under 

E 



50 PHYSIOLOGY OF THE EYE 

ordinary circumstances, the illumination of ob- 
jects being conformable to the distance, the 
pupil, in viewing a distant object, is dilated so as 
to admit as many rays of the enfeebled light as 
is necessary to the distinct perception of the 
object, and on the other hand contracts to ex- 
clude the superfluous rays, which coming from 
a near object, would otherwise create confusion. 
Let a person survey the sun whilst the pupil is 
fully dilated by belladonna, or under the same 
circumstances, the flame of a candle brought 
near to the eye, and in either case he will find 
his vision confused to dimness. But the fullest 
permanent dilatation of the pupil will not in- 
jure the clearness of his vision of any other re- 
mote object, though that of all near objects 
will be in a degree confused, and the confu- 
sion be increased in proportion to the degree of 
their illumination. Where the iris is from any 
cause motionless, the power of adapting the 
eye to distances is lost. I conclude therefore 
that the adaptation of the eye to light co-ope- 
rates with its adaptation to distance. 

corrective By the peculiar constitution of the crystalline 
the lens, lens, before adverted to, its refractive power 
is so adjusted to that of the contiguous 
aqueous and vitreous humors, as to correct 
the aberrations which the figure of the cornea 
would occasion, and to throw the most oblique 
pencils of rays with sufficient accuracy upon 
the concave face of the retina. 



And tts appendages. SI 

Notwithstanding man, compared with ani- and »»e of 

. the pig- 

mals, requires the largest quantity of light for ment* 
vision, the images of objects on his retina are 
undisturbed by reflection, owing to the absorb- 
ing quality of the dark pigment, which being 
spread over the whole interior of the globe, 
renders the eye a most perfect camera obscura* 
Animals, in whom this pigment is a brilliant re- 
flecting surface, have the advantage of seeing 
in feebler light, and this power is in proportion 
to the whiteness of the pigment ; but the ac- 
curacy of their vision, it may be presumed, is in 
the same proportion defective. 

Not only is the clearness of the image un- Achro «>atic 

•> ° power of 

disturbed by superfluous light, but it is also Helens* 
destitute of color, the decomposition of light 
by irregular refraction being in ordinary vision 
prevented or corrected by the structure and 
curvature of the crystalline lens. Light, arti- 
ficially separated, either by refraction, reflection, 
or inflection, produces color ; but the light 
which arrives at the eye in its natural combi- 
nation of elementary rays, undergoes no such 
decomposition in its passage through the hu- 
mors. 

The retina is equally expanded over the vi- field of 

. ... vision. 

treous humor, but the field of vision is limited. 

This is not, however, confined to the axis of 

vision 5 for in certain positions of the eye ? ar- 

e 2 



w 



PHYSIOLOGY OF THE EYE 

tificially induced, we have a clear perception 
of an object from which the rays pass so ob- 
liquely as to fall upon the retina not in the 
axis of vision. It has been long observed, that 
if an image fall upon a certain spot of the re- 
tina, the perception of it is obscured. This 
spot, about one thirtieth of an inch in diame- 
ter, corresponds to the entrance of the optic 
nerve. 

Magnitude The magnitude of the image formed upon 

ofthe i • • : i i i i • u 

image. the retina, is proportional to the angle which 

the two extremities ofthe object viewed subtend 

with the centre of the eye. Hence, the more 

remote the object the smaller the image. 

Duration of The duration of the impression made upon 

the impres- 
sion, the retina is in proportion to the strength ofthe 

impression ; this is illustrated by the appear- 
ance of a fiery circle produced by the rapid re- 
volution of a lighted stick. The principal 
phenomena of ocular spectra admit of an ex- 
planation in some degree similar, as for example, 
the appearance of a luminous halo after looking 
intently at a colored object, remaining even 
after the eyelids are closed. 



Distance, The eye possesses no absolute power of de- 
size, and ... . ,. , 
portion of termining the actual distance, magnitude, and 

objects. .. _ . oii it 

position of objects, buch ^knowledge is rela- 
tive, and results from the experience derived 



AND ITS APPENDAGES. 53 

from the combined agency of the senses of sight 
and touch. 



It remains that I should advert to what 
may be termed the problems of vision ; but as 
I have little from my own observation to offer 
upon these subjects, and as their investigation is 
in a considerable degree connected with the de- 
partment of physical optics, or of metaphysical 
speculation, I shall be excused for touching 
them lightly. 



The images of objects are inverted upon the inversion of 
;ina 3 
erect. 



the image 

retina, yet we see them, as they are in nature, 



If we look in a concave mirror, objects ap- 
pear inverted. The image formed upon the 
retina is in this case erect, and we see the object 
in the same relative position to the image, as all 
other objects. Of this fact any one may con- 
vince himself, by preparing an eye, as before 
mentioned, and placing beside and a little be- 
hind the flame of the candle a spoon, the hollow 
of which reflects it inverted, when he will ob- 
serve on the opposite side of the oiled paper 
the images of the real and the reflected ob- 
ject, the first inverted, the second erect. 

It has been generally supposed that we ac- Common 

theories. 

tually see objects inverted, and that this error of 
the sight is corrected by experience. Some, on the 



54 PHYSIOLOGY OF THE EYE 

contrary,have supposed thatthemindacquiresthe 
perception of objects, not from the picture upon 
the retina, but from the object itself, by retra- 
cing the direction of the pencils to their points 
of radiation. Others assert, that a decussation 
of the fibres of the optic nerve corrects the erro- 
neous impression before it is presented to the 
sensorium. 

Berkley's The celebrated explanation of Berkley, in so 

theory. m 

far as it admits of an abridged exposition, is as 
follows. Visible and tangible ideas occupy dis- 
tinct provinces, and have originally no affinity 
to each other. It is only by experience that they 
become connected. The impressions on the 
organ of sight suggest by association the ideas 
of objects acquired by the sense of touch, just in 
the same way as the word used to denote an ob- 
ject immediately suggests the idea of that object 
to a person who is familiar with the language. 
The image on the retina is merely the instru- 
ment, not the object of vision. Its position has 
originally no influence on the ideas we form of 
the situation of external objects; and the sup- 
posed difficulty in the case of the inverted images 
arises from confounding ideas derived from the 
sense of touch with those derived from the 
sense of sight*. 

* A person born blind and suddenly restored to sight, is 
the case supposed by Berkley and other writers, and so hap- 
pily exemplified by Cheselden. Such a person, it is clear, 
would gain nothing by the aid of sight, until the connection 



AND ITS APPENDAGES. 55 

The association of ideas, derived as they are intercourse 

J . of the 

from the external senses, operates imperceptibly senses ne- 

cessary to 

to an extent that we have no means or ascer- their deve- 
taining, because the original and absolute nega- 
tion of each sense in succession, so that each 
should be in turn insulated, is an impossible con- 
dition, notwithstanding the seemingly possible 
independence, in a state of society at least, of 
the animal and vital functions. Touch, in the 
extended sense of physical feeling, is the basis 
of all; sight, hearing, smell, and taste, like the 
sense of touch itself in its strict and limited 
import, are but modifications of it. That 
either or all of these therefore should be want- 
between touch and sight grew up and established itself in his 
mind. 

" L'objet propre et immediat de la yue n'est autre chose 
que la lumiere coloiee : tout le reste, nous ne le sentons qu'a 
la longue et par experience. Nous apprenons a voir pve- 
cisement com me nous apprenons a parler et a lire." — Vol- 
taire. Physique Newtonienne, Chap. 7. 

Our Shakspeare who * needed not the spectacles of 

books to read nature, but looked inwards and found her 

there,' puts this distinction with admirable force and 

shrewdness, in the dialogue between G!o;ter and the blind feU 

low who feigned to be cured of his native blindness at St. 

Al ban's shrine. 

Gloster. 

Saunder, sit there, the lying'st knave in Christendom. 

If thou hadst been born blind, 

Thou might'st as well know all our names, as thus 

To name the several colours we do wear. 

Sight may distinguish colours : 

But suddenly to nominate them all, 

It is impossible. 

2d Part of King Henry VI. Act 2, 



S6 PHYSIOLOGY OF THE EYE 

ing, is not incompatible with their constitu- 
tion ; but the sense of contact is so essen- 
tially and indivisibly incorporate with the or- 
ganic nervous system, that its negation would 
be paramount to acephalous monstrosity. — 
Hence its influence as a substitute and corrector 
in relation to the rest, when wanting or imper- 
fect, can never be fully appreciated, because it 
cannot, like them, be subjected to analytical 
test. But from what we see of the effects of 
privation of one or more of the external senses, 
and of their reciprocity in general towards each 
other in cases of malformation and disease, is it 
not in the highest degree probable, that their 
natural intercourse and cooperation are essential 
to the developement of each respectively? To 
illustrate my meaning — -If it be possible to sup- 
pose a case in which the eye was the only external 
organ of sense, would the unfortunate possessor 
have any distinct idea of visible objects; or, mu- 
tatis mutandis, the ear of sounds? Certainly not. 
Dumbness is in most cases only a consequence 
of the absence of hearing; the organs of speech 
are perfect: so the loss of visual perception, (not 
of light more than of unharmonized articula- 
tion) would result in the case supposed, from 
the absence of the associated sensations and 
ideas thence derived. 



Vision. 



How it happens that impressions made upon 
our two eyes at one and the same time are repre- 
sented single to the sensorium, we know as little ^ 



AND ITS APPENDAGES. '&l 

as why we hear one sound with two ears, and 
smell one scent with two nostrils. The mind 
is incapable of receiving two distinct impres- 
sions at the same instant. The interval is too 
small to be measurable, but the simple experi- 
ment of Haller affords unexceptionable evidence 
of the fact that we employ our eyes severally, 
and not at the same instant, in distinct vision*. 

But we know that if the direction of the two Double 

vision. 

eyes is in conformity, each with the other, ob- 
jects appear as they are, single; and that when 
a certain divergence or derangement of the ' 
visual axes exists, objects appear double. If 
the image, for example, is thrown upon a 
point of the retina of one eye, not in cor- 
respondence with the spot impressed in the 
other, this effect is produced. The double 
image of a candle is seen when gentle pressure 
is made on the globe of one eye ; and it is 
either in the horizontal or vertical direction, ac- 
cording as the finger is applied to the side of 
the cornea, or below it. It is observed that a 
more considerable inclination of the optical axis 
is required to produce a double image in the 
transverse than in the vertical plane. 

We are not, however, to conclude that a Double vi- 
sion with 
double image is formed only, when the obli- one eye. 

* Elern. Pbys. Vol. V. Sec. IV. 9. 



58 PHYSIOLOGY OF THE EYE 

quity of the optic axis is such, as to throw the 
image beyond the area of the points of corres- 
pondence in the retina. It may happen when but 
one eye is employed, from a partial compression of 
the retina, optic nerve, or cerebrum, or some pecu- 
liarity of figure, or opaque streaks in the humors 
intercepting the radiant pencils, so as to pro- 
duce a double refraction. 

Double vi- Neither is double vision a common result of 

sion from 

strabiimus. strabismus where the distortion of one eye is 
obvious and permanent ; for in squinting, whe- 
ther congenital or acquired, the distorted eye is 
weak in comparison with its fellow, and in the 
majority of cases the loss of association is the 
consequence of its weakness. It is, in fact, 
wholly unemployed in intent vision, which it 
would only tend to confuse. Where double vi- 
sion occurs, it is seldom if ever a permanent 
symptom, although the squint becomes con- 
firmed, or even increases. The disappearance 
of this symptom might be accounted for by 
the very probable accommodation of the de- 
ranged eyes, and the substitution of new points 
of correspondence in the distorted eye under 
the influence of habit ; but in every instance of 
deviation, I believe it will be found that the 
averted eye is unfit, in respect of power, and 
therefore ceases to associate with its fellow. 
Even in the cast or leer the affected eye is un- 
employed in vision. The focal distance of the 

7 



AND ITS APPENDAGES, 

two eyes is in such cases so much at variance, 
that confusion would necessarily result from 
their simultaneous employment, if that were 
possible. This question is not affected by the 
arguments which go to prove, that for the pur- 
pose of intent vision, one eye only is or can be 
employed at the same time, The points of cor- 
respondence are essential to preserve the unity 
of vision, because an indistinct or confused 
perception, or a double image, would be pro- 
duced in the state of indolent vision, when it 
is admitted that both are employed. The defec- 
tive eye, it is true, extends the field of sight ; 
but if the sound eye be closed, the person 
discovers that lie is indebted to it for little 
more ; and therefore, if it correspond in di- 
rection with its fellow, he finds an advantage 
in closing it for the purpose of accurate vi- 
sion ; if it is permanently averted, it is as much 
unemployed, as if it were closed. Cases have 
occurred in which the exclusive employment of 
the averted eye has at, length restored its tone 
and direction. The squinting eye recovers its po- 
sition when the sound eye is closed, but relapses 
when the latter is again opened, because its em- 
ployment ceases. Cases of squint arising from 
mechanical causes are of course excepted in this 
observation, being incapable of even tem- 
porary rectification ; but in these the turned 
eye is idle. 



It must be evident to all persons who con r ofthe«$ 



Uljustment 



60 PHYSIOLOGY OF THE EYE 

to objects at sider the subject, that the rays of light which 
distances, issue from an object at some distance from the 
eye, and those issuing from a much nearer 
object, cannot be collected into foci at the 
same given distance behind the crystalline 
lens, unless the eye have a power of altering its 
focal distance. It must do for itself what a 
convex glass does for those, who by reason of a 
certain configuration cannot see near objects 
distinctly, or a concave glass for those who have 
no distinct sight of objects beyond a moderate 
distance. In the first, owing to a defective 
refracting power, the rays cannot be brought to 
a focus soon enough ; in the second, owing to 
too great a refractive power, they are brought 
into a focus too soon. The picture in the one, 
without the aid of the glass, would be formed 
behind the retina, and in the other anterior 
to it. The point of perfect indolent vision, or 
the extreme focal distance of the eye, and the 
range or space through which it has the power 
of preserving distinct vision nearer to the eye, 
varies in different individuals, and very often as 
before stated, in the eyes of the same individual. 

TOtheses hy ~ * sna ^ content myself with a very brief men- 
tion of the principal hypotheses to explain the 
adjusting' mechanism. To enumerate all with 
barely intelligible conciseness, would occupy a 
large portion of this volume ; such is the inte- 
rest which this subject has excited. It has been 
ascribed to a change of figure in the cornea, to 



AND ITS APPENDAGES. 61 

the variations in the diameter of the pupil, to 
a change of figure of the globe by the action of 
its muscles, to a change of figure of the lens by 
an action proper to itself, to a change of place of 
the lens by the contraction of the ciliary pro- 
cesses and the compression of the vitreous 
humor at its circumference. 

The first supposes a close aponeurotic expan- 
sion derived from the tendons of the recti 
muscles, bracing the anterior segment of the 
globe ; the second assumes the muscularity of 
the iris, or the extension of its texture, by the 
sudden injection of its vessels, and vice versa, 
its abridgment by their contraction ; the third, 
a power in the muscles of the globe either to 
shorten or elongate its axis j the fourth at- 
tributes muscularity to the crystalline ; and the 
fifth a similar structure to the ciliary processes. 

I shall not enter into a discussion of the 
merits of these hypotheses, because no one, I 
believe, disputes the force of the objections to 
which they are more or less exposed. 

A healthy state of the retina, of the crystal- Conditions 

^ ' requisite. 

line lens, and of the iris and ciliary apparatus, 
are conditions indispensable to the perfection of 
this mechanism. It is impaired in proportion 
to the debility of the retina in the various forms 
of amaurosis ; it is suspended during the per- 



62 PHYSIOLOGY OF THE EYE 

manent contraction or dilatation of the pupil, 
and it is lost after the removal of the crys- 
talline under the most favourable circum- 
stances ; but the failure of any one of these con- 
ditions, exclusively, is destructive to it ; as for 
example, though the retina and crystalline be 
healthy, if the iris be motionless, or though the 
retina be sound and the iris active, if the crystal- 
line be absorbed. I know that very different 
statements have been given to the public, so 
different indeed as to be almost the converse of 
these. I am ready to admit that the results 
are subject to modifications, as the cases vary, 
and no two are exactly similar ; but these are the 
general results of my experience. I have already 
said that the iris by regulating the quantity of 
light assists in the office of adjustment to dis- 
tance, and that these functions are in a de- 
gree consentaneous. lam disposed to consider ad- 
justment as the result of a change of figure in 
the lens, such as we may coarsely imitate by 
gentle pressure of the crystalline of the horse or 
ox, held in a vertical position between the 
thumb and fore finger. Its form and lamellated 
texture render it peculiarly susceptible of such 
a change, and the absence of a connecting 
medium between its plates, indeed of any vas- 
cular organization, prevents the possibility of a 
nebulous obscurity resulting from pressure so 
applied. A very slight increase of its curvature, 
we have been informed on competent authority, 



AND ITS APPENDAGES. 6S 

would be sufficient to explain the phenomenon 
of adjustment, assuming its quiescent state, which 
its elasticity tends incessantly to restore while 
subjected to compression, as that fitted for per- 
fect indolent vision. 

Notwithstanding the absence of anatomical Tris '".p"' 

° muscular, 

proof, I cannot but regard the motions of the 
iris as muscular motions, and the pupillary por- 
tion an orbicular sphincter, such as environs the 
several outlets or apertures of the body. To this 
structure I attribute its uniformity under varying 
magnitudes — its incapacity of contraction, when 
having a fixed point, as happens in some mal- 
formations; when confined by adhesion at any 
point of the circle to the capsule of the lens, or 
when its texture has been the subject of adhesive 
inflammation — its recovery of a prolapse through 
a section of the cornea, and resuming its cir- 
cular figure when overstretched, as in extraction, 
by a gentle friction of the eyelid — the extreme ve- 
locity of its contraction, and the comparative slow- 
ness of its relaxation- — its ordinary preservation 
of a mean or middle state between the spasmodic 
contraction induced by acute inflammation and 
the dilatation we must from ascertained phe- 
nomena presume to be induced by absolute 
darkness long continued — its inferior power 
of contraction in children, and the increase of 
its power by exercise, as in artisans incessantly 
employed upon minute objects, in whom it is 



64 PHYSIOLOGY DF THE EYE 

apt to acquire a rigidity which scarcely admits 
of dilatation — its obedience, in all respects, to 
the laws which regulate the muscular system — 
its contractility in proportion to the strength 
and perfection of the nerve of sense with 
which it is associated — its incapacity of perfect 
contraction when tremulous, and its spastic con- 
traction, even to the resistance of the influence 
of belladonna, in tetanus — its relaxation when 
the sphincters are relaxed, as in syncope, as- 
phyxia, apoplexy, or compression of the brain, 
and after the use of alcohol in excess — its com- 
plete dilatation when under the influence of the 
sedative poisons, as opium, hyoscyamus, bella- 
donna, &c. to which its proper nerves are in a 
peculiar manner irritable. 

and partly The ciliary portion of the iris I regard as an 

elastic m J * , m . . . 

elastic structure. It is by virtue of its elasticity 
that the extraordinary dilatation of the pupil, 
such as we see under the use of belladonna, is 
produced. Here, as in other parts, elasticity 
is opposed to muscular action; hence when the 
latter is paralysed or from any cause dimi- 
nished, the former strikingly predominates ; 
when the nervous supply is intercepted, the 
pupil gapes widely, the action of elasticity being 
independent of the sensorium. 

pupils of All animals which have a moveable iris, 

animals. 

have the pupil circular, oblong or elliptical, 
6 



AND ITS APPENDAGES. 6/J 

forms favourable to the arrangement of marginal 
fibres*. In fish the iris is evidently a prolonga- 
tion of the choroid without interruption of conti- 
nuity; it is therefore motionless. I concentrated 
the sun's rays in the focus of a pocket lens, and 
threw them upon the pupil of a perch, at the 
moment of drawing it from the water ; it under- 
went no change. In other animals it contracted 
to a line vertical (cat) or horizontal (adder, 
toad,) according to the figure of the pupil, or 
to a small pin's head aperture, where it was of a 
circular form, as in the common snake. 

If we look through the vitreous humor ex- Theory of 

, r ,, . . , the author. 

posed tor a small space on its posterior side, 
we observe the plicae advancing upon its ante- 
rior surface beyond the margin of the lens, 
like a circular fan or skreen ; if the lens is 
pressed evenly backward, the plicae separate 
and extend the sacculated circle of Petit, to 
which their edges are affixed. On remission of 
the pressure, the lens springs forward, and the 
leaves of the fan are closed. The circumferen- 
tial compression of the globe increases the 
closeness of their application. In the dead body, 
only the most coarse and remote analogies can 
be obtained to the functions of the living. But 
I cannot believe so obvious and yet so exquisite 

* It is worthy of notice, that fish, in whom the iris is with- 
out motion, furnish the remarkable exceptions; viz. the dol- 
phin, the skate, the cuttle, &c. 

¥ 



66 PHYSIOLOGY OF THE EYE 

a contrivance for changing the site and figure 
of the apparatus, as this view affords, can be 
without necessity or occasion. Looking then at 
the posterior origin of the processes from the 
choroid, and their attachment externally to the 
ciliary ring; their insertion into the vitreous 
capsule to the edge of the fossula, their en- 
croachment upon the anterior segment of the 
crystalline, and their termination by distinct 
prolongations in the substance of the iris at its 
great circumference ; assuming the choroid and 
annulus as fixed points, and the iris and pro- 
cesses as the moveable parts of the apparatus, 
it follows that the plicae will be unbraced and 
partially open in the state of mean dilatation of 
the pupil belonging to passive or atonic vision, 
and in the state of extreme dilatation of the 
pupil accompanied with blindness to near ob- 
jects, totally relaxed and floating. On the con- 
trary, by the steadily contracted state of the pu- 
pil suited to the nearest extremity of the focal 
range, they will be closed and braced together; 
and bearing upon the circumference of the crys- 
talline at every point, will necessarily elongate 
the axis of the lens. These being the extreme 
states, so, in proportion, the intermediate de- 
grees of adaptation will be accounted for. 
Hence the actions of the pupil, however excit- 
ed, will extend their influence to the lens, and 
by this catenation of motions the general con- 
formity of adjustment to light and adaptation 



AND ITS APPENDAGES. 67 

to distance be explained. And this forms no 
objection to the hypothesis j because it is only 
in the voluntary and steadily preserved contrac- 
tion of the pupil that the latter object is or 
can be required j for blindness would as surely 
ensue from gazing on the sun, as death from 
suspending the actions of the respiratory 
muscles, were it in our power to do either, and 
therefore the involuntary has the ascendancy 
over the voluntary action in both these cases, as 
it has in all cases of mixed muscles. 

Radiated fibres are described by Zinn and lTvea ip«>- 

» longationsot 

Haller as raised on the posterior face of the iris, the ciliar y 

*• processes. 

and advancing even to the margin of the pupil. 
They are distinct from those seen upon its an- 
terior surface, and regarded as continuations of 
the ciliary processes. In man no such fibres 
are distinguishable by the naked eye, but if the 
observation, however obtained, be correct, it 
affords a strong presumption in favour of the 
power of the iris to change the figure of the lens 
by the instrumentality of the plicae. The cap- 
sule, it is true, is fixed by the processes, but this 
opposes no impediment to the change supposed; 
for the membrane of Petit, to which alone the 
processes are affixed, is relaxed when they are 
closed, and extended when they are separat- 
ed, and thus permits the capsule to yield 
only in the degree required for the change of 
figure of the lens, or in other words, pre- 

f 2 



68 PHYSIOLOGY OF THE EYE 

serves its exact adaptation to the face of the 
lens in its opposite and varying states. This 
I take to be the use of the membranous circle 
of Petit, that it gives the processes the com- 
plete command of the continuous capsule. 

Some cases of dilated pupil are accompanied 
by a bulging of the lens. This is not the ef- 
fect but the cause of the dilatation, for it never 
follows the application of belladonna, provided 
the capsule be entire ; but if from any cause 
the lens be protruded so as to bear down the 
natural resistance of the processes, the pupil 
becomes dilated by its pressure. 

Station ^ would require a more intimate acquaint- 
h °^ a £ en ~ ance than we possess, with the economy of the 
animals. various classes of animals, to determine the se- 
veral degrees in which they enjoy or require 
the power of adaptation to distances ; but al- 
though many unquestionably have a great reach 
of sight, it is highly improbable that any animal 
approaches to man in minuteness or accuracy of 
near vision. The curvatures of the cornea and 
lens, which are inverse to each other, and the 
corresponding variations in the quantity of the 
aqueous humor, are obviously appropriated to 
the different densities of the media in which 
they habitually dwell. 

The crystalline of man, compared with am- 



AND ITS APPENDAGES. 69 

mals, is of the softest consistence, and occupies 
the smallest portion of the volume of the eye- 
ball. The firmness of the crystalline is always 
in proportion to its convexity. 

Tiie absence of the processes in fish ; their 
very slight indication, (being close and delicate 
strise instead of folds,) in birds, and such reptiles 
as possess them ; the absence in all of the mem- 
brane and circle of Petit, and the insertion of the 
processes into the capsule of the lens in the 
latter classes, offer a marked contrast to the ap- 
pearances observed in man and quadrupeds, in 
whom they are full and strongly marked, and 
especially at the salient angle opposite to the 
crystalline, where tfeey are unadhering and free 
to move. In fish as we have said, the pupil is 
without motion ; in birds and reptiles, as in man 
and quadrupeds, its motions are vivacious ; in 
some we are. told, voluntary, which, whether it 
be so or not, must be stated on pure conjecture. 
The adjusting power in fish and birds has been 
attributed to other mechanism, on account of 
certain peculiarities of structure, which seemed, 
prima facie, to be adapted to that purpose, as 
the choroid gland in fish, and the pecten in 
birds; or of such deviations from the human 
structure as rendered the several hypotheses 
inapplicable. 

I believe that the motions of the iris in ani- 
mals are single and obedient solely to the stimulus 



tary, 



70 PHYSIOLOGY OF THE EYE 

of light, and that they have no controul of the 
pupil by volition ; a property which pertains ex- 
clusively to the adjusting power, and which is 
exerted independently of the variations of light. 
It is probable that they possess it in so far 
only as it results from the adaptation to 
light. 

The iris is a mixed muscle ; its motions are 
regulated in part by the stimulus of light upon 
the retina, and in part by an effort of the will. 

inroiun- That the motions of the iris which take place 

upon the sudden changes of light are involun- 
tary, there can be no doubt, for they are ob- 
served even in sleep, when the will cannot be 
exerted, and in the earliest infancy. There is 
another proof that these motions are involun- 
tary, viz. that they occur in some forms of per- 
fect amaurosis. I have seen the pupil act 
briskly, where the person has been totally de- 
void of the perception of light from bright sun- 
shine, or the flame of a candle held before the 
eye. 

The sympathy of the iris with the retina 
must be ascribable to a communication between 
the retina and the ciliary nerves which supply 
the iris. The small lenticular ganglion from 
which these nerves are derived, lies upon the 
optic nerve, and is probably the medium of 
communication. 



AND ITS APPENDAGES. 7 1 

On the other hand, every one may satisfy and voiun- 
himself of a power which the will is capable of Ss of iris. 
exercising over the iris, in viewing alternately 
near and distant objects ; the state of relaxation 
or moderately dilated pupil being suited to the 
remote, and its tonic or relatively contracted 
state to the near object. It is seldom that this 
change is sufficient to be obvious to a bystander 
where the light remains unchanged, because the 
faculty is seldom exercised in these circumstan- 
ces, and still more rare for the state of accommo- 
dation to be preserved in defiance of the changes 
of light, because it is an unnatural effort. I 
have several times observed, in persons whose 
eyes were steadily fixed upon an object at some 
yards' distance, that the approach of a candle 
towards the eye did not stimulate the pupil to 
contraction, until it was so placed as that its 
image should fall upon the most sensible part of 
the retina, when the pupil instantly contracted. 
So that the voluntary is in subordination to the 
involuntary power, where they are opposed ; 
that is, when the stimulus of light opposes the 
adaptation of the eye to distance. But by conti- 
nued application, the mind is capable of acquir- 
ing over the motions of the iris an extraordi- 
nary power, as is well known to be the case with 
other muscles subjected in any degree to voli- 
tion. Of this I have seen two or three re- 
markable instances, but none so striking as that 
of my ingenious and learned friend Dr. P. M. 



72 PHYSIOLOGY OF THE EYE 

Roget, in whom, I may be permitted to say, 
profound scientific knowledge is accompanied by 
a characteristic aversion to ostentatious display. 
It affords me much pleasure to lay before my 
reader the peculiarity to which I have alluded 
in the person of Dr. R. as described by himself, 
at my request. 

Bernard Street, Russell Square, 
Feb. 21, 1820. 
MY DEAR SIR, 

I am much pleased with the view you design 
to take, in your intended work, of the subser- 
viency of the motions of the iris to the changes 
which accompany distinct vision at different 
distances, and of these motions being subordi- 
nate to the effect of light on the retina ; and 
the more so as they accord with a circumstance 
relative to my own eyes which I have often made 
the subject of experiment, and which you will 
probably recollect my shewing to you some years 
ago. 

" When I have stated that I possessed the 
power of dilating and contracting at pleasure 
the iris, the fibres of which are usually consi- 
dered as no more under the dominion of the 
will than the heart or bloodvessels, my assertion 
has in general excited much astonishment. 
Such however is strictly the fact. I can easily 
satisfy any person who witnesses the movements 



AND ITS APPENDAGES. 73 

I can produce in them, that this power is totally 
independent of the influence of light ; since I 
can effectually exert it, although the position of 
my eye with regard to the window or candle, as 
well as the direction of the optic axis, continue 
unchanged. However singular this power may 
appear, it admits, I conceive, of a very na- 
tural explanation. The effort of which I am 
conscious, when performing the voluntary con- 
traction of the pupil, is the same as that which 
accompanies the adaptation of the eye to the 
vision of near objects, and is of course produc- 
tive of an increase of its refractive power. 
This very same power of moving the iris is in 
fact possessed in a greater or less degree, by 
every person who enjoys the faculty of distinct 
vision at different distances. It is accordingly 
well known, that if a person after looking at a 
distant object, transfers his attention to a near 
object, the pupil always contracts. But this 
change,, it is supposed, can never be effected, 
unless some real object or image, from which 
light radiates, be present to direct the sight. 
I have never, indeed, met with any person be- 
sides myself, who, while steadily directing his 
eye to a distant object, and while no other ob- 
ject intervened, could, by a mere effort of voli- 
tion exerted on the eye, augment its refractive 
power so as to adapt it to the vision of near 
objects. That I have acquired such a power I 
can ascribe to no other cause, than to my hav- 



74 PHYSIOLOGY OF THE EYE 

ing from my childhood, been much in the habit 
of observing optical phenomena, and of prac- 
tising various experiments relating to vision, a 
subject which I early took great delight in 
cultivating. 

" It is still more easy for me, while an object 
is placed near my eye and distinctly seen, imme- 
diately to relax the organ so as to fit it for the 
distinct vision of the most distant objects : and 
these changes I can effect in succession with 
considerable rapidity, each change being accom- 
panied with a corresponding enlargement or 
diminution of the pupil. The increasing the 
refractive power of the eye, is always the 
change that constitutes the effort ; the state of 
vision adapted to parallel rays being that of 
complete relaxation. The effort which attends 
this voluntary contraction of the pupil, when 
there is no object before the eye to call for such 
a change, is followed by a sense of fatigue ; and 
if often repeated or too long continued, it be- 
comes painful, and continues so for some time 
afterwards. The fatigue is felt almost exclu- 
sively in the eye to which my attention had been 
directed during the experiment, although the 
same change in the refractive powers takes 
place, and I believe to the same extent, in the 
other eye. It is also remarkable, that when 
there exists a real object of sight which is looked 
at, and which requires an equal change in the 



AND ITS APPENDAGES. 75 

eye for distinct vision, as in the former case, no 
sense of fatigue, or hardly any, is experienced. 

" I need scarcely add, that while I thus alter 
the refractive power of my eye from that which 
adapts it to the distance of the objects I look 
at, those objects appear indistinct, from their 
images either forming before the rays reach the 
retina, or tending to form beyond it. 
I am, Dear Sir, 

very faithfully yours, 

p. m. roget. 

B. TRAVE11S, ESQ. 



I deem it superfluous to add any further ob- 
servations to this very clear and convincing il- 
lustration by example of the obedience of the 
pupil to light and its subordination to distance : 
the inference of its necessity to these coordinate 
purposes seems to me to be unavoidable. 

In addition to the nerves derived from the Ciliary 

, . , , . ... . nerves from 

lenticular ganglion, the ins receives two or more thenasai. 
branches from the nasal nerve, (5th pair,) and 
its actions may possibly be subjected to the will 
by virtue of the influence which these nerves 
convey, for from the same source is derived the 
nerve which supplies the levator palpebral, which 
is purely a voluntary muscle. 



76 PHYSIOLOGY OF THE EYE 

The limited motion which the pupil has, 
when the retina is for the most part insensible, 
may be considered as an involuntary or auto- 
matic motion, similar to that which in a healthy 
eye affords protection to the retina ; and if as 
sometimes happens, the iris contracts in a state 
of blindness, this likewise must be regarded as 
its involuntary action, for volition cannot pre- 
cede sensation. It is probable that those mo- 
tions of the iris, which are in conformity to 
the impressions of light upon the retina, are 
purely involuntary ; and that those which are 
in conformity to the situation of objects, and 
are therefore directly subservient to vision, are 
under the influence of the will. Hence the 
dependence of the adjusting faculty upon the 
perfection of the retina. 

Lenticular The ganglia have been conjectured by an in- 

gangliou. -ill l- 

genious author, to be bars or stops upon voli- 
tion, and this case of the iris, which he assumed 
to be purely involuntary, was incorrectly cited 
in support of the hypothesis. By others 
ganglia have been supposed to be small sen- 
sories or cerebral receptacles, capable of ren- 
dering a supply of nervous energy to their fila- 
ments, by which they are in a measure 
independent of the brain and its appendages. 
The theory, which I have ventured to suggest, 
attributes the voluntary motions of the iris to 
nerves unconnected with ganglia, the involun- 



AND ITS APPENDAGES. 77 

tary to those derived from the lenticular ganglion, 
which I regard as a direct medium of commu- 
nication between these nerves and the retina. 

The phenomena of ocular spectra, or images f c ^" a 
of luminous objects remaining upon the retina 
after the external impression is withdrawn, are 
highly interesting and curious. Luminous sparks 
and flashes, halos or variously colored rings, it 
is well known, are produced at will by friction 
or pressure of the closed eyelids, and the first 
are an instant effect of concussions of the brain. 
The red is that colour called up by the rudest 
artificial pressure ; the violet by the slightest ; 
and the gentlest impulse is the natural one, in 
which the light suffers no decomposition. Are 
these appearances really retinal impressions, or 
illusory mental phantasms founded on the feeble 
and obscure analogy subsisting between mecha- 
nical pressure and the impression of light ? 
Although blind persons see such appearances, 
I doubt if they ever present themselves in cases 
where the retina is disorganized, or after the 
extirpation of the eyeball, as the mutilated feel 
their fingers and toes. They seem to me there- 
fore to establish the essential connection be- 
tween the retina and the faculty of perception, 
or the connection between the corporeal and 
mental impressions ; and this is confirmed by 
what we observe of morbid spectra, which are 



78 PHYSIOLOGY OF THE EYE 

symptoms of various disordered states of the re- 
tina, of which I shall speak hereafter* 

I have said that the duration of an impres- 
sion is in proportion to its intensity. The ex- 
periment of the revolving fire-stick demon- 
strates that the impressions upon single points 
of the retina, although successive, become 
blended or confused by vividness and conse- 
quent proportionate duration ; for if it were 
not luminous, the appearance of a continuous 
circle would scarcely be produced. Spectra 

Direct. are direct or reverse. The first is the impres- 
sion of a luminous object, the shadow of that 
upon which the eye has for some time dwelt, 
although with no peculiar degree of intentness, 
and presenting the outline of the object in color. 
This either vanishes at once, or it presents a 
circle of the primary colors, variously asso- 
ciated or successively exhibited, in the order of 
their relation. The latter is especially the case 
after looking at the sun or a very bright light. 
This is the simple effect of a temporary over 
excitement of the retina, analogous to the echo 
of a noise in our ears, by which the auditory nerve 

Reverse, has been over-excited. The reverse spectrum is 
produced, when a color, occupying a certain 
space, has been so intensely impressed, (as 
when for example we make the experiment,) 
as to exhaust the irritability of the retina, and 



AND ITS APPENDAGES. 79 

render it inexcitable by any and every combi- 
nation of the rays of light, in which that color is a 
constituent. Hence the color of the spectrum 
is that which results from the abstraction of the 
offensive ray from white light, or the reverse of 
that of the object. The stimulus most remote 
from that which has excited the distress, is the 
only one to which the retina is alive, and in this 
it finds the relief of contrast. 

In another case the reverse spectrum seems 
to depend on the excess of susceptibility in the 
retina, as when the eye has been fixed on a 
black ground ; here the spectrum is white. 
Hence it is that the ash grey wall, presented 
to the eye on arriving at the mouth of a cavern, 
has a silvery brightness. The contrast of white 
light is alone capable of exciting the retina 
which has been altogether deprived of its na- 
tural stimulus. 

Thus we have two states or degrees of Explana- 
tion of 
nervous excitement, the first, simple over-ex- these phe- 

. nomena. 

citement to the extent or continued or reno- 
vated impression. The second, excitement to 
exhaustion, leaving only a negative sensibility. 
A third state is that of non-excitement, and 
consequently accumulated excitability. The 
two last are directly opposed, being minus and 
plus states of sensibility, and thus the con- 



80 PHYSIOLOGY OF THE EYE 

templation of a white surface gives a black 
spectrum, as the black gives a white one. 

As they are presented to the healthy eye, 
spectra need no further explanation. They are 
to be referred to the preternatural duration or 
intensity, or to the privation of the natural sti- 
mulus. They are accordingly produced artifi- 
cially and at will in all persons. The organ is 
passive. The hypothesis of spasmodic action 
in the retina is altogether gratuitous. 



In the " Anatomical description," I have 
unavoidably embodied the chief of what it is 
needful to say on the economy of the appen- 
dages. A few additional circumstances how- 
ever come properly to be noticed under this 
head. 

Actions of The levator palpebrae being purely a volun- 
muscies? tary muscle, the simple suspension of its action 
effects the closure of the lids, as its contraction 
opens them in the act of waking. Hence the 
disposition in the upper lid to fall announces 
the approach of sleep. In febrile and exhaust- 
ed states of the system, its impaired energy oc- 
casions the drooping expressed by the term 



AND ITS APPENDAi. 81 

€ heavy-eyed,' one of the most characteristic 
symptoms in the physiognomy of disease. A 
similar state belongs to some morbid a£Fec« 
tions of vision, of which I shall have oc- 
casion to speak hereafter. A voluntary 
closure of the eyelids, as when the eye 
is from any cause irritable to light, is 
performed by the orbicularis palpebrarum, 
which in some casualties and morbid states 
contracts spasmodically, and the relaxation of 
this muscle assists the opening of the closed 
lids. In going to sleep and awaking from it, the 
lower lid is therefore passive; in a voluntary 
shutting and opening of the eye it participates, 
though inconsiderably, in both actions. Wink- 
ing is an alternation of the actions of the levator 
and orbicularis, and therefore a seasonable re- 
lief to the former, and a means of preserving 
the moist and clear condition of the cornea. 
It is performed by a very slight contraction of 
the palpebral portion of the orbicularis. The 
combination of the action of the corrugator and 
orbicularis is seen in the strained closure of the 
lids to resist their separation by external force, 
knitting and depressing the eyebrows, and 
throwing the nose and forehead into folds ; and 
the equipoise of the actions of the orbicularis 
and levator is evinced in the approximation or 
screwing of the eyelids, and peering, as is cus- 
tomary in short-sighted persons. When they 

G 



82 PHYSIOLOGY OF THE EYE 

are both in full action, the corrugator acts as a 
moderator to the levator ; the orbicularis is the 
antagonist of the latter. 

Actions of The actions of the straight muscles in va- 

the nius- ° 

ciesofthe rious combinations, and in succession, explain 

globe. . ' . . » r 

the several intermediate motions to those which 
they singly perform, and the revolving motions 
of the ball round its socket. The rotation on 
its axis inward is performed by the superior 
oblique, that in the opposite direction by the 
inferior. The combined actions of the whole 
preserve the relative position of the eye to the 
object, independent equally of the motions of 
the object and the head. The motions of the 
eyes are in perfect correspondence, and the will 
cannot place them in opposition. 

superei- The prominence of the superciliary ridge, as 

andmus- we ]i as tj ie fulness of the brow, is subject to 
great variety, and is sometimes an impediment 
to the facility of operations. On the physiogno- 
my I need not say its influence is most marked. 
The elevation of the eyebrow performed by the 
occipito-frontalis cooperating with the levator, in 
staring, and its depression and approximation 
to the nose by the orbicularis and corrugator 
in frowning, are habitually employed to a ma- 
nifest advantage in the opposite states of defi- 
cient or .feeble, and of superabundant or daz- 



cles 



AND ITS APPENDAGES. 83 

zling light. The eye's * mute eloquence which 
passes speech,' belongs chiefly to its appen- 
dages. An opera dancer would be as effective 
with a divided tendo achillis, as a tragic actor 
who had lost the moveable apparel of the 
orbits. 

The closed eyelids are penetrated by a full J^"^?® 116 " 
light, so as in ordinary circumstances to occa- n s ht - 
sion waking, and distress to persons whose eyes 
are inflamed. The superior tarsus, when drawn 
up, slides under the arch of the orbit but re* 
tains its apposition to the globe, owing to the 
laxity of its attachment with the integument of 
the palpebra. 

The origin of some fibres of the orbicularis Muscular 

. enmpres- 

from the ligamentous expansion which supports sion of ia- 

. , . . crymal sac. 

and protects the lacrymal sac, gives it a power 
of compressing the sac in its contraction, and 
thus assists in the excretion of the tears. This 
is in part proved by the epiphora which accom- 
panies a fixed state of the lower palpebra from 
injuries, and the paralysis of the orbicularis, 
which states also prevent the due apposition of 
the puncta. Hence too, people wink often and 
forcibly, whose eyes are disposed to water, and 
after shedding tears. 



'o 



The conjunctiva has been supposed to secrete Conjunctiva 

** x l a iiou-se- 

a lubricating fluid, which serves the purpose of cieti llg sm- 



g 2 



84 PHYSIOLOGY OF THE BYE 

keeping the cornea clear, and facilitating the 
motions of the lids. This forms, according to 
that opinion, the habitual lacrymal discharge, 
and the secretion of the lacrymal gland is but an 
occasional one, as when from mental emotion or 
irritation of the conjunctiva the profuse and pal- 
pable discharge which we call c tears' is poured 
out. I believe the notion rests solely upon the sup- 
posed relation of the conjunctiva to the class of 
mucous membranes. But this need be no fetter 
upon our conception of the matter, for not only 
do we see from the varieties of its surface that 
its economy is not throughout the same, but 
anatomists describe its continuity with the cutis 
as much as with the membrana narium. Again, 
the capillaries of mucous membranes carry red 
. blood, which is not the case in the conjunctiva 
of the globe in health. But there is no evi- 
dence of such a secretion ; upon the cornea it 
is not assumed to exist, yet the difference be- 
tween the corneal and sclerotic portion is only 
in the strictness of its adhesion. The follicles 
and caruncula are specifically provided for pre- 
venting the effects of friction, and the incessant 
although insensible escape of the tears from 
the lacrymal ducts, unavoidable under the act 
of winking, in which the upper lid sweeps over 
and preserves the polish of the cornea, renders 
such a provision superfluous and therefore impro- 
bable. In disease, the sclerotic conjunctiva se- 
cretes a mucus which is immediately obvious, (the 



AND ITS APPENDAGES. 85 

corneal surface is excepted because its vessels do 
not admit red blood) and this is in conformity 
with what we see of the mucous membrane 
properly so called, as of the urethra and in- 
testinal canal, which continually shew that 
the secretion can be set up by disease 
upon a whole surface-, while in the healthy 
state this function is confined to its fol- 
licles and lacunae. 

A young woman who had never shed tears, 
and was incapable of doing so, had a shrivelled, 
opake, and cuticular conjunctiva. 

The puncta lacrymalia absorb the tears, not Excretion 

• .11 ... ... of tears. 

by any capillary attraction, but by a vital action 
as absorbent mouths. They are often spasmodi- 
cally contracted, and afford a resistance to the 
introduction of Anel's probe, but yield to the 
point of a pin, so as afterwards readily to admit a 
probe of much larger dimensions. When over- 
dilated, they lose for a time their absorbingpower, 
and the epiphora is increased. When they are 
morbidly patulous and atonic, as sometimes hap- 
pens in age, the epiphora is permanent ; and 
their function is frequently arrested by inflam- 
mation of the sac, for we often find the epiphora 
altogether independent of obstruction. 

The direction of the superior duct varies a 
little in relation to the sac, according to the de- 



86 PHYSIOLOGY OF THE EYE, &C. 

gree of elevation ofthe upper lid. By drawing the 
lid upwards and towards the nose, it is brought 
nearly into a line with the axis of the sac. 

The area of the sac and nasal portion of the 
duct, exceeding that of their orifices, facilitates 
the passage of the tears ; the slight elevations 
ofthe lining membrane and the narrowness and 
obliquity of the nasal opening probably retard 
the excretion, which would be inconvenient if 
constantly taking place. 



PART II. 
PATHOLOGY 



OF THE 



MEMBRANE S. 



CHAPTER I. 



ves- 
sels of the 



SECTION I. 
CONJUNCTIVA. 

LHE vessels of the conjunctiva of the globe B1 °° d 
are derived from two sources: 1. the palpe- conjunc- 

tiva 

bral arteries and veins ; 2. the ophthalmic 
muscular branches, and accompanying veins. 
The first, creeping upon the sclerotic con- 
junctiva in the sinus palpebrales, and at the 
angles of the palpebral, have a reticular distri- 
bution upon the loose portion of the conjunc- 
tiva. The second, after penetrating the tendons 
of the straight muscles, advance in four distinct 
fasciculi. These spreading, as they advance 



88 CONJUNCTIVA. 

upon the opposite sides of the globe, form nu- 
merous lateral anastomoses with each other, so 
as to present a faint circulus arteriosus upon 
the sclerotic coat*. h\ a state of conges- 
tion a free communication is conspicuous be- 
tween these two orders of vessels, and their dis- 
tinctive character is preserved under very high 
degrees of inflammation. In a complete sec- 
tion of the conjunctiva at a short distance 
from the cornea, both sets may be divided with- 
out injury to the sclerotica. It is by infinitely 
frequent and minute subdivisions of these ves- 
sels, that the tissue which unites the con- 
junctiva to the sclerotica is supplied; and hence 
in inflammation, the areolar distribution of these 
vessels is most conspicuously demonstrated 
where this texture is most abundant. At the 
verge of the cornea both orders of vessels 
are rectilinear, and never present the reti- 
cular arrangement; for the looseness of the 
conjunctiva upon the sclerotica gradually dimi- 
nishes from the point of its reflection to the 
verge of the cornea, and its adhesion to the 
cornea is so strict, as to render an artificial 
separation impracticable, This remarkable di£ 
ference in strictness of adhesion subsisting be- 
tween the conjunctiva and subjacent textures, 
suited to their difference of economy, explains 
some varieties in the morbid affections of the 
conjunctiva covering these parts respectively. 

* See Plate!, fiff. j, 



CONJUNCTIVA. 89 

Independent of the accompanying veins of the 
muscular arterial fasciculi, long and tortuous 
branches are seen to proceed from the meshes of 
the conjunctiva, distinguished from the arteries 
by their purple hue, their isolated course, and 
more superficial seat. Their sharp spiral curves 
are larger as they descend towards the base of the 
visible hemisphere of the globe, where their 
attachment to the sclerotica is least strict. 
These are the palpebral veins of the conjunc- 
tiva. 

Although in the tonic and tranquil state of character- 
the eye, little it any red blood is admitted into ence of 

i r% . t -i conjnnc- 

the superficial vessels, yet under a very tempo- tiva of 
rary excitement, colored blood has a ready ad- ami cornea, 
mission into the vessels of the sclerotic conjunc- Bammatioij. 
tiva. Such however is the condensation of the 
connecting texture upon the cornea, as to pre- 
vent the admission of red blood into its vessels 
under a very high degree of inflammation, as 
even where the white ground of the sclerotica is 
extinguished*. The susceptibility of parts per- 
meable to red blood to increased vascularity 
under excitement, is in proportion to the quan- 
tity of cellular texture entering into their 
composition, or connecting them with subja- 
cent parts. Compare, in this view, the mem- 
brane of the fauces and the trachea — pleura 

* 1 believe further that it is inadmissible, except' a morbid 
change has previously taken possession of this texture. But 
«f t his hereafter. 



90 



CONJUNCTIVA. 



pulmonalis and costalis — periosteum and perf- 

chond] 

teries. 



chondrium — lining membrane of veins and ar 



Since the easy admission of red blood into 
the vessels of the sclerotic conjunctiva discovers 
a distribution of vessels, not otherwise known, 
it affords opportunities of observing the acces- 
sion and progress of inflammation; and this por- 
tion of the membrane presents, when inflamed, 
appearances different from those of the inflamed 
corneal conjunctiva. But although the colorless 
circulation of the latter shews the rise and pro- 
gress of inflammation obscurely, its perfect trans- 
parency in health makes the results of it more 
conspicuous. 

comea ob- The fl rs t effect of inflammation upon the 

soured by J 

inflamma- cornea is haze or dimness, which depends upon 
the loaded state*' of its (serous) vessels. The 
dimness is immediately removed by the recovery 
of the circulation, as after the removal of an 
irritant ; for example, a foreign particle on the 
cornea ; or after a free evacuation where the 
cause is less obvious. Hence transient dimness 
is merely a condition of congestion. This state 
however, continued, produces a deeper and 
more permanent opacity; viz. effusion into the 
connecting texture, and thickening of the con- 
junctiva upon the cornea. This is the progress 
of simple ophthalmia in the generic sense of the 
term. Contrast the epidermis in the state of 



CONJUNCTIVA. 91 

blush (congestion) and of incipient vesication 
(effusion). The peritoneal coat of the liver, the 
arachnoid and synovial membranes doubtless 
exhibit, in the distinct stages of congestion and 
effusion, the transient and permanent opacity. 

The conjunctiva is to the cornea, what the Relation of 
periosteum is to the bone. It nourishes the to cornea?* 
superficial lamellae ; wherever it is completely 
detached, the exposed surface of the cornea 
ulcerates, and its vessels repair the breach. To 
pursue the analogy, the interlamellar texture of 
the cornea may represent the medullary mem- 
brane ; gangrene therefore does not ensue 
but from a permanent destruction of both tex- 
tures, as by blows and explosions, which me- 
chanically disorganize ; by the action of lime, 
gunpowder, strong acids, and other chemically 
destructive agents ; or by the strangulation of 
the vessels of both textures, as in the excessive 
chemosis, which destroys on the same principle 
as the paraphymosis, or the strangulated hernia. 

The forms of inflammation of the conjunctiva 
which I shall now proceed to refer to, I consi- 
der as specific variations from the simple acute 
inflammation*, of which the ordinary signs are fa- 
miliar toeverypractitioner,originatinginahealthy 
subject from an obvious occasional or accidental 
cause, as an extraneous particle, or a blow 
not injuring the texture, or a blast of cold 

* See Plate I. fiff. 2. 



92 CONJUNCTIVA. 

air. An inflammation purely local, uninfluenced 
by constitution, both from the nature of its 
origin, its recent existence, and the health of 
the subject in whom it occurs. Such is the 
simplest example we can suggest of the morbid 
disposition natural to this organ, or to any 
organ ; it is frequent, for all are liable to it, 
if all are not equally exposed : it is in fact an 
instance of what may be termed, without a 
misnomer, the inflammation of health. 

inflamma- ^he inflammation of the conjunctiva, termed 

tion oi con- «» * 

junetiva (. strumous' where it has not proceeded to 

modified L 

by scrofula. a change of texture, is not marked by any pro- 
minent local character. The vascularity is in- 
considerable. This inflammation sometimes ac- 
companies pustule of the sclerotic conjunctiva, 
in which case the vascularity is diffused instead 
of being partial, as in pure pustular inflamma- 
tion, and the intolerance of light characteristic 
of the strumous inflammation is present in a 
greater or less degree. It accompanies also the 
morbid secretion of the lids when the eyeball 
becomes affected by the acuteness and duration 
of that disease, and the pustule on the cornea, 
especially the variolous pustule. In its simplest 
form it is almost peculiar to young children, 
stationary, marked by a very slight redness of the 
sclerotic conjunctiva, and the greatest possible 
degree of intolerance. I have known it in more 
than one instance of such severity and duration* 
as to occasion a distortion of the spine from 



CONJUNCTIVA. 93 

the habitual depression of the head, and the 
obstinate maintenance of an awkward and un- 
natural posture of the body to screen the eyes 
from light. 

The disproportionate degree of inflammation 
makes it difficult to account for this excessive 
morbid sensibility. It is purely a disorder of 
function ; for although it far exceeds that which 
accompanies the acutest inflammation to which 
the organ is liable, it never in my experience 
impairs the faculty of vision. I attribute it to 
a morbid sympathy of the retina with the se- 
creting surfaces of the prima? vise and the skin, 
for neither of these organs perform their healthy 
functions during its existence. The tongue, 
the index of the former, shews by various signs 
gastric irritation or disordered digestion, and 
the cutaneous surface is remarkably dry and 
harsh. Accordingly it is cured by diaphoretics, 
as tartar emetic to nausea, James's powder, or 
calomel combined with opium in small doses ; 
by the warm bath ; and materially corrected, 
if not removed, by a preternatural secretion in 
the vicinity, as by an open blister on the nape 
of the neck. I have often seen an aggravated 
intolerance removed in twelve hours by the ap- 
plication of a blister. 

This state of intolerance bears an analogy to 
cases of depraved, or rather of painfully acute 
sensibility in other organs of sense. The 



94 CONJUNCTIVA. 

senses of hearing and of smell are in some 
rare cases rendered morbidly acute, inde- 
pendent of the slightest organic affection, so 
that the ordinarily agreeable stimuli of these 
organs in a state of health, viz. an acute 
sound and a pungent odor, become causes 
of distress. An amateur of music, when la- 
bouring under an occasional disorder of the 
auditory passages, compared his sensations du- 
ring a fine performance of instrumental music 
to those of Hogarth's enraged musician ; all was 
jar and discord. Every snuff-taker knows the 
effect of a catarrh to spoil his enjoyment. 

The nebula and the pustule of the corneal con- 
junctiva are the terminations of this inflammation 
when it affects the texture of the organ, to 
which may be added the small herpetic ulcers, 
reddish brown points, giving to the cornea a 
scabrous appearance. The healing action is al- 
ways remarkably languid and protracted, as if 
the state of excessive irritability checked its 
progress, and prevented its completion. 

Aphthous The conjunctiva of the sclerotic is dis- 
taflamuta* 1 posed to form aphtha? or pustules at the verge 
junctiva!° n " of the cornea, or near to it. In the former 
situation, where the more lax adhesion becomes 
abruptly strict, the pustule is elevated or cone- 
like, and is the termination of a distinct pen- 
cil of vessels ; which arrangement sometimes 
precedes and announces the disposition to pus- 



CONJUNCTIVA. 95 

tule. When it is situated at a distance of a 
line or two from the corneal margin, it is broad 
and flattened. It is a small speck or patch of 
lymph, and seldom advances to suppuration. 
It is common to see one on either side of the 
cornea, in the transverse axis of the globe*. 
Sometimes they appear in detached clusters, 
or a zone of pustules environs the cornea. 
This resembles the aphtha of the mouth and 
fauces and intestinal canal. 

The pustules of the corneal conjunctiva, 
which are less frequent, except in children, are 
generally situated near to the margin of the 
cornea, where one or more pustules of the scle- 
rotic portion appear. Like the aphtha of the 
glans penis and the stricter parts of fine cuta- 
neous texture, the pustule on the cornea usually 
forms an ulcer. 



The ophthalmia with puriform discharge is a {jj^jf" 

disease of the palpebrae. The secretion is sup- follicles . 
1 r * with pun- 

plied by the meibomian follicles and the con- iormdis - 

1 ^ charge. 

junctiva bordering them, and likewise by the 
caruncula lacry maris. 



A puriform discharge is furnished by the cryptae 
of the tonsils, the lacunae of the urethra, and the 
mucous glands of the nares, fauces, rectum and 
vagina, in mild inflammation of these parts. 
But in the vehement acute form of inflammation, 

* Sec Plate I. fig. 6. 



96 CONJUNCTIVA. 

the matter of suppuration is furnished by the 
tumid and villous surfaces of these mem- 
branes. 

Acute sup- The sclerotic conjunctiva in acute suppu- 

purative in- . i 1 1 • 1 /» 11 

/lamination rative ophthalmia presents the following states. 

juncUva. n " 1 st. Serous effusion (oedema) which is common 
to other inflammations, and especially those of 
a less vigorous kind. 2d. Effusion of lymph 
(chemosis) peculiar to this form of inflammation, 
by which it acquires a solid augmentation of 
bulk. fid. Villosity, or a subsequent prolonga- 
tion of the extreme vessels in the form of villi, 
which secrete pus. The strict adhesion of the 
conjunctiva to the cornea prevents these changes 
from taking place upon that membrane. Upon 
the tarsi the conjunctiva thus affected becomes 
preternaturally vascular, thickened, and scabrous, 
or forms fleshy eminences. That the vascular 
villi of the conjunctiva secrete pus, may be as- 
certained by the aid of a lens. The pus, when 
formed, collects in the interstices of the villous 
texture. We have no evidence, as before ob- 
served, that the conjunctiva is a secreting sur- 
face in the healthy state. 

Mild acute A form of disease intermediate to these 

suppurative # . . . f . 

infiamma- m extent and severity, a modification of the 



tion of the 
conjunc 



suppurative ophthalmia, is the villosity and puri- 
form secretion of the conjunctiva palpebralis, 
as seen upon eversion of the lids, while the 
membrane upon the globe is simply intu- 



CONJUNCTIVA. 97 

mescent giving it a more rounded figure, and 
moderately vascular. This is the mild acute 
suppurative ophthalmia, which seldom injures 
the cornea, but frequently leaves after it the 
same fungous or granulated state of the con- 
junctiva palpebralis which so often follows the 
most acute form. 

The difference then between the inflammation 
of the meibomian follicles and caruncula, (the dis- 
ease which if neglected terminates in lippitudo), 
and the suppurative inflammation of the conjunc- 
tiva, whether of the palpebrae or the globe, is a 
difference in kind as well as in seat ; the one is 
the conversion of a transparent and bland se- 
cretion proper to the organ (meibomian) into a 
viscid and irritating mucus, puriform in appear- 
ance ; the other is the de novo production of a 
true suppurative surface by inflammation. 

The highly contagious nature of the suppura- suppura- 
tive ophthalmia, whether, in the mild or vehe- timimia 
ment acute form, is surhciently proved. J 1 or t-ated by 
one person affected with this disease above three 
months old, I should think at least twenty are 
subject to it under that age. The mother is 
the subject of fluor albus or gonorrhoea, and the 
discharge is usually perceived about the third 
day. In new born infants the disease begins in 
the conjunctiva palpebralis, and is often con- 
fined to that portion of the membrane. Where 
by neglect or improper treatment, it extends to 

H 



contact. 



98 CONJUNCTIVA. 

the conjunctiva of the globe, it often destroys 
the cornea. v I have repeatedly seen the most 
virulent form of the disease produced by acci- 
dental translation of the matter of gonorrhoea 
from its source in the same subject, and 
from one to another, as from the husband to 
his wife. I have also known it set up 
by the fluid injected into the eye of a pa- 
tient, spirting into the eye of the medical 
attendant, and by the use of a sponge which had 
been recently employed to cleanse the eyes of 
an infant affected with the disease. The mild as 
well as the acute form of the disease, it is well 
known, runs through armies, schools and families. 
There is much reason to believe it epidemic as 
well as contagious, but the former is a point less 
easy of decision. 

chemosis. The Chemosis, as must appear by the de- 
scription above given, is an affection widely dif- 
fering from ecchymosis, with which it has been 
by some writers confounded. It is after the 
existence of this morbid condition which is 
characteristic of the suppurative ophthalmia, 
that the conjunctiva forms fungous excrescences, 
pendulous flaps, or hard callous rolls protruding 
between the palpebral and globe, and everting 
the former, (ectropeon) or if not protruding, 
causing the turning of the lid over against the 
globe, (entropeon.) The tarsal portion takes 
on from the same cause the hard granulated 
surface, which keeps up incessant irritation of 



CONJUNCTIVA. 99 

the sclerotic conjunctiva, and at length renders 
the cornea opaque. These eminences, some- 
times cone-like and sometimes flattened, are 
not granulations in reality, /. e. adventitious 
glands secreting pus. Granulations, I believe, 
are never formed without breach of texture. 

Preternatural elongations and excrescences of Elongations 

o and excres- 

the conjunctiva, concealed in the hollows of the cences - 
palpebrae, are a sequel of the protracted mild sup- 
purative ophthalmia, where the palpebral con- 
junctiva has been the principal seat of disease. 
They are similar to those of the membrane lining 
the rectum, and the fine skin at the verge of the 
anus after inflamed piles, and the pudendum 
muliebre in acute gonorrhoea. All such membra- 
nous growths are, I believe, referable to irritation 
of inflamed parts by the diseased and confined 
secretion, as the warts in external gonorrhoea. 

A firm fleshy fungus, which sometimes attains Fungous 

conjunc- 

considerable bulk, so as to project from between tiva. 
the eyelids and globe in an orbicular figure, 
even to the circumference of the orbit, I have 
extirpated. Such fungi are exclusively formed 
of the conjunctiva, and usually originate from 
injury. 

There is a malignant fungus of the con- carcinoma* 

>> im .1 , , tous fungus 

junctiva, tor like the mucous membrane of of conjunc- 
other parts, this is sometimes the seat of car- 

h 2 



100 _ CONJUNCTIVA. 

cinoma ; and excepting the lacrymal gland, I 
believe no other texture related to the organ of 
vision is ever primarily so affected. I have re- 
moved the contents of the orbit for a painful 
tubercular fungus, with ulcerated depressions 
containing an ichorous discharge. The coats 
and humors of the eye were for the most part 
absorbed, the lacrymal gland schirrhous. The 
disease afterwards returned upon the palpebral 
and destroyed the patient. I have at this time 
a similar case under my observation. The fleshy 
tubercles grow from the conjunctiva, both on 
the cornea and sclerotica, and the inferior pal- 
pebra is extensively ulcerated *. It is accompa- 
nied by lancinating pains in the supra-orbitar 
region, and an unhealthy discharge. 

Pannus. The Pannus is a chronic thickening and 

opacity of the conjunctiva of the sclerotica, 
generally unaccompanied by inflammation. By re- 
laxation of the connecting tissue the membrane 
becomes redundant in extent, and forms folds 
or duplicatures, on one, or on all sides of the 
cornea, which encroach upon it considerably in 
the motions of the globe. The elongated uvula 
is the only analogy that occurs to my mind. 
This is often unpreceded by inflammation, and 
the extension is purely membranous. 

pterygium, The membranous pterygium is a true nebula 

* See Plate II. fi<r. I. 



CONJUNCTIVA. JO] 

of the sclerotic conjunctiva ; the fleshy is an membra- 
adipose or sarcomatous growth beneath the fleshy. 1 
sclerotic conjunctiva. It extends from either 
canthus or sinus palpebralis, most commonly 
from behind the caruncula lacrymalis j and by 
its increase forcibly detaches the conjunctiva 
from the cornea. In its progress it oc- 
casions a permanent and indelible opacity by 
the thickening of the conjunctiva, and the 
deposition of lymph in the interspace of 
these membranes, in the form of a lit- 
tle tongue-shaped process. The wedge-like 
figure of the fleshy pteryx, and its gradual 
extension upon the cornea, afford the best pa- 
thological demonstration of the continuity of the 
conjunctiva ; and the spread fan-like figure of 
the membranous, its semi-transparency as well 
as its termination in simple nebula of the corneal 
conjunctiva, shews the difference in the nature * 
of the two diseases. Both this and the disease 
last mentioned, like other morbid growths of 
the cellular texture or beneath it, are most 
prevalent in warm climates. 



Adipose, steatomatous, and even cartilagi- Conjunct 
nous tumors form in the cellular tissue of the mors on" 
conjunctiva sclerotica^, and produce the same tJ, ^ er °* 
change when situated in the vicinity of the 
cornea as the disease last mentioned, viz. a mar- 
ginal interstitial deposition. 



Circumscribed tumors of a dense and firm an d, 



102 CONJUNCTIVA. 

texture are sometimes formed upon the surface 
of the cornea, and attain a considerable mag- 
nitude; but such cases are rare. I excised the an- 
terior hemisphere of the eye-ball in an elderly 
lady, in whom the cornea was concealed by 
a tumor, of a dark purple colour, protruding 
to such an extent between the eyelids, as to 
occasion great inconvenience and deformity. It 
had the appearance of being disposed in lobes, 
somewhat resembling a bunch of currants of 
unequal size. On dissection, the cornea and 
sclerotica proved to be entire, and the morbid 
growth, lying upon and adhering to the corneal 
and a small portion of the sclerotic surface, had 
acquired the lobulated appearance, as if by de- 
generation of the covering conjunctiva, for de- 
licate white bands, the only vestiges of this mem- 
brane, were seen intersecting the lobules at irre- 
gular distances, in the form of septa. The sub- 
stance, on section, was firm, of a dark colour 
here and there mottled with white, and mea- 
sured a quarter of an inch in thickness from the 
external surface of the cornea. 

Encantius. The Encanthis is a morbid enlargement 
of the lacryinai caruncle, in the form of a 
granular tumor, involving the valvula semilunaris. 
Sometimes the short down growing upon this 
gland takes on a morbid growth and harshness. 
The disease is extremely irritating, and occasions 
epiphora by a forcible diversion of the lacrymal 

* Plate II. fiff. 2. and fisr, 4, 



CONJUNCTIVA. 103 

puncta from each other, and from the surface of 
the globe. I have never known it assume the ma- 
lignant character ascribed to it by some writers. 

The elongated valvula semilunaris retains Elongated 

f, ! n , valvula se- 

lts crescentic figure even to the margin of the miiunaris. 
cornea, where it has a loose and thin edge. 
By this and other parts of the conjunctiva, 
fringes or clusters of soft red caruncles are 
sometimes produced, resembling those occa- 
sionally seen in the site of the carunculse myr- 
tiformes, and about the os externum vaginae. 

The frena or frenula connecting the con- Frena. 
junctiva palpebrarum and conjunctiva sclerotica?, 
a troublesome, and often irremediable deformity, 
follows burns and wounds of the conjunctiva 
tarsi, and the excision of tumors connected with 
this portion of the membrane. They are mem- 
branous bands formed by adhesive inflammation 
of the opposed and contiguous surface, (pleura 
costalis and pulmonalis — peritoneum of the in- 
testines and parietes.) It is not necessary that 
both surfaces should be wounded, if the position 
be by a mistake of treatment preserved, as by 
the application of a bandage. " The opposite 
uninflamed surface," as Mr. Hunter observes, 
" accepts of the union." I have seen 
these frena produced by a slit eyelid from 
a fall, and trifling as the inconvenience might 
seem, it so restricted the motions of the globe, 



104 CONJUNCTIVA. 

and the disease was so materially aggravated by 
operations to relieve it, i. e. by the multiplica- 
tion of frenula, that the patient became dis- 
turbed in his intellects from an exaggerated 
sense of his misfortune. 

co ad- ^he co-adhesion or concretion of the tarsi 

frenog tarsi. 

by organized adhesion of the conjunctiva tar- 
sorum is rare. I saw a remarkable case of it in a 
full grown boy, whose eye was found perfect after 
the division, though he had been thus blind from 
his infancjr. It is similar to the co-adhesion of 
the nymphse or labia pudendi, and the closed 
anus in new born infants. 

indisposi- The conjunctiva is not prone to ulcerate, 
iunctivato whilst the substance of the cornea readily 

ulcerative . . r 

inflamma- assumes that action ; hence the frequency 
of ulcers not opening externally, and of 
ulcers penetrating into the anterior cham- 
ber. Its readiness to assume the adhe- 
sive inflammation is evinced by the rapid 
formation of a superficial speck where it has 
been scratched or abraded, and the assistance 
it affords in healing open ulcers of the cornea. 
There is a marked disposition in these cicatrices 
-. to ulcerate in subsequent attacks of inflamma- 
tion, which are in the same degree as in other 
parts slower to heal than the original texture. 
The synovial membrane is as much less disposed 
Lo ulceration than the cartilage, as the conjunc- 



CONJUNCTIVA. 105 

tiva is than the cornea, or the periosteum than 
the bone, or the peritoneum than the mucous 
coat of the bowel. All these external close 
membranes accord in their disposition to adhe- 
sive inflammation. 

The conjunctiva, viewing its compound Pathoiogi- 
pathological character, bears in its respective tionsof 
relations to the sclerotica and the cornea, an !X U,U 
affinity to the two distinct classes of membranes: 
vlz.the mucous upon the sclerotica, and the serous 
upon the cornea ; hence the frequency of pus- ' 
tule and the tendency to suppurative inflamma- 
tion of the sclerotic portion, and the indisposi- 
tion to ulcerate and proneness to adhesive 
inflammation, of the corneal. 



SECTION 11. 



CORNEA. 



uiters of The CO rnea is disposed to adhesive in- 

the cornea, A 

flammation, ulceration, and sloughing. It 
rarely suppurates. The ulcer of the cor- 
nea begins, not in abscess, but in a circum- 
scribed deposit of lymph, or in pure ulce- 
rative absorption without pus. In most in- 
stances, when of spontaneous origin, it begins 
in the interlamellar texture. When the con- 
junctiva has been detached, and the cornea 
deeply injured, as by a large spiculum, or by an 
ulcerated pustule of the corneal conjunctiva, 
the ulcer is rilled by an inspissated mucus, or 
a little dirty white slough which may be picked 
or washed out, leaving a clear but rough fovea. 
The ulcerative process is unaccompanied by any 
appearance of coloured vessels, and the adhesive 
process is in many instances conducted by colour- 
antui.eir less vessels. That the proper vessels of the cornea 
heaibg! are capable of secreting adhesive matter, is 
proved by indelible opacities both with and 
without breach of its texture, and the healing 
of interstitial ulcers, without any appearance of 
a coloured vessel. 

The organizing process is however, in some 



CORNEA. 107 

instances, performed by coloured vessels. 
Where interstitial ulcers open externally, 
or pustules of the conjunctiva terminate in 
ulcers of the cornea, a narrow pencil of ves- 
sels is produced from the sclerotic conjunc- 
tiva to the breach, which organizes the lymph 
deposited by the proper vessels of the corneal 
texture. I have sometimes observed, that the 
fasciculus of red vessels produced to complete 
the healing of an ulcer, opening externally, in- 
stead of coming from the nearest point of the 
sclerotic, crosses the greater diameter of the 
cornea. I have never seen such a production 
of vessels without a narrow and very delicate 
substratum of recent lymph in their track; nor 
have I observed this peculiar deposit distinct 
from the production of vessels, prior to their ap- 
pearance, but the vestige of it is discernible for 
a short time after the vessels have disappeared. 
In superficial lesions of the cornea, as from the 
insinuation of a foreign particle, the part is at 
once restored by adhesion, and marked by a 
superficial speck j it is only where the ulcera- 
tive process has supervened and the conjunctiva 
is at the same time destroyed at the mouth of 
the fovea that nature adopts the mode of heal- 
ing by coloured vessels. Their office is, I 
think, limited to the organization of lymph de- 
posited by the transparent vessels of the inter- 
lamellar texture ; because when the ulcerative 
process is checked, the ulcer presents the 
signs of the adhesive action, viz. the marginal 



108 CORNEA. 

halo of lymph and the contraction and filling 
up of the fovea, before the vessels of the scle- 
rotic conjunctiva are produced. In this state 
there is often a pause in the restorative process, 
when the stimulus of a single injection is fol- 
lowed by the appearance of the red vessels, the 
effect of which is speedily manifested by a 
reddish brown tint communicated to the depo- 
sit, which soon becomes distinctly vascular. In 
other words, the adhesive process is already 
commenced before this phenomenon is ob- 
served. I have never seen the conjunctival 
fasciculus running to a transparent fovea. When 
the conjunctiva is entire, as in the intersti- 
tial ulcer, no red vessel appears, nor can be 
made to appear by stimulant injections, al- 
though they certainly quicken the adhesive pro- 
cess in such cases. 

From analogy we are led to conclude that 
the vessels which secrete are distinct from those 
which organize the deposit, in open breaches of 
all textures. An insulated pellicle formed upon 
the bed of an ulcer never becomes skin, but if 
it be connected by never so narrow an isthmus 
with the circumference, its organization is per- 
fected. After the ligature of an artery, the 
barrier of lymph is deposited from the vessels 
opening upon the divided cellular membrane, 
as is evident from its origination within the fis- 
sure, but injections shew that it is organized by 
the vessels of the lining membrane. The same 



CORNEA. 109 

fact is still more clearly demonstrated after the 
division of the sclerotic conjunctiva, for we 
may observe a distinct interval to transpire be- 
tween the deposition of new matter in the breach, 
and its vascularization byramuli from the divided 
trunks. This is in opposition to the opinion of 
Mr. Hunter, who cites the same example to 
prove the reunion of divided trunks, or inoscu- 
lation, an hypothesis which has been totally 
abandoned, since it has been ascertained that 
the permanent obliteration of arteries is the in- 
variable consequence of a solution of their conti- 
nuity, whether occasionedby wound or ulceration. 
I believe that in all parts the capillaries terminat- 
ing upon the newly exposed surface furnish the 
deposit, and that this becomes the matrix of new 
vessels opened from its ramifications, under the 
extraordinary impulse consequent upon the ob- 
struction of the trunk. 

The appearance of coloured vessels upon coloured 
the conjunctiva of the cornea is to be referred upon the 

n i n 11 • -t cornea. 

to one or other of the following states, and 
may be classed accordingly: 1st, To the pre- 
sence of adhesive inflammation excited by a 
pustular ulcer of the cornea *, as in the 
instance last described, and in that of 
acute insterstitial ulcer opening externally, 
described at page 114. 2nd, To the dura- 
tion of acute strumous ophthalmia, in which 
the serous vessels of the cornea are opened to 

* See Plate I. fio;. 3. 



1 1 CORNEA. 

red blood upon its entire circumference, in the 
form of radii converging to a centre, to an 
equal extent of from one to two lines*. In this 
case the cornea is more or less obscured. 
3rd, To a state of chronic inflammation, 
in which straggling solitary vessels, having 
a varicose appearance, run to one or more 
specks, or proceeding from opposite sides 
of the sclerotic conjunctiva, course over the 
opaque cornea and freely anastomose upon itt. 
This state is a common sequel of the suppura- 
tive ophthalmia, whether accompanied or not 
with the granular conjunctiva tarsi, and which 
I have been accustomed to designate " chronic 
inflammation with vascular cornea." It is com- 
monly seen in cases of disorganized globe and 
spoiled cornea, from whatever cause. 

The first of these conditions I consider ad- 
ventitious to the adhesive inflammation excited 
by the open ulcer of the cornea. It is proved 
to be so by a temporary deposition of a narrow 
layer of lymph ; the direct course of vessels along 
it to the breach ; their passage not always by the 
nearest route, i. e. from the nearest point of 
the sclerotic ; the entire freedom of the cornea 
from blood-vessels in other parts ; and the spon- 
taneous disappearance of the vessels and the 
lymph track after the healing of the ulcer. It 
is the most striking and beautiful instance we 
have of the handicraft of nature, of the produc- 
* See Plate I. fig-. 4. i See Plate I. fig. 5. 



CORNEA. Ill 

tion of vessels in inflammation for a specific pur- 
pose, and their gradual contraction to oblitera- 
tion; the determination ceasing when that pur- 
pose is accomplished. 

The second and third description of appear- 
ances I consider to be produced by the con- 
tinued vis a tergo overcoming the resistance 
opposed by the enfeebled tone of the vessels. 
The second is combined with recent and dif- 
fused nebula of the conjunctiva, capable of re- 
moval by absorption. The third is as often 
present with ulcerated specks as with simple 
opacities, which, whether partial or complete, 
are seated in the corneal texture, and have usu- 
ally existed prior to the appearance of the red 
vessels, and neither the vessels nor the opacities 
spontaneously disappear. After repeated cir- 
cular sections of the conjunctiva near the cor- 
nea, these vessels undergo contraction, especially 
under the use of styptic applications, as the liq. 
plumb, acetatis, and solutions of copper, alum, 
&c. ; that portion of the opaque matter which 
has been recently deposited, is at the same time 
absorbed. This operation seems to act bene- 
ficially in two ways ; viz. by throwing up a bar- 
rier of lymph to impede the direct course of the 
vessels, and by diverting them to the purpose of 
its organization. 



When I speak of the c production* of vessels, Production 

of vessels. 



* 12 CORNEA. 

I am not unaware of the ambiguity or im- 
preciseness at least of the term, which is so 
different in a mathematical and a general sense. 
It would be wandering widely from the sub- 
ject of this treatise to enter into a discussion of 
the question, whether the phenomenon of or- 
ganization is to be referred to an elongation 
of vessels by virtue of a force operating upon 
their elasticity, or an occasional forma- 
tion of ramusculi from contiguous branches. 
To divided vessels the former supposition 
cannot apply, as their orifices, as before ob- 
served, become permanently closed. I may 
observe also, that elongation of vessels im- 
plies a looseness of cohesion in the textures in 
which they appear, which does not belong to 
the corneal conjunctiva in its healthy state ; and 
the example which I have given in illustration 
of the formation of vessels, is strikingly op- 
posed, in this respect, to the instance adduced 
of original vessels acquiring increased capacity, 
and being rendered, by the colour of their 
contents, conspicuous. In the first, the corneal 
surface is otherwise healthy; in both the second 
and third, it is raised, thickened, and more or 
less disorganized. 



l &' 



We are led by analogy to conclude that the 
effect of vascular congestion from altered or inter- 
rupted texture is only less in degree than that from 
complete obstruction in larger vessels ; viz. the 



CORNEA. 113 

extension and enlargement of collateral branches. 
Observe the vessels of the sclerotic conjunctivain 
organic amaurosis ; of the skin covering indu- 
rated tumors ; and lastly, the communicating 
branches after the ligature of the trunk in aneu- 
rism, Mr. Hunter thought that the vessels 
might be formed in a patch of lymph indepen- 
dent of the circulation. " I think," says he, 
" I have been able to inject what I suspected to 
be the beginning of a vascular formation in a 
coagulum, when it could not derive any vessels 
from the surrounding parts. By injecting the 
crural artery of a stump above the knee where 
there was a small pyramidal coagulum, I have 
filled this coagulum with my injection as if 
it had been cellular, but there was no regular 
structure of vessels." Then, likening extrava- 
sation under inflammation, and the vasculariza- 
tion of the membranes of the chick to this ap- 
pearance of a self-organized coagulum, he adds, 
" I conceive that these parts have a power of 
forming vessels within themselves." — " But 
where this coagulum can form an immediate 
union with the surrounding parts, it either re- 
ceives vessels at this surface, or forms vessels 
first at this union, which communicate with 
those of the surrounding surface*." 

The infinitely more probable theory of the 
derivation of vessels from parent branches for. 

* Hunter on the Blood, p. 92 tt seq, 
I 



114 CORNEA. 

the organization of deposits, is supported by 
daily observation, and satisfactorily explains the 
phenomena. 

That vessels are capable of producing their 
kind is as certain as their reproduction of bone, 
tendon, and other elementary textures. The 
dependence of one order of vessels upon ano- 
ther is shewn by the existence of vasa vasorum ; 
and it seems to me most probable that the ves- 
sels first seen in a patch of lymph are fabricated 
by the vasa vasorum, bloodvessels and absorbents, 
of the terminal vessels of the wounded surface. 



Acute in- ^he acu te interstitial ulcer sometimes opens 

terstitial L 

ulcer of externally, by absorption of the conjunctiva, as 
well as of that portion of the lamella? superja- 
cent to it. Its figure and extent are deter- 



cornea. 



mined by the deposit of adhesive matter. This 
is frequently crescentic,and traverses apart or the 
whole diameter of the cornea. It is most fre- 
quently situated near the upper or lower margin 
of the cornea, but occasionally crosses the cen- 
tre. Upon close examination, the conjunctiva 
will be found to be absorbed at the part opposite 
to the ulcer, and the exposed scabrous surface 
of the cornea renders the motions of the upper 
lid acutely painful. The deposition of the ad- 
hesive track precedes the appearance of red ves- 
sels, which are derived to it in one or more fas- 
ciculi from the sclerotic conjunctiva, and by 



cornea; 115 

which its healing is perfected, as in the ulcer 
opening from the surface, before described. 

The terms onyx and unguis have been ° n y* »«»<* 

. . unguis. 

indiscriminately applied to extensive collec- 
tions of lymph and pus between the layers of 
the cornea, and to similar collections situated 
in the anterior chamber. They are applicable 
only to the crescentic interlamellar depositions 
above described. The acute interstitial ulcer 
in debilitated habits of body or when it is pro- 
duced by considerable violence done to the cor- 
nea, instead of opening upon either of its sur- 
faces, spreads between its lamellae, and in this 
case a considerable quantity of purifbrm matter 
is secreted. If it occupy a large and central 
portion of the cornea, it usually terminates by 
slough of the entire membrane. 

When, as more frequently happens, the in- Hypopion, 
terstitial ulcer opens into the anterior chamber, 
it produces the hypopion, which is a mixed se- 
cretion of lymph and pus ; the former flaky and 
inorganizable, and situated exterior to the fluid. 
The soft lymph pendulous from the mouth of the 
ulcer is often observed connecting the hy- 
popion with it. I never recollect to have 
seen the puriform hypopion unaccompanied 
with ulcer penetrating the interior lamella 
of the cornea. In these cases, the in- 
tegrity of the chamber is preserved, and the iris 
has no share in the restoration, 

1 2 



116 CORNEA. 

Procidentia When the external ulcer opens into the 

iridis. . r 

anterior chamber, so that the cornea is perfo- 
rated, the iris falls into the breach and becomes 
united to it by adhesion. When the opening is 
small, as from simple ulceration, the iris pre- 
sents a small black point ; if large, as from 
sloughing, the opposed portion of the iris is 
protruded in the form of a little sac ; and when 
this happens, the adhesive process is sometimes 
set up at once, by its pressure on the margin of 
the aperture in the cornea, and by the ready 
disposition of the iris to take on a correspond- 
ing action. But the adhesive process is not so 
promptly set up in this case as in the prociden- 
tia following wound, and the prolapsus often 
increases in size until a stimulant is employed. 
The healing action is marked by a dusky white 
line at the verge of the opening. The contraction 
of the chamber and the disfiguration of the pupil 
are proportioned to the extent of the prolapsus. 

Procidentia In the progress of an external ulcer to the inte- 

coruese. . . . • 

nor of the cornea,and before it penetratesmtothe 
chamber, a remarkable appearance is occasionally 
presented, viz. a transparent vesicle, which fills the 
aperture, and is supposed to be the membrane of 
the aqueous humor. I have never seen this 
state maintained ; the prolapsus iridis follows in 
a few hours, notwithstanding the use of the 
lunar caustic and other stimulants. This has 
led me to question its being a distinct texture, 
and its appearance corresponds accurately to 



CORNEA. 117 

that of the innermost lamella of the cornea, 
which after losing its support yields to the pres- 
sure of the humor, and assumes the vesicular 
form. The falling-in or cup-like depression of 
the continuous surface of the cornea, where the 
circumscribed interstitial ulcer opens into the 
anterior chamber, serves to confirm this con- 
jecture. I have never seen the nppearance which 
1 have heard others describe as demonstrating 
the adhesive inflammation of this tunic, viz. 
coloured vessels arborescent upon a deposit of 
lymph coating the interior of the cornea. If 
the observation be accurate, the case is very rare. 

Chronic interstitial ulcers from pure ul- chronic 

. . . ' n interstitial 

cerative absorption succeed to acute innamma- ulcer of 
tion, in which large quantities of blood have 
been lost, and occur frequently in children im- 
perfectly nourished, or adults much debilitated 
from various causes. The cornea is perfectly 
transparent, but indented like a bonce when 
struck upon a marble hearth, or pitted, accord- 
ing as the ulcers are diffused or circumscrib- 
ed ; the vision very slightly affected. Under 
nutritive diet, effective tonics, and moderate 
topical stimuli (vin. opii. sulph. zinci) they be- 
come hazy ; and this denotes the commence- 
ment of the adhesive action. 



Opacities are of three kinds : opacities; 

their kinds. 

1. Thickening of the conjunctiva and effusion 



US CORNEA* 

of adhesive matter between it and the cornea, or 
between the lamellae of the latter. This is com- 
monly the product of acute strumous ophthal- 
mia. The corneal surface loses its smoothness 
and polish, as well as its transparency, when 
the conjunctiva is affected ; when the opacity is 
in the cornea this is not the case. This is that 
form of opacity which, while recent, admits of 
removal by excitement of the absorbents more or 
less completely, and especially by that which mer- 
cury produces, the corneal texture being sound. 
It is what I have been accustomed to call nebula, 
and though presenting great varieties of shade, 
it has a soft, diffused, semitransparent character. 

2. A slow change of texture without breach, si- 
milar to that by which the pleura, or choroid, or 
capsule of the lens is converted into bone. The 
yellow pearly opacity, resembling the inside of an 
oyster-shell, is of this kind. It is the result of 
continued, or frequently relapsing (strumous) 
rather than violent inflammation, and is deep- 
seated. In this case the layers of the cornea 
become opaque, indurated, and condensed, so 
as not to admit of separation by the knife or 
maceration ; and if such opacities are in any 
degree relieved, it is by an absorption of the 
interlamellar deposit in their vicinity. 

3. New matter, supplying an absolute loss of 
substance of the cornea, from ulceration or gan- 
grene. This differs from the second chiefly in 



CORNEA* 119 

its figure being more abruptly circumscribed, 
and bearing more resemblance to a cicatrix. In 
point of density the second often exceeds it, as 
when the cicatrix does not penetrate the cornea. 
Both these species of opacity are white in the 
recent state, and in general the more conspicu- 
ously their colour is contrasted with this ap- 
pearance, as yellow or brown, the less is the 
probability of reducing them. 

The peculiar hue and loss of tension, as well Gangrene 

preceded 

as lustre, of the dead cornea in acute suppura- by adhesive 

deposition 

tive ophthalmia, has been aptly pictured by Mr. in acute 
Saunders, by the terms ' cindery, ragged, floe- ophthai- 
culent.' It is important, because I have sa- 
tisfied myself that the first change of the 
cornea in this disease is purely nebulous, pro- 
duced by the deposition of adhesive matter ; 
and if the inflammation be arrested even on 
the verge of gangrene, the cornea is sus- 
ceptible of restoration by absorption. This 
fact I had lately an opportunity of establishing, 
in the case of a lady who was rendered blind 
by acute suppurative inflammation of the con- 
junctiva : so inevitable to all appearance was the 
destruction of the cornea, which had sloughed 
in a deep sulcus at its junction with the scle- 
rotic above, that the most experienced practi- 
tioner of my acquaintance in this branch 
of surgery pronounced the case hopeless and 
irremediable, and took his leave. The highest 
tonic regimen, bark, wine, and opium, followed 



120 CORNEA. 

close upon a very active and bold depletion, 
and the anterior chamber was fortunately and 
unexpectedly preserved. No sooner was a sign 
of the arrest of sloughing ulceration obtained, 
than I commenced a mercurial course ; in three 
days the system was affected ; the recovery 
of the figure and transparency of the cornea 
was rapid and complete beyond all expectation, 
and an equally perfect state of vision was restored 
and established. 

The gangrenous opacities of the cornea pro- 
duced by lime or other substances destroying its 
texture, are sometimes superficial and defined 
in extent, and a process somewhat resembling 
exfoliation ensues. More frequently this disor- 
ganization is integral and complete. The cornea, 
disorganized by acids, is rendered instantly 
opaque, shrivelled, and of a yellow colour, almost 
resembling a piece of wash leather. 

In general, opacities which have a recent dif- 
fused semitransparent character (nebulous) admit 
of absorption ; not so those in which the inter- 
stitial deposition has been abundant and of long 
standing, and the lamellae are compacted, owing 
to the entire obliteration of the cellular texture ; 
or in which a new portion of cornea is formed. 



cuticuiar J have seen several cases of the conver- 

conjunc- 

tivaofthe sion of the conjunctiva into a skin, rugous and 

cornea. _ ° 

opaque, knitting the lids close lo the globe, so 



CORNEA* 121 

as to obliterate the sinus palpebrales. I have 
called it cuticular conjunctiva. In these cases 
there is no secretion of tears. I have had occa- 
sion to observe the accession and progress of 
this disease in early and advanced life, among 
the sequela? of chronic inflammation of the con- 
junctiva, and am disposed to consider it depend- 
ing on an obliteration of the lacrymal ducts. 

All stimulant substances, not escharotic, Action of 

,. , ••/■>» topical 

applied to remove opacities or the cornea, act stimuli on 

. opacities. 

in the same manner as rubefacients upon the 
skin ; they excite a temporary vascular action, 
which is followed by a corresponding excite- 
ment of the absorbents. I have often seen an 
opaque portion of the cornea cleared by a punc- 
ture with the couching needle. If the point 
of salutary excitement is exceeded, the increased 
vascularity is permanent, and occasions in- 
creased deposition. Injections applied to ulcers 
do not excite the absorbent action in the same 
ratio, but occasion a permanent increase of the 
vascular action, which is here below the or- 
dinary standard. This instance of the adapta- 
tion of the same means to different ends, ac- 
cording to the state of the part, is perhaps the 
best practical illustration of Mr. Hunter's quaint 
but expressive phrase, " stimulus of necessity." 

Opaque specks, even cicatrices are obli- Absorption 

l n i • during 

terated during the period of growth, and as is growth. 



122 



CORNEA. 



observed of cicatrices in other parts of the 
body, change their relative position remarkably 
in the years of growth. Thus a remarkable 
speck, encroaching upon the pupil in the in- 
fant, becomes a small and scarce discernible 
a speck in the grown child, situated near the 
verge of the cornea. In other instances, if 
originally small, it has disappeared altogether. 
Like cicatrices of other parts they are always 
considerably smaller than the ulcers of which 
they are the vestiges. 

staphyio- The staphyloma is of two kinds, viz. 

kinds. from dilatation and from breach. In the first 
case the corneal lamellae have not completely 
given way, but are only bulged, the membrane 
having been so far weakened by ulceration as to 
have lost its due resistance, and the staphyloma 
consequently affects the whole diameter of the 
cornea, (spheroidal). In the second the staphy- 
loma is circumscribed, the recent lymph cor- 
responding to the breach, yielding at one or 
more points to the pressure of the humor, (co- 
noidal.) 

In the spheroidal staphyloma the effect of 
pressure is to thicken the remaining lamellae by 
a deposition of adhesive matter, as in the aneu- 
rismal and herniary sac j so that the transverse 
section of it greatly exceeds in diameter that 
of the healthy cornea. In the conoidal staphy- 



CORNEA. 123 

loma the recently deposited matter yields to the 
pressure a tergo before its organization is com- 
plete. Sometimes the two forms are combined, 
and one or more conoidal protrusions are formed 
upon a spheroidal staphyloma. When, as in 
the first case, the corneal texture has not ac- 
tually given way, the anterior chamber is in 
most instances preserved, and the iris is free. 
In the other case the iris is usually complicated 
with the staphyloma. The remediableness of 
the deformity occasioned by the disease, by 
means of an operation, depends upon a suffi- 
cient portion of the iris being left. The iris is 
kindly disposed to granulate, as we see in 
sloughs of the entire cornea from suppurative 
ophthalmia. I have seen in such cases a per- 
manent staphyloma of the iris, the pupil closed, 
and the exposed iris retaining its character, 
occupying the situation and presenting the 
figure of the cornea. The case is not com- 
mon, as the cicatrization of the pupil precedes 
the fall of the cornea. Three or four days after 
the operation for the staphyloma, the iris is 
seen coalescing with the conjunctiva and throw- 
ing up fleshy pullulations, which contracting 
into a little button-like eminence, seal up and 
permanently secure the crystalline and vitreous 
humors ; thus the spherical figure of the globe 
is preserved to support the lids. But if the 
section be posterior to the plane of the iris, the 
vitreous humor escapes and the globe collapses 
and sinks in the socket. 



124 CORNEA. 



cornea. 



conical The cornea is occasionally subject to 

a process of thinning, or an absorption of its 
interlamellar texture, and in consequence, loses 
its natural tonic resistance to the pressure of 
the contents of the globe. It usually assumes 
a conoidal figure, but this is not always the 
case ; the projection of the cornea is some- 
times uniform, describing the segment of a 
larger sphere. The apex of the cone corres- 
ponding to the centre of the cornea, when this 
figure is assumed, exhibits a degree of tenuity 
and brilliancy which gives it the appearance 
of a pellucid fluid, like a dew-drop suspended. 
The patient's vision becomes so inconveniently 
short as to render objects confused at a very 
moderate distance ; the change is sometimes 
slow, occupying months, and even years ; and 
on the contrary, I have seen it produced in its 
greatest extent in the short space of eight 
weeks: both eyes are generally affected, though 
not always in the same degree. The disease is 
unpreceded by inflammation, or any obvious 
assignable cause ; it is more frequent in women 
than in men, and in my experience affects mid- 
dle life. I have never seen it commencing in 
childhood or old age. It is as much the disease 
of the robust as of the weakly constitution and 
frame of body. If inflammation is excited by 
stimulants, the apex of the cornea turns opaque ; 
if left to itself, the cornea does not give way, 
but remains in the condition described. No 
remedy yet proposed has been followed by a 



CORNEA. 125 

beneficial result; but a pupillar aperture set 
in a black ring frame, about a quarter of an 
inch or more in depth, greatly assists the 
patient by lessening the confusedness of his 
vision. 

It seems that the presence of adhesive in- 
flammation is the chief distinction between the 
staphyloma from dilatation and the conical cor- 
nea : the absorption is therefore in the one 
case the ulcerative and in the other the inter- 
stitial. 

The last stage of healing in external ul- Finishing 
cers of the cornea exhibits beautifully the third ulcers. 
kind of absorption, viz. the modelling, as de- 
scribed by Mr. Hunter. We see it in the low- 
ering, rounding, and smoothing of the jagged 
edges of the cup of the ulcer, a compromise 
in some sort with the full and complete finishing 
of the adhesive process, viz. indelible opacity ; 
and in some cases this state of imperfect resto- 
ration is perpetuated to a manifest advantage, 
for a transparent indentation occasions little, 
if any impediment to vision. 



SECTION III. 



SCLEROTICA. 
Vessels of Branches from the straight vessels of the 

sclerotica. 

conjunctiva penetrate the sclerotica obliquely to- 
wards the margin of the cornea 9 and the long 
ciliary vessels pass in sulci of this membrane to 
the plexus ciliaris at the root of the iris. At 
the interior border of the sclerotica, where the 
annulus ciliaris is adhering closely to this tunic, 
the ciliary communicate with the muscular 
branches, and being in deep-seated inflam- 
mation fully injected with red blood, the con- 
densation of colour gives the well known and 
remarkable appearance of a vascular zone at 
the margin of the cornea. Injections do not 
demonstrate this anastomosis ; for the communi- 
cating vessels, like those which are continued 
upon the cornea, are too delicate to admit of 
artificial injection, and only admit red blood 
after a strong and steadily supported inflamma- 
tory action*. When once they have received 
red blood they very slowly recover their healthy 

* A very successful injection of an eye in the state of acute 
iritis, could alone demonstrate this fact to the entire satisfac- 
tion of anatomists. 



SCLEROTICA. 127 

calibre, as is proved by the faint appearance of 
the zone long after the inflammation has ceased, 
and the almost instantaneous reproduction of 
the state of congestion on forcibly separating the 
lids. When an inflammation at first affecting 
only the conjunctiva is allowed to progress, 
the ciliary vessels partake of the action, and 
this sign of the extension of it to the interior 
tunics makes its appearance. But the sclerotica situation 
from its situation and texture serves as a shield ture, e their 
to the finer tunics, from external inflammation 
as well as from external violence. By the in- 
terposition of the sclerotica the vascular commu- 
nication of the choroid and conjunctiva is ren- 
dered extremely minute and anastomotic ; and 
for this reason inflammation of the conjunctiva 
may and often does reach to a considerable 
height, without any indication of its extending 
to the parts beneath the sclerotica. An acute 
and obstinate inflammation of the conjunctiva, 
not threatening injury to the cornea, as the 
pustular, and that with puriform discharge, 
does not in any degree affect the choroid and 
iris. On the other hand, when inflammation 
has extended to these tunics the vision is af- 
fected in a much greater degree than appear- 
ances would often lead us to expect. I only 
mean to remark that if the transmission of 
blood to the deeper seated tunics had followed 
readily to that of the conjunctiva, the conse- 



128 SCLEROTICA. 

quences of every severe superficial ophthalmia 
would have been mischievous. 

2flammL When the sclerotica partakes of the inflam- 
roUca^se!" mat i° n °f tne conjunctiva, for it is only as inter- 
condary. mediate to the conjunctiva and the other tunics 
that it is usually affected, the vessels which 
pursue a straight course to the margin of the 
cornea are strongly distinguished. They have 
a somewhat darker hue than the areolar vessels 
upon the loose portion of the conjunctiva. I 
have exhibited this difference of arrangement 
of the vessels in the sclerotic and conjunctival 
inflammation, as seen in a singular case of in- 
flammation accompanied with pustules*. This 
appearance is always observed during the morbid 
changes upon the cornea, as interlamellar de- 
posits of lymph and ulcerations. 

sclerotitis; I have occasionally observed in a recent 
maticoph- ophthalmia this turgescence of the straight 
vessels, unaccompanied by any affection of 
the iris, and with so slight a vascularity of 
the loose conjunctiva, as to give reason to con- 
sider it a primary sclerotitis. The inflammation 
is not acute; the motions of the ball are painful. 
This inflammation of the sclerotica sometimes 
accompanies, and is sometimes metastatic with 
rheumatic inflammation. This is not surprising, 
* See Plate I. fig. 6. 



thalmia. 



SCLEROTICA. 129 

as its texture is of the same class with the li- 
gaments of the joints. This inflammation, it 
continued, presents the zonular arrangement of 
the vessels, and a pupil contracted or drawn a 
little to one side. It is often seen in company 
with eruptions or sore throat of a pseudo-syphi- 
litic character, or secondary to gonorrhoea ; and 
this is the description of pains to which, in my 
experience, it is generally allied. 

The sclerotica, although a firm texture, 
possesses in certain persons such a degree ot 
tenuity and consequent transparency, as to con- 
vey an obscure tint of the subjacent choroid in the 
vicinity of the cornea. This is most observable 
in those of light-coloured hair and iris, and in 
persons of lax and weakly habits. It is rela- 
tively thinner in such persons. It is evidently 
slenderer in its texture adjoining the cornea, 
than elsewhere. A morbid discoloration of 
the sclerotica is usually combined with an or- 
ganic amaurosis, whether congenital or induced 
by inflammation or its consequences. The scle- staphy- 
rotica sometimes yields in the spheroidal staphy- sclerotica. 
loma, a disease proper to the cornea, so much as 
greatly to increase the conspicuousness and de- 
formity of the disease. This happens in hy- 
dropic and other degenerations of the humors. 
It also frequently becomes extenuated or bulged 
near its junction with the cornea, in theamaurosis 
which follows inflammation of the choroid. This 
protrusion, larger or smaller, is sometimes cir- 

K 



130 SCLEROTICA. 

cumscribed, and in other instances diffused over 
a large portion of the ball. It is often seen en- 
circling the cornea, and presenting a sacculated 
or pouched appearance. It has a bluish grey 
tint, and the globe is of course misshapen in 
proportion to its size. An increase in size of 
the whole globe, or hydrops oculi, is often joined 
with it. 

Persons who are not aware that it is the 
result of a chronic process, viz. an interstitial 
absorption of the sclerotica, sometimes mistake 
it from some faint resemblance to the black 
fungoid tumor, for a malignant disease. I have 
heard it pronounced a fungus hasmatodes, and 
the extirpation of the organ advised. I think 
it may not improperly be designated, staphy- 
loma sclerotica?. 

staphy- I have met with one or two instances of the 

loma of the ' . 

choroid, actual protrusion or the choroid at the margin 
of the cornea, which had the appearance of 
resulting from the separation of the sclerotica j 
like the staphyloma iridis from the fall of the 
cornea, described page 123. 



SECTION IV. 



CHOROID AND IRIS. 

The appearance of the vascular zone at Choroiditi 
the margin of the cornea, which, taken by 
itself, is a sign of the inflammation having ex- 
tended to the sclerotica, if accompanied with 
dulness of the humors, a spastic contraction, 
or a very sluggish and limited motion of the 
pupil, an impatience of light, and a considerable 
dimness of vision, demonstrates that the choroid 
and iris participate in the inflammation. We 
ought to consider 'that the local and vascular 
relations of the choroid and iris, distinct as they 
certainly are both in texture and properties, are 
such as to make it exceedingly improbable that 
the one should not, in all cases, participate more 
or less in the inflammation of the other. We 
are permitted to see the primary changes in- 
duced by disease in the living organ, upon the 
iris only, and we have not as yet any precise 
marks by which we can ascertain the com- 
mencement of inflammation in the one or the 
other texture. It is probable, however, that 
as the iritis presents considerable varieties in its 
form, its access and progress, relatively to the 
superficial inflammation, and the kind and 
degree of pain and dimness which accompany 
it, that the choroid is the seat of the primary 
inflammation in those cases in which the 
changes upon the iris take place later than the 
k 2 



132 CHOROID AND IRIS. 

other signs of internal inflammation, viz. the ar- 
rangement of the vessels, the pain, and the ob- 
scurity of vision. I have often seen cases of 
this description which I have felt disposed to 
denominate " Choroiditis." 

iritis. The indications above mentioned, are still 

further confirmed by the presence of an habi- 
tual aching pain affecting the globe of the eye, 
forehead, and region of the orbit, and by cer- 
tain appearances of inflammation upon the iris, 
as hair-like red vessels and specks of extrava- 
sated blood in its substance. Adhesive inflam- 
mation takes place between the fibres of this 
muscle ; the pupil loses its thin flowing edge, 
and becomes thick, stunted, and gibbous. Iritis 
of moderate acuteness is often unaccompanied 
by any other appearance of inflammation; there 
is no distinct deposit of lymph, and it is rather 
inferred from the fixedness or slight change of 
figure of the pupil, than demonstrated. I be- 
lieve the adhesive matter, in this case, is depo- 
sited on the posterior surface, formerly called 
uvea, for in the course of a few days, the 
opacity of the capsule of the crystalline, and 
the co-adhesion with it of the pupillary margin, 
becomes evident, provided the inflammation be 
unchecked. In this form of inflammation 
the pain is often augmented in the evening, 
or at an early hour of the morning, to such 
intensity as to compel the patient to rise, 
and even totally to deprive him of rest. Some- 



fc^IOROID AND IRIS. 133 

times the pain affects the whole corresponding 
side of the head. In other instances, it is con- 
fined to the eyeball and its immediate vicinity, 
as the forehead, and tempie, and bones of the 
cheek. The sensation is sometimes that of pul- 
satile pain, marking every injection of the oph- 
thalmic artery, as of the radial artery in a 
vvhitloe. A sense of continued pressure or 
constriction, as from extreme distension of the 
vessels, is the more common character of the 
patient's sufferings. In the vehement acute 
iritis, lymph is variously deposited upon the 
face of the membrane, in small tufts here ami 
there, or larger tubercular masses. The pupil, 
in this case, is usually much misshapen, being 
rendered angular at those points of the circle at 
which the deposithas taken place, or is most abun- 
dant. Its aperture is sometimes partially covered, 
and sometimes completely blocked by a deposit of 
lymph. The pain, in this state, is not always 
augmented in proportion. It affects more the 
head than the organ. The vision is nearly, if 
not quite extinguished. The appearance of a 
stratum of lymph, coating the face of the iris, 
with a turbid state of the aqueous humor, be- 
longs to chronic inflammation, which tends to 
opacity of the capsule of the lens, and con- 
striction of the pupil. 

A primary inflammation of the iris, as for Primary. 
example, from syphilis, or from mercury, is 
distinguished from the secondary, or that by 
extension from the conjunctiva, by the more 



134 CHOROID AND IRIS. 

sparing vascularity of the conjunctiva, and con- 
sequently more distinct and conspicuous appear- 
ance of the vascular zone. The attack is more 
sudden, the pain in the region of the orbit and 
head, commences with the inflammation, and is 
more severe; the vision is more quickly and com- 
pletely bedimmed. The effusion of lymph is en 
masse, and the disfiguration of the pupil greater. 

Secondary. In the inflammation of the iris by conti- 
nuity, the conjunctival vascularity is more con- 
spicuous and diffused, and the cornea is so 
much clouded, as partially to obscure the view of 
the iris; the albuminous deposit is wanting, or if 
any has taken place, it is small in quantity, white, 
flocculent, and partially diffused in the aqueous 
humor, or is deposited at the ciliary margin of 
the iris, forming a lymphatic hypopion ; the 
pupil is little, if at ail misshapen. The pain in 
the secondary iritis is usually confined to the ball, 
and is comparatively inconsiderable. Although 
the vision is much bedimmed, there is greater 
susceptibility to the painful impression of light. 
This state I have heard others describe as the 
adhesive inflammation of the anterior chamber. 

Termina- The terminations of iritis, if unsubdued, are, 
iritis. 1st, constricted or closed pupil, with opaque 
capsule; 2d, coadhesion of the iris and cornea, 
partial or entire, the former assuming the con- 
vexity of the latter ; 3d, organic amaurosis, fol- 
lowed by disfiguration of the globe, and often 
by protrusions of the choroid and sclerotica. 



CHOROID AND IRIS. 135 

The iritis, as I have formerly observed, is Mercurial 

r 1 • -i t ilitis ' 

very frequently in company with, or succeeding 
to syphilis, and the symptoms called mercurial, as 
peculiar eruptions, sore throat, and pains of a 
rheumatic character. Primary iritis is rarely 
seen unaccompanied or unpreceded by such 
symptoms. I have never said or thought that 
it could not exist independently of these symp- 
toms, and their supposed causes, having seen 
such instances. But I have since had many ad- 
ditional opportunities of confirming the facts be- 
fore advanced, that where mercury has been 
used in various ways before the iris was affect- 
ed, and before the other symptoms appeared 
which were referred to its use ; — where the pri- 
mary affection was either altogether question- 
able, or at most a gonorrhoea, or a superficial 
sore, which healed by a simple topical applica- 
tion — the iritis has yielded to the steadily sup- 
ported influence of mercury upon the system, 
in a manner the most satisfactory; and that no 
other remedy with which I am acquainted, was 
competent to this effect*. 

* I think it right to state, that the salutary effect of mer- 
cury in iritis, unassociated with any specific action, was an 
observation made at the same time by Dr. Farre and myself, at 
the ' London Infirmary for Diseases of the Eye/ It was first 
given to the public in the second edition of Mr. Saunders's 
work, then in the press. I am quite satisfied that the obser- 
vation was original, notwithstanding all the attempts of the 
German scholars to convince us, that at Vienna and elsewhere 
it was a matter, " Lippis et tonsoribus notum." 

I shall further add, that I am unacquainted with any fact in 



136 CHOROID AND IMS. 

Morbid The iris undergoes a change of color as well 

changes of o o 

iris - as texture by a continuance of inflammation. 

This is owing to the loss of its transparency, 
andthe interruption given to its proper secretion 
by thelymph deposited upon its posterior surface. 
The healthy iris is transparent, as may be seen 
in the albino, white rabbit, and ferret j hence 
the use of the pigmentum nigrum. 

It suffers a loss of mobility from the agglu- 
tination of its fibres, and ultimately of its pos- 
terior surface to the tunica hyaloidea, by which 
the posterior chamber is annihilated. It is 
from this morbid condition extending to the 
plicae ciliares, that the loss of figure of the 
globe, or the staphyloma of the sclerotic and 
choroid results. A notable thickening and ri- 
gidity, a leather-like toughness of the iris, and 
a varicose state of its vessels, are changes ac- 
companying the state of chronic closed pupil, 
after reiterated attacks of inflammation. 

A morbid change sometimes, but rarely 
witnessed, is the conversion of the choroid into 
a shell of osseous matter. 

I shall have occasion to speak of others un- 
der another head. 

Medical Surgery which ranks with this in point of impor- 
tance ; whether we consider the urgency and frequency 
of the occasion, or the indispensable necessity, and almost 
unerring efficacy of the remedy. 



SECTION V. 



RETINA. 



The retina is sometimes, though rarely, inflamma- 
the seat of inflammation ; but it is an error to retina. 
suppose that intolerance of light is a sign of 
this affection, as is clearly proved in the stru- 
mous ophthalmia, in which, although the intole- 
rance is in excess, the retina is uninjured : and 
secondly, because the effect of inflammation upon 
a nerve of sense is to produce direct palsy, not 
increased excitability. Inflammation of the pas- 
sages and auxiliary textures of the organs of 
sense may render the impression of their na- 
tural stimuli painful, but here, as in the case 
before referred to, and probably in all cases, the 
increased acuteness of the sense is sympathetic. 
The organic sensibility, we may conclude, is 
increased in the sentient, as in other organs, by 
inflammation. This is probable from the first 
and predominant symptom of inflamed retina, 
viz. a sudden attack of vehement dashing pain 
of the most distracting kind, which is described 
to extend from the bottom of the eyeball to 
the occiput, or in the reverse direction, and the 
supervention, within a few hours, of total blind- 
ness, with occasional sparks and flashes of vivid 
light. The pupil, upon inspection, is gaping 
and motionless, as in confirmed amaurosis, and 
the humors are thick and muddy. The ex- 
ternal signs of inflammation are in the com- 



1 38 RETINA. 

mencement disproportionate, and quite insuffi- 
cient to account for the symptoms. 



Accompa- In some cases, however, the signs of choroid 

nied with . 

inflamma- inflammation are present with the attack of pain 

tion of the 

other tu- and the loss of sight. The pupil is not thrown 



nics. 



open, but it is without motion. In addition to 
diffused vascularity of the conjunctiva, the 
straight ciliary vessels are remarkably loaded, 
so as to give a livid red hue to the sclerotica 
around the cornea. The pupil becomes in a , 
few days plugged with lymph, or the whole iris 
bulges forward, changes colour, and the crystal- 
line turns opaque ; or instead of this, the same 
splendid tapetum-like appearance presents itself 
which is observed in the commencement of the 
medullary fungus, upon looking obliquely 
through the pupil. The pain in this attack is 
accompanied with a sense of confusion so alarm- 
ing, that the patient apprehends the loss of his 
intellects. I once saw the disease marked 
throughout with so much disturbance of the 
nervous system, e. g. vigilance, temporary wan- 
derings, catches of the muscles of the face, 
startings and frightful dreams, in the short in- 
tervals of repose from exhaustion, — coupled 
with a sense of heat, constriction, and tender- 
ness of the whole scalp, — that I was disposed to 
consider the ophthalmia as secondary, and sub- 
ordinate to inflammation of the brain or its 
membranes. When the internal signs of in- 
flammation are less obvious, and the humors 



RETINA. 139 

and internal tunics undergo a slow but com- 
plete disorganization in the progress of the 
disease, meteoric flashes are frequent, even after 
the inflammation has run its course ; and I have 
known patients gratified with this ignis fatuus, 
although conscious that it was no more. I have 
seldom seen an example of this inflammation, 
which seemed to afford time for the beneficial 
operation of a remedy. I have in more than one 
instance given a full trial to the lancet, and the 
immediate operation of mercury ; but though 
both were carried as far as could be permitted 
with safety, the vision was lost. In others the 
external inflammation has been subdued, and 
the vision has been recovered so far as to enable 
the person to distinguish surrounding objects 
with tolerable precision ; but the gaping and 
motionless pupil, the discolored humors, and the 
superficial congestion, which remained, afforded 
little hope of its continuance. One lamentable 
instance occurred under my observation, of its 
destroying both eyes in a middle-aged lady within 
the short interval of a fortnight. She expressed, 
in the agony of her suffering, a conviction that 
she must either lose her sight or her senses. 

Amaurotic affections, as is well known, Amaurosis, 
differ infinitely in degree, but they differ also in fuKona?. 
kind j and this affords a more scientific basis of 
classification. I divide them into two classes, 
the organic and the functional. The first com- 
prehends alterations, however induced, in the 
texture or position of the retina, optic nerve, or 



140 RETINA. 

thalamus. The second includes suspension or 
loss of function of the retina and optic organ, 
depending upon a change either in the action of 
the vessels, or in the tone of the sentient appa- 
ratus. As causes of the first, we may enumerate, 

1. Lassion, extravasation of blood, inflam- 
matory deposition upon either of its surfaces, 
and loss of transparency of the retina. 

2. Morbid growths within the eyeball, dropsy, 
atrophy, and all such disorganizations as directly 
oppress or derange the texture of the retina. 

3. The state of apoplexy, hydrocephalus, 
tumors or abscesses in the brain, in or upon 
the optic nerve, or its sheath, and thickening ex- 
tenuation, absorption, or ossification of the latter. 

As causes of the second, 

1. Temporary determination ; vascular con- 
gestion, or vacuity, as from visceral and cere- 
bral irritation ; suppressed, or deranged, or ex- 
cessive secretions, as of the liver, kidneys, 
uterus, mamma?, and testes; various forms of in- 
jury and disease; and sudden translations of re- 
mote morbid actions. 

2. Paralysis idiopathica, suspension or ex- 
haustion of sensorial power from various consti- 
tutional and local causes ; from undue excite- 
ment or exertion of the visual faculty; and from 



RETINA. 141 

the deleterious action of poisons on the nervous 
system, as lead, mercury, &c. 

From this description it will be understood 
that organic, and many forms of functional 
amaurosis are incurable; and the functional, by 
continuance, lapses into the organic disease. 
Even under the continued suspension of func- 
tion, much more the duration of a state of ex- 
citement, the power of the retina, as of other 
parts, gradually fades,and is at length exhausted. 
Thus the removal of a cataract from the eye of 
a person who had been the subject of the dis- 
ease for thirty years, was unsuccessful in re- 
storing useful vision. This was a sensorial 
defect, for the eye had every appearance of 
health, both before and after the operation. 

I am aware of the objections to which this, 
like most other attempts at a scientific arrange- 
ment of such subjects, consistent with practical 
views, is exposed. Thus the comprehending 
under the same heads the states of temporary 
and permanent congestion of the vessels of the 
retina and brain, and the disordered actions of 
the vascular and proper texture of the retina, 
may, prima facie, appear to be examples of in- 
congruity. But for the purpose of descriptive 
arrangement, a line of division must be some- 
where drawn ; and opposed to the gradual and 
often imperceptible transition from functional 
to organic disease, this division must appear 
more or less forced and artificial. I conclude 



142 RETINA. 

that the difference between the disposition to apo- 
plexy and the state of apoplexy, may be acknow- 
ledged in the eye as well as in the brain, and that 
the purely functional irregularities of the former 
organ as a whole, may be classed with as much 
propriety as those of the heart or the stomach. 

In treating of the disorders of any sense or 
function, I deem it an essential character of 
a scientific arrangement, to include in one view 
the entire organ, philosophically speaking, sub- 
servient to that sense or function : hence, the 
brain and retina should not be considered 
separately, but in conjunction. Secondly, to 
regard the locality and demonstrabieness of 
diseased states, as affording the best ground of 
division ; because the presence or absence of 
certain external characters affords a stronger 
distinction between functional and organic dis- 
orders, than we could hope to obtain from any 
analysis of the symptoms characterising the va- 
rieties of disordered function, in the present state 
of our knowledge. 



History, The history and concomitant appearances or 

and con- . . . 

currentdis- morbid states associated with amaurosis, usually 
indicate to which class it belongs : as for exam- 



easeii. 



pie, diseased changes in the situation or texture 
of the eyeball, or in the brain, a hemiplegia, or 
partial paralysis, with other signs of apoplectic 
or hydrocephalic pressure, whether resulting 
from an injury of the head or otherwise ; or an 
acute deep-seated inflammation, whether accom- 



RETINA. 141 

parried by a visible opacity or not, point out the 
organic nature of the affection. I have seen 
such an amaurosis produced by abscess in the 
cerebral substance, and by the medullary fungus 
of the cerebrum. On the other hand, I have 
known the following distinct sources of irritation 
operating to produce functional amaurosis, viz. 
wound of the scalp*, caries of the skull, abscess 
and caries of the antrum maxillare,with excessive 
oedema of the integuments of the lids and cheek, 
a large abscess under the masseter and mus- 
cles of the cheek, and an abscess at the extre- 
mity of a molar tooth, while the crown of the 
tooth was sound. In all these cases it is to be 
understood that the eye was sound, and the 
orbit was untouched by the disease of the parts 
in the vicinity, to which the amaurosis was 
clearly attributable. In like manner an exces- 
sive use or rather abuse of the visual faculty, 
the disordered functions of the stomach, liver, 
uterus, &c. ; sudden and alarming depletion, ex- 
cessive or obstinately suppressed secretions, diffi- 
cult dentition, the presence of worms in the intes- 
tinal canal, and the deleterious effects of noxious 
agents upon the organ or the system, are suffi- 
ciently obvious causes of the functional amaurosis. 

The professions, circumstances, and habits 

* A laesion of the frontal nerve is mentioned among the 
occasional causes of an amaurosis from Hippocrates down- 
wards. A striking example is reported by Sabatier. Traite 
d'Anatomie, Tom. 3. p. 228. 



144 RETINA. 

of patients throw much light on the origin 
and nature of amaurotic affections. Such as 
have a direct influence are, sedentary occupa- 
tions disposing to torpid liver and bowels, 
combined with the continued exercise of the 
eye in a depending position of the head 
upon minute objects* ; in too strong or in- 
sufficient light, upon polished reflecting sur- 
faces t ; habitual exposure of the organ to 
a high degree of heat t ; to acrid fumes and 
vapours §; and the customary employment of 
optical glasses ||. Immoderate grief, excessive 
indulgence in venery, protracted suckling, con- 
tinued diarrhoea, repeated haemorrhages, pro- 
fuse salivation ; and on the other hand, ob- 
stinate amenorrhcea, or constipation of bowels, 
with determination of blood to the head in a 
full habit, are ordinary predisposing or constitu- 

* Needle-workers, writers, draughtsmen. 

f Inspectors of linen and scarlet cloths, and of new hank- 
notes ; money-counters. It is a curious fact, that several 
persons so employed at the Bank, at the issue of a new coin- 
age of silver, were affected with symptoms of amaurosis. Co- 
lour-manufacturers, burnishers, landscape-painters. 

1 Smiths, Stokers in iron furnaces and glass-houses, tavern 
cooks, &c. 

§ A wholesale manufacturer of blacking became the sub- 
ject of gutta serena. He had been a constant superintendant 
of the process upon a large scale. The mixture of sul- 
phuric acid, with the several ingredients, disengages a pungent 
and offensive vapor, by which the eyes are very painfully 
affected. 

|| Watch-makers and engravers, philosophical instrument- 
makers, sea officers. 



RETINA. 145 

tlonal causes of this disease, as I have had abun- 
dant opportunities of learning*. 

Amaurosis of whichever class is either perfect 
or imperfect. The first is marked by total insen- 
sibility to light ; the second, by defect of vision, 
infinitely varied in kind and degree. I need 
scarcely remark, that not only the appearances 
and symptoms vary, but the essential character 
of the disease varies in its stages. Thus, an af- 
fection, purely functional in its origin, by dura- 
tion becomes an organic disease. 

* There are strong shades of difference in the cases of 
these unfortunate persons, as regards the intensity of their 
feelings under the hopeless privation of sight. The man of 
pure life has the support of the best philosophy. The lite- 
rary man has not enjoyed his ' Nodes Attica? in vain. They 
have provided him with resources. Even the aged voluptu- 
ary rises with some degree of complacency as a ' conviva 
satur' from the banquet of nature, and contemplating the 
various evils of the common lot in the circle of his friends, 
meets his calamity with somewhat of martyr fortitude. 
The most pitiable is the amaurosis of early life, from 
excess of sexual indulgence, and especially of solitary vice. 
The following are strong examples : — A country lad, of 
robust constitution, became the alternately favoured paramour 
of two females, his fellow-servants, under the same roof. He 
was the subject of gutta serena in less than a twelvemonth. 
Another at an early period of puberty, suddenly fell into des- 
pondency, and shunned society. He never left his chamber 
but when the shade of night concealed him from observation, 
and then selected an unfrequented path. It was not disco- 
vered until too late, that in addition to other signs of nervous 
exhaustion, a palsy of the retina was the consequence of ha- 
bitual masturbation. 

L 



146 RETINA. 

ORGANIC AMAUROSIS. 
signs of When the eyeball is the seat of organic amau- 

organic . 

change in l'osis, it commonly presents some, or all or the 

the eyeball. ni 

following appearances : 

1. A pupil fully or preternaturally dilated, 
contracting feebly, in the first case, on the sud- 
den admission of light, and absolutely motionless 
in the second. This appearance is not peculiar 
but common to both classes, though by no means 
invariable in either. 

2. A congestion of the superficial vessels, es- 
pecially of the long fasciculi of conjunctival veins. 

3. A peculiar bluish grey tint of the sclerotic 
coat; sometimes a degree of bulging or protru- 
sion on one or more sides of the globe ; or simply 
a loss of sphericity, its sides appearing flattened. 

4. A diffused turbidity or milkiness, ap- 
parently of the vitreous humor, strikingly ob- 
servable when contrasted with the jetty bright- 
ness of a healthy eye. It is little more than the 
healthy appearance of the humors in the eye of 
the horse. This state, which the antients termed 
glaucoma, is very often mistaken for incipient 
cataract ; and I have known it called a black 
cataract, and the operation of extracting the 
transparent lens performed. It appears deep- 
seated, diffused, and of uniform density; and in 
examining some such cases at long intervals, I 



itETINA. 147 

have not found the appearance vary. The lens 
remains transparent. There are, however, some 
cases of a deep-seated opacity so closely resem- 
bling that of incipient cataract, that it becomes 
next to impossible to decide the actual state of 
the lens. I have seen the latter, upon an ex- 
perimental extraction in such a case, semi-trans- 
parent, and of a bright yellowish tint throughout, 
and the sight of the patient has been consider- 
ably improved. The vision is in general defec- 
tive in a much greater degree than the visible 
opacity explains ; and this combined with the 
depth of the opacity, a dilated and sluggish 
pupil, and some other symptoms of amaurosis, 
makes for the opinion that it belongs to the latter 
class. But where other signs of impaired retina 
are wanting, and the states of dimness and opa- 
city correspond, the operation would be war- 
rantable, although the site of the opacity should 
be disputable, if it were the express desire of a pa- 
tient properly in possession of the circumstances. 

5. Another yet more common appearance 
is that of a white or greenish yellow spot, appa- 
rently in the fundus of the eye, a little to one 
side of the visual axis ; sometimes it has a disc 
of such breadth and splendor, as to look like 
the tapetum of sheep, or the coloured choroid of 
fish j but more commonly it occupies a circum- 
scribed annular space, and is seen only in a 
strong light, and in particular directions of it. 
Although this appearance is commonly associ- 

l 2 



14S RETINA. 

ated with impaired vision, I have now and then 
seen it in persons who made little, if any com- 
plaint of their sight. This appearance has been 
referred to a circumscribed opacity of the retina, 
and the central spot supposed to correspond to 
the porus opticus, or axis of the optic nerve. It 
has also been conjectured to be the macula lutea 
of Soemmering*. It is probably with more 
propriety to be attributed to a deficient se- 
cretion of the choroid pigment, a preternatural 
adhesion betwixt the choroid and retina, and a 
discoloration or resplendent appearance of the 
retina from that cause. I have been led to this 
opinion from observing it combined with that 
form of amaurosis in which the vision is con- 
fused to dimness in the broad light of day, and 
is tolerably clear and agreeable after sunset 5 and 
also with that which is disturbed by the partial 
illumination of objects. 

I have also been enabled to make the fol- 
lowing observations regarding this appear- 
ance. It is neither suddenly induced nor pre- 
ceded by any signs of inflammation ; there is 

* A point of opacity within the reflecting mirror of the 
eye must, of necessity, create so much delusion, that we can 
scarcely venture, by inspection, to determine its precise seat. 
Even the opacities of the cornea and crystalline capsule are 
liable, in some instances, to be confounded. It is highly 
doubtful whether anatomy would determine the point in ques- 
tion; except by a nice comparison with the sound organ at a 
very early period after death, the morbid opacity of the retina 
would certainly pass undetected. 



RETINA. 149 

often a degree of blindness joined with it greater 
than its extent could account for ; and a reco- 
very of vision to which I have been witness 
under such circumstances, is not accompanied 
by any perceptible change in the appearance. 
I am therefore disposed to regard its connection 
with amaurosis, whatever it may be, as a casual 
coincidence, a change incidental to age, like the 
arcus senilis of the cornea; for it is by no means 
a constant appearance in that disease, nor is it 
incompatible with useful vision. 

I have more than once seen a condensed °P ac ' t y° f 

the retina. 

and palpable opacity at the fundus of the eye 
succeeding to inflammation of the choroid, 
which had destroyed vision ; and this I have con- 
sidered to be produced by a change in the tex- 
ture of the retina. "What adds to the probability 
is, that the crystalline in this case afterwards, 
as if progressively, becomes opaque ; a common 
sequel of amaurosis induced by inflammation. 

In the amaurosis from inflammation of the Amaurosis 
choroid or retina, where the diseased action has seated i«- 
entirely subsided, the veins of the conjunctiva 
are varicose, the iris is discoloured, thick, tough, 
inelastic, and preternaturally vascular ; the 
substance of the crystalline is more or less absor- 
bed, or converted into a fluid and discoloured ; 
the vitreous humor is opaque and of a deep 
yellow colour. The retina, like the other trans- 
parent textures, becomes opaque under inflam- 
mation, and it is probable that under these 



flam mat ion. 



150 RETINA. 

circumstances, adhesive matter is effused upon 
the interior of the choroid; this supposition Ihave 
never had an opportunity of verifying by dissec- 
tion, in cases of which the history was known. 

Fromab- j some time ae;o dissected the eyes of a 

sorption ot a j 

the vitreous man ^q } iac i cataracts with amaurosis. The 

humor and 

collapse of cataracts had been formed ten vears prior to his 

the retina. * l 

death ; one of them fell down behind the pupil, 
and he was spontaneously restored to sight, as 
by a natural couching. Gradually he lost his 
sight, the eye still remaining plump, and the 
pupil clear of any opaque substance. The 
change which had taken place was an inter- 
stitial absorption of the vitreous humor, which 
was proved by the immediate discharge of an 
unusual quantity of watery humor, on opening 
the tunics, and the appearance of the vitreous 
capsule collapsed into a little opaque bag, and 
adhering to the ciliary body at the inferior 
margin of the iris. A remnant of the crystalline 
was involved in it, not exceeding in size a 
large pin's head. The remains of the retina 
were a mere film or string extending from its 
attachment, at the back pf the globe, to this 
bag or net of the vitreous capsule. The pupil 
of the other eye, in which the cataract had re- 
tained its place, was closed, and the lens ad- 
hered firmly to the iris by its capsule, which 
was involved with the collapsed tunic of the 
vitreous lying behind it; for the humor was as 
completely absorbed in this as in the eye first 
examined, and the texture of the retina as nearly 



RETINA. 151 

obliterated. Thus the amaurosis resulted from 
collapse of the retina, owing to absorption of 
the vitreous humor. The fall of the lens in one 
eye resulted from the absorption of the vitreous 
humor, and would have occurred from the same 
cause in the other eye, but for the adhesion pre- 
viously existing betwixt its capsule and the iris. 
The eyes preserved their figure by the increased 
secretion of the aqueous humor, which is al- 
ways in proportion to the default of the vitreous; 
and could the retina have retained its position, 
the vision, which was for a time recovered, 
would probably have been retained. 

A young gentleman, the subject of amauro- From cere- 
sis in his left eye, was affected with symptoms mor. 
of a diseased action in the brain; as, deep-seat- 
ed pain in the fore part of the head on the same 
side, disposition to sleep, and inability to em- 
ploy his mind as heretofore. He was repeated- 
ly blooded and blistered without relief. The 
digestive functions were much disordered, and 
he was put upon a course of alterative medicine. 
The disease, however, advanced ; the eyelid be- 
came paralytic, and a slight degree of strabismus 
was accompanied with occasional double vision. 
The lethargy and the derangement of the se- 
creting organs, and consequent emaciation and 
debility increased, and his death soon followed. 
The eye had no unhealthy appearance; the 
pupil was regular, and moderately active. On 
examination, a firm lardaceous tumor, of the 
size of a garden bean, was found compressing the 



152 RETINA. 

optic ganglion and nerve at its origin thence, of 
the same side. 



fv^ U co°n- S I nave seen several cases of amaurosis from 



cussion. 



concussion, as by a blow on the temple, or the 
eye. Of these some were attended with signs of 
disorganization — some were superficially inflamed 
— and others presented no external appearance 
of injury. One was the case of a captain of ar- 
tillery, who was struck by what is called the wind 
of a ball 9 on the right side of the head. He re- 
ceived no wound, but lost, instantly and irreco- 
verably, the sight of his right eye. 

In another case, a young gentleman received 
a blow on the eye, by which it was inflamed; the 
inflammation was superficial and easily subdued, 
but the vision was so much impaired, that a sur- 
geon was consulted, who observed the pupil to 
be dilated and without motion. The iris reco- 
vered its activity by depletion, but useful vision 
was lost. It is not always the eye on the same 
side of the head which has received the blow 
that is affected. One remarkable case I shall 
take the liberty to mention. 

A man who had good vision of the right eye, 
and was nearly dark from a cataract in the left, 
received a violent blow on the left temple. From 
that time he lost totally the sight of his right (or 
well) eye, which has now the faded appearance 
of an incurable organic amaurosis, and owing to 
the rupture of the lens which was at the time 



RETINA. 153 

undergoing absorption, recovered sight with his 
left eye, which he still enjoys. Frequently the 
amaurosis from concussion is purely functional, 
and is cured by a full blood-letting, blisters, and 
purgatives. 

I have observed several forms of congenital or- Con-enitai 

° organic 

ganic amaurosis : one, in which the organ is amauiosis - 
preternaturally small and soft, and even flaccid 
to the touch, as if from deficiency of the vitreous 
humor: the iris tremulous, and not influenced 
by the belladonna ; the globe affected with an 
incessant tremor, and not subject to the control 
of the will. I have often seen this motion of the 
globe uncombined with the tremulous, iris in 
cases where there was little more than a natural 
feebleness of the retina. 

A second depends on a deficiency of the pig- 
mentum nigrum; here the tremulous motion of 
the globe is present ; strong light produces un- 
easiness, and vision is dazzled and confused; 
the vessels of the choroid give the interior of 
the eye a deep red tinge, but not the bright 
scarlet of the albino, or the white rabbit. I 
have seen several of the children of two families 
thus affected; they are considerably aided by 
cylindrical shades, such as are used by connois- 
seurs in pictures; goggles ; glasses covered with 
black gauze, and every other contrivance to 
absorb light ; even a coat of black varnish be- 
smeared around the eye. I may observe in 
general, that an amaurotic disposition, greater or 



154 RETINA". 

less, exists in all persons whose hair and eye- 
brows approach to white*. 

A third form of congenital amaurosis is that 
in which the sclerotica so encroaches upon the 
cornea, that the latter scarcely exceeds the dia- 
meter of the pupil, while the volume of the 
globe appears somewhat greater than natural. 
Various malformations of the pupil, an extreme 
diminutiveness, and even a total deficiency of 
the iris, are not in my experience ordinarily as- 
sociated with an imperfectly organized retina. 

A fourth kind of congenital amaurosis is un- 
accompanied by any appearance of organic de- 
rangement. The eyes move in concert as if at- 
tracted by a faint perception of light, in an ob- 
lique direction ; but the infant is too certainly 
blind. A diseased state of the thalami or optic 
nerve would, I apprehend, be discovered by in- 
spection of these cases after death. It is proba- 
ble that the opaque retina is sometimes congeni- 
tal as well as the opaque cornea : of the latter I 
have seen instances; others are related by the late 
Mr. Ware. 

* Professor Beer states, that dark coloured eyes are more in- 
clined to become amaurotic than those of lighter colour. This 
observation is not at variance with my own, since the above re- 
mark refers only to white-haired persons, the characteristic of 
whose amaurosis is photophobia, or intolerance of light, and in 
whom the disposition depends on a defective pigment. 



RETINA. 155 

FUNCTIONAL AMAUROSIS. 
The functional amaurosis admits of the follow- 
ing subdivision. 

1st. The symptomatic, or that which is only a 
symptom of some general disease or disorder of 
the system, as for example, general plethora, 
general debility, &c. 

2nd. The metastatic, or that produced by the 
sudden transference of the morbid action from 
another organ of the body ; as for example, from 
the skin, the testicle, &c. 

3rd. The proper, or that which immediately 
depends upon a peculiar condition of the reti- 
na ; as for example, the visus nebulosus, muscae 
volitantes, &c. 

I proceed to treat of them in succession. 

1. Symptomatic. 
Like nervous deafness amaurosis sometimes Amaurosis 

■, i n i . fromconsti- 

follows typhus and scarlet rever, and the various tutionai dis- 

case nnf3 ^c- 

forms of acute constitutional disease. This I nerai debiii- 
have several times met with as a result of in- J 
fantile fevers. It is also sometimes a consequence 
of chronic wasting diseases, in which organic 
changes interrupt the nutrition of the system. 
I have seen a rapid and severe salivation institut- 
ed for a remote affection, and where no disease 
had previously affected the eyes, terminate in 



1S6 RETINA. 

gutta serena of both. The same has been 
observed of the sense of hearing. The state 
of the circulation has a marked influence 
upon imperfect amaurosis*. I know patients 

* The effect of fever upon a nervous deafness, was strongly 
evinced in the case of a lady whom I knew. She had been 
incurably deaf many years, when, during the existence of a 
puerperal fever, it was remarked, that she had recovered dis- 
tinct and even acute hearing, which again left her, after the 
febrile action had subsided. 

I was once consulted by a gentleman who was the subject 
of this species of deafness to a painful degree. He informed 
me that he was in possession of a remedy for the disease, but 
unfortunately it was available only while in actual use, and too 
severe to be employed incessantly. His object was to ascer- 
tain if a less objectionable one was known. It consisted in oc- 
casional drastic purging, abstemious diet, and the hard daily 
exercise of a man training to walk against time, or fi°ht, or 
ride a race. Under this alterative plan, he had so excited the 
action of the extreme vessels as to restore the sentient tone of 
the nerve. By adopting it, he had more than once recovered 
a perfect state of hearing, which remained while he had reso- 
lution to pursue it. But he thought, as would most others, 
' le jeu ne vaut pas la chandelle/ 

While upon this subject, I shall take the liberty of still fur- 
ther extending this digression by adding a much more remark- 
able proof of the influence of vascular action upon the brain 
and its more immediate functions, and leave the reader to form 
his own conclusions. 

" A young woman, who was employed as a domestic servant 
by the father of the relator when he was a boy, became insane 
and at length sunk into a state of perfect idiocy. In this con- 
dition she remained for many years, when she was attacked by 
a typhus fever; and my friend having then practised some time, 
attended her. He was surprised to observe as the fever advan- 
ced, a developement of the mental powers. During that pe- 
riod of the fever, when others were delirious, this patient was 



ItETINA. 157 

whose vision is benefited in a high degree, and 
others in whom it is as much deteriorated by the 
quickened circulation of a full meal and a few 
glasses of wine. The former are persons of 
spare and meagre habits ; the latter plethoric. 

The influence of mental emotion in producing 
this disease is most frequently seen in the in- 
stance of grief. Young widows are peculiarly 
liable to amaurotic affections : cases are related 
in which, what the poet calls e a short madness* 
has been productive of the same unhappy conse- 
quence. 

What might be called the " amaurosis lac- 
tantium," in which the infant preys upon its 
mother, and that in which the impaired energy 
of the whole nervous system, occasioned by va- 
rious states of physical disorder, shews itself es- 
pecially in this organ, may be taken as familiar 

entirely rational. She recognized in the face of her medical 
attendant, the son of her old master, whom she had known so 
many years before, and she related many circumstances, re- 
specting his family and others, which had happened to herself 
in her earlier days. But alas ! it was only the gleam of rea- 
son. As the fever abated, clouds again enveloped the mind ; 
she sunk into her former deplorable slate, and remained in it 
until her death, which happened a few years afterwards." 

Tuke's Description of the Retreat for Insane Persons of the 
Society of Friends, p. 137. 

A man labouring under recent concussion of the brain, and 
from this cause comatose, was freely let blood, and afterwards 
took a full dose of emetic tartar. After vomiting he be- 
came immediately sensible. 



158 RETINA. 

instances of the amaurosis from constitutional 
debility. 

Amaurosis Amaurosis depending on vascular congestion 

from pie- L 

thoric con- is marked by some or all of the following symp- 

gesticn. J . . ° J r 

toms, viz. dilated and sluggish or immoveable 
pupil, ptosis, or strabismus, and oblique or dou- 
ble vision of the affected eye ; a preternatural 
action of the carotids, flushed face, sense of 
weight, pain, or stricture of the scalp, lethargy, 
occasional tinnitus aurium, with greatly disor- 
dered and irritable stomach. The patient fre- 
quently complains, particularly in straining, 
stooping, or on first lying down, of seeing lumi- 
nous sparks or flashes*, and a reflection of one 
or more of the choroidal vessels, the visible pul- 
sation of which is a cause of much distress to 
him. A person thus affected accurately de- 
scribed to me the zona minor iridis, as distinctly 
presented to his view. 

Fromde- A loss of balance in the sanguiferous system, 

termination m ' 

of biood to occasioning an undue determination of blood to 
the head, often exists, distinct from general ple- 
thora, and is aggravated by loss of blood. The 
following case is an example : 

A young medical man came to me one morn- 

* Persons labouring under dyspepsia are often troubled with 
this symptom, on first closing the eye to sleep, and in the pro- 
gress of amaurosis from nervous exhaustion, it is sometimes ac- 
companied with the sensation of a crackling or snapping noise. 



KETINA. 159 

ing from the country in extreme anxiety, with 
an earnest solicitation that I would instantly ap- 
ply a ligature to his carotid artery. This gen- 
tleman, aged 25, was of short stature, and con- 
stitutionally healthy. His pupils were large, and 
his countenance was suffused and bore the ap- 
pearance of preternatural determination of blood 
to the head. He had been the subject of two 
attacks of inflammation; one in April, the other 
in October of the same year ; during which he 
lost upwards of an hundred ounces of blood. He 
had now a constant heavy pain in the head 
chiefly over the coronal suture, and in the di- 
rection of the sinuses, with tinnitus of the left 
ear. After stooping the giddiness was extreme, 
and a golden coloured spot, edged with black, 
appeared floating before the eye. He had been 
troubled with muscse in excess, for a year and a 
half past; he had now fire sparks flashing before 
the sight, and saw a pulse in the choroid syn- 
chronous with that of the wrist *. When look- 
ing at near objects he was not troubled with 
musca?, but they were always numerous, in pro- 
portion as the object was remote. He did not 
complain of much dimness. His complaints 
were not relieved by topical blood-letting. He 
recovered gradually but perfectly, under a regu- 

*The subjects of chronic iritis, and in whom the pupil is 
fixed, and the capsule of the lens more or less opaque, are of- 
ten distressed with this or other signs of undue determination 
of blood to the head, which is not in any degree relieved by 
drawing blood. 

7 



160 RETINA. 

lated diet, and a course of the blue pill with sa- 
line aperients. 

Amaurosis The amaurosis, from depletion, is sometimes 

from inani- •»!/»• • r- 

mation. mistaken for its opposite, viz. that from pletho- 
ric congestion ; this is owing to the coincidence 
of a dilated and immoveable pupil, muscae, and 
a deep-seated pain in the head, with occasional 
vertigo ; and its occurrence often in a corpu- 
lent habit. It succeeds somewhat abruptly to 
uterine floodings, and large and sudden deple- 
tion for acute diseases. The pain is not con- 
fined to the region of the orbit, though it affects 
chiefly, if not exclusively, the same side of the 
head ; it is that peculiar nervous pain to which 
women are subject after uterine haemorrhage, 
attended with a sense of defined pressure, as of 
an iron finger on the brain ; and sometimes a 
distressing jarring noise like that of a mill or 
threshing-floor, or the rattling of the shingles 
as a heavy wave of the sea recedes. It is per- 
haps connected with an imperfect injection of 
the medullary substance. By a cautious use of 
tonics it is relieved ; by whatever lowers or sti- 
mulates, whether diet or medicine, it is deci- 
dedly aggravated. The vision in this form of 
amaurosis is further enfeebled by the loss of as 
much blood as flows from two or three leech-bites. 
This is not imaginary ; I have seen distinctly 
marked cases of it, in which large and copious 
venesection was still urged as the only resource 
of art. This I consider to be a fatal mistake. 



RETINA. 16. I 

As the causes of amaurosis, to whichever Amaurosis 

sympathe- 

class it belongs, present infinite gradations, so tic with ir- 

i,. r. r> . . A iii ritable con- 

do the imperfections of vision. An unhealthy junctiva. 
secretion of the meibomian follicles and carun- 
cula lacrymalis, a very inconsiderable obstruc- 
tion in the excretories of the tears, or a preter- 
natural excitability of the conjunctival surface 
from any cause, will give occasion to such a de- 
gree of weakness and dimness, from constant 
suffusion, as greatly to interfere with, if not to 
interrupt, the transaction of business. The im- 
provement of the vision in strength and clear- 
ness, during the use of astringent lotions and 
stimulant • ointments, is continually observed. 
Persons affected with an irritable state of the 
conjunctiva from any cause frequently com- 
plain, not that their sight is indistinct, but weak ; 
by which nevertheless they mean, that they can- 
not maintain distinct vision for any consider- 
able time together. The retina appears to be 
sympathetically affected in these cases. They 
are often accompanied with muscae, and remark- 
ably benefited by blisters, as well as by applica- 
tions, which improve the condition of the con- 
junctiva and eyelids. 

FUNCTIONAL AMAUROSIS. 
2. Metastatic. 
Amaurosis by metastasis is not unfrequent. Amaurosis 

t i n i i ■ en "Y melasta- 

1 have seen it from the state threatening effu- sis from the 
sion into the chest, from gout in the foot, and 
swelled testicle j in all which cases the oppres- 

M 



162 RETINA. 

sed organs were suddenly relieved, and the eye 
as suddenly affected. Thus a person goes to 
bed with good vision and rises blind. 

A lady, above the middle age, who had 
long been subject to occasional attacks of pul- 
monary congestion, after one of unusual seve- 
rity, threatening hydrothorax, was suddenly 
affected with paralysis of the upper eyelid of 
the left eye ; the sight was slightly, if at all 
impaired. On the following day however she 
had totally lost the sight of that eye, the pu- 
pil of which was dilated and motionless. On 
the morning of the third day, the upper eye- 
lid of the right eye was paralysed, and the vi- 
sion of that eye was also much impaired. On 
the fourth day the ptosis on the left side had 
disappeared, and the eyelid on the right side 
resumed its position. She was now in a state 
nearly approaching to complete blindness ; both 
pupils dilated, although the left most so, and 
nearly, if not quite inactive. The attack was 
accompanied by a marked simultaneous relief 
from the threatening symptoms of the original 
complaint, and occasional fugitive pains, across 
the front and top of the head. Upon inspect- 
ing the eyes opposite the light, the appearance 
described 5, page 147, was conspicuous in both 
eyes, and led her physicians, who were of the 
first eminence, to apprehend an incipient opa- 
city in some interior texture. Under the fre- 
quent administration of calomel and rhubarb, in 

7 



HETINA. 3 63 

moderate closes, and the alternate repeated ap- 
plication of blisters behind the ear, and to the 
nape of the neck, with abstemious diet, the vi- 
sion of both eyes was gradually restored. 



testis. 



A man, the subject of hernia humoralis, From the 
lost an unusual quantity of blood by the bites 
of leeches applied to the part. The testes were 
suddenly and greatly reduced, and he com- 
plained of uneasy sensations in his head ; to 
use his own phrase, a pain like opening and 
shutting*. Without any other visible sign of 
amaurosis than a dilated and sluggish state of 
the pupils, he described a dark screen seeming 
to rise gradually from below upward, and at 
length, totally obscuring the sight. He lost 
blood from the head repeatedly, and underwent 
a full course of mercury without benefit. A 
state of perfect amaurosis ensued. 

The gout attacks the eye, through the me- 
dium of the stomach. Vomiting occurs with 
pain in that organ, on the subsidence of an in- 
flammation in the extremities, and is succeeded 
by violent pain in the head. The loss of sight 
is sudden and permanent. 

A gentleman, after an attack of gouty in- From the 
flammation in the foot which suddenly ceased, 

* I once saw an attack of hemiplegia originate under simi- 
lar circumstances, viz. a sudden reduction of enormously en- 
larged testes by leeches and cold lotions. 

M 2 



foot. 



164 RETINA. 

was attacked with pain in the stomach and vo- 
miting ; this in the course of the day subsided, 
and in the night, a violent pain in the head was 
succeeded by an almost total loss of sight, 
which was never afterwards in any degree re- 
stored, although by steeping the feet in a hot in- 
fusion of mustard, the great toe inflamed so much,, 
as entirely to relieve the head and stomach. 

To this class belong the cases of amauro- 
sis consequent upon the sudden suspension of 
the catamenia, and of habitual hemorrhoidal 
discharges ; the rapid healing of large ulcers of 
long standing, and the sudden retrocession of 
cutaneous eruptions. 

FUNCTIONAL AMAUROSIS. 
3. Proper. 

Amaurosis A short case or two will best explain what 
excite- ' I would call a temporary palsy of the retina 
from over excitement. 

The following account is that of a young 
gentleman who was ardently engaged in the 
study of the profession when thus interrupted. 



" Having habituated myself for the preced- 
ing twelve months to intense study, reading 
and writing to a very late hour, which had 
been only interrupted for a few days by a slight 
inflammation of my right eye, I quitted London 
to recruit my health in the pure air of . 



RETINA. 165 

This daily improved, but I found a growing 
imperfection in the vision of my left eye, which 
advanced unaccompanied by inflammation, pain, 
or any other external symptom of disease. It 
seemed at first a film before the sight, but at 
length amounted to a total loss of vision. On 
examination, I found the pupil greatly dilated, 
and learned that the iris had little or no action. 
By the advice of Mr. T. whom I now consulted, 
I applied a blister, extending from the centre 
of the forehead round the eye to the root of 
the nose. This drew well, and I continued it 
open for ten days, closing the eye from light 
during that period. I took at the same time a 
calomel and opium pill thrice a day. In the 
space of a few days my mouth became sore ; 
the pupil acted, though unequally, and I expe- 
rienced a gradual recovery of vision. In the 
course of six weeks, I was enabled to resume 
my studies, and could perceive no defect of vi- 
sion. I had gradually reduced the dose of ca- 
lomel, and now discontinued it, drinking the 
decoction of sarsaparilla. At the distance of 
four months from this occurrence, the pupil is 
regular and active, and the sight unimpaired." 

One of our most eminent and indefatigable 
artists in landscape, was the subject of a super- 
ficial irritable ophthalmia, accompanied with 
much dimness and confusion of vision. This 
continued after the inflammation had subsided 
under the ordinary treatment. He became se- 
riously alarmed to find, upon attempting to 



166 RETINA. 

renew his occupations, that he was unable to 
discriminate the shades of colour from each 
other, and that in fact he had lost the visual 
tact, if I might so express myself, essential to 
his pursuit. He submitted, by my advice, to a 
gentle course of mercury, and has since enjoyed 
his former accuracy of vision. 

Examples of this species of amaurosis fre- 
quently occur among sea officers and others, 
suddenly, and without any preceding inflam- 
mation. I have repeatedly seen it of sudden 
accession with no other external sign than an 
inactive pupil. 

A captain in the navy had made much use of 
his right eye for many years in observations with 
telescopes and sextants. About a week before 
he applied to me, he observed a mist before this 
eye, which increased until it was so dense, that 
he could neither distinguish the features of his 
friends, nor the large letters of a title page. 
The eye was free from inflammation, the pupil 
large and sluggish j he had no pain either in the 
eye or the head. He was bled copiously from 
the arm and temple, and briskly purged with 
calomel and jalap at short intervals. Blisters 
were applied to the temples. He then rubbed in 
a drachm of the strong mercurial ointment for 
several nights in succession ; this produced a 
copious flow of saliva and violent diarrhoea, so 
that no benefit was obtained. By the calomel 
and opium pill taken night and morning his 



RETINA. 167 

gums were immediately made sore. In three 
days the mist began to clear, and he was de- 
lighted to find that he could tell the hour by his 
watch. He continued improving so rapidly that, 
at the expiration of ten days, he could read an 
ordinary print with perfect facility. The pupil had 
recovered its ordinary magnitude and activity. 

In one instance this form of the disease fol- 
lowed a long exposure to the heat of the sun 
with such suddenness as to lead the patient to 
attribute it to a ' coup de soleil / and in another 
it was referred to the habit of reading by fire- 
light. It is seldom that both eyes are affected, 
and probable in some cases that the discovery 
of the amaurosis, and not the disease itself, is of 
recent occurrence. This point, however, can 
generally be ascertained. 



I now proceed to mention the leading symp- symptoms 

n a r T/y i of amauro- 

toms of amaurosis. A great source of dimculty sis. 
in the arrangement of this extensive and com- 
plicated subject is the circumstance of many 
symptoms being common to both classes. I 
shall appropriate them, as far as I am able, in 
my description. Pain affecting the forehead and Pain. 
temples is a precursory symptom of amaurosis, 
diminishing in proportion as the dimness in- 
creases ; when the amaurosis is perfect, it usu- 
ally ceases altogether if the disease has its seat 
in the eyeball. We must judge by its situation 
and extent, but especially by its association 



168 RETINA. 

with other symptoms, if the pain be character- 
istic of organic amaurosis. Pain affecting the 
parts before-mentioned, occasionally inconsider- 
able, and declining as the dimness increases, is 
common in some forms of functional amaurosis. 
If it be severe, remitting imperfectly, immedi- 
ately increased by exercise, whether diffused 
over the entire side of the head, or circum- 
scribed to a small space of the anterior cerebral 
lobes, it is usually connected with an organic 
cerebral change ; but in this case, derangement 
and torpor of the primse viae, loss of strength 
and flesh, disposition to stupor, occasional con- 
fusion of intellect, inaptitude to exertion, and 
paralysis of one or more muscles, will be con- 
comitant symptoms. 

I have met with cases of amaurosis clearly 
depending on cerebral disease or irritation, in 
which the scalp was universally tender even to 
soreness. 

spasmodic There is an intermittent spasmodic pain ac- 
companying some cases of amaurosis, shooting 
through the orbit into the head, of the most 
acute and distressing severity ; it makes a pe- 
riodic attack at or about the same hour, every 
night, or every second night, and continues for 
several hours ; it is accompanied with convul- 
sive quivering of the muscles of the eye and eye- 
lids, and profuse lacrymation ; there is nothing 
in the appearance of the organ to explain its 
nature and origin. What has been described 



HETiNA. 169 

as an intermittent' ophthalmia, is I think impro- 
perly so termed — the pain, not the inflamma- 
tion, is intermitting. The pain of tooth-ache 
and ear-ache, according to the state of the vas- 
cular system, is subject to intermissions more 
or less complete, but the periodic pain to which 
I refer, is independent of any visible sign of in- 
flammation. I believe it is a tic douloureux 
affecting one or more of the orbitar branches 
of the fifth pair. I have cured it in two cases 
by arsenic, where opium failed to prevent the 
paroxysm. I have known one instance of a 
similar affection, without any defect of vision. 

Paralysis of the levator palpebral is a sign of Paralysis, 
cerebral pressure, and always accompanied with 
some degree of imperfect vision ; this, how- 
ever, varies considerably. Paralysis of the or- 
bicularis palpebrarum is less frequent. A pa- 
ralysis of either of these muscles is sometimes 
attended by a degree of vertigo so considerable vertigo. 
as to make the patient in danger of falling, if 
the eye be uncovered. In these cases near ob- 
jects appear remote, and much diminished in 
size, as if seen through an inverted opera-glass. 
The vertigo seems to be excited by this illusion, 
as it happens to most persons in looking from 
such an eminence as renders objects dwarfish, 
for it ceases as soon as the affected eye is closed. 
This symptom is usually removed by depletion. 

In other cases of fallen eyelid the affection ptosis. 
of vision is so slight as scarcely to occasion 



1 70 RETINA. 

inconvenience, so that a person may read or 
write while he supports the lid ; but the pupil 
is invariably over dilated, and I have observ- 
ed that the pupil does not recover its activity 
proportionably with the recovery of vision ; 
on the other hand, I have seen both palpebra? 
affected with paralysis in succession, each for a 
dav or thereabouts, and in this case the blind- 
ness supervened upon the removal of the ptosis. 

Ptosis follows injuries of the head and top of 
the spine : I have known a permanent ptosis 
and dilated pupil follow an injury of the cervi- 
cal vertebrae after an interval of some months, 
without any other symptom of palsy. It is re- 
markable that there was no paralytic affection 
below the seat of injury. But paralysis from 
irritation may happen in any direction. In this 
case vision was in great measure restored by a 
course of mercury. The use of strong lead 
washes will produce a ptosis. I lately saw a 
temporary paralysis of the muscles on one side 
of the face, from frequently touching an ulcer 
of the fauces with the oxymel aeruginis. 



Loss of as- In proportion as vision fails, the eye affected 

sociation , * 

and di- with amaurosis loses its fellowship with the sound 

rection. . 

eye, and this loss or correspondence becomes a 
conspicuous character of the disease. It is owing 
to this loss of correspondence that persons, af- 
fected with an imperfect amaurosis of one eye, 
often mistake the relative position and distance 
of objects, and frequently see them reflected. 



RETINA. 171 

In perfect amaurosis, or gutta serena, as it is 
absurdly called, the peculiar inexpressiveness or 
vacancy of countenance, depending on the non- 
convergence of the optic axes, is too remark- 
able to escape an ordinary observer, especially 
if both organs are affected. The patient has 
either a fixed unmeaning stare, or a constant 
rolling motion of his eyes. The loss of asso- 
ciation in strabismus results from a relative de- 
bility of one of the straight muscles, and if both 
eyes are employed, is generally accompanied 
with double vision j but that which I have just 
described is in no degree depending upon loss 
of muscular energy, partial or general, direct or 
indirect ; but on the total failure of sensation, 
by which the actions of all muscles subject to 
the will are directed. 

Strabismus is either congenital, or from the strabismus. 
debility of scrofula, like the paralysis of the 
lower limbs in children ; or from a morbid as- 
sociation accidentally contracted and impressed 
by habit in childhood ; or from a wound of the 
frontal nerve ; or a speck upon the cornea ren- 
dering the vision oblique ; or from violence 
done to the affected straight muscle. I have 
seen a complete internal strabismus, the effect 
of a blow on the temple, which a school-boy 
received in fighting*. From its suddenness, 

* Mr. Cheselden relates the case of a gentleman who had 
strabismus, with double vision, produced l>y a blow on the 
head. By degrees, the most familiar objects came to appear 



172 



RETINA. 



and the ecchymosis of the conjunctiva on the 
temporal side, I concluded the abductor was 
lacerated or palsied ; and so it proved ; for in 
a few weeks the distortion was entirely re- 
moved. It is also a symptom of irritation aris- 
ing from difficult dentition, worms, &c. ; or of 
pressure at the origin or in the course of its 
proper nerve. 

There is a complaint of cross sight occasion- 
ally made by persons who have no perceptible 
strabismus. It happens in looking downwards 
as in ordinary reading. In looking at objects 
on the same horizontal plane with the eyes, it 
is not perceived. It is a relaxation of one of 
the inferior straight muscles. 

Hemiopsia The retina is often partially affected in orga- 

or partial . . „ 

impairment nic amaurosis. JLhus some persons describe a 
tiua. horizontal, others a vertical screen, eclipsing one 
half of the object viewed, or even of the field 
of vision. In order to see a given object en- 
tire, which is upon a level with the eye, they 
are compelled to move the eye or the head, in 
the direction which the obliquity of their vision 
requires. Again, cases now and then occur in 
which persons have lost their lateral vision, 
while they see objects in the direct line of the 
axis of vision. In the greater number of cases, 
however, the vision of amaurotics is oblique, 

single again, and in time all objects did so, without any 
amendment of the distortion. 



RETINA'. 173 

and in perfect amaurosis, the perception of light* 
if any, is also oblique. The gradual return of 
vision is generally first perceived in this direc- 
tion. The sensibility of the retina, whether 
more or less, seems to be greatest at the part 
farthest removed from the axis of vision, or 
rather from the entrance of the nerve, for it 
is more frequently observed on the temporal 
than on the nasal side. I am unable to offer a 
satisfactory conjecture in explanation of this fact. 

A gentleman, who died of apoplexy in his 
36th year, and who lost eight pounds of blood 
in the three days preceding his death, consulted 
me for depraved sight of one eye, six months 
before that event. The pupil was permanently 
dilated. He had double vision whilst looking 
directly forward ; if he looked obliquely to ei- 
ther side, his vision was single. A slight stra- 
bismus was perceptible. Many cases analogous 
to this have fallen under my notice, in which no 
opportunity was afforded of ascertaining the 
cause of disease. The vision is sometimes per- 
fect or nearly so with the eye, which by loss of 
correspondence with its fellow, occasions the 
duplicity of objects viewed with both. I have 
known it equal in power to that of the other 
eye when employed singly. The double vision 
and giddiness cease, when either eye is em- 
ployed alone, or is closed. The paralysis af- 
fects the nervi motores oculorum directly in 
such cases, and the optic nerve suffers by sym- 



1 74 RETINA. 

pathy. Where the vision of the affected eye 
is materially bedimmed, the ptosis or strabismus 
are more marked, and the symptoms of double 
vision and vertigo in proportion. 

Distorted A distorted relative position of objects is also 

position of _ 

objects, not an uncommon symptom of organic amauro- 
sis. Thus, the lines of a printed page seem zig- 
zag, and the two eyes of a face appear in dif- 
ferent planes, whether one or both eyes are 
affected. If one object is seen in its proper 
place, the situation of a contiguous object is 
erroneous, both as to distance and parallel. If 
only one eye is affected, the employment of 
the sound eye exclusively, corrects the error. 
In the case of simple non-correspondence, it is 
corrected by either eye, indifferently. This is 
the reverse of what happens when the eyes are 
perfect, in which case the delusions, arising 
from the use of one eye only, are corrected by 
employing both. Both this and the preceding 
are for the most part, not always, symptoms of 
an organic affection. I have been led to this 
conclusion from observing the morbid appear- 
ances and the inefficacy of remedies, where 
such signs of the disease were established. But 
I have known instances of their removal. 

Musc^ Muscse are either fixed, when they are usually 

fixed and _ 

floating, allied to spectra, and belong to organic amaurosis; 
or floating, when they are I believe characteristic 
of functional sympathetic or proper amaurosis. I 



RETINA. 17^ 

have known the first permanent, withoutvariation 
for years, darkening a certain defined portion of 
the field of vision. In some rare instances, it 
precedes acute choroid inflammation ; more fre- 
quently it is unconnected with any particular 
morbid state. Around the opaque spot persons 
have sufficiently distinct vision. The spot va- 
ries in density in different individuals, and un- 
der a long but gentle mercurial course, I have 
known it become considerably less dense, so as 
not to intercept bright light. Its circumference 
sometimes reflects a tinge of colour or a lumi- 
nous halo. The fixed musca seldom prevents 
the fantastic shapes of the floating *, but it is 
not uncommon for the two forms to co-exist. 

The musca volitans is sometimes solitary, 
following the eye at a fixed angle as it passes 
along a line ; sometimes two, three, or more 
are presented j more frequently an immense 
assemblage, descending in a cloud as the eye is 
raised, aad ascending as it is depressed. They 
are obvious to so many analogies, and appre- 
hension of impending blindness makes patients 
so minute in their observation and description 
of them, that it is scarcely possible to do justice 
to our experience in attempting to describe 
them. Sometimes they are represented as glo- 
bular, sometimes annular and flat like a piece 

* To this remark there are exceptions. A gentleman, who 
a short time ago consulted me, compared the spectrum con- 
stantly before each eye to a large dragon fly, darkening the 
field of sight. 



176 RETINA. 

of money. Portions of flue, of soot, insects' 
wings, transparent vesicles, or minute glo- 
bules of quicksilver, connected like the links 
of a chain, or short hairs with their bulbs 
attached to them, are ordinary resemblances. 
They occupy the air with some persons, and 
are seen upon looking at the sky, or upon a 
white sheet of paper, and especially in shifting 
the eye from one object to another j to some 
they appear in the fire or candle only, and with 
others they seem to cover the ground, so that 
they walk in them knee-deep. Almost every 
person has, at some time or other, seen these 
appearances, but especially those subject to dys- 
pepsia, and disordered function of the stomach 
and liver. At the moment of approaching de- 
liquium, they appear in one vast cloud, and they 
are harbingers of the intense bilious headache. 
At the instant of their appearance, the sentient 
extremities upon the fingers and tongue are so 
benumbed, that objects of touch and taste con- 
vey a very indistinct impression, as if some 
muffle were interposed. These sensations I am 
describing ad vivum, for I was formerly often 
the subject of this attack, which was followed 
by a certain degree of confusion of intellect, 
and temporary suspension of memory, so as 
greatly to embarrass, if not to take away the 
power of intelligible expression. I mention 
these opposite and transitory states of empti- 
ness and plethora concomitant with the floating 
muscae, to shew the purely functional origin of 
the affection. The one (deliquium) is an un- 



RETINA. 177 

injected, the other (sick headache) an over-in- 
jected or congested state of the nervous tex- 
ture ; or suspension from vacuity, and suspen- 
sion from plethora. An analogy is plainly to be 
perceived between the corresponding states of 
the sentient and visual extremities, described in 
the last affection, to that of a temporary incom- 
plete paralysis. 

The fixed musca is generally an organic af- 
fection, probably a deposit or extravasation be- 
tween the choroid and retina, compressing to a 
certain space, the papillae of the retina, to 
which the musca corresponds in figure. In 
other instances, it is independent of deranged 
structure, and may be presumed to be only an 
insensible point on the retina. The single 
muscae sometimes coalesce, and form a larger 
spot. The floating muscae are altogether a 
functional affection, not interfering with useful 
vision, and sometimes, though not often, re- 
moved. To some persons they disappear upon 
looking through glasses, and others see them 
only upon remote objects. Their magnitude 
diminishes as the distance is increased, to those 
who see them at all distances. They are simply 
a disordered circulation in the vessels of the 
retina *, and occur oftener in nervous and spare 
than in plethoric and robust persons ; they are 

* By some practitioners they have been supposed to depend 
on floating particles in the humors or minute scabrous points 
in the cornea. 



178 RETINA. 

generally induced by overstraining the organ, 
almost always accompanied with a weak and ir- 
regular digestion, and varying with, if not de- 
pending upon, the condition of the stomach. 

Morbid Colored spectra, or luminous impressions of 

spectra. x r 

objects remaining upon the retina, are usually 
preceded by the fixed muscse, and may then be 
regarded as a more advanced stage of the com- 
plaint. This is not always the case, I have 
known them to be symptoms of functional de- 
rangement, and to disappear as the vision reco- 
vered. In this affection, a halo of light en- 
circles the opaque spot during the exercise of 
vision ; and if a bright luminous object be con- 
templated, a colored image or the reflexion 
of it is presented to the mind for a time, 
greater or less, after the eye is withdrawn or 
closed. Of the same species are the various 
morbid refractions of luminous bodies, present- 
ing the object double to one eye, or curiously 
divided and distorted, as in looking through a 
crinkled pane of glass ; and the appearance of 
prismatic colors in the forms of circles, rain- 
bows, cones, &c. Sometimes ordinary objects 
are imperfectly represented, or even dark, so 
that they would not be known but from their 
outline being illuminated. Thus a man, a tree, 
or a house, appears fringed with a glory ; and 
on the other hand, it is not uncommon for the 
outline of objects to be lost in shade, while the 
centre is clearly discerned. 



RETINA. 179 

I might illustrate these observations by a mul- 
titude of cases in my possession, which I omit 
for the sake of conciseness, and in conformity to 
the plan of this work. On this subject, how- 
ever, I shall take the liberty of introducing the 
case of an intelligent young gentleman, very 
accurately drawn up by himself, for the pur- 
pose of shewing the gradations of this disease 
in its progress, as well as its origin. 

" About a year and a half ago the first symp- Case of 

, . . . . muscaj and 

toms appeared, winch gave me any uneasiness spectra. 
with respect to my sight. For several months 
I read incessantly, not only throughout the 
day, but also for five or six hours each night by 
candle-light ; and I now perceived numerous 
circular motes, which combining, formed clouds 
of irregular figures before my eyes. These 
motes always appear when I look at the sky or 
any light-colored object in a strong light ; they 
move with the eye, retaining for some time the 
same position with relation to each other and to 
the centre of vision : each consists of a slightly 
opaque circumference and a central spot, the 
diameter being, as well as I can judge, about 
four or five minutes of the circle of vision. 
Sometimes films appear curved or twisted like 
hairs, and of the same degree of opacity as the 
motes. There is a collection of these films al- 
ways before the right eye, but at such a dis- 
tance from the centre of vision as not to disturb 
sight. The number of the motes seems in- 

N 2 



180 RETINA. 

creased by violent exercise as well as by close 
reading, or a disordered state of stomach. Some- 
times for a moment a small circular black spot ap- 
pears near the centre of vision, and sometimes, 
though not so frequently, one faintly luminous. 

" The candle next appeared surrounded with a 
faint halo, which became more vivid as I conti- 
nued this severe exertion of my sight. "When my 
eyes are unusually weak, or a light is presented 
to them after I have been some time in darkness, 
instead of the halo a globular appearance of a 
muddy yellow colour surrounds the flame. 

"About six months ago, I began to be annoyed 
by the retina retaining impressions made upon 
it. After looking at any w 7 hite or bright metal- 
lic object, on turning away my eyes I distinctly 
perceive its outline in a darker shade, on any 
surface to which I may direct my view ; the im- 
pression lasting from two or three seconds to 
half a minute, according to the strength of 
light, the brightness of the object, and the 
length of time for which I have viewed it. 
The flame of a candle leaves its image impressed 
on the retina frequently for a couple of minutes j 
the sun for a still longer time j the image in both 
instances being of a muddy yellow color. 

"A kind of penumbra surrounds light-colored 
objects in a strong light, and prevents me from 
accurately distinguishing their outline. When 



RETINA. 181 

the object is under a sufficiently small angle 
to be seen entire without moving the eye, it 
seems double, one image being such as would 
appear to a healthy eye, the other much fainter ; 
thus is the moon seen, a piece of money, or 
the gilt letters over shop windows. These 
appearances take place indifferently, whether I 
use either eye or both. 

" In a few instances, a very severe exertion of 
my eyes produced the appearance of innume- 
rable black particles dancing before them. 

" When I read for any considerable time, I 
have a disagreeable sense of heat in my eyes, 
with pain in the eyeballs, extending to the lower 
part of the forehead. I am not constantly sub- 
ject to headaches, though occasionally afflicted 
by them, especially if I delay breakfasting for 
any length of time after rising. My tongue is 
frequently foul for weeks together, my digestion 
seems weak, and I seldom enjoy a good appe- 
tite. 

" I ought to observe, that most of the above- 
mentioned symptoms seem to have been miti- 
gated since I came to London. Since the ap- 
plication of the blisters, the halo round the 
flame of the candle has nearly disappeared." 

Amblyop- 

A very frequent and characteristic symptom i OU sor 
of functional amaurosis is a thin mist, fog, s i 0n . 



182 RETINA. 

smoke, or gauze, or as I have heard some pa- 
tients represent it, an indefinable something, as 
if vision required a peculiar atmosphere, inter- 
vening between the eye and the object, which 
takes off the ' acies oculorum acer, claraque,' the 
sharp edge of clear vision. Letters of a book 
run together, and the outline of all minute ob- 
jects is indistinct. In some cases this indistinct- 
ness is constant and unvarying ; in others it is 
the result of exercise of the organ, for a period, 
varying in different persons from ten minutes 
or even less, to half an hour. Repose of the 
organ, whether obtained by closing the lids, or 
looking vacantly on distant objects, or gentle 
friction of the lids, or a slightly stimulant appli- 
cation, enables the person to resume for a short 
time ; but the hindrance returns, and if the em- 
ployment be persisted in, the dimness becomes 
little short of blindness, and sometimes occa- 
sions pain, always a painful sense of weakness. 
This affection is unaccompanied with irritable 
conjunctiva; there is no tendency to suffusion. 
It is seldom relieved by glasses, and never per- 
manently. It is sometimes combined with 
muscse, but more frequently distinct. The iris 
appears irritable and unsteady ; it contracts 
often quickly, but vacillates between contraction 
and dilatation without a change of the light. 



vision 



oscillatory Another functional affection is an oscillation 
or wavering of objects, so that the want of stea- 
diness occasions a dazzling and confused per- 



RETINA. 183 

ception. This may be the result of simple con- 
gestion ; but I have known it unaccompanied 
by any sign of this state, and in persons of a 
frame and temperament distinctly opposed to it 
With this is often combined a delusion of some- 
thing waving or flapping in an oblique relation 
to the eye, as towards the temple, unaccompa- 
nied by any distinct perception of figure. 

An occasional symptom of functional amau- Lo . ss of th ^ 

J L adjusting 

rosis is a loss of the faculty of distinct power, 
vision at different distances. A gradual 
abridgment of the focal range at its near ex- 
tremity occurring in advanced life, and requir- 
ing the aid of convex glasses, has been sup- 
posed to depend upon a permanent change in 
the figure of the globe ; I should rather refer it 
to a loss of power of the retina incidental to 
age, and a consequent imperfection of function 
in those parts, which execute the office of ad- 
justment. It is a change similar to this, taking 
place in early or middle life, and with more 
abruptness, (the indistinctness sometimes per- 
vading near objects exclusively, and in other 
cases, remote ones,) which I consider to be a 
symptom of amaurosis. It cannot be ad- 
mitted, that the distinct vision of an object, 
at a permanent focal distance, proves the power 
of the retina to be unimpaired. If the organ 
is originally perfect as an optical instrument, 
so that the rays of light flowing from near, as 
well as from remote objects, form images 



1 84; RETINA. 

upon the retina sufficiently perfect for distinct 
vision ; and if the range of distinct vision be, 
whether suddenly or gradually, so abridged, that 
the eye is incapable of relieving itself by a 
change of focus, the feebleness of the retina is 
invariably demonstrated by other signs, for the 
imperfection of adjustment seems in all cases to 
be in proportion to the loss of vigor of the re- 
tina. Ordinary observation proves that the ef- 
fect of wear and tear is to allow of good distant 
vision, in which the parallelism of the rays of 
light supersedes the necessity of adjustment, 
while the near sight, which requires the active 
or tonic state of the adjusting faculty, is im- 
paired or lost. But if, as sometimes happens, 
the vision of near objects remains good while 
the distant is obscured, the evidence of the 
faultiness of the retina is direct. The correc- 
tion of a defective adjustment by the use of 
glasses, in either case, proves no more than that 
the retina is not organically affected, while the 
failure of this corrective, which is frequent in 
the cases referred to, demonstrates the func- 
tional debility of the retina. In most of these 
cases the use of glasses is of temporary benefit, 
but if continued, it is followed by uneasiness or 
pain in the eyeball. 

Many phenomena of impaired adjustment 
. correspond to the degree of mobility of the 
iris ; for in some persons it is quick to con- 
tract, but unable to preserve its contraction, 



RETINA. 1 85 

and falls open or fluctuates in the same 
quantity of light, and I have observed that 
the point of clear vision shifts accordingly j 
in others it contracts slowly and imperfectly ; 
in others again it is permanently contracted 
or dilated, and this, independent of any other 
defect of sight than an abridgment of the ori- 
ginal range of distinct vision, at one or other 
extremity. 



I have met with different reports,as to the time influence of 
of day, in which persons affected with imperfect amaurotic*, 
amaurosis enjoy the best sight. Some see clearest 
on first waking in the morning, whereas others 
are particularly dim for an hour or two after 
rising. In these cases, the state of the stomach 
has an obvious influence. Emptiness will pro- 
duce muscle and a temporary blindness. Some see 
only in a full light, others in a weak one, as after 
sunset. Candle-light, though generally least fa- 
vourable to such persons, is not invariably so. 
In a considerable proportion of cases, amaurotic 
patients see clearest in the evening, and their 
vision seems to gain strength by exercise. They 
see better for example on retiring to rest, than 
they have seen at any period of the day. 

These differences are, in most cases, referrible according 

, ... m -I- n i • i to the state 

to the varieties in susceptibility ot the retina, de- of thereti- 
termining the requisite degree of illumination of 
objects for vision, and the adaptation of the 



186 RETINA. 

pupil to that purpose. But in other instances, 
as I have before hinted, a reflection takes place 
within the eye, owing to some change in the 
quality or quantity of the pigment, which ren- 
ders a screen or colored glasses, or a dark day 
or twilight, in their several degrees, favourable 
or even essential to vision. This partakes of 
the nature of an organic disease. 

and of the I have known persons absolutely blind for 

pupil. 

two or three minutes, upon going into a dark- 
ened room, owing to the imperfect sensibi- 
lity of the retina, and consequent slow dila- 
tation of the pupil ; and they made no com- 
plaint, as persons usually do, of dimness from 
the opposite transition. Such persons, in- 
deed, require a full strong light to see at all. 
But that such a defect is not directly or exclu- 
sively depending on the state of the pupil, is 
proved by the occasional coincidence of good 
vision with a permanently contracted pupil. 
I have met with cases of remarkably small and 
habitually contracted pupil, in which the glare 
of light was even painful, and where the incon- 
venience was at once removed by moderating 
the light, without any perceptible alteration in 
the diameter of the pupil. A lady of quality, in 
whom I made this observation, told me that it 
had equally attracted the notice of Mr. Hunter, 
whom she had formerly consulted. The cases 
of day and night blindness, present the opposite 
extremes of variation in susceptibility of the re- 



ItETlNA. 187 

tina, and these must be regarded as cases of 
proper functional amaurosis. The remarkable 
efficacy of blisters upon the temples in these 
cases confirms this fact. 

I had abundant opportunities formerly of ob- 
serving the influence of trades, in aggravating 
as well as producing amaurotic affections : it 
was a common remark with taylors and shoe- 
makers, that they never saw so well as upon 
Monday morning, which they justly attributed 
to the repose of the organ during Sunday. 

The activity of the iris, evinced in the mo- Action of 
tions of the pupil, is, generally speaking, the an index of 
surest indication of the health of the retina. the retina 3 . 
The contraction is slow or it is incomplete, or 
both, upon the sudden admission of light to 
the eye, where the retina is defective in sensi- 
bility. The mean state of the pupil is that of 
dilatation where an amaurotic affection exists, 
and this will sometimes discover to an attentive 
observer, which of the two eyes is affected. 
When the perception of light fails altogether, 
the pupil is generally fully dilated, and abso- 
lutely motionless. It is in other cases not per- 
fectly a circle. 



The activity of the iris requires the free and Phenome- 
uncompressed state of the retina, iris, and ci- tiveirisin 
liary nerves. In the various forms of amauro- amaurosis, 
sis, its activity is proportioned to the degree of 



188 RETINA. 

integrity which these several parts retain, and 
the intensity of the stimulus. If the retina be 
opaque, compressed, or unsupported, the iris me- 
chanically disordered, or the ciliary nerves pal- 
sied, the pupil is inactive, independently of the 
state of vision. In the first of these cases, it is 
evident the vision will be lost ; but we continu- 
ally see useful vision combined with the second 
and third, as after operations in which the iris 
has been half destroyed, or has become perma- 
nently adherent, or in malformations where it 
is half wanting ; and in paralysis of the ciliary 
nerves accompanying the state of ptosis. But 
how shall we explain the activity of the iris in a 
state of absolute blindness ? a case by no means 
uncommon. We can only explain it by conclud- 
ing the organ to be sound, and the cause of the 
amaurosis remote, or at least external to it. Its 
motions in such a case are purely involuntary j 
the mental perception being suspended or anni- 
hilated. All that is required to excite them is 
the impingement of the ordinary stimulus upon 
the unchanged retina, the white sheet upon 
which the images of objects are impressed, the 
instrument, not the organ of perception. The 
iris, in such a case, acts by a sympathy inde- 
pendent of the brain. 

Thus in a case of circumscribed tumor 
compressing the left optic nerve, immediately 
behind the ganglion opticum, although the 
blindness was complete, the iris was active. 



RETINA. 1 89 

In two young ladies, in whom the eyes, as in 
the former case, were perfect, and the blindness 
complete, the iris was even vivacious j and there 
was the strongest presumptive evidence, from the 
symptoms, that the amaurosis was in the cere- 
bral portion of the nerve*. 

If this theory be correct, the activity of the 
pupil in complete blindness proves, that the 
retina and orbitar portion of the optic nerve 
are unaltered, and that the disease has its seat 
in the cerebrum, or cerebral portion of the 
nerve ; while, at the same time, the ciliary 
nerves are unaffected by it in their origin and 
course. On the contrary, the fully dilated and 
motionless pupil shews, that these nerves are 
paralysed — the disease may be cerebral or or- 
bital, or both. We see this exemplified in hydro- 
cephalus, and in orbitar tumors compressing the 
nerve and globe. In cases of perfect amau- 
rosis, in which the pupil, of its ordinary size, is 
absolutely without motion, a case by no means 
uncommon, the retina has most probably un- 
dergone a change of texture. The ciliary nerves 
are uncompressed, as may be inferred from the 
undilated state of the pupil, but the source of 
their excitement, sympathy with the retina, is 
destroyed. The symptoms of the disease, in its 

early stage, will point out its seat, where its 

locality is definable t. 

* Janin relates two cases of lively pupil in a state of total 
blindness. — Mem. et Observ. swrVOeil,p. 426. 

f It is to be regretted that in the many excellent observa- 



190 RETINA. 

Blindness, A man was trepanned for a fracture with de- 

withdi- . r 

lated pupil, pression of the right frontal and parietal bones. 

from frac- 
tured basis. After the operation he became sensible, but it 

was discovered that he was totally blind, being 
unable to perceive a lighted candle held close be- 
fore his eyes. The pupils were fully dilated and 
insensible to light. On the fifth day he died of 
inflammation of the membranes of the brain, 
having continued until his death in total dark- 
ness. On dissection, a fracture of the frontal 
and parietal bones was discovered on the left 
side, corresponding to that on the right, but 
without depression ; and these two fractures were 
connected by a transverse fracture, extending 
across the basis of the cranium,?, e. through the 
orbitar plates of the frontal bone anterior to the 
junction of the optic nerves. This transverse 
fracture extended into the bones of the face, so 
as to separate them from those of the cra- 
nium, and there was displacement of the bones 
sufficient to occasion a considerable pressure 
upon the optic nerves. 

In this interesting observation, given to me by 
my able and excellent friend Mr. Brodie, it is 
evident that all the nerves entering the orbit 
must have been compressed. Hence the pa« 
ralysis of the iris concomitant with that of the 
retina. 

tions of Morgagni and others, of diseased states of the optic 
nerve, the opportunity of learning the signs of the disease 
during life was so seldom enjoyed. 



RETINA. 191 

In hydrocephalus, the pupils are invariably 
fully dilated and motionless. In apoplexy ge- 
nerally, but with exceptions ; sometimes con- 
tracted, but still immovable ; which Dr. Cooke, 
in his late Treatise on that subject, considers 
a fatal prognostic. In injuries of the head, 
with symptoms of depression, the pupils are 
generally dilated and motionless, but some- 
times inconsiderably enlarged, and slightly 
moveable ; in other instances contracted ; and 
very frequently one is permanently dilated, 
and the other contracted. These varieties de- 
pend on the situation in which pressure is ap- 
plied, and the extent which it occupies, and 
in some degree on the nature of the com- 
pressing cause, whether bone driven in or fluid 
effused; in hydrocephalus the result is uni- 
form. But it is not the loss of the sight 
which occasions the dilatation of the pupil, 
in injuries where these circumstances coin- 
cide, but compression of the ciliary nerves, 
or of those from which they are derived ; 
the loss of motion in the iris is a gradual and 
not a sudden effect of the loss of sight, and 
it seldom happens that the vision is lost in those 
casualties, in which the pupil is permanently 
dilated. 

Among the morbid changes of the retina, os- 
sification has been rarely met with *. 

* Vide Morgagni, Lett. 52, Art. 30. 



192 RETINA. 

It is remarkable that in the thickened, atte- 
nuated, softened, ossified, or otherwise morbid 
states of the optic nerve or its sheath, the diseased 
appearance has seldom extended beyond the 
ganglion opticum. The eyeball has frequently 
been free from disease. The blindness has pro- 
bably in as many instances proved a cause, as an 
effect, of the degenerations of the nerve. Cases 
indeed are related, of a considerable and very 
obvious change in the structure of the nerve, 
where the sight of the corresponding eye has 
been unaffected. 



Case of I T } ias occurred to me, in concluding the 

Milton. ' & 

subject of amaurosis, that the case of our 
great Epic Poet, drawn up by himself for the 
purpose of its being submitted to Thevenot, 
a celebrated French oculist, may not be un- 
interesting to my readers. I subjoin it as 
the best account that I know, of the symp- 
toms of amaurosis, in its progress from the 
state of functional debility, to the confirmed, 
perhaps organic, gutta serena, I have pre- 
served his own words for the sake of accu- 
racy. 

" Decennium, opinor, plus minus est, ex quo 
debilitari atque hebescere visum sensi, eodem- 
que tempore lienem, visceraque omnia gravari, 
flatibusque vexari j et mane quidem, si quid 



RETINA. 193 

pro more legere ccepissem, oculi statim penitus 
dolere, lectionemque refugere, post mediocrem 
deinde corporis exercitationem recreari : quam 
aspexissem lucernam, Iris qusedam visa est redi- 
mere: baud ita multo post sinistra in parte oculi 
sinistri (is enim oculus aliquot annis prius al- 
tera nubilavit) caligo oborta, quae ad latus illud 
sita erant, omnia eripiebat. Anteriora quoque, 
si dexterum forte oculum clausissem, minora 
visa sunt. Deficiente per boc fere triennium sen- 
sim atque paulatim altero quoque lumine, ali- 
quot ante mensibus quam visus omnis abolere- 
tur, quae immotus ipse cernerem, visa sunt omnia 
nunc dextrorsum, nunc sinistrorsum natare j 
frontem totam atque tempora inveterati quidem 
vapores videntur insedisse ; qui somnolenta qua- 
dam gravitate oculos, a cibo prsesertim usque ad 
vesperam, plerumque urgent atque deprimunt ; 
ut mihi haud raro veniat in mentem Salmydessii 
vatis Phinei in Argonauticis : 

zocpog $s {Aiv afAtpsKocXv^sv 

Tlog(pvgeog, ycclccv de nigiZ, Idozqo's (psgsirOui 

Sed neque illud omiserim, dum adhuc visus ali- 
quantulum supererat, ut primum in lecto decu- 

* Vertigo vero ipsum circumdedit 

Atra, et terram opinatus est circumagi 
Ab imo, in languidnm vero soporem delapsus est elinguis, 
beck's apollonius rhodius. Lib. 2. v. 20-3. 



194 RETINA. 

buissem, meque in alterutrum latus reclinassem, 
consuevisse copiosum lumen clausis oculis emi- 
care ; deinde, imminuto indies visu, colores pe- 
rinde obscuriores cum. impetu et fragore quo- 
dam intimo exilire ; nunc autem, quasi extincto 
lucido, merus nigror, aut cineraceo distinctus, 
et quasi intextus solet se affundere : caligo 
tamen qua? perpetuo observatur, tarn noctu, 
quam interdiu, albenti semper quam nigricanti 
propior videtur j et volvente se oculo aliquantu- 
lum lucis quasi per rimulam admittit." 

LEONARDO PHILARiE, ATHENIENSI : 

Septemb. 28, 1654. 
Miltoni Opera, Amstelodami, 1698. p. 330. 



PATHOLOGY 



OF THE 



HUMORS. 



CHAPTER II. 



SECTION I. 

AQUEOUS HUMOR. 

X HE simple redundancy of the aqueous hu- H y dro P h- 
mor is a sequel of chronic inflammation, affect- 
ing the internal texture of the globe. Its figure 
is preserved, but the distended sclerotic has a 
dark blue tinge ; the cornea is extended and 
prominent, the pupil dilated and inactive, and 
the vision is inconsiderable, if not extinct. In 
other instances, the state of hydrophthalmia is 
accompanied with loss of figure of the globe, 
and staphylomatous enlargement of the cornea, 
which is specked or exulcerated, and frequently 
presents fasciculi of red vessels on its surface. 
This state is the result of an acute disorganiz- 
ing inflammation. 

o 2 



196 AQUEOUS HUMOR. 

The bulged and transparent cornea, whether 
spheroidal or conical, gives the appearance or 
the idea of a redundant aqueous humor ; but 
this is only the consequence of the increased 
capacity of the chamber. The distinction is 
important ; for the treatment of the hydroph- 
thalmia and the conical cornea proceeds, as it 
seems to me, on opposite principles. 



Rapid re- 
production. 



The aqueous humor is always rendered tur- 
bid by inflammation of the choroid and iris, but 
resumes its transparency when the inflammation 
is subdued. When discharged by accident or 
operation, it is reproduced in a period of from 
eight to twelve hours. It is regenerated in all 
states of the organ, in which the anterior cham- 
ber is even in part preserved, in quantity suffi- 
cient to give plumpness and figure to the globe, 
and to refract the light with accuracy enough 
for the distinct vision of large objects. 



Effusions of lymph, from inflammation of the 
iris, of puriform matter from internal ulcer of 
the cornea and abscess of the eyeball, and of 
blood from concussions and wounds of the organ, 
are frequently observed in the chamber of the 
aqueous humor. 



The solvent action of the aqueous humor over 



Solvent 
power in- 
consider- the exposed fragments of the crystalline leiis 

is not, in my belief, superior to that of water, 



AQUEOUS HUMOR. 197 

which I have found by experiment to be ex- 
ceedingly slow. A knife or needle, too highly 
tempered, has occasionally been broken in the 
operation for cataract, and the point has been 
left in the anterior chamber. This accident 
once happened in my own hands. The rusted 
appearance of the aqueous fluid, and the gra- 
dual disappearance of the fragment have led to 
a conclusion, that it underwent a chemical 
solution. The rapid removal of the fluid and 
flocculent cataract, when dissipated in the 
chamber, has been explained in the same way. 
I believe that the aqueous humor has no greater 
solvent property than common water, and that 
this would be quite insufficient to explain the 
very quick restoration of its clearness, which we 
often witness, where it has been loaded with 
opaque matter. The fragments of the lens 
have no more power of resisting absorption 
than an extraneous substance, and the process 
improperly termed, solution, is essentially re- 
ferable to the operation of the absorbents. The 
secreting function of the chamber is evidently 
a powerful one, from the reproduction of the 
humor in the course of a single night. That 
the absorbent function is nearly equal to it, is 
proved by the facts above-mentioned, but still 
more strikingly, by the rapid diminution and * 
removal of the matter effused under inflamma- 
tion, when quickened by the excitement of 
mercury. 



SECTION II. 



VITREOUS HUMOR. 

The absorption of the vitreous humor is evi- 
dent in cases of floating cataract, and in some 
forms of organic amaurosis, marked by preter- 
natural flaccidity, even without a diminution of 
volume ; also in cases of absorbed crystalline 
and membranous cataract, with adhesions to the 
iris. 

Diseased I examined the decayed eyes of horses, and 
horses! found in a considerable number, the opaque lens 
sunk in the vitreous chamber, and this humor 
almost entirely absorbed. The eye was filled 
by a morbid accumulation of aqueous humor, 
so that on a single puncture, the whole fluid 
contents of the globe, which was larger and 
more tense than usual, escaped uninterruptedly. 
The sclerotic and choroid in these cases, al- 
though often thickened, and even the oppo- 
site sides coadhering, were entire. The re- 
tina was usually drawn into folds, and par- 
tially absorbed. In some cases the globe 
was greatly enlarged and flaccid, resembling 
an undistended dropsical cyst ; the crystalline 
opaque, of its natural size and firm, and some- 
times its capsule thickened and scabrous, bear- 



VITREOUS HUMOR. 199 

ing marks of inflammation, but in place of the 
healthy vitreous humor, a gelatinous fluid, of a 
deep yellow or amber color, filled the globe. In 
other cases, where the tunics were disorganized, 
and thickened from injuries, the space occupied 
by the humors was either exceedingly reduced, 
or obliterated altogether, by the coadhesion of 
the opposite sides of the globe. In most cases 
where the lens was cataractous, and not impact- 
ed in the anterior chamber, nor fastened by ad- 
hesions of its capsule to the iris, the substance 
of the vitreous humor was shrunk as before de- 
scribed ; and the crystalline, partially absorbed, 
had receded and sunk in proportion. The 
globe was supported in its figure by a morbid 
collection of aqueous humor. 



The tremulous iris is, I believe, always con- t« 
nected with a relative disproportion in volume 
of the vitreous humor, whether congenital or 
the result of operations and injuries. Couching 
and the operation by absorption, if roughly per- 
formed, break down a portion of the vitreous 
cells, which become obliterated j hence the fre- 
quency of floating cataract and tremulous iris 
after these operations. The loss of a very con- 
siderable proportion of the vitreous humor may 
take place without permanently impairing the 
vision, except of minute objects, as is proved 
by the successful issue of some cases of extrac- 
tion, in which this accident has happened. 



Tremulous 
iris. 



20O 



VITREOUS HUMOR. 



I have suspected a diseased state of the vi- 
treous humor in some cases of cataract in el- 
derly people, accompanied by a preternatural 
convexity of the globe, in which a slightly 
glairy fluid has distilled in quantity from the 
eye during the operation, of a consistency be- 
tween that of the vitreous and aqueous humors. 



Discolored 

vitreous 

humor. 



A diseased state of this humor, frequent in 
organic amaurosis, with or without cataract, and 
especially accompanying diseased changes of 
the iris, is that in which it assumes a deep yel- 
low or a chocolate brown color. From its rapid 
and uninterrupted egress, in this and the former 
case, even to a partial collapse of the globe, 
there is reason to infer that the cellular contex- 
ture is broken down, for although the cells of 
the healthy humor communicate, a gush only of 
the fluid ensues from wound or rupture of the 
capsule; the support afforded by the closed lids 
prevents its further escape, and the obliteration, 
by inflammation of the ruptured cells, speedily 
follows. 



Hemor- 
rhage into 
vitreous 
cells. 



I have known blood effused into the cells of 
the vitreous humor within twelve hours after 
the operation of extraction, in consequence of 
straining upon the night-chair, which was in- 
stantly followed by severe pain darting towards 
the occiput. The coagulum was visible both to 



VITREOUS HUMOR. „ 201 

the patient and to the surgeon j the former de- 
scribed it as a central circular spot, intercepting 
the light which was strongly reflected from its 
circumference ; in the sunshine it had a bright 
scarlet hue, and was liver colored in the shade ; 
it was in the course of time absorbed, so that the 
patient gradually recovered tolerable vision. 

Another case was one of active and conti- 
nued hemorrhage ; it was not occasioned, as far 
as could be ascertained, by any improper exer- 
tion. It produced an excessive distention of the 
globe, and was attended with exquisite pain. 
These symptoms commenced in the evening of 
the day of operation, and on the day following, 
the humor, loaded with an enormous coagulum 
of blood, protruded at the section. 

I have met with other cases, in which hemor- 
rhage into the vitreous cells occurred in conse- 
quence of a blow. Inflammation and swelling 
of the globe ensued, and the cornea, yielding 
to the pressure, sloughed, when the humor pro- 
truded gradually in the form of a large spongy 
mass, loaded with coagula of blood, so as for- 
cibly to separate and distend the lids, and oc- 
cupy the entire circle of the orbit. In these 
cases a severe pain is felt in the head two or 
three inches above the orbit, and in the 
temple. The occasional hemorrhage is pro- 



202 



VITREOUS HUMOR. 



fuse. The pain is relieved by opiates, and 
the eyeball ultimately sinks with a total loss of 



figure. 



I have reason to believe that this disease, 
which at one period assumes much of the as- 
pect and character of a fungus, has sometimes 
been mistaken for one of a malignant character; 
a mistake not very unlikely to occur, judging 
from first appearances, where disorganization is 
complete. 



The vitreous humor is subject to a complete 
change of consistence and a total loss of trans- 
parency, the texture of its cells and its volume 
and figure remaining ; the secretion is convert- 
ed from a transparent albumen into an opaque 
substance resembling curd. In one case it was 
like ground rice boiled. Although the opacity 
is visible, the appearance differs widely from 
that of cataract. While the crystalline remains 
transparent, the same bright-colored appearance 
is seen at the bottom or sides of the eye, which 
is supposed to announce the incipient medullary 
fungus. In the progress of the disease also, as in 
the malignant disease, the lens appears to become 
opaque, and is protruded so as forcibly to di- 
late the pupil ; this becomes fixed, its edge 
roughened by detached pigment, and the iris 
convex, so as to give a conoidal figure to the 
sdobe. 



VITREOUS HUMOR. 203 

Several years ago I extirpated the eye of a 
fine infant, eight months old, in whom this dis- 
ease was concluded from the appearances de- 
scribed, to be the malignant fungus in its nascent 
state. The child has since grown to be a fine 
healthy boyj the other eye has remained sound. 
Upon section of the eye, the vitreous humor 
presented the appearance which I have de- 
scribed j the tunics were all entire*. As the 
loss of vision had been but recently discovered, 
and the appearances had in the interval sensibly 
changed, so as to denote the progress of the 
disease, this case could not be considered as a 
congenital mal-organization. 

I have since seen several cases of a convex 
and permanently dilated pupil, with a deep- 
seated opacity of a splendid yellow tint in chil- 
dren, and doubting from the preceding history, 
and the child's freedom from indisposition, that 
such appearances indicated a malignant disease, 
I have abstained from operating. To my sur- 
prise, the appearances have continued station- 
ary for years, unaccompanied with any disorder 
of the health. One, a child of four years old, 
I have very recently examined, having seen it 
at intervals during that period, since the first 
notice of the disease at the age of three months. 
I can discover no difference in the appearance 
of the eye at this time, from that which it then 
* See Plate III. fier. 4. 



204? VITREOUS HUMOR. 

assumed. The bright yellow tint occupies the 
temporal hemisphere of the globe, supposing it 
were bisected in a vertical direction ; the figure 
of the globe is slightly conoidal, the pupil much 
dilated as if from pressure, not perfectly cir- 
cular, and its edge apparently everted, form- 
ing a narrow white line, while small detached 
flakes of the pigment lie behind it next the 
lens, The pupil of the other eye is con- 
stricted, and closed by an opaque capsule. The 
child is well grown and in perfect health. 

I therefore regard these cases as a simple and 
uniform conversion of the substance of the vi- 
treous humor, by an altered action of the 
secreting vessels, wholly independent of a ma- 
lignant character. Unfortunately we have no 
accurate signs by which to distinguish in their 
incipient state, the malignant fungus and the 
disease above described; nor do we know 
that the disease may not sooner or later take on 
an active and malignant character, as is cer- 
tainly now and then occurring in the testicle, 
female breast, and other textures. 

The peculiar tint and splendor of the opaque 
substance, (a mother described it to me as 
resembling, when first perceived, the scale of a 
tench,) is not to be depended upon as a sign 
of malignity. It evidently depends upon an 
opaque reflecting surface at the fundus of the 



VITREOUS HUMOR. 205 

globe ; and the appearance is produced equally 
by an opaque retina, as by a morbid growth, 
except that in the latter it is somewhat more 
lustrous, from its greater density and projec- 
tion ; the convexity of the iris, the immo- 
bility of the pupil, and the apparent opacity of 
the crystalline, are secondary signs, and com- 
mon to both. There are, however, two marks 
of distinction sufficiently strong, between the 
malignant fungus and this disease of the vi- 
treous humor; viz. the progressive or stationary 
condition of the disease, denoted by the state 
of the tunics and the eyeball generally, and se- 
condly, the presence or absence of pain and 
constitutional irritation. To these I might add, 
especially as regards children, the affection of one 
or both organs, as affording a strong presumption 
that the disease is harmless in the first case; inthe 
second, a conclusion that it is malignant. 

It is remarkable, that both the fungus hsema- 
todes, or malignant fungus of the eyeball, and 
the disease which I have just described, are of 
most frequent occurrence in infancy ; I am 
not aware of having seen the latter in the adult. 
1 have now under my observation a very re- 
markable case of congenital malignant fungus. 
The child is eight months old. At its birth 
the eyeball was of the size of a walnut, it is 
now of the proportional size represented by Fig. 
2. Plate V. 



SECTION III. 



CRYSTALLINE HUIWOR. 
Abscess of I AM no t aware of havinsr witnessed any other 

the cap- _ ° ^ 

sulc - result of inflammation of the crystalline and its 

capsule, than opacity, with the exception of one 
case. This was that of a lad, who, after a severe 
blow on the globe of the eye, which produced 
acute inflammation, had a suppuration within 
the crystalline capsule, which projected through 
the pupil in a globular form, and was filled with 
pus. There was no deposit upon the iris. Under 
the action of mercury the pus and lens were ab- 
sorbed together. The continued application of 
belladonna did not prevent the gradual constric- 
tion of the pupil, and the case terminated in a 
capsular opacity, with constricted and mis-shapen 
pupil, and co-adhesion of the iris and cornea. 

Capsular The capsule readily unites by adhesion, when 

opacities. * * " 

simply incised. This is of course prevented by 
the intervention of any portion of lens. The 
capsule, when adhering to the iris, receives de- 
licate red vessels, which run in small brown pe- 
duncles or foot stalks of lymph, produced from 
the interior border of the pupil 5 small flaky 



CRYSTALLINE HUMOR. 207 

portions of the pigment are also frequently de- 
tached, and conspicuous upon the margin of the 
capsule. This is an appearance commonly seen 
in the constricted pupil with partially transpa- 
rent capsule, after chronic iritis. It is often the re- 
sult of repeated attacks of inflammation at short 
intervals, to which a constricted state of the 
pupil certainly pre-disposes. The iris is much 
thickened by repeated depositions of lymph, 
until its texture becomes quite altered. There 
is a very imperfect and deranged state of vision, 
according to the degree and extent of opacity 
of the capsule, which admits of no improvement 
by the direction of the light ; and sometimes 
a marked and painful determination of blood to 
the head. Except in this case, and in punc- 
tured wounds, the capsule is seldom partially 
opaque, but though its opacity is diffused, it is 
often not of uniform density, so that it has a 
dotted or mottled appearance. When calca- 
reous matter is deposited, it is in small flakes or 
scales, which have a brighter tint than the 
opaque membranous portion. The opacity of 
the capsule, as of the cornea, varies in degree, 
from the slightest nebula to the opacity from 
change or conversion of texture. The inci- 
pient nebulosity is often, as before observed, dif- 
ficult of discernment. Where the capsule is 
completely opaque, the lens undergoes a slow 
absorption; the capsule, however, remains trans- 
parent in most cases of senile cataract, not pre- 



208 



CRYSTALLINE HUMOR. 



ceded by inflammation. The capsule, like all 
other textures of the body, undergoes absorp- 
tion, when detached. 



Amaurosis 
mistaken 
for cata- 
ract. 



Species of 
lenticular 
cataract. 



The cataract, from opacity of the humor 
Morgagni, is in my belief purely hypothetical. 
There is an appearance of semi-opacity and 
yellowness in the lens, in some cases of defec- 
tive vision, insufficient to account for the degree 
of dimness. I believe that this is not the cause 
of it, and that the disease is amaurosis. This I 
judge from the appearance being stationary, and 
the symptoms being those of the latter disease. 
I have known it to be confidently pronounced 
an incipient cataract, and the patient to remain 
in anxious expectation of an operation for years, 
without any sensible change of its density, al- 
though in the interim the person had lost his 
vision. On the contrary I may remark, that 
the degree of opacity of some soft caseous ca- 
taracts, when held up to the light immediately 
after extraction, appears quite insufficient to ex- 
plain the degree of blindness, although the 
sight has been restored by the operation. 

The fluid, flocculent, caseous, and hard cata- 
ract, are the four principal and easily distin- 
guished degrees of density, of the opaque crys- 
talline. The caseous admits of division into soft 
and hard, as it approaches nearer in consist- 
ence to the second or fourth species. . The 



CRYSTALLINE HUMOR. 209 

nucleated and mixed cataract — the first an opa- 
city confined to the centre, the circumference 
and superficies transparent, the second a soft 
caseous or fluid superficies upon a firm cen- 
tre — are well marked varieties. I refer the 
reader to my Papers on this subject in the fourth 
and fifth volumes of the Medico-Chirurgical 
Transactions*. The opacity of the posterior 
capsule, i. e, the tunica hyaloidea, is very rare, 
which it would not be if the lens were invested, 
as most persons suppose, in a capsula propria, 
especially after the operation of extraction, in 
which the anterior capsule only is lacerated, and 
the lens alone escapes. Where it is met with, 
the lens and anterior capsule are usually trans- 
parent, and when this is not the case, and the 
cataract escapes with a posterior fold of opaque 
capsule, it is always in my experience accom- 
panied with a considerable discharge of vitreous 
humor, for it is owing to a detachment of the 
tunica hyaloidea, beyond the angle of union 
with the crystalline membrane, or a separation, 
beyond the margin of the lens, of the opaque 
from the transparent portion of that tunict. 

* Vol. IV. p. 278., and Vol. V. p. 391. 

f Until the perfect capsule of the crystalline lens can be 
exhibited detached from the eye, and the vitreous capsule and 
Petitian canal at the same time demonstrated entire, and ca- 
pable of complete inflation, I shall continue to believe, through 
evil and good report, that the appearances actually and uniformly 
presented, and supported by all the phenomena of the patho- 
logy of these parts, warrant the opinion which I have else- 

P 



210 CRYSTALLINE HUMOR. 

What has been called £ black cataract,' when 
this term is used as applied to the lens, and not 
synonymously for amaurosis, is a modification of 
the fourth or hard species. A yellowish brown 
is the ordinary tint, but I have seen it occasion- 
ally of a blackish brown color. 



Formation Some peculiar circumstances relative to the 

of cataract. . . 

formation of cataract, deserve to be briefly 
noticed. 



Although the period of its completion from 
its first appearance is very variable, and can 
never with any certainty be predicted, it is 
usually slow; and sometimes a clouded or semi- 
opaque state or a distinct nucleated opacity re- 
mains stationary for years, or even for life ; yet 
it occasionally forms with rapidity although no 
inflammation is present. 

The rapid formation of cataract is generally 
attended by inflammation, or preceded by 
diseases of other textures. This result of iritis 
has been already explained. I have seen a 
yellow-coloured opacity posterior to the lens 
preceding the rapid formation of cataract. 
The eye became the subject of a superficial but 

where given, that the lens is incased betwixt the strong 
membranous production, commonly called the anterior cap- 
sule, and the proper capsule of the vitreous humor. 



CRYSTALLINE HUMOR. 211 

violent inflammation, from sympathy with its 
fellow which was acutely inflamed. The cata- 
ract was completely formed in two days. The 
pain was of the most acute kind, affecting the 
eyeball, temple, and cheek. In the former 
state some useful vision remained, which was 
now completely extinguished. The previous 
opacity was a morbid state, I believe, of the 
vitreous humor, and the lens transparent until 
the attack of inflammation. 

The residence of a perfect cataract in the Partial di*. 

plaremeat. 

eye is injurious, or at least attended with much 
risk of destructive inflammation. The vitreous 
humor undergoes a partial absorption, and the 
lens, losing to the same extent its support, 
bulges forward and presses upon its capsule and 
the iris. What operators call a narrow anterior 
chamber, arises more or less from this cause. 
Where the capsule yields from a blow or by ab- 
sorption, and the pupil is dilated by the protrud- 
ing lens, a violent inflammation, attended with 
very acute pain, is the invariable consequence. 
I have known this happen suddenly and inde- 
pendent of external injury, where the formation 
of the cataract has been gradual, and unattend- 
ed with pain ; and the spontaneous occurrence, 
though not so frequent, is precisely similar to 
that produced by the too free laceration of the 
capsule with the needle. 

p 2 



212 CRYSTALLINE HUMOR. 

spontane- I have heard of the complete spontaneous 

ous ab- L L 

sorption, absorption of the congenital cataract at an early 
age, and although the eyes had a constant tre- 
mulous motion, the person was in after-life 
enabled to follow useful occupations. I have 
never seen such a case, but I refer to an instance 
which is well authenticated. The tremulous 
motion of the globe is not incompatible with a 
perfect state of vision. 

Progress of The absorption of the matter of the opaque 

absorption. * * 

lens is quick in proportion to the looseness of 
its texture, and its complete exposure, by break- 
ing up and detaching its fragments, to the ope- 
ration of the aqueous humor ; and also to the 
plentiful secretion of healthy aqueous humor *. 
In confirmation of the latter statement I have 
observed, that in all cases of narrowed ante- 
rior chamber, by the partial co-adhesion of the 
iris and cornea, consequent upon the injury 
which produced the cataract, or inflammation 
from any other cause, it is slow ; and that ab- 
sorption does not take place during the ex- 
istence of inflammation, in which state, the 
aqueous humor is in a morbid condition, and 

* I do not consider this fact as militating against the opi- 
nion given at page 196. The turbid state of the humor indi- 
cates the arrest of its secretion ; and its copiousness and 
transparency the unabridged extent and health of the secret- 
ins surface. 



CRYSTALLINE HUMOR. 213 

if the inflammation be deep-seated and pro- 
tracted, the vitreous humor partakes of it. 

I have seen a case of dislocated lens occu- 
pying the anterior chamber, followed by inflam- 
mation of the iris j from which membrane it has 
derived an adventitious capsule of lymph, or- 
ganized by coloured vessels. 



SECTION IV. 



DISEASES AFFECTING THE EYEBALL. 
Effects of Under this head might properly be classed, 

injuries. . . , 

the morbid changes which result from the va- 
rious forms of injury, to which, as all parts are 
exposed, all are liable in common. These, how- 
ever, it is impossible to enumerate, and indeed 
would be, for any practical purpose, unneces- 
sary, after describing the peculiar morbid dis- 
position of each texture, and the characters of 
inflammatory action which they severally ex- 
hibit. The mode and extent of the injury, and 
the instrument with which it is inflicted, will 
determine its importance, as regards the pre- 
servation of the organ and its functions. Con- 
cussion and extravasation of blood are, both of 
them, frequent causes of a sudden loss of vision, 
which is, in many instances, gradually restored. 
The lesions of the internal tunics are to be se- 
riously apprehended, from the probability of 
the retina being included in the mischief — the 
case of foreign bodies penetrating deeply into 
the globe, from the probable disorganization and 
dissolution of the vitreous humor, and the con- 
sequent suppuration, or state of atrophy, of the 



DISEASES AFFECTING THE EYEBALL. 21. 

globe. Sometimes the organ is at once de- 
stroyed by rupture of the nerve and muscles, 
and a partial evulsion of the globe from its 
socket ; or by so free a lacerated wound, as to 
occasion large staphylomatous protrusions of the 
choroid, or the escape of the humors in toto, 
and instant collapse. More frequently, how- 
ever, the cornea, or lens, or iris, are so far se- 
verally or exclusively affected, as to leave the 
figure of the ball uninjured, and to make the 
secondary changes which may be expected to 
supervene, an object worthy of the most inte- 
resting and anxious attention ; and, I may add, 
to afford considerable scope for the salutary ex- 
ercise of art. 



From a long continued and exasperated Supp " r ^ 
inflammation of the interior tunics, but more eyeball. 
frequently from injury, the eyeball suppurates, 
and its texture is totally destroyed. The globe 
becomes rapidly enlarged, greatly protruded, 
and exceedingly tense. The conjunctiva, highly 
tumid and vascular, is rolled out upon the 
cheek, so as completely to evert the lower eye- 
lid. The pain is very acute, lancinating through 
the eyeball and head, and continues day and 
night without intermission. The patient's health 
is greatly disturbed, and the symptomatic or irri- 
tative fever, as in the thecal abscess, or acute pa- 
ronychia is considerable. The anterior cham- 
ber is at first filled by soft white lymph, then pus 



216 DISEASES AFFECTING 

collects in quantity j the clouded cornea turns 
opaque and slowly yields by ulceration, or dies 
and sloughs off, when the contents of the globe 
are more or less discharged, and. the pain and 
symptoms of irritation gradually subside. The 
eyeball afterwards shrinks up, and the cornea is 
obliterated. The hypopion or purulent secretion 
filling the anterior chamber, originating from 
internal ulcer of the cornea, is not accompa- 
nied by the enlargement, or the acute pain 
and high irritative fever which mark the ab- 
scess of the globe ; these are referable to the 
extreme distension and corresponding resistance 
of an unyielding texture like the sclerotic, as in 
the abscesses of tendinous sacs and thecse. The 
termination is the same in both ; riz. the pe- 
rishing of the cornea. 

Malignant I had formerly been led to suppose, that the 

diseases. 

malignant disease termed, cancer, affected the 
bulb or globe of the eye. Such is the doctrine 
of most writers on the subject. I have, how- 
ever, satisfied myself that as regards the eye, 
this disease is peculiar to the lacrymal gland, 
conjunctiva, and eyelids ; and I have classed it 
accordingly. On the contrary, I had believed 
that the disease termed, soft cancer, medullary 
fungus, or fungus haematodes — for these latter 
terms are descriptive of the appearances of the 
same disease in its different stages — had its origin 
in some individual and peculiar texture ; some 



THE EYEBALL. 217 

writers giving it to the retina and medullary 
substance, others to the fibrous texture of the 
sclerotica. I am, upon the evidence of many 
cases and dissections, assured, that this is not 
the fact as regards the eye ; that on the con- 
trary, each and every texture, if we except the 
crystalline and cornea, is capable of generating 
it, and is occasionally its proper nidus. The 
disease therefore comes properly to be noticed 
in this section. 

The early appearances of this formidable dis- Malignant 

. . fungus. 

ease, of which it has fallen to my lot to see nu- 
merous instances, have been accurately de- 
scribed by Mr. Saunders and Mr. Wardrop. 
The disease, in my experience, has proved 
speedily destructive, when arrived at that stage 
in which the visible enlargement and loss of 
figure of the ball, the consequent livid blue 
tint of the sclerotica, and the distended vessels 
of the conjunctiva and eyelids present them- 
selves. The character of the disease is by these 
decided ; they are proofs of its rapid and de- 
structive progress, and taken together with the 
primary appearances, must be regarded as fatal 
prognostics. The staphylomatous protrusions 
of the sclerotic and choroid coats, may, without 
the exercise of a careful discrimination, be con- 
founded with this disease. I speak from a dis- 
tinct remembrance of two cases in particular, 
in which the existence of the malignant fungus 



218 DISEASES AFFECTING 

was a matter of dispute between very compe- 
tent persons, prior to the extirpation of the 
organ, by which its existence was instantly de- 
monstrated ; and from the recollection of se- 
veral in which the proposal of an operation was 
overruled, and as the event proved, judiciously, 
the patients having remained well, and the 
organ tranquil. Abscess of the globe, chronic 
enlargement and disfiguration of it from cho- 
roidal inflammation, proptosis from enlargement 
of the appendages, and tumors within the 
orbit, hydrops oculi, &c. are on the contrary 
sufficiently easy of distinction from the malig- 
nant disease, by the absence of the characteris- 
tic signs of the latter. Nevertheless I have 
known some of these mistaken for it. I iiave 
before noted a case, viz. protrusion of the 
vitreous humor from the eyeball, with which 
the fungus protruding through the slough of 
the cornea might, prima facie, be confounded 
by a person unacquainted with the history of 
the case. But it rarely happens that the origin 
of the disease has not been accurately noted by 
the patient or his friends, or that the germ of 
the disease, in the infant at least, is not apparent 
upon inspection of the other eye. The com- 
plexion, as the disease proceeds, acquires the 
leaden paleness of cancer, and the rest is broken 
by deep and lancinating pain. If a child is the 
subject of the disease, it is heavy-headed and 
lethargic, as one affected by hydrocephalus ; 



THE EYEBALL. 219 

disturbed by occasional convulsive starts; the 
stomach often rejects food, the frame emaciates 
rapidly, and the highest possible degree of irri- 
tability and fretfulness is present. The child 
usually expires in convulsions. The adult suffers 
from spasmodic shoots of pain through the ball 
and head, and simultaneous startings in going 
to rest; but the constitutional disturbance is in- 
considerable previous to the protrusion of the 
fungus ; and haemorrhage, which usually comes 
on at this period, is exceedingly distressing. 

The metallic appearance at the fundus of the 
eye sometimes presents coloured blood-vessels, 
branches of the arteria centralis, which pene- 
trate the vitreous humor ; the opacity seems to 
advance towards the pupil, and might be mis- 
taken for a protruding soft cataract, an appear- 
ance which, as Mr. Saunders has remarked, is 
altogether delusive. In a case in which Mr. 
Hunter was consulted, the operation for cata- 
ract was actually undertaken, and the lens being 
found transparent, the eye was immediately ex- 
tirpated, from a conclusion that the disease was 
malignant. 

A dissection of the eye, after the destruction 
of the cornea, furnishes a very indistinct clue 
to the original seat of this disease ; it is in this 
state a firm semi-organized mass of lymph in- 
termixed with and surmounted by coagula of 



220 DISEASES AFFECTING 

blood* ; all the textures of the eye are broken 
up, but here and there the vestiges of one or 
more may be traced. If examined at an earlier 
period, that is, before it fungates, the section 
presents the real character of the disease, the 
medullary or soft brain-like substance, which 
we see in other organs of the body, com- 
monly arranged in small lobes or moleculae. 
Sometimes one, and sometimes another of the 
proper textures, appears to be the matrix of the 
disease. The fungus, in one instance, adheres 
intimately to the sclerotica, and detaching the 
choroid and retina, throws these and the vitreous 
humor to the opposite side of the globe. Fre- 
quently it splits the sclerotica into two lamellae, 
distinctly originating in the interstitial sub- 
stance of that coat. Its progress, by absorption 
of a part of the sclerotic, gives occasion to a 
rapid growth of the diseased texture, external 
to it, within the orbit; but more frequently the 
diseased growth is luxuriant upon the outer 
surface of the sclerotic, to which it is as firmly 
attached as on the inner, while that tunic retains 
its integrity and forms a perfect septum be- 
tween the diseased masses. Hence, fibrous 

* It is seldom that the blood-coloured fungus acquires that 
enormous size, and protrudes to such a deforming extent as 
is seen in Saunders, PI. III. It is to be regretted that an ex- 
amination was* refused in that case, although there can be 
little doubt that it would have confirmed this description of 
the ultimate state of the ditea^e. 



THE EYEBALL. 221 

membrane has been supposed to give origin to 
it. But in other cases, the disease unquestion- 
ably begins in the choroid, and that tunic gra- 
dually degenerates into the diseased mass which, 
occupying a large portion of the globe, is 
throughout deeply tinged with the black pig- 
ment. Sometimes the sclerotica has a morbid 
growth externally, and the choroid on the inte- 
rior. Again, these tunics seem to be often only 
secondarily affected, and are removed by partial 
absorption, in the progress of the disease; the 
septiform productions, extended, displaced, and 
broken down, of the tunica hyaloidea, inclose 
the fungus, and although no vestige of the vi- 
treous humor remains, it is plain that it has 
formed the nidus of the diseased growth. The 
iris and corpus ciliare evidently degenerate in 
the same manner as the choroid. Again, the 
disease has seemed to originate at the point of 
entrance of the optic nerve into the globe, 
pushing the humors before it ; and the nerve 
itself has upon section been found diseased, 
both contiguous to the sclerotic, and at the 
distance of three quarters of an inch from that 
tunic, where the intermediate portion has pre- 
served its healthy aspect. Nay, the optic gan- 
glion, tractus opticus, and thalamus, have been 
repeatedly found, one or other or all diseased, 
and the surrounding adipose substance in the 
orbit has exhibited the disease in its genuine 
character, and to a considerable extent, where it 



222 DISEASES AFFECTING 

had no direct communication with the diseased 
contents of the globe*. So also, the lymphatic 
glands, at the angle of the jaw, frequently take 
on the same character of diseased structure. It 
appears to me therefore, that this is not a disease 
of this or of that texture, as writers would in- 
sinuate, but of all the textures, the crystalline 
and cornea excepted, which yield to its pro- 
gress, but never exhibit a specific change of 
texture. The process of suppuration, ulcera- 
tion, and sloughing, have no share in the dis- 
eased action, and are only seen in the cornea. 
The other tunics and humors yield by progres- 
sive absorption, without pus. Its appearance, in 
comparing the sections before fungating, is evi- 
dently modified by its situation, as for example, 
in the sclerotic and choroid, adipose substance, 
and vitreous humor ; the phenomena of color, 
of hemorrhage, &c. depend much upon situa- 
tion, also the preservation of figure, degree of 
enlargement, and the rapidity of growth, ac- 
cording as it is confined to the interior, or ori- 
ginally affects the exterior of the globe, or com- 
municates with the orbit. We see these 
modifications of appearance, upon comparing 
it in the different viscera, and in the cellular 
membrane, tendinous aponeuroses, and the 
nerves. The deep blue and black tubera, cha- 
racterise the choroid fungus ; the medullary, 

* I have a coloured drawing which accurately exhibits this 
state, taken at the moment of inspection. 

S 



THE EYEBALL. 223 

the substantia alba of the optic nerve or brain ; a 
more dense fibrous brown tuber, clear of stain, is 
the production of the sclerotica. These several 
parts are found to be directly and peculiarly in- 
volved, upon dissection. 

I have a preparation exhibiting a genuine ex- 
ample of the disease affecting the anterior right 
lobe of the cerebrum, and protruding the eye 
from its socket, while the eye itself was per- 
fectly free from disease. This shews the pro- 
gress of the disease by absorption, and not by 
contiguity, conformable to our opinion of its 
nature. 

I must refer the reader to Plates 3, 4, and 5, 
and the accompanying descriptions, for further 
details on this subject. 



PATHOLOGY 



OF THE 



APPENDAGES 



CHAPTER III. 



SECTION I. 

ORBITAR APPENDAGES. 

Abscess. jf\.BSCESS sometimes forms within the orbit, 
and previous to its discharge occasions an equal 
protrusion of the globe, with eversion of the 
palpebra, dilated pupil, and suspended vision. 
Its situation and effect upon the eye give 
much pain and apprehension to the patient, as 
well as considerable disturbance to the system 
at large. The sight is sometimes permanently 
extinguished. In other cases it returns after 
the discharge of the abscess, and consequent re- 
moval of pressure. 



Adipose Adipose and steatomatous tumors are occa- 

ed tumors, sionally formed, in the cellular and fatty tex- 



ORBITAR APPENDAGES. 225 

ture cushioning the globe. They occupy the 
interspace of the recti muscles, and in their pro- 
gress emerge between the globe and the orbitar 
circumference. They have therefore an oblong 
figure. The globe of the eye is turned and fixed 
in an opposite direction, and so compressed as to 
be rendered dim. I have removed them when 
projecting over the top or on one side of the 
globe, in several instances. When theconjunctiva 
is freely divided, the fatty tumor is easily hooked 
forward, and dissected out by a few touches of the 
narrow bistoury. The cyst containing a fluid, 
which is usually transparent, it is not so easy to 
remove entire, owing to its tenuity and the in- 
stant escape of its contents if it be accidentally 
torn or wounded. In the empty or collapsed 
state it is scarce possible to extirpate it com- 
pletely, and even though the integrity of the 
cyst be preserved, its extent backwards within 
the orbit renders this in some instances a mat- 
ter of much difficulty. If the cyst be cut in half, 
although the lips of the wound heal kindly, it 
suppurates periodically and discharges many 
times at the cicatrix,which closes in the intervals. 
The encysted tumor, although it extend to the 
bottom of the orbit, seldom occasions the distor- 
tion of the globe. A disagreeable sense of numb- 
ness and coldness affects the integument of the 
glabella and forehead, after the division of the 
frontal and supratrochlear nerves ; these therefore 
should be avoided in the operation. The tumor 



226 ORBITAR APPENDAGES* 

sometimes projects exterior to the tarsus, so as 
to rise upon the palpebra, but more commonly 
it is beneath the tarsus and contiguous to the 
globe. In the former case the cyst lies upon the 
periosteum of the orbit and is adherent to it; in 
the latter it is adherent to the globe. 

Hydatid j n the last annual report of the London 



tumor. 



Infirmary for diseases of the Eye, is the notice of 
a singular case of hydatid cyst protruding the 
globe, with the following remark. " One of 
these cases was a protrusion of the eye from the 
orbit, by a cyst containing hydatids deeply seat- 
ed in the cavity. The hydatids were evacuated 
by a puncture in the cyst ; the eye returned into 
its natural situation, and the patient was com- 
pletely cured. This is the only instance of such 
an affection that has occurred since the opening 
of the Infirmary." 

Aneurismai The looseness of the connecting texture in 
the orbit, and the number and tortuosity of the 
vessels, seem to predispose to that disease of the 
arterial and venal extremities, which gives ori- 
gin to those peculiar vasculo-cellular tumors, 
the precise nature of which is not yet satis- 
factorily ascertained ; which add to a structure 
most resembling that of neevus maternus, the for- 
midable character of aneurism. See my case of 
aneurism by anastomosis in the orbit, in the 
Medico-Chirurgical Transactions, Vol. II. Art. 1. 



ORBITAR APPENDAGES. 227 

and another by Mr. Dalrymple, the able and 
ingenious surgeon to the Norfolk and Norwich 
hospital, Vol. VI. Art. 7. 

Tumors sometimes form beneath the perios- sarcoma* 

L tons and 

teum of the orbit, giving; to the touch a firm cartilage 

00 # nous tu- 

resistance. I have seen several cases of this mor. 
description where the tumor appeared to extend 
the depth of the orbit, and was presenting on 
the nasal side. Their anterior edge is thin, being 
bound down to the orbitar circumference, but 
when they protrude and compress the globe to 
blindness, as is sometimes the case, it is to be 
inferred that they have attained considerable bulk 
posterior to the globe. I once removed one on 
the abductor side of the globe by scraping it clean 
away from the bone ; it was of the hardness of 
cartilage and of great extent. I am unable to 
say whether the disease returned, having soon 
afterwards lost sight of the patient. The im- 
pression I had of the case was unfavourable, 
from the character, as well as the extent and 
connections of the tumor. 

Exostoses of the orbit are not common. I Exostoses. 
have never seen them in the living subject of a 
size to create deformity or material incon- 
venience. 

Polypi of the frontal, sphenoid, and ethmoid Polypi, 
sinuses in their progress burst through the eth* 

Q 2 



228 ORBITAR APPENDAGES. 

moid and lacrymal bones, and sometimes ex- 
trude the eyes, so as to occasion the most hor- 
rible deformity. If when they first appear at 
the inner canthus, having an elastic feel, we punc- 
ture them, a thick glairy fluid is discharged, 
but from the extent of the disease when it has 
advanced thus far, the swelling does not subside. 
I know of no disease which presents so truly 
formidable an appearance as the polypus of these 
parts, when it has arrived at such an extent as to 
break up the bony structure of the nose or an- 
trum, and shew itself in the orbits. 

Diseases of The lacrymal gland is subject to simple in- 

lacrymal „ . ■ . 

gland. terstitial enlargement, to suppuration, and to 
scirrhus, like other glands of similar structure ; 
its enlargement is known by the lobulated ap- 
pearance of the tumor, on further stretching the 
skin of the projected eyelid. It often suppurates 
in children, and occasions an excessive swelling 
above the upper lid, depressing the tarsus upon 
the globe so as completely to conceal it. The 
abscess may be conveniently opened and dis- 
charged beneath the lid, with a narrow curved 
bistoury. I removed the lacrymal gland greatly 
enlarged and in a state of true scirrhus, from 
the orbit of a middle-aged man, a merchant's 
clerk in this city*. The vision of that eye had 
suffered considerably during the growth of the 

* Represented by fig. 6. plate II. 



ORBITAR APPENDAGES. 229 

tumor; in other respects he continued quite well 
when I last saw him, after an interval of some 
years. There was no other deformity than a 
slight drooping of the lid at the outer angle. 
All these operations should be performed be- 
neath the eyelid when the circumstances admit 
of it. 



SECTION II. 



FACIAL APPENDAGES. 

Hordeolum. Palpebr^e. The little abscess called a stye, 
situated on either edge of the palpebra, 
commonly has its origin in an obstruction of 
one or more of the meibomian follicles, like the 
mammary abscess, which is an obstruction of one 
or more of the lactiferous tubes. Obstruction is 
followed by inflammation of the follicle and sur- 
rounding cellular membrane, and it terminates in 
a little painful abscess. Another description of 
stye is an abscess forming around the bulbs of 
the eye-lashes from inflammation of the ciliary 
foveola?, which sometimes has its origin in a dis- 
ease of the hair-bulb. After the discharge of 
the abscess and before the falling off or 
evulsion of the hair, the foveola appears exulce- 
rated within and at its mouth, and continues for a 
long time to discharge a thin ichor by which 
the edges of the tarsi are denuded of conjunctiva, 
or this membrane is kept in a state of exulcerati- 
on; the discharge forms a scab, by which the lids 
are firmly agglutinated during sleep, but it is de- 
tached, and the diseased secretion renewed by 
their separation. By the recovery of the foveola 
the healthy growth of the cilia is restored. 



FACIAL APPENDAGES. 231 

Sometimes the affected foveolae become oblite- 
rated by the adhesive action, when the hairs of 
course are not reproduced. An habitual pro- 
duction of diseased cilia as well as nails is not 
uncommon, and for this state plucking in either 
case is only a palliative remedy. The disease 
is in the glandular structure which forms them, 
and its obliteration or removal, by a natural or 
artificial process, is in most cases the only 
method by which it can be cured. Independent of 
the abscess of the meibomian follicle and ciliary 
foveola, the conjunctiva upon the margin of the 
tarsi, and the continuous cutis, are liable to fur- 
uncular inflammation. The term stye is I believe 
indiscriminately applied to all. The disposi- 
tion to form stye is generally a mark of scro- 
fula, and from one or other of these causes 
is continually recurring as the system is af- 
fected. 

Transparent vesicles and skin warts are not wartsand 

vesicles. 

uncommon upon the margins of the tarsi. The 
former occur upon the meibomian border more 
especially, the latter upon the ciliary. 

The first stage of lippitudo is a simple exco- Lippitodo. 
riation; the second, an ulceration of the borders 
of the palpebra?. It is the result of inflammation 
of the palpebral conjunctiva, aggravated by the 
acrimonious quality of the vitiated meibomian 
secretion. In the chronic form of the disease 



232 FACIAL APPENDAGES. 

in strumous subjects, the conjunctiva is greatly 
thickened, indurated, and altered in its texture ; 
the ciliary glands are destroyed, together with 
the fine cuticle of the lid, to some extent beyond 
the ciliary margin ; and a partial eversion of the 
lids, owing to the tumefied state of the conjunc- 
tiva, increases the deformity. The mouths of the 
meibomian glands are obliterated, and the ducts 
plugged by their inspissated secretion; some- 
times the conjunctiva fungates so as to render 
the eversion complete, and a process of cicatri- 
zation makes it permanent. Thus the ectropeon 
may result from a neglected lippitudo. 



Diseased 
cilia. 



The eye-lashes are subject to become mor- 
bidly dry, harsh, and variously distorted, instead 
of having an equal curve, and their natural 
softness and pliancy. The inversion of one or 
more cilia upon the conjunctiva produces, by 
continued irritation, a painful degree of intole- 
rance with an undue secretion of mucus and 
tears, and an opacity of the conjunctiva of the 
cornea with the prolongation of the coloured 
vessels upon this membrane. In this way the 
marginal opacity extends over the surface of the 
cornea and occasions blindness. This state 
frequently exists independent of entropeon. 
The disordered state of the cilia, above de- 
scribed, is owing to a disease of the glands which 
secrete and nourish the cilia, as mentioned in 
speaking of the hordeolum. 



FACIAL APPENDAGES. 233 

The tinea ciliaris is a disease of the ciliary Tinea ci- 

n i i • t liaris. 

foveola, and hence is commonly combined with 
lippitudo. In the slightest form a branny crust 
surrounds the roots of the cilia, the skin of the 
lid being very partially, if at all abraded ; in the 
more advanced stage, a mucus is secreted by 
the inflamed and excoriated ciliary border, and 
the thinner part of it evaporating leaves a scab. 
In the most inveterate form, the disease is the 
same with the lippitudo which has advanced to 
ulceration ; the cilia fall off, and either diseased 
cilia are produced, so that the pore and the hair 
mutually react and keep up the disease, or the 
hair gland is permanently destroyed and the fo- 
veola obliterated. The porrigo or crusta lactea 
overspreading the eyelids and cheeks, with chaps 
and exulcerations behind the ears, and within 
the meatus auditorius, are concomitant affec- 
tions, especially in children. 

The trichiasis is a morbid incurvation of the Trichia.ii 

^v> • n • or entro * 

tarsus, affecting either a part or the whole or it, i^on. 
from the cicatrization and consequent contrac- 
tion of wounds, burns, and lippitudinous 
ulcers upon its meibomian edge, or the 
palpebral fold of the conjunctiva. Whether the 
entire cartilaginous border or only a part is 
inverted, depends upon the situation and extent 
of the disease which has produced it. But it 
very frequently arises, especially in aged per- 
sons, from a simple loss of elasticity in the carti- 
lage, or a redundancy of the integument of the 



234 FACIAL APPENDAGES. 

lid and cheek, or these causes combined. There 
is a case less frequent, in which trichiasis de- 
pends on a thickened and callous roll of palpe- 
bral conjunctiva, over which the lid turns. 
From whatever cause the disease origi- 
nates, the eye becomes irritable, the motion of 
the lids occasions pain and watering, and from 
the incessant friction of the tarsus upon the 
globe, results the inveterate chronic inflammation 
with opacities, fed by vessels overshooting the 
cornea. It is very rare, with the exception of 
the caseof protruded conjunctiva last mentioned, 
that the excision of an elliptical fold of skin at 
the basis of the lid, is not an efficient remedy. 
In that case, the roll of conjunctiva must be 
excised. The excision of the cartilage I think 
quite superfluous, and a remedy far more severe 
than the disease. 

Ectropcon. The ectropeon is the result of injury to the 
eyelid, as wound, burn, herpetic ulcer, or the 
sequela of chronic lippitudo. The tarsus of the 
lower palpebra sometimes falls outward from an 
apparent loss of elasticity, or the unequal action 
of the orbicularis muscle. The lid receding 
from the globe suffers the tears to collect in 
a pool between them. An unhealthy state of 
the conjunctiva is, if not the cause, as when 
villous and redundant, a certain consequence 
of its eversion and exposure. The case is much 
aggravated when coadhesion, after burns or 



FACIAL APPENDAGES. 235 

neglected wounds, ulceration from any cause, 
or long enduring e version, takes place between 
the skin of the eyelid and cheek. This case 
admits of palliation, but not of cure. I have 
much improved several cases by first detaching 
the fastened lid and forcing it to heal by granu- 
lation, and afterwards, removing a triangular 
portion of the cartilage, according to the pro- 
posal of a modern author, for the correction of the 
eversion, which is the best remedy for such ever- 
sions as do not depend upon the protruded con- 
junctiva*. In this, which is the simplest case 
of ectropeon, the excision of the diseased con- 
junctiva is sufficient. Where the everted lid 
is adherent to the bone, there is a deficiency of 
cellular substance to produce granulations, and 
the case is, generally speaking, slightly if at all 
benefited by operation. 

Tumors of the eyelids are encysted, varying in Tumor* of 
size, and containing a thin yellow fluid, or a fluid briB - 
of the consistence of'honey, or a white and dense 

* This remedy results from considering the relative condi- 
tion of the tarsus and skin at the base of the eyelid, in the two 
diseases, entropeon and ectropeon. In the first the integument 
is elongated, in the second the tarsus. As in the first case by 
removing a portion of the redundant skin we turn out the in- 
verted tarsus, so in the latter by removing a portion of the 
elongated tarsus, we turn in the everted. It will be understood 
that it is only relatively that we speak of the elongation of the 
tarsus. It is everted, and structured in the state of eversion by 
the skin. 



236 FACIAL APPENDAGES. 

caseous substance ; or like the common steatom. 
They are adhering to the tarsi or moveable. 
In the first case, they give a diffused elevation 
to the skin of the lid, are circumscribed, and 
tense to the touch, Upon examination on the 
interior of the tarsus, a white hollow spot is 
discerned, surrounded by a blush, which corres- 
ponds to the point of their intimate adhesion to 
and partial absorption of the cartilage. Upon a 
free incision through the cartilage at this point, 
the entire cyst is easily expressed through the 
section. A thickening of the membrane 
covering the cartilage, will give the sensa- 
tion of a tumor which does not exist. The 
adhesion of these cysts to the tarsus is some- 
times so intimate, that if their removal were 
attempted by dissection externally, it would be 
scarcely possible to detach them, without re- 
moving a portion of the cartilage. They are 
often two or three in number, and their fluid 
contents are not often absorbed. 

The steatomatous tumors form in the cellular 
substance beneath the cutis, and are freely move- 
able, and easily turned out through a free inci- 
sion of the skin. The atheromatous and larda- 
ceous tumors form on or near the edges of the 
tarsi, and are very common in weakly children, 
in whom they acquire a considerable bulk. If 
left, the skin ulcerates, and a scab forms upon the 
top, when they may be readily expressed entire 



FACIAL APPENDAGES. 237 

between the nails of the thumbs. They resemble 
the sebaceous tumors behind the ears, and on 
other follicular parts of the skin, arising from 
obstruction of the follicles, which, being dilated 
and their sides condensed by inflammation with 
the surrounding texture, form these cysts. 

Suppuration of the upper eyelid occurs from Abscess of 

i-i n ' mi 1 l l tne u PP er 

slight causes ot irritation. Ine matter should na. 
be early discharged, for the cellular membrane, 
owing to its laxity and abundance, is subject to 
so rapid and excessive a distention, that if un- 
relieved, it sloughs out, and an ugly puckering 
or even a permanent eversion of the tarsus en- 
sues, from deficiency of substance forgranulations. 
I have known this defect produced in an ag- 
gravated degree, by the suppuration going on 
insidiously and unsuspectedly, under the mask 
of cedema. The origin of it was snipping off a 
small skin wart upon the palpebra with a pair 
of scissors, and the subsequent irritation of the 
wound by the application of court plaister. 

Lacrymal passages. The puncta are some- constricted 

and closed 

times much constricted, sometimes obliter- puncta. 
ated by preceding chronic inflammation ; 
hence epiphora from imperfect or non-ab- 
sorption of the tears, proportionate suffusion 
from excitement, and dimness. The con- 
stricted or closed punctum is always best 
opened with the point of a middle-sized pin j 



238 FACIAL APPENDAGES. 

it afterwards readily admits the dilating probe; 
but if no vestige of the punctum remains, it is 
useless to attempt to form an artificial canal. 
I have seen a congenital deficiency of the 
puncta, but the case is very rare ; obliteration is 
much less so. 

Patulous The over dilated or patulous puncta occur 



puncta. 



in old people, with more or less separation of 
the lower lid from the globe. They are so large 
as apparently to have lost their contractile as 
well as absorbing power ; the conjunctiva of the 
palpebra is tumid and slightly villous, and the 
meibomian secretion is morbidly increased. 

wounds of The lacrymal conduits are subject to be 
duets. a wounded or divided, hence incurable fistulae. I 
have met with several such cases and have tried 
in vain to heal them. Small abscesses occur in or 
adjoining the lacrymal conduits which are broken 
and discharged by the passage of the probe. In 
more than one instance, I have turned out a 
considerable quantity of calcareous matter wed- 
ged in these ducts, like the calculi of the sali- 
vary ducts. 

stricture at With the constricted punctum a stricture of the 
J e thTsac. lacrymal conduit at the entrance of the sacculus 
lacrymalis, is often combined. This stricture is 
readily ascertained, and easily yields to the dilat- 
ing probe. The tears regurgitate and cause suffu- 



FACIAL APPENDAGES. 239 

sion, but there is no evidence of any affection of 
the sac. The most frequent situation of stricture 
is at the point of termination of the sacculus la- 
crymalis in the ductus nasalis. The tumid state 
of the lining membrane, during acute inflamma- Acute, 
tion of the palpebral conjunctiva, occasions a tem- 
porary obstruction, and this will continue for a 
time after the subsidence of the inflammation, but 
in a less degree. The canal in this state is ex- 
quisitely sensible, and the use of probes is im- 
proper. The obstruction is gradually removed 
under the treatment adapted to the inflamed 
palpebral conjunctiva, with which the lining 
membrane is continuous. 

A more considerable and permanent obstruc- chronic 
tion arises from continued vascularity and slow 
thickening of the lining membrane, the sac be- 
comes slightly elevated from habitual distention, 
and a little mucus on pressure is returned upon 
the eye. Yet there is no discoloration of the 
skin or sign of inflammation of the sac, and the 
epiphora is partial, that is, the tears are only im- 
peded, and the epiphora only occurs when the 
eye is employed or in any way excited, and the 
secretion quickened. 

In the state of incomplete obstruction, if the obstrnc- 

v , . ,. , , tion partial, 

tarsi are unanected, no mucus is discharged on 
pressure, nor is the sac perceptibly enlarged, 
nevertheless the suffusion upon reading, writ- 



240 



FACIAL APPENDAGES. 



ov com- 
plete. 



ing, working, or exposure to cold air, is exceed- 
ingly troublesome. Water injected by the 
puncta will find its way into the nostril, but 
slowly and only in part ; so it is with the tears. 
When from long continuance of this state the 
obstruction is confirmed, the epiphora is inces- 
sant, the sac becomes sensibly dilated into a tu- 
mor, and upon pressure a very considerable dis- 
charge of purulent mucus takes place, so as to 
flood the eye. The sac, when once habituated to 
a state of over distention and a secretion of puru- 
lent mucus, will not contract upon its contents. 
Thus a very moderate degree of obstruction, or 
no obstruction at all may co-exist with this state ; 
it may continue, even though the bony part of the 
canal should be destroyed, and the matter on 
pressure flow readily into the nostril. 



Abscess of 
sac. 



The lacrymal sac is liable to acute inflamma- 
tion and abscess, a very troublesome, painful, 
and disfiguring disease, the signs and pro- 
gress of which are well known. The sur- 
rounding cellular membrane becomes (edema- 
tous, and the cheek and side of the face are 
enormously swollen, so as to obliterate the or- 
bitar fossa and fold of the lower eyelid. When 
the abscess is chronic, the sac having been pre- 
viously distended owing to obstruction, the 
contiguous cellular membrane passes into the 
state of adhesive inflammation, so that the 
swelling is not dropsical, but firm and hard. 



FACIAL APPENDAGES. 241 

This occasions considerable embarrassment to 
the young surgeon, from the obliteration of 
the points, the infra-orbitar edge especially, by 
which the operator directs his incision, and the 
depth of the sac from the surface. If the 
disease be left to pursue its course, the skin dis- 
colors, the sac ulcerates, and its contents are 
diffused in the cellular substance ; or as more 
commonly happens where a previous obstruc- 
tion has existed, the skin and sac, being con- 
densed by the adhesive inflammation, yield 
together, and the discharge is external. Hence 
the fistula lacrymalis properly so called, a term Fistula. 
improperly applied to all stages of the disease, 
of which it is but the last. It must not be sup- 
posed, however, that abscess of the lacrymal sac 
is always preceded by obstruction to the tears, 
any more than that abscess of the prostate is 
always preceded by obstruction to the passage 
of urine. It is frequently a sudden and rapid 
disease, unpreceded by any degree of epiphora. 
In other cases it is slow and obviously progres- 
sive from the state of imperfect obstruction and 
retention of mucus and tears. The termination 
of acute abscess is more speedy and favourable 
for this reason, than of the chronic. In the 
former case, upon introducing a common sized 
probe after opening the sac, it passes readily into 
the nose. 

The lining membrane of the lacrymal sac is Fungus of 



242 FACIAL APPENDAGES. 

liable to take on a morbid action. It forms a hard 
and dense tumor, which slowly ulcerates and de- 
stroys the skin to the extent of the sac. An 
irritable button-like fungus, of a malignant 
aspect, is then protruded. A fungus of a looser 
texture sometimes follows the abscess of the sac, 
or in other words, the sac, laid open by ulcera- 
tion, throws up luxuriant granulations. 

Dropsy of The sac is also subject to dropsy, in which 

the sac. , 

state it acquires the size of a pigeon's egg, pro- 
jecting the lower lid next the nose ; the tumor 
is perfectly transparent, containing a fluid like 
that of hydrocele. Its natural openings are 
closed, for it is incapable of evacuation by pres- 
sure ; it is very considerably extended within 
the orbit on the nasal side. This has been termed 
the hydatid tumor of the lacrymal sac. 

Diseases of Injuries, as blows flattening the nose in early 

the canal . . , 

and sur- {jf e or occasioning exostosis of the ossa nasi or 

rounding _ 

parts. * unguis, produce incurable disease, or permanent 
destruction of these passages. To these may be 
added polypi and fungous tumors, so situated 
or of such magnitude as to compress the sac or 
nasal extremity of the canal, or occasion absorp- 
tion of its bony parietes ; and caries of the spon- 
gy, lacrymal, sethmoid, or maxillary bones. The 
ulcerative absorption or exfoliation of the bones 
renders the opening into the nose preternaturally 
large. But in obstinate chronic fistula?, accom- 



FACIAL APPENDAGES. 243 

panied with erysipelatous or herpetic inflam- 
mation, or ulceration of the surrounding integu- 
ment, it is not uncommon to find the bones, 
denuded of their periosteum on the orbitar side, 
still preserved by the pituitary membrane which 
remains attached to the nasal. In such cases the 
proper canal is usually obliterated. 

There is a sponge-like fungoid growth, some- 
times affecting the interior chambers of the 
face, which speedily fills and obliterates the nasal 
duct ; it is hard and brittle, much disposed to 
profuse bleeding, and very quickly regenerated 
when broken down in attempts to remove it en- 
tire. It occasions considerable deformity by 
forcibly expanding the nasal cartilages. I have 
long had a case of this description under my 
care, in a middle-aged woman. Many severe 
operations have been only available to keep it in 
check. The fungus is of five years growth. 

I have often found the canal completely 
obliterated by ossific inflammation at its upper 
orifice in skulls ; and I know cases of enlarge- 
ment of the ossa nasi, and of periosteal inflam- 
mation and thickening, marked by habitual 
overflowing of the tears and occasional ery- 
sipelatous inflammation of the surface, in which 
the canal is evidently destroyed. Malignant 
herpetic ulcers of the lupous class, not unfre- 
quently occurring at this part, expose and de- 
stroy the whole lacrymal apparatus. 

r 2 



PART III. 
TREATMENT 

OF THE 

DISEASES OF THE EYE. 



CHAPTER I. 



XT will be necessary in this department of my 
Work to refer to the states of disease described 
in the Pathology, but I shall endeavour to 
avoid repetition and to seize upon the prin- 
ciples of treatment, to the exclusion of over- 
minute practical details. The leading object 
of my undertaking I have already accomplish- 
ed, however imperfectly ; namely, the de- 
scription of the principal phenomena of dis- 
ease in the several textures of which the organ 
is composed. For the purpose of illustration 
I have unavoidably anticipated in some in- 
stances, the subject of treatment, and the re- 
marks which I have yet to offer will lie in a 
small compass ; for it would be idle to suppose 
that general principles of treatment require to 



TREATMENT OF THE DISEASES OF THE EYE. 245 

be enforced, after the nature of a disease is 
clearly pointed out. The maxims and modes 
of successful practice, so far as they are hitherto 
known, are accessible to all inquirers of ordinary 
capacity; and that man is unworthy of his profes- 
sion who seeks to mystify them, for the purpose 
of being esteemed wiser than his neighbours. The 
innumerable modifications and varieties of dis- 
ease render it impossible to lay down rules that 
admit of universal application, and the gene- 
ral intelligence of the profession in the present 
day forbids such an attempt, if it were in the 
contemplation of any individual to make it. 



SECTION I. 



SIMPLE INFLAMMATION. 



Causes. 



The causes of ophthalmia, like those 
which lead up to inflammation in other or- 
gans, refer first to the state of the system ; 
secondly, to the direct operation of external 
agents upon the organ. A person whose 
Predispos- general health is disordered, or who is re- 

ing. 

cently convalescent from some other malady, 
frequently becomes the subject of ophthalmia. 
Occasional. The extreme states and sudden changes of tem- 
perature ; the prevalence of easterly winds, of 
fog and damp, and peculiar conditions of at- 
mosphere ; exposure to draughts of cold air ; 
concentrated heat and light ; extraneous par- 
ticles, and other less obvious circumstances, 
are regarded as occasional causes. 

Whatever is the exciting cause of inflamma- 
tion of the conjunctiva, the first visible pheno- 
menon is a state of congestion, owing to an in- 
creased influx of blood into the capillaries; it 
may pass away, but the continuance and in- 
crease of this, with certain other phenomena, 



SIMPLE INFLAMMATION", 247 

determine that the act of inflammation is 
set up. 

The sensation of a foreign particle within the symptoms, 
lids, whether real or delusive, commencing with 
the state of congestion, gives occasion to a 
spasmodic contraction of the orbicularis palpe- 
brarum. A pungent pricking pain in the organ 
creates a copious secretion of tears, which col- 
lecting within the palpebral gush out at inter- 
vals, and their discharge affords a temporary 
relief. The increased temperature, volume, 
and sensibility of parts under inflammation ex- 
plain the following symptoms, viz. the sensation 
of burning heat and scalding tears, the con- 
striction or girthing of the eyelids and a sense 
of weight upon the globe ; the involuntary ex- 
clusion of air and light, and sympathetic pains 
in the region of the orbit. 

The simple inflammation of the conjunctiva. Treatment 

r . " . of simple 

i. e. an inflammation not sympathetic with in- ophthai- 
jury to the organ, nor depending upon any 
established disorder of the system, nor modified 
by a scrofulous diathesis, is easily and speedily 
reduced by the ordinary means adapted to this 
end. In its acutest form the loss of a few ounces 
of blood and some brisk doses of purgative me- 
dicine are sufficient to subdue it. Even when 
it arises from superficial injury to the cornea, if 
treated in the commencement, it is scarcely less 
manageable. 



248 SIMPLE INFLAMMATION. 

Febrile irri- It is rarely that any sensible febrile irritation 
is present in simple acute ophthalmia, but if 
there be any, and in certain irritable habits the 
constitution sympathises with the smallest local 
malady, it yields to the means above mentioned ; 
repose of the organ, soothing applications, sus- 
pension of ordinary employments, a light vege- 
table diet and diaphoretic diluents. 

Blood- In many inflammations it is unnecessary to 

draw blood; the organ recovers speedily on the 
removal of excitement, the use of soothing ap- 
plications, and the operation of cathartics. In 
some, general blood-letting is contra-indicated, 
both by -the character of the inflammation and 
the habit of the patient ; while on the other 
hand, the degree of congestion makes it desirable 
to assist the recovery of the organ by unloading 
the vessels in the vicinity. In others, a ques- 
tion may arise as to the mode of proceeding 
to be adopted, in which the patient's conve- 
nience or preference may be consulted, or a 
disposition habitual to not a few persons, to a 
troublesome erysipelatous inflammation after 
leech-bites may be admitted as an objection*; 
but there are cases in which the indication is 
peremptory, both as to the use of topical and 
general blood-letting. If it be important to 



* The swelling and discoloration which so often follow the 
application of leeches to the eyelids, especially the lower, make 
the remedy little less an evil than the disease. 



SIMPLE INFLAMMATION. 249 

make the system sustain and feel a reduction of 
power, blood must be taken by the lancet, 
either from a vein or the temporal artery. Cup- 
ping has a very decided superiority over leeches; 
both are well adapted to relieve local conges- 
tion. But these modes of depletion are obviously 
too indirect, however extensively employed, to 
be used with the first-mentioned view, as a sub- 
stitute for the lancet. Bleeding from the angular 
vein, and scarification of the conjunctiva are 
other means adopted for the relief of the turgid 
vessels. The latter practice is in most cases 
objectionable in the acute stage of inflammation ; 
in the chronic it is highly beneficial, as in the 
thickened and over-vascular state of the palpe- 
bral conjunctiva ; and a considerable discharge 
of blood may be thus obtained if it be briskly per- 
formed with a sharp lancet, the lower lid kept 
everted,and continually fomented with hot water. 

On the subject of local applications in acute Topical ap - 

^ l l plications, 

ophthalmia, there is considerable variety of 
professional opinion, but little in the evidence 
of patients. Dr. Johnson, whose opinion in 
these matters there can be no presumption in 
criticising, had a saying, " that there is little 
virtue in a lotion." In the main and speaking 
of them comparatively, if it refers as I conclude 
to medicated lotions, I am much of his opinion ; 
but warm and cold baths, whether employed for w »rmand 

1 J cold. 

a part or the whole, have very unequivocal and 



250 SIMPLE INFLAMMATION. 

sensible effects. These effects are likewise very 
different, as might be expected. Although 
the sensation of cold is most agreeable to an or- 
gan under acute inflammation at the moment of 
its application, it is generally followed by increase 
of heat and pain ; and in familiar instances, the 
pulsatile action of the vesselsleading to an inflamed 
part is so increased as to evince its stimulating 
effect, and the re-action thereby induced. When, 
however, the acuteness of inflammation has 
subsided, and the sensibility of the part is in 
proportion diminished, the effect of cold is only 
tonic, and has a salutary tendency to restore 
the balance of circulation. I therefore decidedly 
prefer as a general practice, a tepid application 
in the painfully acute stage of inflammation, and 
I appeal to general observation in proof of its 
efficacy in promoting a grateful sense of cool- 
ness, and a more permanent relief from pain. It 
is objected to as being in the common phrase, 
" relaxing," which term exactly expresses its 
recommendation at the period of which I speak. 
We see its relaxing and resolving effect in inci- 
pient acute inflammations of the skin, the lym- 
phatic glands, absorbents, &c. Moisture 
is a condition almost necessary to inflamed 
organs, and when the application is continued 
for some hours, as in poultices, it partakes so 
soon of the temperature of the surface, that this 
question is of less importance, but the indication 
is the same with very few exceptions. To con- 



SIMPLE INFLAMMATION. 251 

elude these remarks on what may be regarded 
as too trifling to excuse prolixity, I prefer tepid 
water to all applications in the painfully acute 
stage of inflammation. 

It is remarkable that even the weaker forms Anodyne 
of medicated lotions irritate, and none more 
than that which is esteemed of all the most se- 
dative, I mean opium. The relief afforded by 
anodyne fomentations in general, is very various. 
I have often known them objected to as painful, 
and patients to inquire if they might not sub- 
stitute warm water for the aqueous solution of 
opium, and infusions of poppy and hemlock. 
The same observation applies especially to pain- 
ful herpetic cutaneous affections, and acutely 
irritable ulcers. Upon these a solution of 
opium often acts as a stimulant and augments 
pain, while the lunar caustic solution as often 
assuages it. I do not deny that there are oc- 
casional exceptions to this remark. I have 
met with cases in which no other application than 
the aqueous solution of opium' could be borne. 
I have also known the vapor of laudanum afford 
the most marked relief to the characteristic 
symptom of the strumous ophthalmia, viz. irri- 
tability to light. 

Although during the state of morbidlyelevated 
sensibility accompanying the outset of acute in- 
flammation, warm applications are most soothing 

3 



252 SIMPLE INFLAMMATION. 

and therefore most eligible, the continuance of 
them beyond their necessity is a loss Of time, if 
not injurious. When the extreme vascular 
congestion and excessive sensibility are re- 
duced, and the inflammation tends to be- 
come chronic, the use of cold lotions of a 
slightly tonic quality is substituted with great 
advantage for ablutions of warm water. The 
sulphates of alum and zinc are the best. The 
smearing of the tarsal edges with cetaceous 
ointment or cold cream at bed-time is useful in 
the acute stage, and as it subsides, the tutty or 
lead or very dilute citrine ointment may be ad- 
vantageously substituted. 

edematous The cedematous elevation of the conjunctiva 

ophthalmia. ** 

is significant of a feeble action, and is by some 
regarded as erysipelatous. A more than ordi- 
nary fulness of the sclerotic conjunctiva is often 
combined with the nausea, foul tongue, and 
precordial oppression which manifest disorder 
of the stomach and liver in cutaneous erysipelas; 
and the solution of emetic tartar given at short 
intervals operates very beneficially in reducing it. 

Atonic oph- There are inflammations which assume a 

thalniia. ... 

chronic character in their commencement, evi- 
dently depending on a state of atony, of very 
partial extent, void of pain, and scarcely pos- 
sessing any sign of inflammation except the 
congestion of vessels, or if any, so feebly 



SIMPLE INFLAMMATION. 25 

marked as to encourage us to disregard them 
in treatment. In such cases a single stimulus 
will often restore the healthy action at once. 
The vinous tincture of opium has acquired a 
nostrum-like importance, from its restorative 
operation in such cases ; a virtue I believe not 
proper to it. A drop or two of the zinc or the 
lunar caustic solution, of water impregnated 
with calomel, or a minute portion of the ci- 
trine ointment, or any other stimulant in- 
troduced within the palpebral would do as 
much. Some old women use their urine with 
admirable effect in these cases. It is the cha- 
racter of the morbid action, not the applica- 
tion, that explains this sudden recovery. The 
re-excited or increased momentum of the arte- 
rial action clears the stagnant capillaries, and 
the unloaded vessels recover their tone. Such 
cases are frequently relapsing, unless means si- 
milar to those of cure are continued as prophy- 
lactics. 

In certain habits, or states of the system, whe- irritable 

l l 1 1 l • • n i °P hthal - 

ther the ophthalmia arises irom constitutional mia. 
disorder or local injury, bleeding, purging, and 
blistering, the ordinary means of arresting in- 
flammation, are employed without apparent be- 
nefit, or at least with a very disproportionate 
degree of advantage ; and if the plan is per- 
severed in, it soon becomes injurious ; the irri- 
tability by which it is marked increasing as the 



254 SIMPLE INFLAMMATION. 

strength fails. These are cases in which opium, 
if we so combine it as to countervail its ten- 
dency to check the natural secretions, has an 
admirable effect, viz. with calomel, antimony, 
or ipecacuanha. 



inflamma- In the treatment of simple acute ophthalmia 

tion threat- 



ening the the object to be kept in view is the soundness 

cornea. 

of the cornea j the organ is in no danger of 
deeper injury. The main indication for an 
activity of treatment beyond that successfully 
adopted in ordinary cases, is furnished by the 
state of this membrane. Where the sclerotic 
conjunctiva is much raised, and the surface of 
the cornea has in any degree lost its polish, 
and still more when lymph is effused in or upon 
the cornea so as to obscure vision, the anti-in- 
flammatory measures must be as vigorous and 
decided as the integrity of the organ is import- 
ant. Blood-letting and blisters, calomel, anti- 
mony, and the neutral salts comprise all the re- 
quisite means. 

chronic It is seldom that the simple inflammation 

simple in- 

flamma- becomes chronic. Blisters, and issues or se- 

tion. 

tons, the zinc and acetous acid washes, and 
tonics, especially pure air and exercise, are the 
most efficacious remedies. But the red and thick- 
ened state of the conjunctiva at the margins of 
the lids, is an occasional and not unfrequent ter- 
mination of it. Here scarification and the dilut- 



SIMPLE INFLAMMATION. 2.55 

ed mercurial ointments are employed with ob- 
vious advantage. But with some persons all 
greasy applications inflame so much as to aggra- 
vate the complaint, and in such instances mo- 
derately stimulant washes, of which a portion 
is to be admitted within the lids, may be sub- 
stituted. 



SECTION II. 



INFLAMMATION MODIFIED BY STRUMA. 

The aphthous inflammation, the inflammation 
of the follicles, and that characterized by 
intolerance of light in excess and commonly 
denominated strumous ophthalmia, are almost 
always of an atonic character ; and although 
obstinate when to a certain degree established, 
are easily subdued in the early stage, or at least 
prevented from arriving at such a height as to 
do permanent mischief to the cornea. They are, 
with very few exceptions, constitutional diseases; 
and the same remark applies to many instances 
of the mild acute suppurative ophthalmia. This 
is proved by the disorder prevailing in the sys- 
tem of nutrition, by the general debility of the 
habit, and by the concurrence of local affections 
in other parts referable to the same source. The 
habit, age, sex of the patient frequently con- 
tribute to the predisposition. The sphere and 
mode of life have also a decided influence in 
the production of these diseases. Children are 
most frequently affected by them, and those es- 



INFLAMMATION MODIFIED BY STRUMA. 

pecially subject from infancy to glandular en- 
largements, chilblains, cutaneous eruptions and 
chaps, psoriasis, tinea, and porrigo. Imperfect 
nutriment, whether from the nature or deficient 
quantity of their food or defect in their powers 
of assimilation and absorption, contributes to 
them. To this may be added an impure at- 
mosphere and want of cleanliness. The ten- 
dency to such diseases is demonstrated before 
they exist, and to prevent their recurrence is 
often more difficult than to remove them. It is 
common for a parent to say," I know what will 
remove the complaint, but I cannot prevent its 
return. " This however arises from neglecting to 
follow up the cure to its completion, and pro- 
perly to employ the interval of the attacks. 

A gentleman determined to relinquish animal 
food, and lived wholly upon vegetables and 
water. From the enjoyment of good ordinary 
health, he was in the course of six months re- 
duced to a lamentable state of disease. The 
whole mucous surface became affected succes- 
sively after a severe and obstinate attack of 
mild acute suppurative ophthalmia. His sys- 
tem was so alarmingly debilitated by the pro- 
traction of his disease, owing to the prostration of 
his restorative powers rather than to the violence 
of the morbid action, that a residence in the 
south of Europe became necessary for the final 
re-establishment of his health. The disposition 



257 



258 INFLAMMATION 

. of such a class of diseases to fasten on the organ 
when once seated, in other words, to become 
chronic, is as characteristic as their tendency to 
re-appear when for the time removed. They 
come slowly, and so depart. Violent means 
fail to cure them. They are, to the surprise of 
persons who mistake their character, unaffected 
by them ; and if such means be long persisted 
in, they are changed for the worse. If the 
remedies^-employed increase the debility of the 
system at large, it must follow that the part 
suffers, if this account of their constitutional 
origin be correct. Hence it is not uncommon for 
those who treat all inflammations alike, to ex- 
press their surprise at the obstinacy of these 
affections, after going through and through 
again the routine of an active antiphlogistic 
treatment. 

When the inflammation is of a sthenic cha- 
racter, as is more frequent where rapid changes 
are taking place upon the cornea, as a diffused 
opacity, or the formation of pustule and its 
passing into ulcer on that membrane, especially 
where the deeper-seated tunics are partaking 
by continuance of the inflammation, the ne- 
cessity of a more active practice is sufficiently 
demonstrated. But as a general observation, 
blood-letting is not salutary in these inflamma- 
tions. They are rarely attended with any very 
acute pain. Rough and depressing purgatives, 



MODIFIED BY STRUMA. 259 

either from quantity or quality, are injurious. 
Warm applications are of no advantage, if not 
injurious. Blisters on the nape of the neck and 
behind the ears, are for the most part of very . 
great utility, where the severity or permanency 
of the inflammation calls for them. "When the 
corneal surface is affected, and the sensibility is 
from this cause painfully augmented, this is es- 
pecially the case. They should in such cases, 
if required, be kept open as long as they do not 
irritate the system. Where the morbid appear- 
ances upon the cornea are notwithstanding sta- 
tionary, or slowly progressive, issues and setons 
are of great avail. 

The principle of treatment indicated in 
such cases is to lessen the irritability without 
materially depressing the power of the sys- 
tem. The selection of medicine and applica- 
tions, the regulation of diet, the degree of relief 
proper for the organ from its natural stimulus, 
when painful, must of course be determined by 
the circumstances of the case under considera- 
tion. The arrangement of the vessels at the 
verge of the cornea, and the condition of that 
membrane, are the special points for observation. 

If the cornea be opaque, calomel, or the blue 
pill, or the oxymuriate of mercury should be 
exhibited in combination with opium, slightly 
to affect the system. The efficacy of the 

s 2 



260 INFLAMMATION 

mercurial mainly depends on its combination 
with opium ; it irritates too much if administered 
alone in quantity sufficient for the purpose. 

The following may serve as a synoptical sketch 
of the treatment for each form. 

1. Strumous inflammation without change of 
texture, vascularity more or less, intolerance 
excessive. 

Calomel and opium at night ; emetic tartar 
to continued nausea ; gentle alvine evacuants; 
diaphoretic drinks; large open blister on the nape 
of the neck ; leeches ? tepid bath ? tepid or cold 
water washes,as most agreeable ; vaporof opium? 
large bonnet shade ; no bandages* ; spacious 
airy apartments and light bed cloathing. 

2. With recent diffused opacity of corneal con- 
junctiva, and vessels raised upon and oVer-shooting 

the corneal margin. 

Calomel and opium to slight ptyalism ; purga- 
tive, alternate days ; leeches ; blisters alternated 
behind the ears and on the nape of the neck and 
temples. As the acute stage passes off^ repeated 

* Close bandages I would observe are always prejudicial. 
They create a morbid sensibility where it had not before 
existed, and greatly add to it when present. 



MODIFIED BY STRUMA. 261 

circular sections of the vessels on the sclerotica 
near the margin of the cornea. 

3. With herpetic ulcers of the cornea. 

The same ; blisters on the temples ; as the in- 
flammation yields, sol. argent, nitrat. : vin. opii : 
sol. cup. sulph. : dilute zinc lotion. 

4. With pustules. 

If partial, weak zinc or alum lotion ; ung. 
hydr. nitr. ; occasional brisk purgatives ; in- 
fusion of roses with additional acid ; tonic 
bitters; calumba, gentian, &c; blisters behind 
the ears, repeated if necessary. If the vas- 
cularity is diifused by the multiplication of pus- 
tules or the duration of inflammation with 
irritability to light, treatment as in strumous in- 
flammation without breach. Ung. sub-acet. 
plumbi. ■ 

5. With iixflammation of the follicles and pu- 
riform discharged 

Active measures at first, but not long con- 
tinued. Blisters; when becoming chronic with 
thickened lids, scarifications ; zinc, alum, or 
copper wash, dilute; ung. hydr. nitr: hydr. 
nitr. oxid: sub-acet. cupri; tonics and sedatives. 
If obstinate, issue or seton. 



262 INFLAMMATION, &C. 

6. Convalescent state. 

Infusion of roses ; cascarilla ; calumba; de- 
coction of bark, with dilute sulphuric or nitric 
acid ; steel : rhubarb and soda, or magnesia, as 
aperients. Tonic colly ria and gently stimulant 
ointments ; nutritive diet ; country air j shower 
or sea bath in the warm months. 



SECTION III. 



ACUTE SUPPURATIVE INFLAMMATION OF THE 
CONJUNCTIVA. 

The suppurative inflammation is of all the most 
dangerous to the organ ; and its sequelae, even 
under a favorable termination, lingering, and 
sometimes difficult of removal. It is in its nature 
acute, but this acuteness is either mild or vehe- 
ment. The former has been confounded with the 
inflammation of the follicles with puriform dis- 
charge, known also by the name of psorophthal- 
mia, ophthalmia tarsi, mucosa, &c. I believe, as 
I have before explained*, that the diseases are 
in their seat and nature distinct, and that the 
discharge is the only symptom common to both. 
From the occasional presence of diffused vascu- 
larity of the conjunctiva with the inflammation 
of the palpebra, the misconception has probably 
arisen. The flakes of mucus lying in the pal- 
pebral sinuses are not indicative of the suppura- 
tive inflammation, for these are often seen in 
the inflammation of the follicles, where the pal- 

* See page 97. 



264 ACUTE SUPPURATIVE 

pebralconjunctivaisvery slightly affected, and the 
secretion is not that of suppurative inflammation, 
but of an irritated mucous surface. (Fluor albus 
andgonorrhcea.) Theintumescenceand elevation 
of the palpebral conjunctiva, (chemosis palpe- 
brarum,) its villosity, and the fluid and truly 
puriform nature of the secretion, are character- 
istic of the mild acute form of suppurative oph- 
thalmia, in which the conjunctiva of the globe 
is also tumid and vascular ; but I do not deny 
that under aggravation, the inflammation of the 
meibomian border and follicles may be followed 
up by the mild suppurative inflammation of the 
conjunctiva. 

In the mild form of the complaint the cornea 
is not endangered, unless the disease be neglect- 
ed or exasperated by stimulants. A very slight 
haze of the cornea is the worst direct result of 
it. There is not that excessive swelling of the 
lids, that intense pain, nor that profuse secretion, 
which characterises the vehement acute form of 
the disease ; but these symptoms exist in a de- 
gree sufficient to require immediate and active 
treatment, and to this the acuteness of the in- 
flammation speedily yields. The alum solution 
should be early substituted for the emollient fo- 
mentations, which, during the acute period, 
should be freely used ; and this should be di- 
rected in a gentle stream over the conjunc- 
tival surface, from a syringe furnished with 



INFLAMMATION OF THE CONJUNCTIVA. 26.! 

an ivory pipe, introduced at the temporal 
angle of the lids without forcibly separating 
them. Simple purging and abstinence are 
generally sufficient to allay the febrile irritation, 
which is moderate. Topical bleedings and a 
suppurating surface opened by blistering the 
back of the neck, are of great efficacy. When 
the pain and irritability to light subside, and the 
discharge becomes gleety, the conjunctiva pale 
and flaccid, tonics, especially the extract of bark 
and the acids, do great good. While we are per- 
mitted to see the cornea, and to see it clear and 
bright, for this is the index by which we are guid- 
ed, we need be under no apprehension. The ve- 
hement acute suppurative inflammation is sudden 
in itsattack, accompanied with most severe darting 
pains ; the upper lid is in a few hours prolonged 
upon the cheek, owing to the infiltration and 
enormous swelling of the tissue connecting the 
conjunctiva to the tarsus. The cornea is nearly 
concealed by the fold of conjunctiva which over- 
laps it all around, and the corneal surface is 
dusky. The system sympathises, chilliness is 
succeeded by a hot and dry skin, and the pulse 
is frequent and hard. The instant relief of a 
large venesection is indescribable. The pain is 
mitigated, if not removed; the pulse softened, 
and the patient sinks into a sound sleep, and 
perspires freely. Upon inspection we observe 
the high scarlet hue and bulk of the chemosis 
sensibly reduced, and the cornea has a brighter 
aspect. 



266 ACUTE SUPPURATIVE 

But it is rarely that a single blow suffices to 
vanquish the disease, especially where it arises, 
as is most frequently the case, from the contact 
of morbid matter. The most violent cases in my 
experience have been those produced by the 
matter of gonorrhoea applied to the eyes of which 
I have seen several unequivocal examples. With 
large blood-lettings repeated, subject to the dis- 
cretion of the practitioner, until the inflammation 
yields, a brisk catharsis should be combined, and 
this followed by a tea-spoonful of a solution of 
emetic tartar every hour, so as to keep up a state 
of nausea, perspiration, and faintness. The dis- 
charge, at first ropy, viscid, and sparing in quan- 
tity, becomes thin, gleety, and more abundant ; 
as the swollen lid subsides, the conjunctiva sinks 
and becomes pale and flabby ; and if at this pe- 
riod, the pain and febrile irritation being past, 
the cornea retains its tone and brightness, all is 
well ; the disease has given way, and a careful but 
prompt exhibition of tonics, with the use of cool- 
ing astringent lotions, will prevent its lapsing 
into a chronic form. But if, when the lowering 
practice has been pushed to the extent of arrest- 
ing acute inflammation, the patient being at 
the same time sunk and exhausted, the cornea 
shews a lacklustre and raggedness of its whole 
surface, as if shrunk by immersion in an acid, 
or a grey patch in the centre, or a line encircling 
or half encircling its base, assuming a similar 
appearance, the portion so marked out will in- 
fallibly be detached by a rapid slough, unless by a 



INFLAMMATION OF THE CONJUNCTIVA. 267 

successful rally of the patient's powers we can set 
up the adhesive action so as to preserve in situ 
that which may remain transparent. 

To know how far to go and not outstep the 
boundary ; to know when to venture upon a 
short and sudden reverse of treatment, is the 
great difficulty of this highly important case. 
It is a fatal mistake to consider the first 
change, which is a true adhesive nebula, as the 
sign of gangrene or death, and thus to temporise, 
or even under this delusion to support the 
diseased action *, Another, is to treat the 
discharge as the disease, which is in fact 
but an inconsiderable sign of it as regards its 
importance, and to stimulate by strong astrin- 
gent injections in its commencement. But the 
pathology which attributed the destruction 
of the cornea to the corroding quality of the 
matter secreted, was so lamentably erroneous, 
that we cannot be surprised at any effects, how- 
ever mischievous, which resulted from the treat- 
ment thence deduced. 

In closing my observations on the treatment 
of inflammation of this organ, I shall take the 
liberty of making one or two general remarks. 
When inflammations in their nature destructive 
are arrested by the vigor of the means employed, 

* See page 119. 



268 ACUTE SUPPURATIVE 

the system stands in great need of the power thus 
lost for its recovery; to restore parts partially in- 
jured, and to supply the place of those which are 
destroyed. We see this fact exemplified in many 
instances both of disease and injury. A patient la- 
bouringunder pneumonia is relieved by excessive 
bleedings of his attack, and dies a month after- 
wards of dropsy. A person threatened with 
apoplexy, who by the advice of his physicians 
is cupped once a month, soon falls a victim to 
erysipelas. 

If much blood is lost in severe injuries, espe- 
cially of aged people, the healing powers are 
prostrate and gangrene ensues. I mention this 
as a caution against that inconsiderate detraction 
of blood, (and it applies as forcibly to the abuse 
of mercury) which proceeds without proportion- 
ing the quantity to the absolute necessity 
of the case, and secondly, without balancing 
the effect upon the system at large against 
the importance of the organ. When I hear, 
as I often have heard, of sixty and seventy 
ounces of blood taken at one time for an oph- 
thalmia, and this followed by repeated smaller 
bleedings, I must protest against the necessity 
of such a practice, and say with Falstaff, " the 
better part of valor is discretion." 

One of the great errors, it appears to me, in 

the treatment of inflammations of the eye. 



INFLAMMATION OF THE CONJUNCTIVA. 269 

though of late years much corrected, has been 
the irritation of the inflamed organ by stimulant 
drops and ointments. The advantage of them 
is fully admitted at a proper season ; but during 
the presence of active inflammation their use is 
as revolting to common sense as it is injurious*, 
lam satisfied many eyeshave been thus destroyed. 
An anomalous species of ophthalmia, or a pseudo 
ophthalmia is produced by it, which differs as 
much from the real character of the disease in 
either of its forms, and may be as readily distin- 
guished from it, as an artificial from a natural 
flower. Thus to mention one of many cases, I 
have seen the star-like arrangement of the vessels 
around the margin of the cornea, the cornea and 
remainingportionof the conjunctiva clear,and the 
choroid and iris perfectly free from inflammation, 
the sequel of an inflammation of the follicles which 

* I have mentioned certain cases in which stimulants act 
beneficially. Even mustard has been applied to inflamed eyes, 
with some real or supposed benefit. The temporary relief 
which follows pungent applications is to be attributed to the 
copious secretion and flow of tears which they occasion, which 
is nature's own mode of relieving- the distension of the vessels, 
quickened by additional excitement. The pain of every in- 
flamed organ is augmented by the retention of its secretion, 
and in proportion relieved by its discharge. Eut the means 
employed to promote this end should not be such as are likely 
to support and increase the morbid action. Pain is only an 
effect of this morbid action, and to assuage it by measures 
calculated to perpetuate the cause, is, to say the least, a most 
unscientific method of proceeding. 



270 ACUTE SUPPURATIVE, &C. 

had been incessantly stimulated ; and I know 
cases of permanent and excessive congestion, or 
rather varices of all the veins of the conjunctiva 
with an actual discoloration of the sclerotic, 
such as would lead to the belief that the person 
laboured under confirmed organic amaurosis, 
where however the sight is perfect. Here the plan 
of irritative applications had been unremittingly 
pursued by several practitioners in succession. 
The anomaly consists in the existence of such 
appearances unallied with the states of which, 
by their habitual association, we consider 
them characteristic. An apprehension sug- 
gests itself to my mind, when I see such cases, 
that the external character may be the proto- 
type of internal disease, or at least, that the 
confirmed existence of the one may predispose 
to the production of the other. 



SECTION IV. 



SECONDARY DISEASES OF THE CONJUNCTIVA. 
The granular state of the tarsal conjunctiva is Granuiw 

, conjunc- 

a very common result of the mild suppurative tiva. 
ophthalmia. It is characterised by a gleety 
discharge, irritability to light, drooping of the 
upper lid, a pricking sensation as of sand in the 
eye, and a preternaturally irritable and vascular 
state of the sclerotic conjunctiva j with these are 
frequently combined, opacities of the cornea. 
The lid should be everted, and the projecting 
granules shaved off from the surface and orbitar 
edges of the tarsus, with a keen edged lancet, 
or if peduncular and prominent, they will be 
more conveniently snipped off with the flat scis- 
sors. In doing this, care should be taken to 
avoid injuring the continuous membrane. 

When in addition to the state above described, with vas- 

. cular cor- 

vessels are ramifying over the cornea, opacity or nea. 
its covering conjunctivabeing a contemporaneous 
result of the inflammation, or a consequence of 
the irritation excited by the granulations, a sec- 
tion of the membrane should be made at one 



272 SECONDARY DISEASES 

line's distance from the margin of the cornea. 
For this purpose, the globe should be thrown 
forward, and fixed in a state of tension by de- 
pressing the edges of the palpebrae with the fin- 
gers. The membrane yields instantly to a light 
hand, and its edges gape asunder ; in aggravated 
cases, the operation, which is painful, requires 
to be repeated, and some adroitness in exposing 
and fixing the globe is requisite to its complete 
performance. After the excision of the granu- 
lations and the division of the conjunctiva, a so- 
lution of the sulphate of copper, or some astrin- 
gent is very advantageously employed in the way 
of injection. A few drops of the liq. plumb, 
sub-acetatis, or the tinct. opii vinos, are often 
highly effective. It should be observed that the 
two states above described often exist apart, but 
the treatment adapted to them respectively is 
equally essential. The application of the blue 
stone, or of the lunar caustic, is often useful in 
preventing the regeneration of the granulations 
after their excision. 

Fungous Another consequence of the disease above 

tomTdon- described, are folds and flap-like elongations of 
crescent, tne conjunctiva filling the palpebral sinuses, and 
pannu*,&f- occasioning such a fulness of the lids as to pre- 
vent the patient from more than half opening 
the eye. Upon eversion of the lids they roll 
out upon the cornea. Another state ensuing 
upon the excessive chemosis, is a fungoid pro- 
5 



OF THE CONJUNCTIVA. 273 

trusion of the conjunctiva in a thickened and 
indurated state. The conjunctiva al"so, at the 
point of its reflection from the lid upon the 
globe, occasionally forms a tumor of considera- 
ble magnitude. I have seen it projecting from 
beneath the upper lid equal in bulk to a middle- 
sized walnut, producing great distortion and in- 
convenience, and rapidly increasing so as com- 
pletely to cover the eye. Such states more fre- 
quently result from injuries, as falls and blows. 
The treatment of all these cases consists simply 
in the excision of the tumors, which is most con- 
veniently done with a lancet shaped knife, cut- 
ting on both sides. The same may be said of 
the disease which I have denominated pannus*, 
the elongated valvula semilunaris, and the carun- 
cular excrescences which sometimes form in 
clusters between the tarsus and the globe. In the 
first named disease, a circular excision of the re- 
dundant opaque membrane should be made with 
the curved scissars at a short distance from the 
margin of the cornea, and the scissars will be 
found most convenient in the removal of 
elongations and excrescences, while such parts 
are raised by a pair of small forceps. The broad 

* This term is differently appropriated. In the disease to 
which I have applied it, the conjunctiva clothes and covers the 
cornea from that side to which the eye is directed, but it has 
no affinity to the membranous pterygium, or any form of ne- 
bulous opacity of that membrane. 

T 



274 SECONDARY DISEASES 

or ring-ended forceps are often convenient on 
these occasions. 



Pterygium The fleshy pterygium is sometimes a chronic 

and encan- * - 1 * o 

t hi£ - and even a stationary condition of disease pro- 

ducing no inconvenience, nor threatening to in- 
terfere with vision. Whenever this is the case, 
I am decidedly of opinion that it should be let 
alone. When, by its progress, it is encroaching 
upon the sight, it should be raised by dissection 
as close as possible to the margin of the cor- 
nea, and the relaxed portion of the membrane 
removed by an incision mid-way between the 
base of the pterygium and the cornea, 
and concentric to that membrane. I have 
experienced the inconvenience pointed out by 
Professor Scarpa, of carrying the excision to the 
caruncula, viz. the deposit of lymph in the site 
of the cicatrix becoming united with the carun- 
cula, and forming a hard frenuin or cord which 
prevents the abduction of the eye. I am also 
satisfied that the disease is permanently arrest- 
ed when the connection with the cornea is dis- 
severed. In this operation I prefer the cornea 
knife to the scissars. It is inadmissible to inter- 
fere with any portion of the pterygium that may 
have encroached upon the cornea. It may be 
necessary to repress the tendency to reproduc- 
tion by the application of the caustic pencil to 
the section of the tumor ; but the frequent or 
diffused application of escharotics is objection- 



OF THE CONJUNCTIVA. 27» 

able, as a morbidly thickened and tubercular state 
of the membrane is the consequence of the irri- 
tation thus excited. The treatment of the mem- 
branous pterygium consists in nipping up a 
crescentic portion of the opaque membrane as 
near as convenient to the cornea, and freely ex- 
cising it with a pair of curved scissars. The 
extremities of the line of excision both in this 
and the former species should extend beyond the 
diseased part. 

The encanthis, when it attains any consider- 
able bulk, becomes condensed with the valvula 
semilunaris, and presents appendices correspond- 
ing to the cornua of this fold. The treatment 
consists in simple excision. 

The membranous bands connecting the lid Ffena « 
to the globe should be divided, with the precau- 
tion to avoid wounding the palpebral conjunc- 
tiva. No bandage should be employed, and 
during the day the patient should not be suf- 
fered to keep the eyelids closed. In my ex- 
perience, escharotics only exasperate the 
evil. 

Tumors upon the globe, unconnected with Tumors, 
the palpebra, should be dissected from the scle- 
rotica j and this is the more important, in propor- 
tion as they are seated near to the cornea. 
Where the tumor is tied by angular folds to the 



276 SECONDARY DISEASES OF THE CONJUNCTIVA. 

eyelid, considerable attention is necessary to 
prevent the adhesion of the conjunctival sur- 
faces during the stage of healing, as in the case 
of frena. The best mode of preventing the ap- 
proximation of the opposed surfaces, is to pro- 
duce a partial eversion of the lower lid, by a 
strip of plaster carried from its margin in an 
oblique direction across the cheek, and fre- 
quently renewed. 



TREATMENT 

OF THE 

DISEASES OF THE EYE. 



CHAPTER II. 



SECTION I. 



DISEASES OF THE CORNEA. 

J_ HE term, inflammation of the cornea, must 
be understood as applied to the compound tex- 
ture so denominated, and not to the lamellae of 
horny substance which has no vessels proper to 
itself, but derives them from the covering and 
connecting cellular tissue. These vessels nou- 
rish and preserve it in the condition essential 
to its economy. The crystalline humor is a 
simpler texture, being wholly dependent on its 
capsule — as the nails, like the horse's hoof, are 
sustained by the lamellae of the cutis in which 
they are implanted — or the hair, by the bulb 
alone to which it is attached. It is rarely that 
red vessels are seen in the interlamellar texture 
of the cornea. Deposits of adhesive matter and 



278 DISEASES OF THE CORNEA. 

of pus are frequent ; the former most so ; those 
of blood are rare, being only a result of severe 
injury, superadded to a state of inflammation. 
The cornea is rendered turbid by a congestion 
in the vessels of its covering or connecting tex- 
ture ; and in this, and the case of interstitial in- 
flammatory secretions, may, if in any, be said 
to be inflamed. But its subserviency in these 
processes to the conjunctiva and sclerotica, make 
the strict propriety of the term questionable, as 
applied to the corneal lamella. It would be as 
incorrect to speak of an inflamed crystalline, 
hair, or nail. 

Nebula and It is only necessary to observe, that the prac- 
tice employed to reduce inflammation, is then 
most strongly indicated when the cornea is ren- 
dered opaque, or presents an onyx of adhesive 
matter. 

superficial The superficial ulcer is commonly attended 
ulcer. with much inflammation of the conjunctiva, and 
by continuance, of the sclerotica. The eye is 
very irritable to light, and the sensation of a fo- 
reign particle in the motions of the lids acutely 
painful. The pain is often spasmodic and re- 
lieved by profuse lacrymation at intervals. Opium 
should be so combined as to operate on the skin, 
and the bowels must be kept freely open. 

Touching the ulcer with the solution of the 



DISEASES OF THE CORNEA. 279 

argentum nitratum is the best local treatment, 
much superior, as an anodyne, to sedative lotions. 
Warm fomentations afford temporary relief. It 
will be found advantageous, if not indispensable 
to prevent relapse, to affect the system with 
mercury where the inflammation of the sclerotica 
is intense. The cicatrix being confined to the 
superficial lamella? is of very inconsiderable den- 
sity, so as in time to be scarcely perceptible, and 
in children to wear quite away. 

The indolent and the deep sloughing ulcer indolent 
maybe touched once oroftener with the caustic Soughing 
pencil, or washed once a day, or oftener, with 
the solution. The cleansing of the ulcer and 
the opaque adhesive circle is the sign for a less 
frequent use of it, and the deposition of new mat- 
ter, undergoing a vascular organization, renders 
its further use hazardous. The occasional use 
of leeches is often a necessary accompaniment 
to this treatment. The administration of tonics 
and sedatives is at the same time essential. 

The acute interstitial ulcer cannot be treated Acute . in - 

terj-titial 

distinctly from the adhesive inflammation ; it is ulcer - 
a sign only of the inflammation which consti- 
tutes the disease. In proportion as this is re- 
duced its disposition to extend is checked, or 
we are enabled to employ auxiliaries to that end. 
But in favorable circumstances of constitution 
they are not wanted. Healing is a spontaneous 



280 DISEASES OF THE CORNEA. 

action, vicarious with destruction, and com- 
mences on the arrest of inflammation. 

Abscess. A large collection of matter in the cornea, 

whether the puriform onyx, or central abscess, 
requires, at the same time, a supporting consti- 
tutional treatment, mild cathartics, and the ap- 
plication of blisters ; calomel should be avoided, 
as in most instances where ulceration is present. 
The puncture of the cornea is seldom practised 
with advantage. By the means above named, 
I have seen large effusions absorbed, and no 
trace left of their existence. 

Hypopion. When the hypopion is so large as to rise 
toward the pupil, and the ulceration of the 
cornea is extending, I think its discharge by 
section near its margin, advisable. If not too 
long delayed, the ulcerative process is checked 
by it, which would otherwise run into sloughing, 
and the cornea recovers with only partial opacity 
and disfigurement. 

Procidentia The prolapsus iridis from ulcer should, if small, 
be touched with the caustic pencil, ground to 
a fine point. If large and extending, it should 
be snipped off with a pair of curved scissars, and 
the caustic pencil immediately applied to the cut 
surface and margin of the ulcer. In this way I 
have seen many cases recover with good though 
abridged vision. This circumstance depends on 



iridis 



DISEASES OF THE CORNEA. 281 

the site of the ulcer and the relation of the pro- 
lapsed portion of the iris to the pupil. The same 
treatment is best adapted to prolapsus from 
wound, as after extraction. The inflammation 
accompanying these states requires the occasional 
application of leeches, gentle purgatives, seda- 
tives, light tonics, and mild nutritive diet. 



nic i 
terstitial 



The chronic interstitial ulcer requires only sti- chro 

. , tersti 

mulant and astringent injections. Blisters in the ulcer 
neighbourhood of the eye, bark and opium, pure 
air and good diet, with a due attention to the se- 
cretions. Rhubarb and aloe are the best aperients. 

The opacities in their nature removable, are Opacities. 
the nebulous, which depend on a loss of trans- 
parency from recent inflammation, or recent in- 
terstitial deposition without breach of texture. 
Cicatrices are only so far benefitted as the sur- 
rounding deposit is of this description, and sus- 
ceptible of absorption. The actually changed 
texture of the entire cornea depending on an 
obliteration of the interstitial texture, like the 
cicatrix itself, undergoes no change from the 
use of stimulant applications. The most ef- 
fective injections are the lunar caustic and the 
oxymuriate of mercury, one to two grains to one 
ounce of water; the former may be used in the de- 
cline of the inflammation ; the latter, not until 
after its disappearance. Levigated glass, calomel, 



282 DISEASES OF THE CORNEA. 

loaf-sugar, are by somecoarse practitioners blown 
into the eye for this purpose. The principle 
of their operation is the same. In the use of 
applications to remove opacities, the points of 
importance to be determined are the time and the 
frequency of their use. They are mischievous 
when inflammation is excited or increased by 
them ; their effects as excitants should be tem- 
porary. The mercurial ointments are less ef- 
fective, in my experience, than the injections. 
Where the internal use of mercury is indicated 
by the character and duration of the inflamma- 
tion which has given rise to opacity, its effect 
upon the latter is more marked than that of any 
local remedy. 

strumous Under the head of strumous nebula with vessels 

nebula of 

*he cornea, overshooting the cornea, I have advised ptyalism, 
upon the strength of several decided proofs of its 
efficacy ; but no form of recent opacity is so in- 
tractable ; and I should be uncandid not to 
state that I have seen it increased from day to 
day under the mercurial action. The vessels 
which shoot in radii upon the cornea and at 
length meet in the centre of the membrane, if 
the disease is unchecked, are situated beneath 
the conjunctiva and belong to the sclerotica, as 
may be easily ascertained by close inspection ; 
and the uncontroulable nature of sclerotic in- 
flammation, of which I shall speak presently, 



DISEASES OF THE CORNEA. 283 

is well known to those who have seen much of 
it. The deposition is interstitial. The hydr. 
c creta, or the oxymuriate, in small but frequent 
doses, will sometimes succeed better in this case 
than the other forms of mercury ; and the com- 
bination of calomel with antimony, better than 
that with opium. 

In constitutions which discover an insuscep- 
tibility to be affected by the mercurial pill, or 
in which its exhibition in sufficient doses is at- 
tended with griping pain and diarrhoea, friction 
should be employed ; and indeed in all cases in 
which the saving of time and strength is pecu- 
liarly an object, this is the more certain and ef- 
ficacious proceeding. I know that the preju- 
dice often existing against the use of the 
remedy in any shape, is most strongly opposed 
to this, its best form. But among persons 
otherwise intelligent, such a prejudice soon 
gives way to the more rational feeling of confi- 
dence in the practitioner. It is necessary, how- 
ever, that he should support this feeling by a 
proper confidence in himself— -by a steady per- 
severance in his design : having, therefore, upon 
mature deliberation decided, that the mercurial 
action should be set up, nothing but the clearest 
demonstration of the patient's inability to sup- 
port it, should interfere with the full and fan- 
execution of the plan. A character notoriously 
abused by indiscriminate excess, is in much 



284 DISEASES OF THE CORNEA. 

danger of being further injured by half mea- 
sures. This I think has been the case of mer- 
cury. It is not the most delicate frame which 
is most ready to admit or least able to sup- 
port it ; and it is not the quantity consumed, 
but the quantity absorbed, which is to be taken 
into account by the practitioner. The progress 
of disease during its exhibition is no argument 
against its continued employment ; in this view, 
unless the system be fairly under its influence, 
all that has been given goes for nothing ; nay, I 
have had occasion to see many cases in which, 
after all the signs of absorption were manifest, 
its operation upon the disease was for a time 
unobserved, or was null, and was yet ultimately 
all that could be wished. I venture upon these 
remarks from having myself felt " afraid to go 
forward lest I should go wrong," in some very 
obstinate cases of strumous nebula in young 
and very delicate subjects, the issue of which 
gave me no reason to regret that my confidence 
had triumphed over my fears. And therefore 
the stationary condition, nay, the natural pro- 
gress of a disease during the period occupied 
by the introduction of mercury, or even after 
its introduction, for a time to be limited, would 
not deter me from prosecuting it in a case 
wherein I placed my dependence upon its 
power j but an alarming degree of arterial ex- 
citement, or certain morbid appearances of the 
organ, not looked for in the natural and ordi- 



DISEASES OF THE CORNEA. 285 

nary course of the disease, would, as a matter 
of course, determine me to withhold it. These 
remarks are not confined to the case under no- 
tice ; they are of general application. 

I shall take this opportunity of briefly ad- 
verting to another point of the treatment of 
this case, of some importance. I have spoken 
of the division of the conjunctival vessels on the 
decline of the inflammation : let me be under- 
stood to imply that this operation is injurious 
during the acute stage of the disease, and that 
its effect upon the vessels, by which the nebula 
is secreted and maintained, is from their situa- 
tion indirect ; so that it stands upon the same 
ground as scarification, and no other. 

The staphyloma, if purely corneal, and of such staphy- 

loina. 

size as to occasion deformity, and expose the 
organ to farther injury, or if producing habitual 
irritation and inflammation of the tarsal borders, 
should be excised j the ligature passed through 
and including two-thirds of the diseased cornea, 
by means of a curved needle, assists the opera- 
tor, by steadying the globe. If the staphyloma 
is from dilatation, the iris will be left ; if from 
breach, it is compacted, and removed with the 
cornea. This circumstance makes no material 
difference in the healing, unless the section be 
made much posterior to the ciliary ring, when 
the globe collapses from the escape of the vi- 

7 



286 DISEASES OE THE CORNEA. 

treous humor ; which is not the case when the 
section is at the base of the cornea, although 
the iris should be included in it, for the vitreous 
humor is in a considerable degree sunk by ab- 
sorption in the staphyloma, and the aqueous as 
much superabundant. A flat double-edged knife 
is the most convenient instrument for a circum- 
cision of two-thirds of the staphyloma, which is 
executed in its passage across the globe j the 
remaining portion may be finished by one 
stroke of the scissars. A compress of soft linen 
should be laid upon the closed lids, and retained 
by a roller. Where the staphyloma is partial 
and conical, the section is corneal, and its 
edges .should be touched with the argentum 
nitratum to prevent a corneal fistula. But 
when, as in many cases, the protrusion is not 
such as to prevent the easy motion of the lids, 
or occasion inconvenience, it should be left, 
screened or not, at the option of the patient. No 
benefit results from tapping the globe of the 
aqueous humor, either in this case or in the hy- 
drops oculi. 

Fungous tumors of the cornea must be treated 
as the staphyloma. They are of very rare oc- 
currence. 



tornea. 



Conical The discharge of the aqueous humor is equally 

useless in this case, and so are all applications to 
arrest the disease. I have found repeated blisters, 



DISEASES OF THE CORNEA. 287 

and the more powerful tonics, as steel or arsenic, 
decidedly serviceable. To these may be added, 
cold bathing, and the practice of often opening 
the eyes in cold spring water. I am unable to say, 
whether a section of the cornea, as in extraction, 
would be productive of benefit. It has occurred 
to me as not improbable. The disease, however, 
is constitutional, and must be so treated. The 
tubular spectacle frame with a pupillar aperture, 
I have found to afford more aid in correcting 
the vision, than any form of lens. 



SECTION II. 



SCLEROTITIS, CHOROIDITIS, AND IRITIS. 

The signs of inflammation extending to the 
sclerotica have been described. It is seldom 
if ever, the cornea being the seat of diseased 
actions, that the sclerotica does not participate. 
Inflammation cannot pass from the surface of 
the eye to the interior tunics, without involving 
this membrane, and the impediment which is 
happily opposed to its progress, the slowness 
with which it is in consequence propagated, is 
accounted for by the texture and properties of 
the sclerotica, and the minuteness of the vas- 
cular communication through its medium be- 
tween the conjunctiva and the choroid. The 
structure and properties of the sclerotica also 
explain why the primary sclerotitis is a rare dis- 
ease. In the commencement of this disease, 
the cornea is slightly, if at all clouded, and the 
activity of the iris but little impaired. An ob- 
tuse pain in the eyeball is materially relieved by 
blood-letting, and by antimony and ipecacuanha 
with opiates. It is by no means so decidedly in- 
fluenced by mercury as the iritis, and its obsti- 



SCLEROTITIS, CHOROIDITIS, AND IRITIS* 289 

nacy and disposition to relapse, render the 
case often difficult of treatment. The sub- 
ject of it is usually reduced and irritable in 
a high degree, from suffering with rheumatic 
inflammation in the elbow, knee, or ancle-joints. 
I have generally observed that the previous use 
of mercury has more or less contributed to this 
state. I have also noticed the frequent accom- 
paniment of gonorrheal inflammation with this 
disease, or its existence a short time previous. 
Though it is necessary to use mercury with 
more reserve than in other forms of in- 
flammation, to suspend its operation at inter- 
vals, and allow the system to recover from its 
immediate effects, yet its exhibition will be 
found, in the majority of cases, indispensable. 
The rude and profuse employment of it hurries 
on the disease, and the extension of the inflam- 
mation to the interior tunics ultimately destroys 
the organ. The nitric' acid may often be exhi- 
bited with marked benefit, in the intervals of 
the mercurial action. 

The oxymuriate in doses of one-twelfth to 
one-eighth of a grain, or the hydr. c creta, five 
grains to ten, twice or thrice a day, are most 
available and beneficial forms of the remedy in 
these cases. As auxiliaries, soothing and allay- 
ing irritation, I should mention the Dover's pow- 
der, hemlock, and hyoscyamus,and the extract of 
sarsaparilla, either dissolved in the decoction, 



290 SCLEROTITIS, CHOROIDITIS, AND IRITIS. 

or taken freely in the solid form. I have seen 
an obstinate chronic inflammation yield before 
these latter remedies, in which mercury had 
been productive of no benefit. In the motley 
diseases now known by the cant term of pseudo- 
syphilis, their efficacy is admitted by the most 
competent authorities. 

On the treatment of deep-seated inflamma- 
tion, whether affecting the choroid or iris, I 
shall not now dwell, having in an Essay on this 
subject, published three years ago, pretty fully 
stated my opinion ; and when treating of the 
signs of these diseases in the present volume, 
having repeated my conviction of the remark- 
able efficacy of mercury, and of the compara- 
tive insignificance of every other remedy. One 
full blood-letting or more should be premised in 
the acute stage of the disease ; and topical 
blood-lettings during the exhibition of it, are 
generally required at short intervals. I have now 
and then found that the incipient inflammation, 
where it has extended from the conjunctiva, 
yields to a copious venesection and two or three 
brisk doses of calomel and rhubarb, followed 
up by the infusion of senna ; but, generally 
speaking, the system must be made to feel the 
influence of mercury before the disease is per- 
manently subdued. The inflammation which 
has proceeded to the effusion of adhesive mat- 
ter, never, in my experience, yields either to 

7 



SCLEROTITIS, CHOROIDITIS, AND IRITIS. 291 

the lancet, continued nausea, or full purging j 
and it is remarkable that the cases presenting 
this termination of inflammation are always most 
sensibly and immediately benefited by the re- 
medy in question, whether the cornea or the 
iris be affected, or any other texture of the body. 

That in many instances, however, the depo- 
sition takes place notwithstanding, or immedi- 
ately succeeding to the action of mercury, and 
is most prone to do so, (I do not say from 
that cause) I am as sure as that it sel- 
dom fails to yield to its continuance or re- 
newal. But when the mercury arrests inflam- 
mation previous to this event of it, there is. rea- 
son to infer that it prevents such termination, 
and its less rapid and decided influence under 
these circumstances, is not a reason why, if the 
inflammation resists the ordinary antiphlogistic 
measures, it should not be employed. I be- 
lieve that the mode of action of the remedy 
varies according to the degree of its influence, 
which again varies according to the habit of 
the patient, the form or stage of the disease, 
and the quantity of the remedy which is 
received into the system. But if any two 
facts are well established in modern medicine, 
I apprehend they are these : — first, the power of 
mercury to arrest acute membranous inflamma- 
tion, both prior to, and after the effusion of ad- 
hesive matter $ and secondly its power rapidly 

u 2 



292 SCLEROTITIS, CHOROIDITIS, AND IRITIS. 

to remove, by an excitement of the absorbing 
system peculiar to itself, the newly effused ad- 
hesive matter. If these facts are admitted, 
then the propriety of its use is indicated in 
iritis, as in carditis, pleuritis, peritonitis, and 
the only practical question that can arise respect- 
ing it is, how far the patient's strength is equal to 
support the remedy. There are, I admit, states 
of the organ as well as of the constitution 
in which it cannot be borne, and no sooner is 
its influence felt, than the inflammation threatens 
disorganization, and if the plan is persevered in, 
quickly runs on to it. The globe becomes enlarged 
or misshapen, the sclerotica assumes a livid hue, 
and the veins a state of varicose congestion ; 
sometimes the eyeball suppurates, and the little 
remaining vision is completely extinguished. 
In cases where age, or the existence of other 
diseases, or the already excessive use of mer- 
cury, has greatly enfeebled the powers of the 
system, it must be used, if ventured upon at all, 
very sparingly, or with intermissions, and the 
system must be supported by every admissible 
means, both of nourishment and medicine, dur- 
ing its employment. 



SECTION III. 



AMAUROSIS. 



The term amaurosis comprehends all those 
imperfections of vision which depend upon a 
morbid condition, whether affecting structure 
or function, of the sentient apparatus proper to 
this organ. That the term is not so defined ac- 
cording to its etymological import is well known, 
but it is thus employed by pathologists, if I have 
rightly understood its meaning. 

The diseases of the other coats and humors of organic 

amaurosis 

the eye which are present in a considerable num- byinflam- 
ber of these cases, are effects of an inflammation 
which has destroyed the retina. Such are es- 
pecially, discoloration and absorption of the 
vitreous humor, or a bright yellow opacity of 
the crystalline lens, which is indurated — its cap- 
sule condensed with it, and firmly adhering to 
the constricted and perhaps irregular pupil, with 
peduncles of lymph or detached flakes of the 
black pigment projecting from its posterior bor- 
der — or a capsule containing calcareous concre- 
tions with an absorbed lens, and a concave and 
tremulous iris, or an obliterated pupil, or a sta- 
phyloma of the sclerotica or choroid. 



294 

By a 

change of 
texture in- 
dependent 
of inflam- 
mation. 



Functional 
amaurosis. 



AMAUROSIS. 

But there are cases in which a change in the 
structure of the retina is to be inferred, of a 
description less conspicuous indeed, but not less 
fatal to vision. This is the result of a slow and 
insidious morbid action, and although sometimes 
accompanied with superficial inflammation, is 
more frequently altogether independent of in- 
flammation. The congestion of the superficial 
vessels, the extenuation and blue tint of the scle- 
rotica, the appearances supposed to indicate a 
caligo of the vitreous humor, or an opacity of 
the retina, or a deficiency of the pigmentum, 
seen upon looking towards the fundus of the eye, 
are the signs of this change. 

When the eyeball has the appearance of 
health, and the loss of vivacity in the mo- 
tions of the pupil is the only sign of an amauro- 
sis obtained from inspection of the organ, we 
are scarcely warranted to suppose any disease of 
structure. I have called such cases functional, 
and my object in doing so is to discriminate them 
from the organic, in the belief that much prac- 
tical advantage may be gained from the dis- 
tinction. Diagnosis is a study interesting in 
a scientific view, but it is awfully important 
as it affects practice and character. An amau- 
rosis depending on a change of structure in the 
brain or eyeball, is an irremediable case. The 
same may too often be said of that which pre- 
sents no evidence of structural disease, of which 



AMAUROSIS. 295 

I shall presently mention examples. It is cre- 
ditable to a practitioner to know such cases ; 
and if his ingenuousness is equal to his know- 
ledge, he will be a gainer in reputation in every 
way. 

Functional amaurosis I have arranged under 
three heads : the symptomatic, the metastatic, 
and the proper. The first includes a class of 
diseases so large and diversified, that to consider 
them and the rationale of their treatment in de- 
tail, would occupy a volume. Suffice it there- 
fore to say, that the amaurosis being subservient 
to the disease which affects the system at large, 
or some one important organ, the latter is the 
proper object of medical treatment. I may 
instance the morbid states and actions of the 
vascular system, the disorder of the digestive 
organs in its several degrees from impaired ap- 
petite to confirmed hypochondriasis, the inter- 
ruption to the healthy functions of the uterus, 
the excess, or deficiency, or accumulation of the 
wonted secretions and excretions, the presence 
of local irritation, as wounds and abscesses, 
caries, worms, &c, and the influence of strong 
mental emotion producing a morbid irrita- 
bility. These co-existing with an amaurosis 
must be regarded as the original and substan- 
tive disease, the removal of which is the 
aim and end of treatment. It must be 
obvious that it is rather the degree, than the na- 



296 AMAUROSIS. 

ture and origin of the functional disease, that 
should in most cases influence our prognosis, 
yet the latter circumstances, it is equally clear, 
afford more or less encouragement in propor- 
tion as the pre-existing states of disease ordi- 
narily admit of relief or otherwise. Thus, for 
the sake of illustration, I may observe, that the 
amaurosis from gastric diseases, from plethora, 
from irritation, are all of them relievable, and, if 
treated at an early period, remediable. Whereas 
paralysis, the sequel of fever or of epilepsy*, or 
severe constitutional diseases, whether acute or 
chronic, or depending upon habitual cerebral 
congestion combined with organic visceral 
disease, or induced by the operation of noxious 
agents on the system, is a hopeless form of the 
malady. It resembles in appearance and cha- 
racter the ordinary gutta serena, or idiopathic 
palsy of the retina, which occurs in early as 
often as in advanced life, in which excepting 
the gaping and motionless pupil, and the ab- 
sence of physionomical expression, no defect ap- 
pears ; on the contrary, the fine, large, well 
opened, and singularly brilliant eye, often ex- 
cites admiration of its beauty as an organ, 
though uniilumined by the mind. 

* I know a family of several well-formed children, three of 
whom have dark hair and eyes, the others light hair and hlue 
eyes. Towards puberty, all the dark haired children have 
become epileptics, and gradually lost their sight; ihe eyes, 
except in the expansion and immobility of the pupils, retaining 
every appearance of health. 



AMAUROSIS. 297 

The metastatic amaurosis is rare but well de- 
fined. The restoration of the original malady, 
if it be practicable without involving the pa- 
tient's safety, or the substitution of an artificial 
excitement or discharge, which may serve as an 
equivalent, appears to be the natural indication, 
and such a practice has been attended with suc- 
cess*. But the prognosis is necessarily one 
of great uncertainty. 

The proper functional amaurosis presents 
great variety ; but if treated at an early period 
is very often cured. The extreme states of light 
and temperature, and the over-exertion of the 
organ, are the chief causes of it. The remission 
or removal of these hurtful circumstances even 
of itself does much towards the cure. The con- 
tinuance of them frustrates the end of treatment, 
and the amaurosis becomes confirmed, and ulti- 
mately passes into the organic form. The 
emeralopiat, and many other cases not assum- 

* See a remarkable case of " Amaurosis from suppressed 
purulent discharge," successfully treated by Professor Beer, 
in the " Analecta" of the " Quarterly Journal of Foreign 
Medicine and Surgery, No. IV." 

Although the metastasis of gout, of which I have known 
two marked instances, has been fatal to vision ; yet in three 
cases, in which I extracted the cataract from gouty subjects, 
and a smart attack of the disease followed the operation, the 
eyes were unaffected, and the sight was well recovered. 

-}• See an excellent paper on this disease as it affects seamen 
in tropical climates, by Mr. R. W. Bampfield, Surgeon of 
the Royal Navy, in the 5th Vol. of the Medico-Chirurg,ical 
Transactions. 



298 AMAUROSIS. 

ing this precise character, are essentially depend- 
ing on the injurious influence of the extremes 
of temperature, and light, and intense colors. 
I call to mind several cases distinctly referable to 
each of the above-named causes. During the 
correction of this sheet I have been consulted 
for an amaurosis immediately succeeding to ex- 
posure, during several hours, to cold and inces- 
sant rain ; and which I have the pleasure to say 
is advancing towards recovery. I have exem- 
plified the treatment of these cases in the pa- 
thology*; if active measures are taken without 
delay they generally warrant a favorable prog- 
nosis, but only on this condition. 

The functional amaurosis varies in its rate of 
progress as well as in its ultimate extent. Some 
are sudden in their accession and perfect, as 
many instances of the metastatic and the proper ; 
others advance steadily but sensibly to a point 
little short of blindness, at which they begin 
to assume an organic character ; and of others 
again the actual progress is scarcely perceptible 
for months in succession, fluctuating from day 
to day between better and worse. I should say 
that the slow and the steadily progressive amau- 
rosis are more to be apprehended in the result, 
that is, are less tractable than either the sudden 
or the rapidly advancing disease, supposing all 
to be alike free from the unequivocal signs of 



organic change. 



* Page 170 $ seq. 



AMAUROSIS. 299 

The removal of an irritating or oppressing 
cause will often effect a sudden and marked relief, 
as by clearing the intestinal canal of vitiated 
secretions therein accumulated, by restoring 
the digestive functions labouring under manifest 
derangement, or by taking away blood where 
the necessity is indicated. I have seen an in- 
cipient amaurosis distinctly arrested by the ex- 
traction of a diseased tooth, when the delay of 
a similar operation had occasioned gutta serena 
on the opposite side two years before. 

The floating muscre, when the disease is once 
established, are seldom if ever removed, yet pa- 
tients retain good sight who have been troubled 
with them during half their lives. When the 
mind becomes indifferent about them, they are 
no longer observed, except in states of anxiety, 
irritation, or bodily weakness; and the subjects 
of them are usually aware of this fact. 

It appears then upon this representation that 
certain cases purely functional, whether the af- 
fection originates in the organ, or in a remote 
part of the system, are, in their character, so 
nearly approaching to the organic class, as at 
once to convey the impression of their irreme- 
diable nature. In common with these they 
have many symptoms, hence the difficulty of di- 
agnosis; and some of them quickly tend to 
altered structure, although the external signs of 



300 AMAUROSIS. 

this change are faintly indicated. On the other 
hand, cases are of frequent occurrence, more 
frequent than has been generally supposed, 
which admit of material and decided improve- 
ment and even of complete recovery ; and I 
would repeat, with the exception of those above 
adverted to, that it is rather the degree than 
the nature and origin of the functional disease 
that should influence our prognosis. 

External The treatment of amaurosis is almost exclu- 

remedies. . . 

sively constitutional. To the various forms of 
external remedies, such as stimulant vapors, 
drops, and ointments j spirituous, ethereal, and 
aromatic embrocations ; sternutatories, &c. &c. 
my experience leads me to attach no value. 
The faith yielded to such applications is a relic 
of the not very remote superstition, which as- 
cribed miraculous powers to the hand of a living 
king, or a dead culprit. Ophthalmic surgery 
has been more degraded by manual officious- 
ness, and the confidence placed in externals 
has been more injurious to its improvement, 
than to that of any other branch of the profes- 
sion. It is fortunately not now-a-days necessary 
to do something when nothing can avail. I 
am quite aware that the transient effect of sti- 
muli is in many of these cases grateful, and 
seems partially to remove the obscurity of 
vision, but the patient soon discovers that this 
is but a fillip. When, indeed, a disordered 



AMAUROSIS. 301 

state of the conjunctiva and eyelids exists in 
conjunction with an imperfect amaurosis, a 
more permanent benefit is often obtained by the 
rectification of this state, sufficient not only 
to afford encouragement in the use of topical 
remedies, but to induce a belief that the 
affection of the retina is, in a degree at least, 
sympathetic with that of the surface *. I should 
make a reserve of cupping, issues, or setons, in 
certain cases which it is unnecessary to specify, 
and of blisters in almost all. These, if managed Blisters. 
as the case directs, are a remedy of great value. 
In some, as temporary irritants only ; in others, 
as irritants and drains. With the former view 
either the vesicle should be preserved by simply 
puncturing it, or the cuticle should be removed 
on dressing the blister, and the simple ointment 
applied. The process should be frequently re- 
peated, and alternately over the superciliary 
ridge, upon the temple, upon the mastoid pro- 
cess, or the nape of the neck, as most eligible. 
Or if a more extended surface of irritation is de- 
sired in the immediate vicinity of the eye, the 
blister should take the shape of a chemist's re- 
tort, reaching from the zygoma to the glabella. 
It should be borne in mind, that the operation 
of blisters is very different in different indivi- 
duals, as regards their susceptibility. The irri- 

* See page 1G1. 



302 AMAUROSIS. 

tation and discharge of an efficient blister, as 
big as a crown, will sink the powers of a delicate 
female for days, and this effect will be especially 
felt in a weak retina. I have often known the 
obscurity of vision decidedly increased for a 
time by the application. Such cases are yet 
more affected by the direct loss of blood, even 
in the smallest quantity, and the permanent 
blister would be injurious. How is it that 
a blister is as useful in a proper nervous 
or paralytic amaurosis, as in one depending 
upon the congestion of the blood-vessels ? I 
have been asked this question by intelligent per- 
sons. The fact is unquestionable, and the answer 
obvious, that a simple and temporary irritation is 
the object in one case, and a permanent irritation 
and derivation of blood in the other; and the blis- 
ter is tobe managed accordingly. Hence in a very 
susceptible subject, or a very irritable skin, a mus- 
tard plaster applied for ten minutes, and repeat- 
ed now and then, may answer the first purpose 
more conveniently. It is in this particular view 
that the moxa is used in this and other diseases 
with so much advantage on the Continent. The 
eschar, if left to itself and not converted into an 
issue, is superficial, but the irritation is of the 
severest kind. 

Electricity. I have heard and read of the effects of elec- 
tricity and galvanism in amaurosis. Some 
narrators of their occasional efncacv are un- 



AMAUROSIS. 303 

doubtedly entitled to credit. I have had re- 
course to them in many cases, some of a very 
favorable description, but have never witnessed 
a single instance of benefit arising from the ap- 
plication of these powers. 

The degree of constitutional power which General 

treatment. 

enters into the disease forms the first and most 
important question in the general treatment. 
Extremes, it is said, meet, and it is certain 
that a strong and delusive similarity often pre- 
vails between the signs of diseases, which re- 
sult from conditions diametrically opposite. 
The treatment in cases of general plethora 
and of cerebral compression I need not point 
out. But I have mentioned cases of undue 
determination of blood to the organ, which 
are especially common after deep-seated chro- 
nic inflammation, or distress from over-ex- 
citement, by which its vessels have lost their 
tone ; an effect decidedly increased by deple- 
tion. Such cases are not difficult of discri- 
mination from the former, if a due attention is 
given to the history. 

All the cases of direct debility and proper para- 
lysis of the retina are aggravated by loss of blood, 
and the great prevailing mistake in the treat- 
ment of amaurosis is the indiscriminate detrac- 
tion of blood. The same observation, it appears 
to me, applies to the treatment of cases of ge- 



304 AMAUROSIS. 

neral palsy. The practical idea of compres- 
sion derived from the demonstrated instance 
of apoplexy, prevails over and puts aside the 
theoretic idea, derived from the admitted con- 
dition of nervous debility or exhaustion. 

I have never known any real benefit derived 
from what are called antispasmodic and anti- 
nervous medicines, camphor, assafoetida, vale- 
rian, &c. Neither do I recollect an instance of 
decided benefit from the emetic practice, al- 
though in respect to its high authority, I have 
tried it fairly in many instances. The cases of 
gastric disorder to which it is especially appli- 
cable are most benefited by a long continued 
course of the blue pill, with gentle saline pur- 
gatives and tonic bitters. 

In most of these cases we must depend, first, on 
the regulation of the visceral functions ; and se- 
condly, on the employment of such restoratives as 
the system requires and can bear. The blue 
pill, with colocynth, rhubarb, or aloes, and the 
combination of soda with rhubarb and Colombo 
s or gentian, are best adapted to the former pur- 
pose. The exhibition of general tonics is often 
strongly indicated, and I have seen much 
benefit derived from the mineral acids, bark, 
steel, when admissible, and arsenic, after a due 
regulation of the digestive functions. I know of 
no article of the class of stimulants that has any 



AMAUROSIS. 305 

direct claim to notice, or any approach to a 
specific virtue, such as has been ascribed to the 
arnica montana, aconite, &c*. 

When the amaurosis is recent and sudden, Mercury, 
and either the signs of an obscure inflammation 
are present, or only the amplitude and inactivity 
of the pupil correspond to the patient's history, 
the indication is less simple ; mercury should be 
introduced with all convenient rapidity into the 
system, I mean so as to ruffle it in the least pos- 
sible degree. No advantage is obtained by sa- 
livation, on the contrary I think it hurtful ; 
when mercury is beneficial its efficacy is per- 
ceived as soon as the mouth is sore. I have 
seen it tried, and have myself tried it in many^ 
cases of perfect amaurosis without the smallest 
advantage ; but in cases of recent occurrence, 
imperfect, but rapidly progressive from bad to 
worse, I have been witness to its power in sud- 
denly arresting the disease in too many instances, 
not to entertain a far higher opinion of it than 
of any other article of the materia medica. I 
shall not again discuss the knotty question of 
its modus operandi j " causa latet: vis est notis- 
sima." The form of its administration must be 
regulated by the circumstances of the case. 

* Some oculists still adhere to the practice of the archangel, 
and 

— — — " purge with euphrasy and rue 
The visual nerve." 

X 



306 AMAUROSIS; 

Dietetic. Superadded to the entire repose of the 

organ, the natural tonics, viz. a pure, dry at- 
mosphere, the cold bath, horse exercise, nu- 
tritious diet, early and sufficient rest, agreeable 
society, and a mind as much as possible diverted 
from the object upon which it is unfortunately 
and pertinaciously prone to dwell — these are 
of greater avail than drugs : and some lighter 
forms of sympathetic amaurosis are as effectually 
cured by them as by the blue pill and rhubarb, 
and upon the self-same principle. 



SECTION IV, 



DISEASES AFFECTING THE EYEBALL. 

The treatment of those injuries to which the suppm*- 
organ is subject from external violence, is com- bail, 
prehended in the directions given for the treat- 
ment of inflammation and its consequences. 
In the suppuration of the ball when the pa- 
tient's suffering is acute, and the constitutional 
irritation severe, and the part notwithstanding 
its great tension affords no immediate prospect 
of relief by a natural opening, the cornea, iris, 
ciliary ring, and some extent of the sclerotica, 
should be so divided by a deep transverse inci- 
sion, as to evacuate the globe of its contents. In. 
this manner about a tea-spoonful of pus, more 
or less, is discharged. The section of the cornea 
alone, effects this object so imperfectly as to af- 
ford little if any reliefl The eye should after- 
wards be lightly covered with a soft poultice 
confined in a cambric bag. 

The extirpation of the eye, when that ope- Extirpation 
ration is determined upon, is most conve* ° 
niently performed with a straight double-edged 
knife, which is to be employed for the pur- 

X 2 



308 DISEASES AFFECTING THE EYEBALL. 

pose of freely dividing the septum of the conjunc- 
tiva and oblique muscles, so as to separate the 
globe and lacrymal gland from the palpebrse and 
base of the orbit. When this is done, the globe 
admits of being drawn gently forward by a ligature 
previously passed through its anterior segment. 
A double-edged knife, curved breadthwise, 
should then be introduced at the temporal com- 
missure of the lids, for the purpose of dividing the 
muscles, vessels, and nerves, by which the globe 
remains attached, with greater convenience and 
dispatch. The hemorrhage is repressed by 
means of asmallportionof fine sponge introduced 
into the orbit, and a light compress of linen 
should then be laid upon the lid supported by 
a roller. The sponge should not be suffered to 
remain longer than the following day, when a 
soft poultice in a muslin bag may be substituted 
for the compress. An opiate should be given 
at bed-time. 

The practice of cramming the orbit with lint 
or charpie, and leaving it to be discharged by 
suppuration, is objectionable. 1 knew one case 
in which this measure was followed by a most ex- 
tensive suppuration within the cavity, and by 
abscesses in the neighbouring integument of the 
lids and forehead ; and another has been com- 
municated to me, in which its ill effects were 
evident. 



DISEASES AFFECTING THE EYEBALL* 309 

I once lost a patient, a middle-aged country- 
man, otherwise in health, within a fortnight 
after this operation, owing to a suppuration of 
the dura mater, on the same side of the head. 
The attack of inflammation was sudden and 
rapid, commencing about a week after the ope- 
ration, and ushered in bv a severe rigor after 
exposure to cold, in the square of the Hospital ; 
an imprudence quite unauthorized. There 
was no continuity of inflamed surface to account 
for this, although the morbid appearances were 
confined to the membranes of the corresponding 
hemisphere. I have performed the operation 
many times without any serious after-symptom. 
The propriety of this measure, from its seve- 
rity and the uncertainty of its preserving life, 
should be always matter of very deliberate 
consultation. I will only observe, that if but Glandular 

enlarge- 

one eye is affected with the disease, and the mentsand 
patient free from any material disorder of health, 
we should be slow to reject the operation on 
account of glandular enlargements in the vicinity 
of the orbit, or of tubercles of a suspicious charac- 
ter in other parts of the body. Such affections, 
supposed to be of the same morbid character, 
have disappeared in more than one case of ma- 
lignant fungus, after the removal of the diseased 
part. 

A gentleman, whose case, a fungoid tumor 
involving the knee-joint, was considered des- 



tubercles. 



310 DISEASES AFFECTING THE EYEBALL. 

perate, and was absolutely abandoned as hope- 
less by the ablest surgeons in this town, on 
account of many tubercular swellings on other 
parts of his body, in addition to extreme weak- 
ness and emaciation, put himself under the care 
of an older practitioner, who considered the ob- 
jections theoretical ; the limb was amputated 
by this gentleman, and the patient recovered ; 
all the tumors subsiding as he regained his 
health. 

In another case which I recently witnessed, an 
enormous swelling of the thigh had its origin in 
the centre of the great sciatic nerve, and the sub- 
cutaneous cellular membrane, both of the trunk 
and limbs, was studded with medullary tubercles 
of various sizes ; on this account amputation 
was considered to be contra-indicated, and it 
was only resorted to when a sudden hemorrhage 
from the ulceration of a vein in the diseased 
mass, threatened immediate dissolution. The 
operation was now held out as a last resource, 
and was dexterously performed just below the 
small trochanter, by my highly valued friend 
Mr. George Young, while I compressed the 
iliac artery at the groin. The stump healed 
slowly, and the man survived three months. 
The advanced stage of hectic to which he had 
been reduced by the duration of the disease, 
was apparently protracted by the removal of 
the limb, From the history of the case, there 



DISEASES AFFECTING THE EYEBALL. 311 

was some reason to believe that this man's life 
might have been saved by the earlier perform- 
ance of the operation ; for the disease was en- 
tirely adventitious, and although the pleura was 
loaded with tubercles, they had not in any de- 
gree injured the substance of the lungs. The 
right sac of the pleura was lined by a thick pel- 
licle of lymph recently effused, and a large 
quantity of pus was also contained in this 
cavity j the other viscera were sound and 
healthy. Admitting therefore the malignant 
character of such a disease, if the symptoms 
do not indicate the affection of vital organs, it 
is possible that the removal of the principal 
source of irritation may admit of a change in 
favour of the constitution, and put a stop to its 
progress. We know not how far the multiplied 
production of these tubercles may be a result of 
sympathetic irritation, and when doubts of this 
description arise, cases like those which I have 
mentioned should be borne in mind, that the pa- 
tient's chance of recovery may not be forfeited 
by indecision. 



TREATMENT 

OF THE 

DISEASES OF THE EYE, 



CHAPTER III. 



SECTION t 

ON THE OPERATIONS FOR THE CATARACT. 

Before speaking of the operations, I shall offer 
a few preliminary considerations. 

The extent and importance of the subjects 
of this and the following chapter, the deep pro- 
fessional interest which they have of late years 
excited, and the copiousness of the historical 
details connected with them, render it impos- 
sible for me to go minutely into them, consist- 
ently with the plan of the present work. Such 
an undertaking, if it were not superfluous, 
would of itself furnish materials for a volume 
of ordinary size ; but so much has been ably 
written upon the subject, that the inquiring 
student can be at no loss for all requisite ele- 



ON THE CATARACT. 313 

mentary information. This premised, I shall 
take the liberty of confining myself to those 
general results of my personal observation, 
which appear to me worthy of communication. 

It has been a custom with oculists where a cataract in 

one eye, 

person has a full formed cataract in one eye, 
and retains the vision of the other, to advise 
the postponement of the operation until that 
also is dark — this advice I think erroneous. I am 
satisfied that the cataractous eye, if it becomes 
the subject of an accidental inflammation, is 
strongly disposed to go into amaurosis ; and 
further, that the retina loses its vigor by the per- 
manent exclusion of light. I speak from repeated 
observation of the fact. The objection to the 
operation on the ground of inconvenience aris- 
ing from the difference of focus of the two eyes, 
when one only is the subject of the disease, is 
trivial, and a consideration altogether subordi- 
nate; such a defect may always be remedied 
by glasses properly adjusted. In several cases 
of amaurosis ensuing upon cataract, I have been 
disposed to regard the change in consistence 
and volume of the lens, as productive of a de- 
stroying inflammation, in others of a partial ab- 
sorption of the vitreous humor. 



The cataractous eye is not unfrequently with 
amaurotic ; nor is it always possible to deter- 
mine the presence of amaurosis, when the 



amaurosis. 



314 ON THE CATARACT. 

opaque lens is so dense as to account for com- 
plete darkness. 

It often happens that a patient has a full 
formed cataract in one eye which presents the 
signs of amaurosis, and an incipient cataract, or 
one as much advanced, in the other, which is at 
present free from these symptoms. In this case 
the cataract of the latter should be removed 
without delay. 

withab- In cases of congenital or infantile cataract, 

sorbed lens. ,.,. ,i i • , n 

which become the subject or operation at an 
adult age, the lens is found to have undergone 
absorption, and the capsule alone remains. This 
absorption does not take place, except in cases 
of injury, in the cataract formed during adult 
life. When the lens has early undergone a natu- 
ral absorption, and the cataract is simply capsu- 
lar, the organ is always imperfect ; the operation 
therefore seldom increases the distinctness of 
vision, although it may enlarge the field of sight. 

Degree of It would be incorrect to say that the opera- 
tion was unadvisable in all cases of cataract in 
which the patient has no sense of light, for it is 
possible that the density of the lens may be 
such as absolutely to exclude the light, and that 
the motions of the iris may be therefore sus- 
pended, or from some degree of pressure of the 
lens, or adhesion of the uvea to the capsule, 



vision 



ON THE CATARACT. SI 5 

that the pupil may be undilated, and the cir- 
cumference of the lens permanently covered. 
But undoubtedly a case of this description is 
unpromising. A strong sense of light by which 
at least to know the direction in which it enters 
the apartment — to be sensible of its falling, on 
the eye, and of a shade, as the hand for ex- 
ample, intercepting it, with a corresponding 
freedom of motion in the pupil, is the most 
favourable state for the operation. There is in 
this case perception enough to determine the 
sensibility of the retina, and not enough to oc- 
casion the unsteadiness of the globe. If a pa- 
tient has vision, the eye is irritable to light, and 
involuntarily rolls as far as possible towards the 
nose on the introduction of the instrument, one 
of the greatest perplexities in the operation. 
Another reason why an operator may naturally 
prefer an eye in which vision is interrupted, is 
this : patients are practical and not speculative 
philosophers, and estimate operations by the 
amount of the good conferred, not by the mag- 
nitude of the evil averted. A blind person re- 
stored to sight, is thus gratified in a much 
greater degree than one whose partially ob- 
scured vision is rendered clear. These how- 
ever are not reasons for deferring the operation 
beyond the period at which useful vision ceases, 
nor do I think any reason can be given for de- 
lay, tantamount to the risque of injury from in- 
cidental inflammation, or impotence from a con- 
tinued suspension of the function of the organ. 



316 ON THE CATARACT. 

Local eir- There are several circumstances in the 



cura- 



sunces. structure and condition of the organ which have 
an important influence on the facility and success 
of operations*. These are shortly, the degree of 
projection of the orbit, or the relative volume 
of the eyeball and its socket; the absolute size, 
prominence and tension of the ball; the dimen- 
sions of the anterior chamber ; the clear and 
healthy, or thickened and partially opaque state 
of the cornea ; the absence or presence and en- 
croachment of the arcus senilis ; the propor- 
tional diameter of the cornea to the globe, and 
its actual diameter ; the healthy state and pro- 
portion of the aqueous and vitreous humors ; the 
free and active, or adhering and constricted 
state of the pupil. A small cornea, a narrow 
or partially obliterated chamber, and a contracted 
pupil, are circumstances decidedly unfavorable 
to any and all operations. 

Couching. The operations have been so repeatedly and 
minutely described, that I shall not fatigue my 
reader with a prolix detail of them. They are 
three in number. Couching or depression, ex- 
traction, and absorption. The first and most 
antient is now seldom performed in this country. 
The cases to which it is alone applicable are 
those cataracts of firm consistence, the circum- 
stances of which offer a serious impediment to 

* To these might be added circumstances of temperament, 
viz. a calm and steady, or an irritable and very move- 
able eye. 



ON THE CATARACT. 317 

the much more eligible method of extraction. 
These circumstances may be inferred from the 
enumeration above given. The needle em- 
ployed by Scarpa is best adapted to the pur- 
pose. The couching-needle may be passed 
through the sclerotica at a line's breadth 
from the cornea, and a little below the hori- 
zontal diameter, so as to avoid the long ci- 
liary artery j or through the inferior part of 
the cornea and pupil j and the lens may be de- 
pressed vertically or horizontally. The term 
* inclination* has been applied to the latter me- 
thod. In both cases the lens must be hitched 
into a breach of the vitreous humor below the 
border of the pupil. Its anterior capsule, and 
the capsule of the vitreous humor, must be di- 
vided or torn through, to render the operation 
effective. The lens corresponds in diameter to 
the iris, and there is therefore no natural space 
into which it can be depressed. The posterior 
capsule, identical with that of the vitreous hu- 
mor, must be lacerated to admit of its disloca- 
tion backwards and downwards j and if its an- 
terior capsule was left entire, it would become 
a secondary capsular cataract, and require a 
subsequent operation. 

The operation of couching through the cornea Kerato- 

i nvxis. 

has of late years been warmly advocated, as be- 
ing unattended by the injurious consequences 
ascribed to the perforation of the sclerotica and 



318 ON THE CATARACT. 

choroid. It is reasonable to prefer that opera- 
tion which inflicts the smallest injury, and to 
conclude that it is least liable to be followed by 
severe inflammation. But the subtleties of 
theory have little weight in the scale against ex- 
perience, and no one who has seen much of these 
operations considers the puncture of the tunics 
to form a material objection, if it is executed 
with a proper instrument, and agreeably to the 
directions which are furnished by a knowledge 
of the organ. I have so often seen the eye per- 
fect in its aspect and function, after several such 
penetrations of the larger tunics, and the in- 
flammation immediately resulting from each 
operation so slight and transitory, as to be con- 
vinced that the objection is either hypothetical, 
or is drawn from unskilful and rash procedures. 

The real objection to couching is the ultimate 
step of the operation, viz. the breaking up of the 
fine texture that fills the globe by the forcible 
depression of the lens. Whether it be de- 
pressed edgeways or breadthways, makes no 
difference in the result ; it must still occupy a 
breach in the cells of the vitreous humor, and 
must derange and disorder that delicate texture 
and those connected with it. A slow insidious 
inflammation marked by a gradual develope- 
ment of the symptoms of disorganization, viz. 
A congestion of vessels, turbid humors, flaccid 
tunics, and palsied iris, is too often the conse- 
quence. The sight, instead of improving when 



ON THE CATARACT. 319 

the immediate effects of the injury are passed 
away, remains habitually weak and dim, 
or declines and fades altogether. The advo- 
cates for inclination seem to forget that the 
principle, which is the same in both operations, 
is the real ground of objection. As to the 
position of the lens, I suspect less mischief is 
done by the old method of depression, as less 
force is required to break a space for the vertical 
than the horizontal lens, provided the depres- 
sion be carried to no greater extent than is 
necessary to clear the inferior border of the 
pupil. After all, the argument is mere trifling 
about the position of the lens, absolute or rela- 
tive ; it can occupy no place but that made for 
it without serious injury to the organ. It is not 
fair to bring against any operation objections that 
apply only to the unskilful performance of it ; 
and this it is easy to see is the secret of the 
frightful catalogue of disasters, which the spirit 
of controversy promulgates, and which those 
whopractise these operations declare to be totally 
unauthorized in their experience. For example, 
what has the wound of the retina, of the ciliary 
body and processes, of the iris, &c. to do with the 
operation of couching properly performed ? Yet 
all these are marshalled in formidable array as 
objections, for the obvious purpose of de- 
monstrating the superior advantages of couch- 
ing through the cornea. 

If the operation just described is attempted Absorption. 



320 ON THE CATARACT. 

upon a flocculent cataract, the lens, instead of 
descending solidly, breaks into pieces, which 
undergo a gradual absorption. This is the 
operation by absorption ; the perfection of which 
however consists in making the free central 
aperture by laceration of the anterior capsule, 
the preliminary step. The needle is introduced 
either through the cornea or the sclerotica. In 
most instances the anterior operation is to be 
preferred, as I have elsewhere stated. The more 
minutely the lens is broken up and divided in its 
texture, and the more its fragments are dissipated 
in the anterior chamber, the quicker the progress 
of absorption ; and the softer the texture of the 
lens, the more readily and safely is this object ac- 
complished. If the substance of the lens is dense 
and compact, this division is not accomplished 
without considerable force, and the inflammation 
w r hich follows is hazardous ; if the fragments are 
bulky and press upon the iris, such a result is 
still more to be apprehended. If therefore this 
operation is resorted to in a case of firm cataract, 
it must of necessity be several times repeated 
if we would preserve the organ uninjured, and 
this forms an insuperable objection to it in all 
such cases*. I would add, that even the ut- 

* I pass over the description of an operation which consists 
in the introduction of a knife, whether through the cornea or 
sclerotica, for the purpose of cutting up the hard crystalline in 
iitu, and throwing the slices into the anterior chamber; and I 
mention it only by way of caution, if caution be necessary 
against a measure so desperate and ill advised. It levels with 
the proposal to extract through the sclerotica. 



ON THE CATARACT. 321 

most caution is inadequate to prevent an in- 
ternal inflammation from the bulging of the 
lens after its capsule is freely rent, or its sepa- 
ration, during the absorbing process, into frag- 
ments of such a size as to oppress the iris. On 
this account an amaurosis is not unfrequently 
the result of this operation, although the slower 
and milder method is decidedly attended with 
the least risque. These objections are not ap- 
plicable to the caseous and flocculent cataract, 
but even in this case the cure is often linger- 
ing, and subject to be interrupted by inflamm'a- 
tion. It is especially to the cataract of infancy 
that the operation of absorption is applicable. 
Here indeed there is no alternative, it is fluid, 
or flocculent ; often so far absorbed, that only a 
a thin scale or flake remains of lenticular sub- 
stance betwixt the capsules, so that its consist- 
ence does not allow of depression, and the eye 
is too unsteady to admit of extraction with 
safety, if this operation was otherwise as eligible, 
which in fact it is not. It is impossible to con- 
ceive a more simple, sufficient, or gratifying 
operation than that of Mr. Saunders, if the in- 
tention is perfectly executed. I have now en- 
joyed extensive opportunities of ascertaining its 
value j having operated, during a period of ten 
years, upon children of all ages from four 
months upwards, and I do not hesitate to affirm 
that it ranks in my estimation as one of the 
finest discoveries of modern science. 

Y 



322 ON THE CATARACT. 

Cataract The p r j mar y cataract adhering to the iris is 

with adhe- ■ * ~ 

sion to the f or tj ie mos t part, capsular ; but whether it 
be so or not, the needle is best adapted to it. 
Its toughness and the firmness of its attachment, 
and the difficulty of couching it, when detached, 
are circumstances which often render the 
operation imperfect. The aperture by lacera- 
tion of the capsule in the centre, and its exten- 
sion as much as possible by the varied move- 
ments of the needle should be the object of the 
surgeon, rather than the detachment of the 
membrane entire. In this, and in all cases of 
operation with the needle, the employment of 
the extract of Belladonna in solution with an 
equal part of distilled water, is a point of the 
first importance. The space included between 
the eyebrow and lash should be thickly painted 
with the solution once or oftener in the twenty- 
four hours, and this varnish should be preserved 
moist for a period of half an hour, in order to 
admit of its absorption. The frequency of the 
application must be determined by its effect 
upon the pupil. The preternatural dilatation 
should not be permanently maintained j for if it 
be, the pupil will in all probability be misshapen 
when its use is suspended and the iris recovers 
its power. 

Extraction. The operation of extraction is by far the most 
perfect ever devised for the cure of cataract ; 
but it is one of considerable difficulty, and the 



ON THE CATARACT. 32! 

several modifications which have been at various 
times suggested, owe their origin to the disap- 
pointments and defeats which operators meet 
with in learning to execute it with success. The 
preference entertained for couching rests on no 
better ground than its greater facility and there- 
fore less risque. No operation in surgery, I am 
well satisfied, requires an equal degree of 
temper and experience for its accurate and suc- 
cessful performance. 

The Baron de Wenzel is reported to have said 
that he had c spoiled a hat-full of eyes' before 
he had learned to extract. This was doubtless 
a figure of speech, but it serves to shew the ap- 
preciation of its difficulty by a great master of 
the art. Excellent directions for the operation 
have been given by Wenzel in his treatise, 
translated by the late Mr. Ware ; and the 
essay of the latter gentleman, who was in no 
respect inferior to the Baron as an operator, upon 
the impediments to the success of the operation, 
is a work of much merit, and should be diligently 
studied by all who undertake it. It is objected 
to this operation, that it is one of which the re- 
sult is a matter of hazard. I reply, not more 
so, in the hands of qualified persons, than 
hernia, lithotomy, aneurism, and other impor- 
tant operations. Secondly, if it fails, it fails 
beyond recovery. This I contend is rarely the 
case in the hands of competent persons. That 
y 2 



324 ON THE CATARACT. 

it sometimes is the case I do not deny, nor 
would I believe that man on his oath, who ven- 
tured for himself to deny it ; but I may be al- 
lowed to ask, is not this exception to the ge- 
neral issue of the operation, a condition of every 
human work ? What operation, I should be glad 
to learn,, is not impugnable by such an argu- 
ment ? Thirdly, it is followed by a higher de- 
gree of inflammation, and one of a less man- 
ageable kind. This again, as the former and 
all the objections in detail, admit of this general 
answer. They apply to the performance, not 
to the principle of the operation. Thus, if the 
eorneal section be clean, and situated midway 
between the pupillar edge and the margin of the 
cornea, or a little nearer to the latter, if it be 
of such extent as to allow of the perfectly easy 
escape of the lens, if the sclerotic conjunctiva, 
sclerotica, and especially the iris be untouched, 
and the capsule freely lacerated, without lesion of 
the vitreous capsule, then the operation is per- 
fect. But although all these points should be 
imperfectly, that is not strictly fulfilled, yet the 
result of the operation is ordinarily successful, 
with a due attention on the part of the surgeon. 
There is not one of them that I have not re- 
peatedly seen reversed, and yet the patient has 
recovered excellent vision. So that the failure 
of the operation is by no means a necessary 
consequence of the casualties that may attend it, 
even although they should be such as to excite 



ON THE CATARACT. 325 

a considerable degree of alarm in the mind of 
the operator. The deviation of the section from 
the course intended, the wound, or removal, or 
prolapsus of a portion of the iris, the escape of 
a part of the vitreous humor, these, I grant, are 
derogations from the perfection of the opera- 
tion. But if the lens be extracted with tole- 
rable facility, such accidents are seldom, with 
the aid of care and time, permanently in- 
jurious to vision. Nevertheless, they are such 
departures from the fair procedure of the 
operation, as ought in common candor to clear 
it of all imputation from an imperfect re- 
sult. 

The main impediment to the success of this inadequate 

1,1 • T i ii section. 

very valuable operation is, as I have elsewhere 
stated, a section of insufficient magnitude. The 
easy extraction of a cataract, like the easy ex- 
traction of a stone, almost invariably does well, 
and the difficult and forcible removal of either as 
certainly augurs unfavorably. The enlargement 
of the section, if too short, is difficult, and always 
dangerous to the iris in the collapsed state of 
the cornea ; it is attended moreover with immi- 
nent risque of a laceration from the want of 
due support, of the vitreous capsule, the loss of 
a, portion of this humor, and the consequent 
sinking of the lens behind the iris. Thus one 
difficulty leads on another. 



326 0N TIIE CATARACT. 

Again the protrusion of the iris before the 
lens in its exit, which only happens from a too 
narrow section, is almost always followed by the 
falling of that membrane into the wound, a 
protracted healing of the wound, and a loss of 
figure of the cornea. 

Escape of The free escape of the vitreous humor, owing 
humor! to an imperfect section, undue pressure, &c. oc- 
casions the sinking of the lens in the globe. 
Such a circumstance may embarrass an operator, 
and induce him to leave the cataract, in the 
hope of its absorption, or of removing it at a fu- 
ture time, rather than risque the further loss of 
vitreous humor. This should never be done. 
For as soon as the wound closes, the cataract is 
raised by the renewal of the aqueous humor, 
and pressed forward upon the iris. I have seen 
an inflammation supervene in such a case which 
speedily went on to suppuration, and destroyed 
the eye. If upon making the section an inordi- 
nate quantity of aqueous humor escapes, and the 
lens sinks from this cause, the case is different ; 
here the vitreous humor is already partially ab- 
sorbed, and the lens is supported by the aqueous. 
The same ill consequences will not follow in this 
case, if the surgeon prefers to relinquish the 
operation. The cornea heals kindly, and he 
may afterwards operate with the needle. How- 
ever, in most instances, the lens may be sup- 



ON THE CATARACT. 327 

ported by gentle pressure on the inferior part 
of the globe, and extracted or rather turned out 
with the hook or spoon end of the curette; and 
I should always pursue this method under such 
circumstances, as long as the globe retained its 
figure. 



It is a point of considerable importance that Section 

verging on 

the section should be purely corneal. I mean sclerotica. 
that it should not be carried so low as to verge 
upon the sclerotica, and thus to leave the cor- 
neal margin of an insufficient breadth for 
union*. Two ill consequences arise from this : 
first, the iris, unsupported at its base, commonly 
falls into and prolapses at the wound, even 
though the section be ample in extent, and the 
escape of the lens perfectly easy j and secondly, 
from the defect or narrowness of the corneal 
margin and the non-apposition of homogeneous 
parts, the healing is always remarkably slow, 
even though no prolapsus should take place. An 
oozing of humor is continually occurring, and 
I have sometimes seen a portion of the capsule, 
now turned opaque, protrude, and subsequently 
slough out at the section. When a prolapsus, of 
whatever kind, prevents the healing of the wound, 

* I have stated elsewhere an additional reason for making 
the section not too distant from the pupil, viz. the easier es- 
cape of the lens. See " Observations on the Cataract." Med. 
Chir. Trans. Vol. V. I prefer it midway between the pupil 
and margin of the cornea. 



328 ON THE CATARACT. 

it should be completely snipped oft' with a pair of 
iris scissars, and the surface and edges of the 
wound touched with the caustic pencil. This 
practice I have repeatedly adopted with the 
best effect, in prolapsus from wound as well as 
from ulcer. 



Extraction 
of soft ca- 
taract. 



Soft and semi-transparent and unadhering 
capsular cataracts may all be conveniently ex- 
tracted. They pass through a smaller section. 
The capsule is easily laid hold of with a hook or 
forceps. The semi-transparent, by which I mean 
the cataract with an opaque nucleus and trans- 
parent circumference and capsule, forms in most 
cases a secondary cataract ; that is, a portion of 
the transparent lamellae and capsule become 
opaque, and occupy the pupil or a part of it. It 
is rent and detached with the greatest ease by 
a touch of the needle passed through the cornea, 
after the healing of the section. 



Instru- 
ments. 



The construction of instruments employed in 
operations is a point which every man must de- 
cide for himself. The knife of the eminent 
Professor Beer of Vienna is that which I am in 
the habit of using, thinking it on the whole 
better adapted than either Richter's or Wen- 
zel's, to make a safe and expeditious section. 



Preparative The more or less inflammation which follows 

and after- . . n 

treatment, the operation is of course depending in great 



ON THE CATARACT. 329 

measure upon the habit of body. The patient 
should be well purged, and live abstemiously 
for a short time previous to it. If disposed to 
fulness in the vessels of the head, cupping may 
be premised the day before the operation. It is 
a matter of some importance to examine the 
section, and adjust it accurately before finally 
closing the eye. I think it useful to let the 
patient rest for a few minutes with his eye 
closed, and then to direct him to open it two 
or three times successively ; a slight friction of 
the lids assists the pupil to recover its figure, 
and dissipates any small floating particle of 
lens. The sitting posture in an easy chair is 
most favorable after the operation, until the 
patient feels fatigued and desires to go to bed. 
Confinement to bed produces great restlessness, 
and is of no advantage to persons not constitu- 
tionally ill. If the patient complains of pain 
on the evening of the day of operation, a full 
blood-letting removes it, and should not be 
omitted*. I never give opiates. A light bandage 
passed round the night-cap and fastened to it is a 
sufficient covering for the eyes. Compresses on the 
eye-lids aregenerally better omitted; thebandage 
may in most cases be laid aside on the second 
or third day, and a deep black shade substituted 
for it. During the night however the bandage 

* It is the custom of M. Roux, of Paris, to apply a blister 
to the nape of the neck after the operation. 



330 ON THE CATARACT. 

should be applied for the first week to prevent 
the accident of rubbing the eyes in sleep. 

I know of no peculiarities requiring a distinct 
notice in the treatment of inflammation after 
extraction. Topical blood-letting and blisters are 
sometimes necessary, and a strict antiphlogistic 
regimen should always be inforced. There is 
often an irritability to light, an aversion to 
open the eye, which is removed by two or 
three brisk doses of calomel. When the section 
protrudes only in a small degree, it soon levels 
down so as to restore the figure of the mem- 
brane. When the protrusion is more consider- 
able, the patient is afterwards subject to repeat- 
ed irritable ophthalmia, and a troublesome ex- 
ulceration of the cicatrix sometimes occurs. I 
have in one case seen small transparent vesicles 
form on the line of the cicatrix at intervals, 
which occasioned much intolerance and distress 
to the patient for a long time subsequent to the 
healing of the section. 

Unfavor- The inflammation of the iris, the interstitial 

able results . i • /» i 1 

of the ope- ulceration and opacity or the cornea, the se- 
paration of the edges of the section by the in- 
tervention of another texture, the redundant 
deposit of lymph in the section, or the ulceration 
of its edges, are the mischiefs which occur after 
unfavorable extractions. Blood shed by a 



ration 



ON THE CATARACT. 331 

wound of the iris in the anterior chamber is 
quickly absorbed. Where it has even filled the 
entire chamber, I have found the aqueous hu- 
mor clear on the succeeding day. 

The coalition of the iris and cornea adjoining 
the section is the result of a prolapsus or a lesion 
of the iris. The iritis may be vehement and 
proceed to amaurosis, or it may terminate fa- 
vorably under the action of mercury, in con- 
stricted pupil. The dimness of the cornea, if 
any, is slight and transient, except an intersti- 
tial herpetic ulcerative action, connected with 
a bad condition of the edges of the section be 
present, when the cornea takes on an opacity 
of a very intractable kind. The sclerotica is 
in this case inflamed, and very minute depres- 
sions appear on the surface of the cornea, which 
undergoes a total loss of brilliancy, although it 
remains obscurely transparent. The restoration 
of smoothness to the surface does not diminish 
the lacklustre appearance of the membrane. 
The patient has a perception of light, but no 
vision of objects. In fact, the cornea precisely 
resembles that of the dead subject. Mercury 
is of uncertain efficacy in this case, which fortu- 
nately is very rare. Time and tonics do most for it. 



I have now adverted to the principal miscar- 
riages of the operation, both during and conse- 



SS2 ON THE CATARACT. 

quent upon its performance, which I have met 
with, or witnessed in the practice of others. 
When the operation is perfect, its pre-eminence 
is too conspicuous to admit of illustration. It 
exacts the homage of admiration beyond any 
effort of the art. 

The adjustment of the light, its exclusion 
from the other eye by a compress and bandage, 
the regulation of the seats of the patient and 
the surgeon, the light and firm support of the 
upper lid, the calm and easy penetration, and 
the quick and steady passage of the knife across 
the chamber, and without a pause, through the 
opposite border of the membrane, so as to an- 
ticipate the escape of the humor and preserve 
the iris in situ, the deliberate completion of the 
section, all pressure being removed, either by 
the progress of the knife, or by a clean back 
stroke, or by the aid of the finger-nail dividing 
the cornea upon its edge, as may be most expe- 
dient, are, in brief, the material points of the 
operation. I will only add the capsule should 
be freely lacerated in the centre, not incised 
concentrically to the lower border of the pupil. 

It would scarcely be credited by a by-stander 
who saw the operation happily executed, upon 
a steady and well-formed eye, that it presented 
any difficulty; a conclusion applied to every 
thing well done, whether warranted or not. 



ON THE CATARACT. 333 

But the incidental embarrassments are too fre- 
quent and numerous to admit of being always 
anticipated, and the only security against them 
is the constant habit of practising the operation 
and the confidence thence acquired, tempered 
with a due sense of responsibility. 

Habit will make any man ambi-dexter ; and 
the rest for the elbow, so much insisted upon, if 
once laid aside, will prove a hindrance rather than 
a help to an operator. After once thoroughly un- 
derstanding the minutiae of the operation, habit 
will also render it unnecessary for him to rehearse 
the several steps and stages of the performance 
before advancing to it. The memory of a suc- 
cessful operator is altogether technical, and his 
mementos are carried, to use a homely figure* 
sur le bout du doigt. 



SECTION II. 



OF THE OPERATIONS FOR ARTIFICIAL PUPIL. 

From morbid alterations of the cornea, or iris, 
or both, result those several states of the organ 
which suggest the formation of an artificial 
pupil. The disease may be simple, that is, af- 
fecting exclusively the cornea or the iris, or it 
may be complicated, and involve both textures. 

Simple states : 

1. An indelible central opacity of the cornea, 
more or less eclipsing the healthy pupil. 

2. A closed or obliterated pupil ; the crystal- 
line capsule opaque, and adhering to the iris ; 
and probably the lens also opaque, unless the 
disease is consequent upon the operation of 
couching or extraction. 

The first supposes a healthy state of the iris 
and anterior chamber, the second a transparent 
cornea. 



OF THE OPERATIONS, &C. 335 

Complicated states : 

1. A closed pupil, with or without conceal- 
ed cataract, combined with a partially opaque 
cornea. 

2. A central opacity of the cornea combined 
with a constricted pupil and cataract. 

3. In addition to the closed pupil, a partial 
adhesion of the iris to the opposite surface of the 
opaque cornea. 

4. A permanent prolapse of the iris through 
an ancient breach or section of the cornea, in- 
volving more or less of the pupillary margin. 

In both the latter cases, the anterior chamber 
is reduced in dimensions in proportion to the 
extent of the adhesion or prolapse. 

These are the chief circumstances — it would 
be endless and useless to detail all their possible 
modifications, — which have given rise to the pro- 
posal of an operation, having for its principle, 
the formation of a permanent aperture in the 
iris opposed to a transparent portion of cornea. 

Many very ingenious methods of accomplish- 
ing this object have been devised both by fo- 
reign and British surgeons and oculists. The 
tracts of the late Mr. Gibson of Manchester, and 



336 OF THE OPERATIONS 

of my friend Mr. Guthrie, surgeon to the West- 
minster Eye Infirmary, are well entitled to the 
diligent perusal of students investigating this 
subject. A remark, which I had early occasion 
to make in reference to the treatment of cata- 
ract, is pointedly applicable to this subject, to 
wit, that no one method of operating commands 
an exclusive preference, and that the eligibility 
of either can only be determined by the pecu- 
liar character and bearing of the case before us. 
It follows therefore that a particular description 
of the various modes of operating, without re- 
ference to the precise conditions to which they 
are applicable, although interesting as an expose 
of professional ingenuity, can have no other ten- 
dency than to embarrass by a multiplicity of 
materials, and that it is quite impossible to ar- 
rive at a fair estimate of the respective merits of 
each operation by such a mode of proceeding. 
Infinitely varied as are the states which call for 
the operation, a sufficient fertility of invention 
has been exhibited to admit of an unhesitating 
preference of some one or other method well 
suited to every case that can occur, and so far 
as regards this point, the judgment of the young 
surgeon requires only to be assisted in its de- 
cision by the experience of those who have en- 
joyed repeated opportunities of putting the 
merits, general and comparative, of each ma- 
noeuvre to the test. 

In the hope of simplifying a subject which has 



FOR ARTIFICIAL PUPIL. 337 

been in some degree complicated by useless am- 
plification and over refinement, I shall content 
myself with setting down the operative method 
which I regard as best adapted to each parti- 
cular state described. 

Simple states : 

1. A central opacity eclipsing the pupil. A 
section is to be made, with the cornea knife, in 
the transparent portion of the cornea, from two to 
three lines inlength. This being done,by a gentle 
pressure upon the opposite side of the eyeball, 
the iris protrudes in the form of a little sack or 
bag at the wound, which is to be snipped off 
with a fine pair of scissars* The iris then re- 
cedes, and presents a permanent aperture more 
or less circular. The corneal section may be 
made on either side of the pupil as required. 
The merit of this highly ingenious operation is 
due to the late Mr. Gibson. It is applicable 
only to the above state, for if the pupil is closed 
and in adhesion with the capsule, or if adhe- 
sions exist between the iris and cornea, no pro- 
trusion will take place. In making the section, 
it is very important that the direction of the 
knife should be perpendicular to the cornea, for 
if its passage is oblique, the cicatrix will be so 
much extended as to obscure the new pupil. 
On this account, the practice of Professor Beer 
to draw out with forceps and excise the pupil- 

z 



338 OF THE OPERATIONS 

lary margin, more completely answers the in- 
tention. 

There is another operation which I have per- 
formed successfully in this case. A narrow 
bladed and finely pointed knife, cutting on one 
edge, such as was used by Mr. Cheselden for 
dividing the iris, is introduced through the 
sclerotic coat and ciliary margin of the iris into 
the anterior chamber, with its cutting edge op- 
posed to the face of the iris ; that membrane is 
then to be completely divided on the tem- 
poral side, including the border of the pupil, by 
repeated gentle nickings. The iris being sound, 
and consequently elastic, the section imme- 
diately assumes the figure of an equilateral tri- 
angle. The superiority of the operations before- 
mentioned consists in their less liability to be fol- 
lowed by cataract. If cataract ensues, as is pretty 
uniformly the case in the simple division, it 
must be broken up for absorption in a subse- 
quent operation with the needle, provided that 
measure should ultimately be necessary. 

2. A closed pupil, the crystalline capsule 
opaque and adhering, and probably the lens also 
opaque, if not previously extracted or depressed. 
It should be observed, that in the majority of in- 
stances the capsule and lens have undergone the 
change here presumed ; but this is a matter not 
always possible to be ascertained, and one which 



FOR ARTIFICIAL PUPIL. 339 

affords no ground for varying the plan of oper- 
ation. It is therefore best to provide for it. 
The section should be made precisely as in ex- 
traction. The centre of the iris should then be 
raised under the flap of the cornea with the 
forceps, and as large a piece of the membrane as 
can be embraced by the convex scissars, should 
be clipped off. Through such an opening there 
will be no impediment to the passage of the 
lens. I have repeatedly performed this opera- 
tion with perfect success. 

Wenzel, finding the mere division of the 
closed fibres then only useful when they are on 
the stretch, included a central portion of the 
iris in the section of the cornea, and removed 
the triangular flap thus formed, with a stroke of 
the scissars ; a method perfectly efficacious in 
the state of closed pupil, whether the cataract 
remains or not. It is only necessary to bear 
in mind, that a sufficient portion of the iris 
must be excised to allow of the easy escape of 
the lens, a point to which Wenzel's directions 
do not extend, since his operation supposed the 
previous depression or removal of the cataract. 

In the seventh volume of the Medico-Chirur- 
gical Transactions is an interesting paper by 
Professor Maunoir, of Geneva, relating three 
successful operations for artificial pupil performed 

z 2 



340 OF THE OPERATIONS 

with his scissars in the manner recommended 
by him. In two of these cases the pupil was 
constricted upon an opaque capsule and lens. 
To this paper is appended a letter from Scarpa, 
justly complimenting M. Maunoir on his skill 
and success, and adding his opinion that an 
operation compounded of Wenzel's and Mau- 
noir's, is the most appropriate to the case of 
constricted or closed pupil with opaque lens. 

Complicated states : 

1. Closed pupil \combined with a partially opaque 
cornea. To this state either of the operations 
last described may be applicable ; this must 
however depend upon the extent of the opacity. 
A section of the opaque part of the cornea is un- 
advisable, as it is strongly disposed to ulcerate in- 
. stead of healing kindly. I should therefore avoid 
it, if a portion of the cornea remained sound, 
sufficient to allow of the unavoidable en- 
croachment of the cicatrix. But in all cases of 
closed pupil, the iris retaining its position, I 
hold it to be expedient, if possible, to remove a 
portion of that membrane ; and to this end the 
section of the cornea is indispensable. The mere 
division of the fibres of the iris is ineffective, by 
reason of the loss of its elasticity. An opacity of 
the cornea however may be of such extent as to 
leave no choice of operation, as the cicatrix of 



FOR ARTIFICIAL PUPIL. 341 

the section of that membrane would obscure the 
small portion which remains transparent. In 
such a case, the separation of the ciliary margin 
of the iris, after the manner of Scarpa or Schmidt, 
is the only practicable proceeding. 

2. Central opacity of the cornea, combined 
with constricted pupil and cataract. In this 
case we need only deviate from the usual 
method of extracting, by dipping the point 
of the knife behind the pupillary margin on 
the nasal side, so as to include a sufficient 
portion of the iris. If after the removal of the 
lens, the incised portion should not be com- 
pletely detached, the flap may be easily snipped 
off with the iris scissars. It may be useful to 
remark, that pressure should, as much as possible, 
be avoided during the extraction of the lens. 
Other modes of procedure in this case are as 
follow : 

1. An opening is to be made in the cornea, 
distant about three lines from the point at which 
the new pupil is to be formed. Through this 
aperture the ciliary margin of the iris, detached 
by the double hook of the ingenious M. Reisin- 
ger of Augsburg, is to be drawn out and excised. 
If the cataract should impede vision, it must be 
treated in a subsequent operation. 

2. Dividing the iris horizontally on the nasal 
side, and couching or breaking up the cataract 



342 OF THE OPERATIONS 

before withdrawing the needle, which must be 
adapted to that purpose. 

I do not hesitate to prefer to either of these 
modes, the extraction of the lens by the removal 
of a part of the iris, a thing so easy to be done 
that it is often difficult to avoid it. The dis- 
tinct performance of the operation for artificial 
pupil, and the treatment of the lens by the ab- 
sorbing process, after the lapse of an interval, is 
for obvious reasons objectionable, when it is 
possible to avoid it. 

3. Closed pupil and partial adhesion of the iris 
to the opaque cornea. The separation of the 
cornea and iris when in adhesion, is an attempt 
altogether unadvisable. It is only at that part 
of the transparent cornea, which is free from ad- 
hesion to the iris, that the attempt to make an 
artificial pupil can be of any avail. The remo- 
val of a portion of the fixed iris, by hooking it 
through a limited section of the cornea, for 
the purpose of strangulation or excision, is an 
operation of much delicacy. It is however in 
high repute with the German surgeons. If the iris 
is at any part rendered tense by adhesion to 
the cornea, an extensive vertical or oblique 
division of its fibres with the iris knife, or 
Maunoir's scissars, is best adapted to this case. 
The simple incision of the iris is enough, if it 
either retain its natural and healthy texture, or 
be placed upon the stretch ; and if not, it is in- 



FOR ARTIFICIAL PUPIL. 343 

efficient, as before observed, owing to its in- 
elasticity. But in this, as in all cases, if the 
opacity of the cornea is of such extent as not to 
allow of incision, the operation of Scarpa must 
be resorted to. 

4. Permanent prolapse of the iris through a 
breach of the cornea, involving more or less of the 
pupillary margin. This is the state for which 
the operation was first devised and practised, 
and when it is consequent upon the removal 
of the lens, is the most favorable condition for 
the artificial pupii. The appropriate procedure 
is that of Mr. Cheselden, viz. the transverse 
division of the stretched fibres of the iris j and 
which, if the section be made in front of the 
membrane, i. e. from before backwards, admits 
of no improvement. The edges of the section 
instantly recede, and form an excellent pupil. 
If the lens has been previously extracted, the 
intention is completed atonce \ otherwise the lens 
must be couched or broken up, and in the latter 
case, may require a subsequent operation. Sharp, 
Woolhouse,and others, who followed Cheselden's 
plan indiscriminately, naturally complained of 
their want of success. Wenzel discovered the 
cause, and demonstrated the necessity and the 
mode of removing a portion of the membrane. 
This was a very important step in advance, and 
is the principle of the most successful operation 
since performed for the artificial pupil. 



344 OF THE OPERATIONS 

It may happen that a partial adhesion of the 
pupillary margin to the cornea may be combined 
with a healthy lens. In this case, the removal 
of the free border of the pupil, drawn by means 
of forceps through an incision of the cornea, 
will be preferable on account of preserving the 
transparency of the lens. 

I am fully aware, not only that other states 
than those which I have mentioned, may fre- 
quently occur ; but that even in these, circum- 
stances may possibly arise, to render other modes 
of operation more expedient than those which I 
have recommended. In fine, I consider it quite 
impossible to reduce a subject in its nature so 
purely circumstantial, and therefore discretional, 
to the rule and line. The rationale of such 
operations is simple and intelligible, and it may 
safely be left to the genius of the surgeon to 
meet the exigencies of each individual case, 
in this as in many other instances. Manual 
adroitness is, in an especial degree, required in 
these operations, not only because the space 
within which the instrument is to move is so 
confined as to endanger contiguous parts, but 
because the division of textures in a morbid 
state is opposed — especially of the iris, on ac- 
count of its inelasticity and over-vascularity — 
by a greater degree of resistance and a larger 
effusion of blood, than the division of the same 
parts in health. Hence the operation must be 



FOR ARTIFICIAL PUPIL. 345 

executed as quickly as is consistent with gentle- 
ness. For another reason this is important ; the 
organ upon which we are operating is an un- 
sound one, and having been recently and per- 
haps repeatedly the subject of inflammation, 
is in too irritable and delicate a state to 
admit of violent or long continued manual 
efforts. For the latter reason, it is also 
highly desirable to finish the operation at 
one sitting, and I therefore decidedly disap- 
prove of coupling with the formation of an ar- 
tificial pupil, the displacement and breaking up 
of the lens to undergo the tedious process of 
absorption, whenever it is possible to extract or 
even to couch it. The organ has already suf- 
fered too much, and the operator should either 
not interfere with the transparent lens, or should 
remove that which is already opaque ; and as 
the latter may almost always be presumed, while 
it remains in situ behind a closed pupil, that 
operation is preferable, which provides for its re- 
moval. 

So much for the mechanism of the operation ; 
it now only remains for me to add a remark or 
two on the more important question of its prac- 
tical application and value, and the circum- 
stances which should influence our prognosis 
and determine our practice. There are two 
main questions for consideration when these 
cases present themselves to our notice, both of 



346 OF THE OPERATIONS 

which should be determined as far as we are 
able to decide them, before the operation is 
undertaken. The first in importance as in order 
is, whether the retina retains its sensibility, and 
the vitreous humor its texture and transparency. 
The second, whether the manipulation required 
is so far practicable as to afford a fair prospect 
of success. The circumstances under which 
vision has been suspended are more or less 
favorable, according to the seat, extent, dura- 
tion, and character of the inflammation. If 
the disease is confined to the cornea, the case 
affords the best encouragement. In the pro- 
lapsus iridis from ulceration of the cornea, 
the iris is only passively concerned, and here it 
seldom happens that the retina has suffered. If the 
closure of the pupil has supervened upon wound 
or injury, as the operation of couching or extrac- 
tion, it is in general more favorable than when it 
results from idiopathic inflammation of the cho- 
roid and iris of long standing, or of repeated 
attacks of inflammation. In the latter cases, 
the organ usually presents certain signs of an 
organic change in its altered volume and figure, 
in the permanent congestion of the sclerotic 
and choroideal vessels, the great convexity and 
discoloration ot the iris, and the yellowness of 
the opaque lens, if any part of it is visible, the 
partial detachment of the pigmentum nigrum, 
&c. An extensive adhesion of the iris to the 
cornea denotes the greatest degree of organic 



FOR ARTIFICIAL PUPIL. 34? 

derangement, and constitutes the most unfavor- 
able state for operation. 

In a great proportion of cases in which the 
operation might, in a manual view, be executed 
with perfect success, no advantage would result 
from it; just as in cataract, complicated with 
amaurosis, the extraction proves to be of no 
avail. 

Difficult as the execution may be and often is, 
it is the state of the eye by reason of the disor- 
ganizing inflammation which has preceded it, 
that forms the most frequent impediment to its 
success. When the signs of organic change in 
the eyeball are present, the operation should 
never be attempted ; without some healthy 
perception of light, I should think it afforded a 
very small chance of success*. In the most fa- 
vorable circumstances, the patient should be led 
to entertain a moderate degree of expectation ; 
and as persons in a state of blindness are inva- 
riably over-solicitous to submit to any experi- 
ment for the recovery of vision, the surgeon, for 
his credit sake, should be careful not to limit 
his inquiry to the mere practicability of an 
operation ; nor, when taking a larger and more 

* I say, healthy, because the morbid perception, as of 
gleams and flashes of blue or variegated light, stars, and sparks, 
so common in these cases, is decisive of the disorganization of 
the retina. 



348 OF THE OPERATIONS FOR ARTIFICIAL PUPIL. 

deliberate view, to be drawn into it against his 
judgment. If this is undecided, let him so state 
the circumstances as to make himself respon- 
sible only for the mechanical process. Let it, 
for example, be expressly understood that without 
it the case is hopeless, and that if unhappily no- 
thing should be gained, nothing will be lost by 
the operation. It is seldom, if ever, wise to do 
the operation upon one eye, the other remain- 
ing sound. 

The ensuing inflammation is in general mo- 
derate, particularly so, if the lens has been 
previously removed. The success of the 
operation, however, is sometimes foiled by 
the train of morbid actions which ensues from 
the thoroughly diseased condition of the cor- 
nea and iris, where the instant result had in- 
spired a hope of better fortune. 



TREATMENT 



OF THE 



DISEASES OF THE EYE. 



CHAPTER IV. 



DISEASES OF THE APPENDAGES. 

Of the treatment of diseases of the orbitar ca- 
vity and appendages much cannot be said. I 
have spoken of the excision of adipose tumors 
and cysts. Such cases are sufficiently within 
the observation of the general surgeon to render 
a fuller discussion of them unnecessary in a 
work, the more particular object of which is to 
communicate information upon a department of 
pathology, which, unfortunately for mankind, 
he has too much neglected to cultivate. 



SECTION I. 



DISEASES OF THE EYELIDS. 

Hordeolum. Styes, if large and painful from inflaming the 
eyelids, should be discharged with the point of 
a lancet, and poulticed, or bathed with a slightly 
astringent w 7 ash, according to circumstances. 
When phlegmonous, indurated, and slow to 
suppurate, occasional friction will often promote 
absorption of these little swellings, as we may 
conjecture was known of old, from the reputed 
specific effects of a wedding-ring, or the tail of 
a black cat. 

The disposition to stye is not only very 
troublesome, but very injurious to beauty. The 
permanently conspicuous redness of the borders 
of the tarsi, a slight degree of thickening and 
elevation of the conjunctiva, and small cuticular 
denudations, are the results of their frequent 
formation, and the loss or scantiness of the cilia 
greatly increases the deformity. The nitrated, 
or red or white precipitate ointment of mercury, 
diluted so as to give a momentary smart upon 
closing the lids, should be used daily or thrice 
a week at bed-time, till the part acquires a 



DISEASES OF THE APPENDAGES. 351 

healthy aspect; and the lids should be occa- 
sionally smeared with any soft and unirritating 
salve at intervening periods. Alum and zinc 
washes assist this object. The chronic indu- 
rated stye, if not dispersed by the stimulant 
ointment, should be excised. An appropriate 
attention to the habit of patients is essential, for 
this is always faulty. 

The acute lippitudo generally yields to a Lippitudo. 
single stimulant application. Some exceptions 
however occur. The lead ointment, or one 
combined with opium, will often agree with 
those slight, but very irritable lippitudos some- 
times met with ; but there are persons to whose 
sensations even cetaceous ointment is painful, 
and who derive no benefit whatever from unc- 
tuous applications. In this case hot water affords 
most relief. 

The chronic lippitudo is a very deforming 
disease, and often veiy intractable. It is 
accompanied with much intolerance. The ves- 
sels of the palpebral conjunctiva are turgid, and 
at length varicose, the membrane a little over- 
laps the thickened tarsal border ; this is partially 
if not quite denuded of cilia, and small surfaces 
of the adjoining cutis are excoriated. The fol- 
licles are plugged, and here and there is one so 
much distended by inspissated mucus, as to oc- 
casion aclite inflammation. These should be 



352 DISEASES OF THE APPEMDAGES. 

opened with the point of the lancet, and the 
white consolidated secretion removed, the con- 
junctiva should be occasionally scarified, and 
the meibomian borders stimulated by one of the 
ointments above-named. The tarsal edges should 
also be frequently bathed with an astringent lo- 
tion. In the aggravated and obstinate cases of 
lippitudo, where the conjunctiva is altered in its 
texture, the sulphate of copper lightly carried over 
the thickened conjunctiva and ulcerated border of 
thetarsus,ishighly useful; and stimulant solutions 
of copper, zinc, lunar caustic, or sublimate, ap- 
plied by a camel-hair brush to the tarsal edges 
before smearing them with the ointment, are 
likewise advantageous. 

The degree of strength in which the ointment 
should be used, the quantity to be used, and 
the mode of applying it, are points of no small 
importance in the treatment of these diseases. 
Unless it excites a pretty smart irritation and 
provokes a copious flow of tears, it does little 
if any good; but the irritability of the conjunc- 
tiva varies so much according to the stage of the 
disease, the time of making the application, and 
even the general habit, that it is impossible to 
fix a standard of strength. As to the manner, 
patients should be instructed in the intention ; 
and for the strength and quantity, in the de- 
sired effect of the remedy. The degree of irrita- 
tion should be such as to prevent the patient 



DISEASES OF THE APPENDAGES. 351 

from keeping his eyes open for some succeeding 
minutes j but no increased congestion should be 
apparent on the following day. The patient 
therefore should feel his way, and measure the 
irritability of the conjunctiva, by advancing gra- 
dually from a lower to a higher stimulus. In 
acute lippitudo a little cold cream or spermaceti 
will occasion a severe smarting and profuse flow 
of tears, whereas in the chronic form, the 
strong mercurial ointment is often necessary to 
produce this effect*. 

*The ' golden ointment,' as it is called, is an excellent reme- 
dy. I shall be accused of heterodoxy, but I must in justice 
assert, that the inventor of this arcanum deserves well of his 
country, for if his patriotism be equivocal, the virtue of his 
nostrum is at least certain, when judiciously prescribed. If it 
did not unfortunately aspire to be a panacea, its beneficial 
operation would be without exception ; and indeed the greatest 
evil of quack, as of regular medicines, is their abuse. Few 
things capable of doing much good, are not also capable of 
doing mischief. An old lady of Paris, whose husband had 
become famous for an eye-water, had the misfortune to lose 
her spouse and his secret together. In this dilemma, 
harassed by applications for the nostrum, she had recourse to 
the water of the Seine, and was not more gratified than sur- 
prised to find that the colly rium had lost nothing of its vir- 
tue. After having enriched herself by the successful traf- 
fick, it so chanced that she fell sick, and conscience-stricken 
at the prospect of death, she applied to an eminent professor of 
surgery, instead of a priest, to relieve herself of the burthen of 
sin with which her soul was encumbered. " Soyez tranquille, 
mon amie," said the professor, '* de tous les Medecins vous etes 
le plus innocent : vos remedes n'ont fail du mal a personne I" 
A A 



354 DISEASES OF THE APPENDAGES. 

Tinea d- The correction of the diseased states and se- 

liaris. 

cretions of the ciliary apparatus proceeds upon 
the same principle as the cure of lippitudo, with 
which, in a greater or less degree, they are very 
generally combined. The re-establishment of a 
healthy conjunctival surface and a healthy mei- 
bomian secretion, is the object to be attempted. 
In general the mercurial ointments are the 
best remedies for this disease. 

Cleanliness is a point of the first importance, 
and it is the more necessary to mention it, be- 
cause the disease is often set up, and is always 
aggravated, by neglect of it. The margins of 
the lids and the roots of the cilia should be tho- 
roughly cleansed from loose scabs and branny 
incrustations before anointing them : the oint- 
ment, liquefied by a gentle heat, should be ap- 
plied upon both edges of the cartilage with a 
camel-hair brush ; keeping them through the 
day slightly besmeared with a mild ointment, as 
the tutty, prevents the formation of fresh crusts. 
It is needless to say, that more depends upon the 
patient than the surgeon in the cure of these 
complaints, and that the incurable states, those 
which admit only of palliation, are invariably 
the consequence of neglect, and might therefore 
have been prevented. 

Trichiasis. When cilia are inverted from a diseased growth, 
they must be kept plucked until by the improved 



DISEASES OF THE APPENDAGES. 355 

condition of the hair gland, under the means 
used, the disease is removed. If a case occurs 
in which the vitiated site or incurvation of one 
or more cilia does not admit of correction, the 
corresponding follicle should be obliterated by 
repeatedly touching it with a fine caustic pencil. 
When the incurvation is depending on a dis- 
ease of the tarsus, the case must be treated as 
entropeon. 

The treatment of the inverted eyelid, upon the Entropeon. 
plan recommended by Scarpa, will, according to 
my experience, be effective in nine cases out of 
ten j that is, by the removal of a fold of skin with 
a pair of scissars from the surface of the eyelid. 
The relaxation of the integument operating as 
a cause of the disease, is more frequent upon the 
lower than the upper lid, but the operation is 
applicable to cases originating from other causes. 
The surgeon should be careful to adapt the po- 
sition and extent of the wound to the site and 
degree of the inversion. I have now and then 
met with a case in which the inversion was 
clearly depending upon a callous roll of conjunc- 
tiva at the orbitar edge of the tarsus, in which 
case the disease was removed by the excision of 
this roll, which is of itself a disease requiring 
such a remedy, as before noticed. In cases of 
a circumscribed inversion produced by cicatrix 
from burn or wound, I have found an operation 
a a 2 



356 DISEASES OF THE APPENDAGES. 

similar to that of Dr. Crampton an effective 
remedy ; sometimes the complete division 
of the conjunctiva and tarsal cartilage, in- 
cluding the inverted portion, and parallel 
to its border, with the aid of sticking- 
plaster, has proved sufficient. I should see 
no objection to the entire removal of that por- 
tion of the tarsal edge which was incorrigibly 
inverted from such a cause, especially when com- 
bined with distichiasis, by which is meant a pre- 
ternatural growth of cilia from the meibomian 
border of the tarsus; but the removal of the entire 
cartilage, which I have twice performed in aggra- 
vated cases of this disease, although by no means 
difficult of execution, is an operation of great 
and needless severity, and one which is not 
warranted by the degree of relief which it af- 
fords. The permanent deformity which it en- 
tails upon the patient should deter the prac- 
titioner from having recourse to it, without an 
absolute and pressing necessity. 

Eetropeon. The ordinary ectropeon is cured by the ex- 
cision of a portion of the thickened or redun- 
dant conjunctiva which occasions it. The per- 
pendicular division, or the removal, as the cir- 
cumstances require, of a triangular portion of 
the tarsal border by a double incision, as men- 
tioned p. 234, is the operation best adapted to 
the long-established and aggravated forms of the 
disease ; an adhesion of the everted eyelid to 



DISEASES OF THE APPENDAGES. 357 

the cheek, adds much to the difficulty of the 
case, and renders all modes of treatment merely 
palliations of the deformity. I have however 
succeeded in greatly lessening the deformity in 
some such cases. 

Concerning tumors of the eyelids I have little to Palpebral 

r • tumors. 

add to what will be found in the pathology. Often 
the encysted tumor is seated superficially, and 
loosely connected to the tarsus, in which case it 
must be removed on the outside of the eyelid, by 
just separating and turning to either side the fi- 
bres of the orbicularis muscle. It is only when an 
intimate adhesion subsists, (the cyst is often 
formed betwixt the cartilage and the ligamen- 
tary membrane which covers it,) and the appear- 
ance of a white circumscribed indentation is 
seen upon everting the tarsus, that the excision 
is to be made from the interior by division of 
the cartilage j in which case it is always executed 
with perfect facility. If the cyst be not extir- 
pated, but merely incised and its contents ex- 
pressed, the tumor speedily re-appears. If its 
adhesion to the tarsus be such as to prevent the 
entire removal of it, the remnant of the cyst 
should be touched with the caustic pencil. 

For the permanently drooping lid, if an oper- La g o P h* 
ation be ever desirable, — which, as an unclosed 
state of the lids, is a pretty certain fore-run- 



358 DISEASES OF THE APPENDAGES. 

ner of diseased conjunctiva, amounts with me 
to a question — a fold of integument may be re- 
moved by the knife, or by pencilling out a por- 
tion of it with the strong nitric acid. It is unne- 

and cohe- ° 

ring tarsi, cessary to describe an operation for dividing the 
cohering tarsi. When complicated with adhe- 
sion to the globe, the case is incurable. 



SECTION II. 



OBSTRUCTION OF THE LACRYMAL PASSAGES. 



The treatment of the disease improperly stricture of 
termed " fistula lacrymalis," has occupied a maiand 
large share of the labor and talent of the pro- 
fession*; yet, notwithstanding this advantage, 
the practice is to this day unsettled and unsatis- 
factory t. 

* See the numerous papers in the Memoirs of the French 
Academy, and the works of Sharp, Pott, Desault, and other 
eminent writers. 

f In proof of this remark, I may observe that nearly all 
the schemes hitherto suggested have been executed within my 
knowledge by different surgeons, viz. the small probe and in- 
jecting syringe of Anel, the sound and syringe for the nasal 
duct, the seton of silk or catgut, the bougie or nail-headed 
style, the metallic tube, &c. In Paris, M. Dubois employs the 
silk seton of Mejan, M. Dupuytren the permanent tube of 
Wathen, M. Roux the mesh seton introduced by means 
of a watch-spring from the sac. M. Beer, of Vienna, uses, 
for a seton, a coil of catgut, such as is used for fiddle- 
strings. Among the surgeons of this town, Mr. Ware's style 
is chiefly in use, although the practice is evidently losing 
credit. 

6 



360 DISEASES OF THE APPENDAGES. 

Mr. Pott was in error when he concluded in 
his criticism of Anel's practice, that the stric- 
ture of the lacrymal ducts w r as very rare, be- 
cause the mucus of the sac was habitually, or 
upon pressure, discharged at their orifices ; the 
stricture of the ducts is, on the contrary, fre- 
quent 5 and although this morbid secretion of 
the sac is often present with a free state of the 
lacrymal ducts, the cases of obstruction on the 
nasal side are very frequent, in which no such 
symptom exists. 

Mucous The absorption of the meibomian mucus by 

discharge. r •> 

Professor the puncta lacrymalia, and its regurgitation on 

Scarpa's r J o o 

hypothesis, pressure, as described and considered by Scarpa 
to constitute the first stage of the disease, inde- 
pendent of a permanent stricture, is, I think, 
hypothetical ; for, if founded in fact, this symp- 
tom would be present in every severe lippitudo 
or ophthalmia with puriform discharge, which 
every body knows is not the case. Besides, if 
the duct were open, there is no reason why the 
fluid, once admitted, should be arrested or re- 
gurgitate instead of passing into the nose, but 
the office of the puncta is the absorption of the 
lacrymal fluid, as that of the lacteals is the ab- 
sorption of chyle, and absorbent mouths are 
distinguished from capillary tubes by the selec- 
tion of their proper fluid. It by no means fol- 
lows because a purulent secretion is discharged 
from these orifices that they have derived it 



DISEASES OF THE APPENDAGES. 361 

from the eye. Further, there is every reason 
to believe that the fluid so discharged is the 
proper secretion of the sac, and cases are fre- 
quent in which it is retained and cannot be ex- 
pressed, owing to strictures both of the la- 
crymal and nasal ducts. As to the proof of the 
meibomian border of the lid of the affected eye 
being more vascular than the other, I need only 
remark that the irritation of an obstructed sac 
naturally produces this appearance upon a con- 
tinuous and highly sensible membrane j if the 
redness proves any thing, it proves the presence 
of irritation, and stricture is as probable a 
source of it as any. But it is demonstrable that 
the " flusso palpebrale" is as seldom present 
with the symptoms of obstruction in a degree 
sufficient to support the hypothesis of obstruc- 
tion from that cause, as the actual obstruction 
is rare in those cases of its excess which are of 
ordinary occurrence. 

The effect of a severe cold in the head to origin of 
produce a coryza and troublesome watering of 
the eye, may enable us to form a pretty accurate 
idea of the cause of a permanent stillicidium ; 
for although an over-excitable state of the con- 
junctival surface may occasion a more plentiful 
secretion of the lacrymal fluid, yet it cannot be 
questioned that the same temporary condition 
may prevail in the membrane lining the sac and 
duct, as in the other parts to which it is distribut- 



362 DISEASES OF THE APPENDAGES. 

ed ; I mean a state of vascular congestion and in- 
tumescence. This continued, would lead to a 
permanent thickening of this membrane, and 
from that cause a diminution of the calibre of 
the canal. An adhesive process, whether pri- 
mary or consecutive to the states of suppura- 
tion and ulceration, finally closes the duct, so as 
to render it absolutely impervious. The actual 
obliteration of the canal by the degeneration 
of the membrane into a texture resembling 
cartilage, is a secondary morbid change, 
and only the result of long continued ob- 
struction. 

Abscess in- I have had occasion before to observe that 

dependent 

of stricture, the inflammation and abscess of the sac, though 
frequently preceded, and in great measure pro- 
duced by obstruction of the nasal duct, is by no 
means always referable to that cause ; a con- 
siderable degree of obstruction endures for 
years without a tendency to excite inflamma- 
tion of the sac ; and on the other hand, the 
inflammation and abscess of the sac in its acutest 
form, as from exposure to cold and other ex- 
citing causes, and sometimes from injury, often 
exists without any degree of obstruction. In 
proof of this I may remark that the incipient 
inflammation of the sac often admits of resolu- 
tion by the use of leeches, &c, without further 
inconvenience to the patient ; and the whole 
treatment required for the abscess in many 



DISEASES OF THE APPENDAGES. 363 

cases, is simply the discharge of the matter, 
or in other words, the treatment applicable to a 
common abscess. 

A free opening of the sac for the purpose of dis- 
charging its contents, shortens the sufferings of 
the patient, and saves the skin; but unless the pre- 
vious existence of symptoms demonstrates the 
presence of a stricture, an abscess of the lacrymal 
sac is by no means a sufficient proof of it, to war- 
rant the employment of any further measures. 
The existence of an abscess is of itself a cause of 
temporary obstruction, and the stage immediately 
preceding the formation of abscess may have 
been the cause of a temporary stricture, of which 
the abscess and its discharge are the termination. 
Of this I am well satisfied : that the supposed 
invariable connection of an abscess of the lacry- 
mal sac with a stricture of the duct, enforced in 
the writings of the French Academicians, Mr. 
Pott, M. Desault, and others, have led to an offi- 
cious and often injurious treatment of this painful 
and sufficiently distressing malady ; and at all 
events, the first indication is simply that of giving 
issue to the matter, by a free incision of the 
sac, and applying a soft poultice in a bag to 
the inner angle of the orbit. 

Supposing, therefore, the case of abscess so Treatment 

r * °* # of abscess. 

far advanced, instead of introducing a style into 
the ductus nasalis, after opening such abscess, I 



364 DISEASES OF THE APPENDAGES. 

recommend simply the examination of the duct 
with a fine probe ; if the probe passes without 
resistance into the nose, the case requires no 
further operative treatment, the integument re- 
covers its healthy condition under an emollient 
application, the discharge gradually diminishes 
and the wound heals. If, on the other hand, 
upon examination with the probe introduced 
through the wound into the sac, resistance is 
offered to its passage into the nose, no more fa- 
vorable opportunity will be presented for over- 
coming such resistance. This therefore should 
be accomplished, but to this the operative pro- 
cess should be limited, and the wound should 
be suffered to heal without further disturb- 
ance. 

Erysipeia- An erysipelatous inflammation of the integu- 

tous inflam- . ... n . , 

mation. ments of the face m the vicinity ot the lacry- 
mal sac, in which the peculiar characters of 
that inflammation seem to indicate that the 
cutis is primarily affected, however this may be 
in fact the case, requires to be narrowly watched, 
especially if it extend to suppuration ; for then 
there will be reason to apprehend a sloughing 
ulceration of the cellular texture, and probably, 
the destruction of a portion of the sac from this 
cause 5 so that a lacrymal fistula will be the 
termination of the disease. But a more imme- 
diate cause for apprehension exists, if inflamma- 
tion has been preceded by any sign of obstruc- 



DISEASES OF THE APPENDAGES. 365 

fcion to the passage of the tears, and this, I be- 
lieve, will be found to be most frequently the 
case. The inflammation symptomatic of deep- 
seated suppuration is erysipelatous, as is well 
known to every practical surgeon, and this is 
more especially the case where any fascial or 
ligamentous texture intervenes, like that which 
covers and supports the sacculus lacrymalis. 
Therefore, although the incision of the sac is 
manifestly improper and unadvisable, unless it 
is distinctly ascertained to be the seat of 
suppuration, the erysipelatous nature of the in- 
flammation must not be considered to indicate 
the confinement of the disease to the integu- 
ment, and the previous healthiness of the sac. 
I do not hesitate to say that the evil of an un- 
called-for incision of the sac is, in every point 
of view, less than the opening formed by a pro- 
cess of disease under the circumstances sup- 
posed, for in the latter case it will be difficult 
to prevent a permanent fistula. 

The tear falling over the cheek is a sign of Moist or 

1 watery eye. 

complete obstruction, except under strong ex- 
citement, when indeed it happens even though 
the duct is free ; but the moist or watery eye 
indicating the retardation, not the arrest of 
the tear, is by much the more frequent case. 
This depends upon an imperfect obstruction of 
the nasal duct. This state often exists without 
any other external symptom of disease, and it 



366 DISEASES OF THE APPENDAGES. 

is a source of considerable inconvenience from 
the continual suffusion which it occasions, and 
the necessity it imposes of incessantly wiping 
the eye. 



Constrict- 
ed puncta 
and ob- 
structed 
ducts. 



The epiphora, or more properly, the c stilli- 
cidium lacrymarum,' resulting from the con- 
stricted puncta, or obstructed lacrymal ducts, 
is relieved by the introduction of a small silver 
probe into the sac once, or oftener, as may be 
required. Frequently the obstruction is con- 
fined to the saccular extremity of the duct. The 
case is common, the inconvenience considera- 
ble, and the relief complete. The obliterated 
punctum or canal is a case which admits of no 
remedy. 



Patulous 
puncta and 
atony of 
sac. 



The patulous puncta are usually combined 
with a swollen and atonic state of the canals 
and sac ; there is no contraction of the orifice 
on contact with the probe, no obstruction to 
its passage into the nose, nor any excretion of 
mucus upon the eye or from the nostril ; the 
situation and figure of the sac are conspicuous 
from its prominence. Such a state, most fre- 
quent in elderly persons, may in part depend 
upon a feebleness or paralysis of the orbicularis 
muscle, and a redundant fulness of the skin 
producing a partial eversion, or an enlargement 
of the semilunar fold of the conjunctiva, dis- 
placing the puncta or disturbing their relative 



DISEASES OF THE APPENDAGES. 367 

position. It results also from long continued 
distension of the sac, owing lo a morbid increase 
and retention of its secretion ; and under such 
circumstances, it may be partially relieved by 
astringent washes, but it is not in my expe- 
rience curable. 

The stricture which is occasioned by the ex- stricture 

J symptoma- 

tension of conjunctival inflammation to the la- tic of con- 

° juDCtival 

crymal excretories, should be treated only as a inflamma- 

t * tion. 

sign of that disease. When under the influence 
of a treatment purely antiphlogistic and sooth- 
ing applications, the inflammation subsides, 
the temporary interruption to the function 
of these organs ceases ; or if it should not 
cease altogether, the use of a gently stimu- 
lant colly rium will put an end to it. When, 
however, the state of distended sac, the re- 
gurgitation of mucus upon the eye, and the 
gathering of the tears in the lacus lacryma- 
lis are altogether chronic, there can be little 
doubt of the existence of a stricture, partial or 
complete; and I am unacquainted with any other 
mode of treating this disease than such as is 
adapted to the removal of the stricture, and 
the restoration of the canal. I am satisfied 
that the practice of introducing stimulant li- 
quids into the hollow of the inner canthus, in 
the supine position of the head, and of injecting 
the sac with astringent lotions, has no other ef- 
fect than that of aggravating the symptoms of 



368 DISEASES OF THE APPENDAGES. 

the complaint ; how indeed can any other result 
be rationally expected ? 

permanent When from the duration of this state the 

distension, 

threatening overflow of tears becomes continual, the disten- 

suppura- 

tion. sion of the sac and the discharge of mucus 

excessive — the conjunctiva towards the inner 
angle has a preternatural vascularity, the outline 
of the sac assumes a circumscribed phlegmonous 
hardness, and a blush begins to appear upon the 
skin covering it — when the eminences of the 
puncta lacrymalia are shrunk and absorbed in 
the swelling, and in short, the mucous is about 
to pass into the purulent secretion — even at 
tins period I have repeatedly averted the forma- 
tion of abscess by re-opening the nasal duct. 

Fiuctua- But when the disease has advanced another 
stage, and the pointing of the tumor and sense 
of fluctuation are perceptible, no advantage 
could be expected from the introduction of the 
probe through the lacrymal canal if it were pos- 
sible ; we have now a disease requiring a distinct 
treatment, and to prevent a complicated fistula — 
such as results from the yielding of the sac, the 
diffusion of its contents into the cellular sub- 
stance, and sinuses spreading in various direc- 
tions beneath the integument, — the free incision 
of the sac should be made without delay, and the 
treatment of the original disease postponed. 

The nail- 
headed When the integrity of the parts is restored, 



DISEASES OF THE APPENDAGES. 369 

it will be necessary in this case to have recourse 
to the same mode of proceeding which is adapt- 
ed to the other stages of the disease, and which 
appears to me to be the only method of treat- 
ment applicable to it upon a rational principle j 
for I confess myself at a loss to understand how 
relief can be afforded by the practice of intro- 
ducing a style to remain in the duct, and I am 
strongly disposed to doubt whether any permanent 
benefit was ever derived from such a practice. 
I am quite aware that the mere opening of the 
sac affords an immediate and considerable degree 
of relief ; and if a stricture has existed in the 
nasal duct, which is at the same time over- 
come by the introduction of a probe, the relief 
will be still more complete ; but the style 
which occupies the sac and duct can have no 
conceivable beneficial influence until it is with- 
drawn. The disease is transferred from the 
eye to the cheek, and the oozing of the tears 
through a small fistulous aperture in the sac, is 
substituted for their overflow of the natural 
channel. This state is, upon the whole, less 
irksome to patients, and in so far the prac- 
tice must be considered as palliative ; but I 
may fairly say that I have scarcely seen one in- 
stance in which this practice had been adopt- 
ed, and the style was still retained, whether 
at the expiration of three weeks, or three 
months, or three years, or double the latter pe- 
riod, in which the disease did not exist in un- 

B B 



370 DISEASES OF THE APPENDAGES. 

diminished force, under the modifications which 
I have just described, that is, as an established 
lacrymal fistula. Patients are reluctant to part 
with the style, because, as is natural, they as- 
cribe the degree of relief they have obtained 
from the opening of the sac and the diversion 
of the excretion, to what appears to them to be 
an essential part of the process. 

Dilatation, j j lave recommended the introduction of a probe 

gradual or * 

immediate. i nto t i ie nosej w h e n such an opportunity is pre- 
sented, from unwillingness to lose one so favora- 
ble for the restoration of the canal; and the only 
circumstances in which the permanent dilatation 
is required, is when the passage of the instrument 
in the direction of the duct is so firmly resisted, 
as to compel the forcible renovation of the ca- 
nal. In this case it is obvious that some 
means must be used to preserve it, and for this 
purpose two modes of practice are employed. 
Some surgeons having introduced a dilator into 
the duct, so far as the obstruction permits, fasten 
it there, and from day to day renewing the 
attempt to overcome the obstruction gain upon 
it by little and little, until at length the instru- 
ment enters the nostril ; here it is left for some 
days, when either an instrument of larger di- 
mensions or a seton is substituted for it, which 
is not finally withdrawn until the object is ac- 
complished. Others forcibly overcome the ob- 
struction at once, and afterwards place a style 



DISEASES OF THE APPENDAGES. 371 

or tube in the newly formed passage. I am 
not now speaking of the penetration of the os 
unguis or the breaking through of the bony pa- 
rietes, but of the re-opening of the original pas- 
sage ; which being obliterated by a morbid 
structure of the lining membrane, of such firm- 
ness as to require the employment of force, and 
to occasion a free hemorrhage from the nostril, 
is, in fact, the same thing as an artificial chan- 
nel. Of the two practices, I decidedly prefer 
the latter ; the former is drivelling, tedious and 
painful to a degree. 

Averse to any and every permanent tent, I 
formerly introduced a probe into the nose for 
many days in succession, but the daily increas- 
ing facility with which it passed was not a 
compensation for the pain it inflicted, and the 
ulceration of the wound by the repeated inter- 
ruption of the cicatrizing process. 

The practice which I have long employed, and The au- 
thor's prac- 
which I adopted as the most successful, after a trial tice. 

of the several methods of which I have made men- 
tion, the tube only excepted, is too obvious to 
have the merit of novelty. In a large propor- 
tion of Cases, it has proved successful in curing 
the disease, both in slight and aggravated forms, 
in early and advanced stages, without entailing 
the inconvenience and deformity inseparable 
from the various contrivances for permanent di- 
b b 2 



372 DISEASES OF THE APPENDAGES. 

latation, and avoiding altogether a fistulous 
aperture. Contented with accomplishing the 
passage of a moderate sized probe into the nose, 
after the incision of the sac, my attention is 
exclusively directed to the reduction of the in- 
flammation, and the restoration of the soft 
parts, with which, be it expressly understood, I 
never interfere, except in the case of abscess 
discolouring the skin, and threatening fistula. 
Thus, with this single exception of abscess, the 
treatment of the obstruction is one and the 
same, so far as the point of obstruction is con- 
cerned ; and it is a point always important to 
be ascertained ; the more so, as it is by no 
means of uniform occurrence. 

It can hardly be required that I should oc- 
cupy the time of the reader in shewing that 
the practice of opening a passage partially closed, 
or even an artificial passage, as nearly as pos- 
sible in the same direction, when the former is 
obliterated, commands a decided superiority 
over the practice of making an artificial opening. 
This applies to the treatment of the urethra, as 
well as of the ductus nasalis, and it is only in 
case of abscess, in which the distended and in- 
flamed integument threatens to give way by ul- 
ceration, that in either case I think it neces- 
sary to deviate from it. 



Lacrymai A set of silver probes, of about five inches 

prober. 



DISEASES OF THE APrENDAGES. 373 

long, varying in size, flattened at one end, and 
slightly bulbous at the point, are the instru- 
ments I use for the purpose of restoring the 
passage. The probe is introduced with perfect 
facility by one who is familiarly acquainted 
with the anatomy of the part, from either of 
the puncta lacrymalia, into the corresponding 
nostril, where no obstruction is offered to its 
passage. If the punctum be constricted, it is 
readily entered and dilated by a common pin ; 
and upon withdrawing it, by one of the smaller 
probes : the direction and relative situation of 
the lacrymal ducts, the sac, and the nasal canal, 
point out the proper course of the instrument. 
It is confirmed by its advance without the em- 
ployment of force, and the sensation conveyed 
by the free and unencumbered motion of its 
point ; until the point is fairly within the sac, 
it is necessary to keep the eyelid gently stretched 
and slightly everted ; the upper lid being drawn 
a little upward toward the brow, the lower as 
much downward toward the zygoma. The 
point carried home to the sac and touching 
lightly its nasal side, the lids may be left at li- 
berty, while a half circular motion is per- 
formed by the instrument ; the surgeon neither 
suffering the point to recede, or on the other 
hand, allowing it to become entangled in the 
membrane* 

The probe now rests in a perpendicular di- 



374 DISEASES OF THE APPENDAGES. 

rection upon the eyebrow towards its inner 
angle, and in this direction it is to be gently 
depressed until it strikes upon the floor of the 
nostril, where its presence is readily ascertained 
by a common probe, passed beneath the infe- 
rior turbinated bone. The probe of smallest 
dimensions is of sufficient firmness to preserve 
its figure in its passage through the healthy 
duct, but it is too flexible to oppose any con- 
siderable obstruction, without danger of a 
change of figure : for the stricture of the la- 
crymal ducts it is of sufficient strength. 



Very many cases of recent origin, and in 
which the stricture has no great degree of 
firmness, are completely cured by three or four 
introductions of the probe into the nostril, at 
intervals of one or two days. 

I have seldom met with a stricture so firm as 
not to yield to the full-sized probe. I am fully 
aware of the objection that immediately pre- 
sents itself, viz. that a passage so obtained is 
not permanent ; by several repetitions of the 
operation it is often rendered so; but if the re- 
sistance is not altogether removed, after a trial 
of the experiment for some days in suc- 
Lacrymai cession, I introduce a style having: a small 

styles. '. 

flat head, a little sloped, through the punc- 
tum la cry male into the nose, and leave it for 
a period of twenty-four hours in the duct. 



DISEASES OF THE APPENDAGES. 375 

If worn longer, as for two days, it ulcerates the 
orifice ; but I have never seen it injure the 
punctum in the smallest degree, when worn 
for the full period first named. A day or two 
should be suffered to elapse before the style is 
again introduced, and it should then be passed 
through the other lacrymal duct. The injec- 
tion of tepid water should be made on the inter- 
vening days with Anel's syringe. The plan re- 
quires perseverance, as may be said of all plans 
by which so difficult an object is sought to be 
effected. In many cases the resistance, in the 
first instance opposed, is inconsiderable, yet it is 
sufficient to maintain the disease. The probe 
passes daily with increasing facility, and after a 
very few repetitions, with as much ease as through 
the healthy canal ; yet the stillicidium, and even 
the mucous discharge do not immediately sub- 
side, because, although the obstruction is removed 
by which these symptoms were originally set up, 
the parts have not yet recovered the loss of tone 
which the state of habitual obstruction and inac- 
tion has induced ; and here the use of the probe 
is unavailing, if not injurious, as in all cases in 
which the full-sized probe passes without impe- 
diment. It is important that operators should 
consider this, and not lose sight of the vital 
function of the parts, in treating the morbid al- 
terations of structure which have interrupted 
and deranged them. For this mitigated, but 
not recovered state, time alone, with attention 



376 DISEASES OF THE APPENDAGES. 

to prevent distension by occasional gentle pres- 
sure of the sac if accompanied with mucous 
discharge, is often sufficient; but the injection 
of a solution of alum, or even of cold spring 
water, and the use of astringent washes will assist. 
Sniffing a stimulant vapor, as of vinegar, or 
diluted nitric acid, into the nostril, 1 have 
also found useful. It is of course unneces- 
sary to pass a probe, when the fluid injected 
by the punctum drips in a stream through the 
nostril or into the throat, as the head of the 
patient is inclined forwards or backwards ; but 
this test of the freedom of the passage should 
be had, before the use of the probe is laid aside. 

If it be objected to this operation, that it is 
always painful, and often tedious, I can only re- 
ply, that there is too much truth in the objec- 
tion. I shall be happy to be instructed in one 
equally effective, and free from these objections. 
I am far from assuming that alltheother measures 
employed might not be crowned with success in 
favorable cases ; this, like other complaints, 
sometimes recovers, not so much in consequence, 
as in despite of treatment. 

seton. Of all the other modes, the seton of 

Mejan alone appears to me to be a rational 
practice ; it too is tedious, and during its use, 

Tube. deforming. The tube seems, on the other hand, 
to be of all the most objectionable. I have seen 



DISEASES OF THE APPENDAGES. 377 

cases of its employment, in which it very speedi- 
ly became plugged with mucus, the sac habitu- 
ally loaded, the nostril dry, and the stillicidium 
permanent. But how a metallic tube can be ex- 
pected to form a substitute for the natural duct, 
an inorganic to serve in lieu of an organized 
part in perpetuity, the functions of the puncta 
and sac to be restored, and as it were in con- 
sent with it, I confess myself at a loss to con- 
ceive. I have more than once heard patients 
sorely regret that they had submitted to its in- 
troduction, having received no degree of per- 
manent benefit from the operation, and I have 
been called upon to remove it, which is not 
easily done, in one case from the disease 
which it had set up in the contiguous soft 
parts, and in others from an exasperation of 
the symptoms of the complaint. I am now 
speaking from what has incidentally passed 
under my notice of the practice of others ; but 
I ought in candor to add, that some very intel- 
ligent surgeons, both English and Foreign, have 
lately assured me of the general success of the 
practice in the able hands of M. Dupuytren, at 
Paris. 

In the use of the lacrymal probes, caution is 
requisite ; they must be passed with great gen- 
tleness, and if the extremity becomes confined, 
a little withdrawn, so as to prevent their hitching 
in the membrane, and passing beneath it j the 



378 DISEASES OF THE APPENDAGES. 

size should never be such as to distend the la- 
crymal canal, least it should injure the texture 
and destroy the tone of the part ; and no consi- 
derable degree of pressure should be made with 
one so slight as to be in danger of becoming 
curved. A probe of sufficient dimensions and 
firmness to preserve its straightness, is quite 
within the measure of the lacrymal orifices and 
ducts, and of sufficient strength to overcome 
an ordinary stricture. Injections should be fre- 
quently employed to ascertain the progress of 
the case towards recovery. They are of great 
use in almost all stages of the disease. 

Epiphora There are undoubtedly many cases of slight 
enuKb-" epiphora not depending upon mechanical ob- 
struction of the lacrymal excretories. The zinc 
and the lunar caustic solutions, the thebaic 
tincture, the mercurial ointments introduced 
between the lids will remove such forms of the 
complaint, if the patient is so far inconve- 
nienced as to apply to his surgeon for relief, 
which is not always the case. Again, the 
gleety discharge of the sac, as it is not always 
present with stricture, is sometimes, though 
not often, present without it. Stimulant col- 
lyria, cold water, and alum injections, and 
constitutional tonics must be employed to cure 
it. The chronic, thickened, and hardened state 
of the sac after abscess, and in the state of fis- 
tula, is removed by leeches, cold poultices, and 



DISEASES OF THE APPENDAGES. 379 

saturnine lotions; and if the skin be free from 
inflammation, it is reduced by the mercurial 
ointment. A small fistulous aperture, where 
the disease has been left to nature, is a common 
and troublesome case. The aperture should be 
freely dilated, the open state of the canal as- 
certained by the pocket probe, and the part af- 
terwards treated as above directed. 

No peculiar treatment is required in the ab- Abscess 

x with caries. 

scess with caries of the bones ; a case much less 
frequent than would be imagined from its de- 
scription as a stage of the disease. In this 
case, as in that where the sac has yielded to ul- 
ceration before the integument, the skin should 
be freely divided, that is, beyond the confines 
of the sac. 1 never met with a case requiring 
the use of a trocar, nor do I believe the per- 
foration of the os unguis is ever really required. 

I am not practically acquainted with the effect Reh«a 
of pressure upon the relaxed or hernial lacry- 
mal sac. It is an old, and I believe for a far 
better reason, an obsolete practice, viz. the 
difficulty of its application, and the feebleness of 
its effect. 

For the opportunity of seeing and treating an Dropsy of 
interesting case of dropsy of the sac, (the dis- 
ease described at page 242,) I am indebt- 
ed to the kindness of Mr. Alexander, to 



380 DISEASES OF THE APPENDAGES. 

whose extensive observation of this class of 
diseases it was new, as it was to mine. 
I exposed the distended and transparent sac by 
dissection, and removed by the scissars the two 
anterior thirds of it. A process of suppuration 
which ensued was for some time troublesome, 
but the wound at length healed soundly, 
and the complaint was cured by this treatment. 

With the disease in which the sac is said to 
acquire the size of a pigeon's egg from an accu- 
mulation of inspissated, or rather indurated se- 
cretion, having a cartilaginous hardness, and a 
livid color, I am entirely unacquainted. 



APPENDIX. 



Dr. Christian Salamon, of the Medical and Chirurgical 
Academy of St. Petersburgh, one of ten gentlemen deputed 
two years since, by his Majesty the Emperor Alexander, to 
visit foreign schools for the purpose of acquainting them- 
selves with the state of medical science, an appointment 
equally honourable to both parties, has politely favoured 
me with the following anatomical sketch, which is the 
result of some very delicate and laborious dissections. Some 
of these I have derived much instruction and pleasure from 
being permitted to witness, and although I do not feel satisfied 
in all points of the accuracy of Dr. Salamon's conclusions, I 
have nevertheless seen enough of his general professional in- 
telligence, his talent for minute investigation, and his method 
of conducting it, to feel assured that the following brief me- 
moir, in his own words, will make no inconsiderable addition 
to the interest of this work. I have the pleasure, at the 
same time, to announce, that those who take an interest in 
these researches, will shortly be gratified by the appearance 
of an anatomico-physiological dissertation on this subject, 
upon which Dr. Salamon is at present employed. 



OBSERVATIONS 

ON 

SOME POINTS 

OF THE 

ANATOMY OF THE EYE. 



Sclerotica, before reaching the cornea, increases in thick- 
ness and divides into two layers ; the outer advances be- 
yond the inner, and is connected with the exterior layers of 
the cornea ; the inner corresponds to the interior layers of 
the cornea. On the inside of the inner layer of the sclero- 
tica, near its termination, is an annular groove in the whole 
circumference, which receives a tendinous ring, (annulus ten- 
dinosus *) ; this ring is situated without the choroid, and 
firmly adherent to the sclerotic coat ; on its inside it is con- 
nected with the origin of the venous layer of the choroid 
coat. 

Cornea, consists of layers which are more firmly united at 
its centre than at the circumference. The inner surface of 
it is covered with a serous membrane, (membrana humoris 
aquei, Wrisbergi,) the existence of which is easiest shewn 
in eyes of aged persons ; this membrane can be separated 
from the innermost layer of the cornea, and diners from it in its 
greater tenacity and transparenc y. The latter quality it preserves 
in spirit; the greater firmness and more express character of a 
serous membrane distinguish it from the layers of the cor- 
nea ; it is not so liable as these to ulceration, or to be destroyed 
by an ulcerative process, and therefore sometimes protrudes 
aad forms the disease called by Professor Beer, ' Keratokele/ 

* Doellingerl descriptio oculi humaui. Wurceburgi. 



APPENDIX. 383 

Iris. Having subjected the iris to maceration, as I knew 
that by such a process the choroid coat may easily be di- 
vided into two layers, I succeeded in doing the same with 
this membrane. To such a division of the iris into two layers, 
I was led by the observation of some writers on the anatomy 
of the eyeball that the membrane of the aqueous humor is 
continued over the iris into the posterior chamber ; but with 
them it has been a mere supposition, and not proved by dis- 
section. If there is such a continuation over the iris, this mem- 
brane must be divided into two layers ; in ascertaining this 
I succeeded, and shall now endeavour to give a description of 
my dissection. I performed the division more easily from the 
pupillar margin of the iris, where this membrane is thicker, and 
at this place I could evidently distinguish the turn which is 
formed by the anterior layer of the iris continued into the uvea; 
betwixt these two membranes I saw distinctly the nerves and 
vessels distributed in a tortuous manner. Both membranes ap- 
peared somewhat transparent. The anterior layer, constituting 
the fore part of the iris, secretes on its inside, and between the 
two layers a pigmentum, which exhibited itself to me in dark 
eyes, darker than in light ones. From the remarkable differ- 
ence of this pigmentum in its colour, I am inclined to think, 
that the different colour of the iris particularly depends upon 
it, which then only can appear evident, when the uvea se- 
cretes its pigmentum. The anterior layer is afterwards con- 
tinued to the tendinous ring, where it unites with a serous 
membrane, which I consider the origin of the venous layer of 
the choroid coat, under an acute angle. The posterior layer 
or uvea secretes on its back part the pigmentum nigrum ; 
when this pigmentum is removed, there appear small white 
processes going off" from the ciliary processes to the uvea, 
being continued from the ciliary towards the pupillar margin, 
but not quite reaching the latter; these processes are, like the 
ciliary processes, more distinctly seen in dark eyes, and differ 
from them only in their smallness. 

Choroidea is easily divided into two layers, after maceration 
of several days. 1 . The outer layer, or choroidea stride sic 



084 APPENDIX. 

dicta, is the thinner serous membrane, in which the ciliary- 
veins are distributed to form the vasa vorticosa; it appears 
more distinct at its origin on the inside of the tendinous ring, 
where it unites with the anterior layer of the iris, and exhibits 
here evidently in its transparency the nature of a serous 
membrane. I think that this origin of the venous layer of 
the choroid coat has been described by Duverney as a pecu- 
liar serous membrane, covering the choroid coat. This venous 
layer appears more pallid at its beginning, on account of the 
ciliary ligament situated under it, and the deficiency of pig- 
ment; just behind the ciliary ligament it is perforated by the 
ciliary nerves and vessels of the iris. 2. The inner layer,or ruy- 
schiana, isfirmer, andsecretesitspigmentumnigrumin the back 
part of the eyeball on its outside ; as soon as it reaches the 
origin of the zonula ciliaris, it forms the ciliary body (corpus 
ciliare), which begins with a dentated margin, and secretes 
here its pigmentum nigrum on the inside; hence the im- 
pression of it appears on the zonula ciliaris. Professor Beer 
distinguishes the posterior part of it as the ' pars non plicata 
corporis ciliaris/ which is larger on the temporal than on the 
nasal side of the globe, on account of the retina advancing 
more forward on the nasal side, as the optic nerve enters 
more on that side of the globe. This pars non plicata is the 
very part through which the needle is brought into the vitre- 
ous humor in operations through the sclerotic coat, and it is 
the part which is united by cellular tissue with the zonula 
ciliaris, to which the processus ciliares have no adhesion in the 
human eye. Professor Beer calls the anterior part of this body 
pars plicata, to the formation of which the ciliary processes con- 
tribute. The ruyschiana, after having formed this body, con- 
tinues forward, having to its inner surface firmly united the ci- 
liary processes, and to its outer the ciliary ligament, to the back 
part of the iris into the uvea ; so that I consider the ruyschiana 
as the mere continuation of the uvea. This continuity is not 
disturbed, after having separated the ciliary 7 processes with their 
origins ; and the appearance of both membranes is com- 
pletely the same, each exhibiting the nature of a thin serous 
membrane. 



APPENDIX. 385 

Having now described the choroid coat and the iris, and 
the connexion of them anterior to the tendinous ring, I must 
here remark, that when this tendinous ring is separated from 
the sclerotic coat, the venous layer of the choroid and the ante- 
rior lamina of the iris form one membrane turning towards 
the cornea for the space of about one line ; which appearance 
makes me believe, that it is the membrane of the aqueous hu- 
mor, though I could not follow this membrane further by 
dissection, so as to shew clearly its continuation. Yet it is 
evident that this membrane divides before the tendinous 
ring into two, the outer and posterior forming the 
venous layer; the inner and anterior, forming the iris, 
continues, uvea and ruyschiana. That it is a division of 
this membrane in these two different directions, I conclude 
from the finer structure of each of these two membranes than 
of that before the tendinous ring. The expressed character 
of a serous membrane in the latter, and its similarity in 
structure with that of the aqueous humor, make me believe, 
that it is really the membrane of the aqueous humor itself; 
pathological observations prove also such a contiguity to the 
iris, i. e. the corneitis so quickly followed by iritis, and vice 
versa ; so that the primary inflammation of the cornea is de- 
nied by eminent pathologists. 

As to the nature of the iris, choroidea, and ruyschiana, I 
am inclined to think that they are of a serous kind, from the 
appearance which they exhibit in their natural state, and the 
more so, from the morbid alterations to which they are sub- 
jected during inflammation, which is most evident in the 
iris, viz. the disposition to throw out coagulable lymph 
even in the slightest degrees of inflammation, and thus to 
pi*oduce an adhesion of the uvea to the capsule of the lens, or 
to close the pupil entirely ; in other cases to form partial or 
total adhesions of the iris to the cornea. The tubercles in the 
syphilitic iritis, which Beer calls condylomata, and appear 
at the ciliar or pupillar margin of the iris, are of a more or 
less brownish and red color, which variety of color depends 
on the smaller or greater organization of the coagulable 

c c 



386 APPENDIX. 

lymph. In a higher degree of iritis, though more rarely, 
there may be formtd an abscess, which occupies, as Beer ob- 
serves, the middle of the iris ; in these respects, as to the 
liability of adhesive inflammation, and rare occurrence of sup- 
puration, in the substance of the iris, it coincides in its nature 
with that of serous membranes. The same liability to adhe- 
sion we may observe in the choroid coat, when a dissection of 
the eyeball is performed after a deep-seated inflammation, 
when we shall find not rarely adhesions of the venous mem- 
brane to the sclerotic coat, but more frequently of the ruyschi- 
ana to the retina; or after the operation for cataract, adhesion of 
the zonula ciliaris to the ciliary processes. The difference of func- 
tion in the iris and ruyschiana, though they are the continua- 
tion of a serous membrane, I explain from the addition of other 
parts, as in the iris, of the ciliary nerves and vessels, to which 
I think the motion of the iris is to be attributed ; and in the 
uvea and ruyschiana, from the other ciliary arteries, which 
secrete the pigmentum nigrum. 

Ligumentwn ciliare, is a cellular substance of a conical 
shape, situated between the choroidea and ruyschiana, just 
above the corpus ciliare and ciliary processes, its basis turned 
to the iris, its apex backwards. It is of various colors; 
in light eyes it is lighter, looser, and larger. As to the 
use of it, I think it is for defending the vessels and nerves of 
the iris, which go through it. These vessels and nerves are 
situated at the back part of the globe without the venous layer 
of the choroid coat, and as soon as they reach the ligament 
perforate this membrane. 

Processus ciliares, are situated on the inside of the ruyschi- 
ana, occupying nearly the anterior half of the ciliary body ; 
they originate by their bases in the angle formed by the 
uvea, continuing into the ruyschiana ; they are situated out- 
wards and backwards; their attenuated termination is where 
the connection of the zonula ciliaris with the ciliary body 
begins. They may be separated from the corpus ciliare by the 
help of a needle, and elevated. There appear some laiger and 



APPENDIX. 387 

some smaller processes, and two commonly arise together. The 
origins of these processes form the boundary of the posterior 
chamber in its entire circumference. From this descrip- 
tion it is evident that the depression of the crystalline 
lens into the posterior chamber (as described by some oculists), 
cannot be done without a violent injury to the ruyschiana or 
iris. From these processes arise smaller ones, continuing to 
the back part of the uvea. As to these processes, I have still 
to remark, that they are described by some anatomists as con- 
nected with the choroid coat, but I could not find such a 
connection. That they are formed by the ruyschiana, I can 
also not admit, because, 1. they may be separated and raised 
from the corpus ciliare without injuring the continuity of the 
ruyschiana; 2d. they are different in their structure, endowed 
with greater firmness and elasticity; 3d. they do not secrete 
pigmentum nigrum in the human eye. I consider these pro- 
cesses as consisting in themselves of a different structure from 
that of the membranes of the eyeball ; they appear to me 
very elastic, and of a substance which I might call one be- 
twixt tendon and ligament. These processes are covered with 
a cellular tissue, which I have seen fully injected ; this cellular 
tissue seems to be the secreting apparatus of the aqueous hu- 
mor in the posterior chamber. 

Retina, covers the corpus hyaloideum, and is connected 
with it at its back part, after having entered the eyeball, but 
much firmer in its connection at the anterior part, where the 
zonula ciliaris originates at the dentated margin of the ciliary 
body; here it forms the ora serrata, which is considered the 
end of the retina. Professor Doellinger describes a thinner 
continuation under the zonula ciliaris as far as the canal of 
Petit. I repeated these dissections, and found that there ex- 
ists a substance exhibiting itself as cellular texture, destitute 
of medullary substance ; whether this is mere cellular texture, 
or a continuation of the inner layer of the retina, is uncer- 
tain. As to the membrane described by Jacob in a late 
number of the Philosophical Transactions, I have seen it in 
brutes; it appears evidently of a serous nature. 

c c2 



388 APPENDIX. 

Zonula Ciliaris. An accurate description of this part has 
been given by Professor Doellinger (Liber das Strahlen-blattchen) 
of which I shall mention shortly the anatomical facts. The 
zonula ciliaris is situated under the corpus ciliare, and the 
serrated margin of that body denotes its commencement, from 
which place it goes to the anterior capsule, and unites with it 
intimately. The ruyschiana is easily separated from the 
retina until it reaches the zonula ciliaris ; it is united with this 
by firm cellular texture. The zonula Zinnii has about three lines 
of breadth, has an anterior and posterior margin, an outer and 
inner surface ; the outer one is connected with the corpus ci- 
liare; the inner surface is connected with the attenuated con- 
tinuation of the retina ; the anterior part of the zonula is free. 
The canalis Petiti is formed by the zonula Zinnii and hyaloid 
membrane; the hyaloid membrane is connected with the pos- 
terior capsule of the lens more backward, and the zonula 
Zinnii more forwards with the anterior capsule, so as to leave a 
triangular space. The zonula consists of fascicles, which ap- 
pear more evident when the canal k filled with air (Zinn); 
these fascicles are connected with the serrate prominences of 
the retina. — Since Window's time, this zonula is derived from 
a splitting of the hyaloid membrane; but the following obser- 
vations are opposed to thisopinion: l.The h) aloidmembranehas 
such a thinness, that it cannot be divided into two layers, as 
Zinn had already observed. 2d. The zonula has a quite different 
structure; the hyaloid membrane has nothing fibrous. 3d. The 
hyaloid membrane is at the posterior convexity of the lens 
not thinner than in the other regions of the vitreous humor. 
4th. Between the corona ciliaris and hyaloid membrane is situ- 
ated the continuation of the retina under the zonula. I have 
to mention last, the distribution of vessels in the zonula, 
which also proves, that it is not a continuation of the hyaloid 
membrane ; the anterior part of the zonula obtains its vessels 
with the anterior capsule of the lens ; the posterior part of the 
zonula from the arteria centralis after its division upon the 
posterior capsule of the crystalline lens, and forming here an 
anastomosis with the other vessels ; and finally, the zonula has 
been injected with the capsule, but the hyaloid membrane has 
not shewn the least trace of injection. 



APPENDIX. 389 

Lens crystallina, is included in a proper capsule; the anterior 
is firmer than the posterior, which depends on the connection 
withthezonula ciliaris, and itobtainsits vesselsfrom the corpus 
ciliare. In the posterior capsule is distributed the arteria 
centralis, and it is connected with the hyaloid membrane by- 
loose cellular tissue. 

Humor vitreus, consists of cells, filled with a fluid like 
aqueous humor. It obtains its vessels from the retina, and the 
central artery going to the capsule gives off the arteria latera- 
lis Albini. When the cells are destroyed, they are not restored,, 
but the space is filled by a fluid, which resembles aqueous- 
humor. 




•.'/;,,. 9. 



PLATE 








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EXPLANATION OF THE PLATES. 



PLATE I. 



Fig. 1. A plan of the muscular branches of 
the ophthalmic artery, from Soemmering. 
Icon. Ocul. Hum. Tab. 4ta. 

This figure was accidentally misplaced by the 
engraver; the tendinous insertion of the supe- 
rior oblique muscle demonstrates that the mus- 
cle in front of it is the attollens, or rectus supe- 
rior, which consequently should have been 
placed uppermost. The abductor muscle is 
marked by its bicipital origin. See page 88. 

Fig. 2. Simple acute inflammation of the 
conjunctiva. See page 91. 

Fig. 3. A plan to shew the cicatrization of 
an ulcer of the cornea, whether pustular or in- 
terstitial, and communicating with the surface, 
by a fasciculus of vessels carrying red blood. 
See page 109. 

Fig. 4. The state of strumous nebula with 
vessels in the form of radii overshooting the 
cornea. These are not continuous with, but 



392 EXPLANATION 

distinct from the vessels of the conjunctiva, and 
beneath it. See page! 10. 

I have seen cases of the prolongation of these 
vessels even to the centre of the cornea, orga- 
nizing the nebulous deposit, affecting both eyes 
of the same patient, and occasioning total opa- 
city and blindness, perfectly restored by con- 
tinued ptyalism. The first change was the 
breaking and clearing of the dense deposit of 
lymph, then the fading away of the rose- 
colored zone at the verge of the cornea, and 
lastly, the gradual disappearance of the vessels 
on the cornea. See page 282 <N seq. 

Fig. 5. A plan of the anastomosis of co- 
lored vessels upon an opaque cornea; ' chro- 
nic inflammation with vascular cornea.' See 
page 110. 

Fig. 6. Aphthous or pustular inflammation 
of the conjunctiva. Two large aphthae are seen, 
one on either side of the cornea, situated nearly 
in the transverse axis of the globe. This figure 
was selected for the purpose of shewing the pe- 
culiarity of two distinct orders of vessels bound- 
ed by the pustules. The upper segment of the 
hemisphere presents the ordinary superficial 
vessels of the conjunctiva, having the areolar 
distribution. The lower are the straight ves- 
sels penetrating the sclerotica, and appearing 



OF PLATE I. 393 

through the transparent conjunctiva. This two- 
fold arrangement is seldom so distinctly seen. 
See pages 95 and 128. 

Fig. 7. The blue tumor of the sclerotica, 
■ staphyloma sclerotica^/ accompanying various 
disorganized states of the globe. See pages 
129, 130. 

The figures 2. 4. 6. and 7. in this plate, are 
from nature. The three former have an appear- 
ance of unnatural magnitude, from the artificial 
elevation of the upper and the depression of the 
lower lid, for the purpose of exhibiting the 
conjunctival surface around the cornea. 



( 394 ) 



PLATE II. 



Fig. 1. Carcinoma of the conjunctiva affect- 
ing the globe and eyelids. 

This very accurate representation of the dis- 
ease was taken from the eye of a patient of mine 
in St. Thomas's Hospital, by Dr. Zuckerbecker, 
a very intelligent physician now settled at Mos- 
cow. See page 100. 

Fig. 2. A section of the fungous growth 
represented in situ, Fig. 4. 

Fig. 3. The state of central slough of the 
cornea in the last stage of acute suppurative in- 
flammation. 

Fig. 4. A peculiar fungous growth intersti- 
tial to the conjunctiva and cornea. See page 
102. 

This figure represents the appearance of the 
disease, as it was presented to me in the person 
of an elderly lady from Somersetshire, and the 
idea I then formed of it was, that the fungus had 
originated from the iris, or choroid tunics, con- 
sequent to a slough of the cornea. Finding 
that the sclerotic tunic was sound, I proposed 
the excision of the tumor by an operation simi- 
lar to that for staphyloma. This was executed 







^ 






Mra-sii r-, J 








■ 



EXPLANATION OF PLATE II. 395 

with facility, and the patient quickly recovered, 
the remaining portion of the globe collaps- 
ing in the orbit. The surface had the deep 
blue tint, and the currant or berry-like appear- 
ance denoted, likening it to what is termed by 
the Germans ' Staphyloma racemosum,' but it 
proved to be totally different in its nature from 
that disease. 

The section Fig. 2. is shrunk from immersion 
inspirit; it is varicolored and of unequal con- 
sistence ; in some parts pulpy, in others firm ; 
the sclerotica is not altered in its structure ; the 
iris is thickened by inflammation, the pupil closed, 
and the capsule of the lens, which is shrunk and 
opaque, adherent to the uvea. The red line is 
the section of the iris, aud the yellow substance 
beneath and adhering to it represents the shrunk 
crystalline. These parts were quite free from 
the disease and changed only by compression. 
The cornea which is seen at the base of the fun- 
gus has lost its lamellated structure, and hence 
appears firmer ; its surface is rough and has a 
brownish tint, as if beginning to degenerate into 
the morbid mass which lies above it. This not 
only covers the cornea, but at one part a little 
overlaps the sclerotica. The section discovers 
a subdivision of the larger into lesser lobes, sepa- 
rated by whitish lines intersecting the mass per- 
pendicularly. The lobes differ in structure and 
in color, as if originating in cells and distinct from 



396 EXPLANATION OF PLATE IT. 

each other. In one part adjoining the surface 
a whitish spot is conspicuous, of a cartilaginous 
hardness. The fungus is covered by a mem- 
brane easily torn ; if this be not the conjunctiva, 
no trace of that membrane remains ; but I am 
disposed to think from its relation to the tumor, 
and the continuity of the conjunctiva sclerotica^ 
with this membrane, at that part of the circum- 
ference of the cornea where the pulpy mass has 
encroached upon the sclerotica, that the covering 
membrane is formed of the conjunctiva in an 
altered state. The intimate adhesion of the 
fungus to the covering membrane, the total 
change in texture of the conjunctiva, and the 
fuller evolution of the disease next the surface, 
lead me to suppose that the disease originates 
from that membrane j and from its lobular ar- 
rangement I conclude, that the morbid growth 
occupies the cells of the connecting membrane 
indicated by the white lines intersecting it. 

Fig. 5. Abscess of the eyeball terminating 
in ulceration and death of the cornea and dis- 
organization of the globe. See page 215. 

Fig. 6. Schirrus of the lacrymal gland. See 
page 228. The deformity was removed by ex- 
tirpation of the gland. 



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( 397 ) 



PLATE II L 

Fig. 1. and 3. represent in different positions 
the eye of a child affected with the malignant 
fungus, prior to the opacity of the cornea ; in 
which are observable the change of figure of the 
globe and annihilation of the anterior chamber, 
by the bulging of the opaque lens and iris. 

Fig. 2. is a section of the same eye. 

These drawings having been made immedi- 
ately upon the removal of the eyes after death, 
represent accurately the recent appearances, 
but by a minute dissection after hardening in 
spirit, I have been enabled to trace some ves- 
tiges of the several textures which the mere sec- 
tions do not exhibit, in a manner which would 
have given the representation, if that had been 
possible, additional interest, as it throws much 
light on the origin and progress of the diseased 
growth. 

A substance answering the description of the 
' sarcoma medullare,' occupies the upper and 
back part of the eyeball, by which the vitreous 
humor, which has undergone a similar degene- 
ration, is compressed and pushed forward and 
downward. The sclerotica is in a perfectly 
healthy state, as are also the cornea, iris, and a 



398 EXPLANATION 

considerable part of the choroid ; the lens ab- 
sorbed, its capsule firmly adherent to the uvea. 
The diseased mass is evidently deposited be- 
tween the venous and arterial layers of the 
thickened choroid coat ; the former adherent to 
the sclerotica, being situated external to the 
morbid mass ; the latter, (which has been de- 
scribed as the tunica ruyschiana,) separated and 
protruded by it, is denoted by a line crossing 
the section obliquely. Here no pigmentum ni- 
grum is secreted. The corresponding posterior 
part of the retina is destroyed, the anterior is 
adherent to the choroid. At the back of the 
eyeball is a medullary tumor contained in a cap- 
sule, formed by the surrounding cellular texture. 
A similar tumor is formed by the optic nerve at 
its entrance. The texture of these is somewhat 
firmer than that within the ball, and between 
these tubera and the internal diseased mass there 
is no communication. 

Fig. 4. represents the other eye of the same 
subject, wlien, by the progress of the disease the 
cornea had perished by ulceration, and the fun- 
gus, represented Fig. 5., was just about to pro- 
trude. The leaden tint of the extenuated scle- 
rotica is characteristic. 

Fig. 5. represents the contents of the orbit 
on removal after death. 



Fig. 6. is a section of the fungous mass. 



OF PLATE III. 399 

The optic nerve filled with the morbid 
deposition has its neurilemma thickened ; and a 
similar substance occupies the cellular texture 
within the orbit. The white lines bifurcating 
from the extremity of the nerve, represent the 
sclerotica thickened. On both sides of the en- 
trance of the optic nerve, a mass is formed on 
the interior of the sclerotica, resembling that on 
its outside except that its texture is firmer. 
Forwards, on the right side of the figure, the 
sclerotica is distinctly split into two layers by 
the pulpy substance which has insinuated itself 
between them. This corresponds to the upper 
half of the globe. 

The plate, which represents only a recent sec- 
tion, does not illustrate the remaining points of 
the description. They have been since made 
out by sub-division and careful separation of 
the several parts of the mass from each 
other. As they are highly curious I sub- 
join them. 

The interstitial deposit is seen in the whole 
anterior circumference of the sclerotica, but the 
layers of this membrane are less widely separated 
from it at the inferior part of the ball. At the 
posterior part, where the sclerotica is single, the 
membrane is much altered, but it has no where 
given way, so that the diseased masses upon its 
opposite surfaces have no direct communication. 



400 EXPLANATION 

By the mass formed on its inside, the choroid 
coat is distinctly -1 len to be protruded forwards. 
At the anterior part, the sclerotica is firmly con- 
nected with the thickened choroid coat. The en- 
tire centre of the cornea has perished by an ul- 
cerative process, but a fragment of corneal 
lamella remains to denote its place, and behind 
it is a portion of membrane adhering, and re- 
sembling the iris much altered in its structure. 
The softest part of the fungus is connected with 
this membrane, and between it and the choroid 
no trace appears of the humors or retina. This 
anterior mass is distinguished from the posterior 
growth of the sclerotica, from which it is sepa- 
rated by the choroid, by its softer texture and 
darker color. Hence it appears that the mor- 
bid substance within the ball consists of two 
different formations ; first, of the sclerotica de- 
generated on its exterior and interior surfaces, 
and likewise in its substance ; secondly, of the 
choroid degenerated on its interior surface. 

Fig. 7. This figure represents the section of 
the eye of a child, aged eight months, which I 
extirpated several years ago. The subject of 
the operation has since enjoyed perfect health. 
See page 203. 

The cells of the vitreous humor are filled 
with an opaque lardaceous substance, by which 
the lens was slightly protruded, and the iris ren- 



OF PLATE III. 401 

dered convex. The eyeball was but little in- 
creased in size or altered in figure. The scle- 
rotica was in some parts thinner than usual, and 
had a bluish hue from the preternaturally firm 
adhesion of the choroid coat. The retina was 
for the most part, absorbed, the other tunics per- 
fect, and the optic nerve free from disease. 

There is no evidence to prove this change of 
structure malignant, although the external ap- 
pearances closely resembled those of Fig. 3. 



D D 



( 402 ) 



PLATE IV. 

Fig. I. 2. and 4. are from preparations in the 
Museum at St. Thomas's Hospital. 

Fig. 1. Is the section of an eye extirpated 
by the late Mr. Ware. The morbid growth 
fills the thickened sheath of the nerve, and tu- 
bera are seen on both sides of the globe formed 
in the substance of the sclerotica. The mass, 
distinguished by a greyish tint and occupying 
the posterior third of the globe, protrudes the 
choroid tunic. The crescentic line of division 
is formed by the choroid. The anterior mass, 
which is darker, and closer in texture, cor- 
responds to the vitreous humor. The choroid 
and iris are anteriorly compacted with the scle- 
rotica and cornea ; the retina has disappeared. 

Fig. 2. Section of an eye in which the dis- 
ease spreads from the sheath and substance of 
the nerve through one side of the sclerotic tunic 
almost as far as the cornea. It forms a broad 
and compact mass of a yellow color. On the 
opposite side this tunic is unaltered. The 
choroid adjoining the tumor of the sclerotica 
has undergone a similar change, being of a deep 
claret color, equally dense in structure, and about 
half the breadth of the diseased sclerotica with 



PLATE IV 








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EXPLANATION OF PLATE IV. 403 

which it is compacted. The shrivelled retina 
is seen proceeding from the extremity of the 
nerve encompassed by the choroid tunic, which 
on the side opposite to the morbid growth, re- 
tains much of its color and texture. 

Fig. 3. is a representation of a fine specimen 
of this disease in its more acute form. See page 
309. The man from whose eye this drawing 
was taken, was a farmer's servant, of temperate 
habits, who had always enjoyed good health. 

The following brief particulars of the case are 
extracted from my clinical register. 

Five months before his admission into St. 
Thomas's Hospital, October, 1817, he first per- 
ceived a dimness in the vision of this eye, and 
after this had continued about a week, he was 
attacked with an ophthalmia, accompanied by 
severe pain across the forehead and orbits. 
The pain was much exasperated by stooping, 
which excited a sensation of the eyes being ex- 
truded from their sockets. After a period of three 
weeks the inflammation subsided, and he after- 
wards felt only occasional pains darting through 
the temples. About eight weeks since, he dis- 
covered that he had totally lost the vision of 
his right eye, and about a month ago the fun- 
gus seen beneath the cornea, first made its ap- 
pearance. On his admission into the hospital, the 

d d 2 



EXPLANATION 

fungus had the size of a filbert, of a reddish brown 
color and irregular figure, protruding from the 
under part of the ball, driving up and shrivelling 
the cornea with which it was unconnected, and 
covering the lower lid. He now suffered little, 
if any pain ; and was free from glandular en- 
largements. His digestive functions were un- 
impaired, his general health good, and the op- 
posite eye healthy in appearance. Towards the 
end of the month the fungus had much increased 
in size, and was disposed to frequent and free 
hemorrhage. On the 7th of November, I per- 
formed the operation of extirpation. Some 
pieces of soft lint were afterwards placed 
within the orbit, and the lids supported by 
a compress. The patient continued in a 
perfectly favorable state until the 10th, when 
he had a slight chilliness followed by per- 
spiration. He complained of pain darting to- 
wards the back of the head; his pulse was 72, 
and hard. A free suppuration having com- 
menced, the lint was removed from the cavity 
of the orbit. Sixteen ounces of blood were 
drawn from his arm. His bowels had been 
freely open since the operation. From this day 
until the 15th he continued free from fever and 
from pain ; a healthy and copious suppuration 
was established ; he had a soft and natural pulse, 
except that it was sometimes a little irregular. 
On the 16th he left his ward and remained for 
some time in the square of the hospital, thinking 



OF PLATE IV. 40.! 

the air would be of use to him. Soon after 
coming in he was attacked with a very severe 
rigor, followed by heat and profuse sweating. 
On the 17th he had considerable fever. The 
scalp above the external angle of the orbit was 
considerably puffed and tender to the touch, 
and a free incision was made to the bone, 
when a collection of matter was discharged 
from beneath the periosteum. On the 18th, 
his febrile symptoms having yielded to the 
exhibition of antimonials, the skin clammy, 
occasional intermission of the pulse, and great 
lowness, he was put upon a nourishing diet, 
and ordered to take bark, and an opiate 
at night. 19th. He had slept well, but his 
looks were much altered for the worse ; 
he was partially comatose, and his answers 
were lingering and not always coherent. 
The pulse was slow and feeble, and the inter- 
missions more frequent and longer ; his tongue 
when protruded was tremulous and drawn a 
little to the left side. On the 20th he was at- 
tacked with convulsions, which continued until 
an early hour of the morning of the 21st, 
when he expired. 

On examination, thirty -five hours after death, 
a large quantity of purulent matter escaped 
from beneath the dura mater. Upon raising that 
membrane, a purulent deposition extended over 
the whole of the right hemisphere, to which it 



406 EXPLANATION 

was confined. The dura mater retained its at- 
tachment to the cranium j no communication 
could be traced between the morbid appearance 
of this membrane and the orbit ; the optic fora- 
men being completely closed and the nerve in a 
perfect state. The substance of the brain had 
a natural appearance, allowing for some con- 
gestion occasioned by pressure. 

I cannot avoid remarking the importance of 
this history, setting aside the consideration of 
the malignant disease, with which in fact the se- 
quel had no connection. 1st. To shew the ten- 
dency of an extraneous substance to provoke a 
more copious suppuration from the orbitar ca- 
vity than otherwise follows the operation. 
2ndly. To demonstrate the tendency of mem- 
branous inflammation to spread, both by conti- 
nuity (pericranium) and by contiguous sympathy 
(interior membranes of the brain.) 3dly. To 
prove the ill effects of exposure to cold during 
a free suppurative process in the vicinity of the 
visceral cavities, of which I have seen several 
well marked examples ; two, for instance, of the 
extension of the suppurative action from the pa- 
rietes of the chest to the pleura, under circum- 
stances very similar. 

Dissection of the Eye, 
The whole cavity of the eyeball is filled witii 



OF PLATE IV, 407 

a dark friable fungous mass, and no trace of 
the textures within the choroid can be distin- 
guished. The sclerotica, much extended and 
thinner than in health, is in various parts of a 
purple hue, from the intimate adhesion of the 
choroid, which is thickened and filled with 
blood-vessels. Anteriorly this coat could be 
separated from the sclerotica ; but backwards 
it had completely degenerated into the morbid 
substance. On the outside of the optic nerve, 
in the situation of the foramen centrale, the 
sclerotica had given way, and the morbid mass 
projected in the form of a tumor of the size of 
a large pea. The iris and lens were completely 
destroyed, the cornea in its middle part ulce- 
rated, and the tumor beginning to protrude 
through it j the optic nei ve was free from dis- 
ease. 

Fig. 4t. is the section of a diseased eye, 
the history of which is not known. The 
sclerotica, it will be observed, is in parts, mor- 
bidly thickened, the cavity appears to be di- 
vided into chambers, which are rilled by a dark- 
colored substance, compacted with the sclerotica, 
and interspersed with specks and patches of 
white, giving it a marbled appearance. The 
light-colored mass on the lower and right side 
of the drawing, corresponds to the vitreous 
body ; and a remnant of lens, inclosed in its 
capsule, retains its relative situation to that 



408 EXPLANATION 

body, but is so displaced by the extension of 
the morbid growth adherent to the cornea, as 
to be situated almost at right angles with that 
membrane. The sheath of the nerve is thick- 
ened. The disease seems to be a degeneration 
of the choroid and iris. 

Fig. 5. is a very exact representation of 
an eye which I extirpated at the commence- 
ment of the present year. 

The subject of this disease was a respectable 
tradesman, forty-two years of age. He had en- 
joyed good health until two years before, when 
he experienced a sensation of heaviness in the 
upper eyelid, as if unable to raise it, though no 
ptosis appeared. Pain commenced in the same 
side of the head, extending from the fore- 
head to the occiput, and was subject to fre- 
quent exasperation, depriving him of rest. By 
slow degrees the sight of the eye, at first only 
misty, totally fiiiled. The cornea became glazed 
and dead in appearance. Three months prior 
to the operation, the eyeball became also the 
seat of pain, for that in the head was not dimi- 
nished by day or night, and the ball at the same 
time began to enlarge. The vessels assumed 
the varicose appearance represented, and the 
sclerotica protruded in several points, which had 
a deep blue color, and seemed threatening to 
burst. About this time he was three or four 



OF PLATE IV. 

times seized with a dazzling of vision, giddiness, 
and momentary confusion, like slight shocks of 
apoplexy. Lastly, the principal protrusions 
gave way, and a continual hemorrhagic oozing 
took place. In this state the operation was 
done. It was followed by scarce any indisposi- 
tion ; in a fortnight he resumed his employ- 
ment, and has continued to this time free from 
uneasiness and in the enjoyment of perfect 
health. 

Fig. 6. is a section of the same eye. The 
disease is here in its most advanced stage ; the 
eyeball is double its natural size ; the sclerotica 
of a deep blue color, being in some parts so 
much extenuated as to seem on the point of 
bursting; the veins of the conjunctiva varicose 
and turgid with blood. The mass contained in 
the eyeball, wherein are no traces of the inter- 
nal parts, has a greater vascularity than in Fig. 
3. At the upper part of the cornea, the scle- 
rotica has yielded to the disease, and a large 
tumor projects. The cornea is not altered in 
structure, otherwise than by compression and 
collapse. By the side of the optic nerve, and 
beneath it, a distinct tuber presents itself, the 
section of which corresponds in appearance to 
that of the mass which occupies the globe. The 
nerve is not affected with the disease. 



409 



( 410 ) 



PLATE V. 

Fig. 1. represents the eye of a girl, a pa- 
tient of Mr. Astley Cooper, in Guy's Hospital. 
The disease was accompanied with glandular 
enlargements, and of several months standing. 

Fig. 6. is the eye of an infant, aged eight 
months, likewise a patient of Mr. Cooper, in 
Guy's Hospital, in whom the disease was con- 
genital. See page 205. 

Neither of these cases was the subject of an 
operation, and I have not been able to obtain 
any information inspecting them since they 
quitted the Hospital. The disease in the infant, 
from the central position of the cornea, and from 
the enormous protrusion and equal figure of 
the ball, was supposed to be seated in the or- 
bitar appendages. It is remarkable that the 
child was well nourished and apparently suffered 
little constitutional disturbance. The right eye 
was sound. 

This engraving was reduced from a drawing 
of the size of life upon a scale of 25 to 36. 



A proptosis or protrusion of the ball conveys 
a delusive idea of the increased magnitude of the 



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EXPLANATION OF PLATE V. 411 

organ. I have occasionally met with cases of 
proptosis to such an extent as to occasion a 
morbid change upon the cornea, with a varicose 
state of the vessels of the conjunctiva; and with 
others in which, although the cornea remained 
clear, the vision was materially deranged, where 
the cause of the protrusion was altogether ob- 
scure, and the progress of the disease had been 
so slow as to occupy a period of several years. 

In these cases both eyes are equally affected; 
they are attended with a distressing degree of 
deformity, obtuse pain in the forehead, and 
other occasional signs of determination of blood 
to the head. It is probably a morbid increase 
of the adeps contained in the orbit, obstructing 
its circulation, as well as protruding the eyeball. 
The disease, when acute, is of a different and 
more formidable nature. The following short 
history is an example: — 

Highland, a lighterman, stout and healthy, 
aged twenty-nine, after frequent bleedings from 
the right nostril, with an obstructed and snuf- 
fling respiration, for which he was unable to 
account, was attacked with a severe pain over 
the whole front of the head, with a sense of 
weight in that part, and extreme lethargy. Al- 
though naturally of an active cheerful disposi- 
tion, he became morose, indolent, and fond of 
solitude; at intervals he was attacked with 



412 EXPLANATION 

tremors, cold perspirations, and syncope. These 
symptoms had become established, when the 
right eye began to protrude from its socket ; 
his pain was at this time more severe, and a 
copious glairy discharge was set up from the 
nostril. As the disease advanced, his manner 
to his relations became strange, his intellect 
confused, and his gait unsteady. The protru- 
sion steadily increased for several weeks without 
abatement of his pain, except for a few hours 
after occasional blood-letting. Convulsions at 
length ensued, and terminated his existence 
about three months after the commencement of 
the proptosis. It is remarkable that he retained 
the vision of the affected eye up to the period of 
its protrusion ; and before that was obvious to 
his friends, he described the sensation of some- 
thing pushing the eye out of its socket. It is 
also remarkable, that through the whole period 
of his disease, although his bowels were ex- 
tremely torpid, he had a good appetite, and 
little, if any, febrile irritation. These particu- 
lars I learned from his surgeon and relatives, 
having myself seen him only a few days before 
his death. Upon dissection I found the follow- 
ing appearances. Behind the cavity of the 
right orbit lay a tumor, which had the appear- 
ance of an oblong polypous cyst, and anterior to 
this was a blood-colored fungus filling the orbit 
and extruding the globe. The cyst lay anterior 
to the dura mater, adhering to its surface, and 



OF PLATE V. 413 

so situated as to make the right hemisphere of 
the cerebrum appear truncated of its anterior 
lobe. The aethmoid bone, frontal sinus, and 
orbitar plate of the os frontis on the same side 
were in a state of caries, so that the finger 
passed readily from the orbit into the cavity of 
the cranium and posterior nares. A large 
quantity of yellow viscid matter occupied the 
frontal sinus, such as had been discharged du- 
ring life by the nostril. The os frontis in front 
of the sinus and above the orbit was denuded, 
and presented numerous worm-hole ulcerations. 
The anterior lobe of the brain was discolored 
and softened 5 there was an extra quantity of 
water in the left ventricle, and some fluid blood 
in the right. On a transverse section of the 
right hemisphere of the brain, it was found 
broken down in its texture, and the dura mater 
partially absorbed at its basis, the tumor having 
opened into the ventricle. The right thalamus 
was much diminished in bulk, though entire. 
The ha^matoid fungus in the orbit was mingled 
with spicula of bone, and distinct from the 
tumor. The dura mater to which the cyst ad- 
hered was continuous behind the cyst, except at 
the lower part, where it was destroyed. The 
disease appeared, therefore, to be connected with 
the external surface of the dura mater, and by 
its increase to have occasioned absorption of the 
bones and displacement of the eye, (which was 
sound, as were also the optic nerve and muscles 



414 EXPLANATION OF PLATE V. 

of the globe,) and ultimately to have ulcerated 
through the dura mater and anterior cerebral 
lobe, and discharged itself into the right ven- 
tricle. All the nerves were sound except the 
olfactory; this had disappeared, together with 
the aethmoid bone, on the right side. 






J%. 




























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( 415 ) 

PLATE VI. 

The drawings in this plate are from the port- 
folio of Dr. Savenko, a gentleman whose accu- 
rate knowledge of anatomy adds greatly to the 
value of his elegant talent for delineation. 

Fig. 1. represents a malignant tumor of the 
eyeball in a boy aged four years. This dread- 
ful disorganization had attained a magnitude 
nearly equal to that of half the head. The eye- 
lids were enormously extended and swollen, with 
varicose veins running over the surface, many 
times larger than their natural size. The tumor 
was of a reddish color, elastic, and very painful 
to the touch. Betwixt the margins of the lids 
grew a fungus, having an unequal surface, which, 
during the progress of the disease, assumed vari- 
ous colors from red to black, secreting a bad 
smelling ichor intermingled with blood. At the 
most prominent part of this fungus, the cornea 
could be distinguished. The continual flowing 
of the blood and ichor into the mouth increased 
the hideous appearance of the face. The tumor, 
from the excessive elongation of the upper lid, 
hung over the cheek and covered one side of 
the mouth. 

The origin of the tumor could not be dis- 
tinctly ascertained, and the case was dismissed 



416 EXPLANATION 

from the hospital as incurable : its termination is 
not known. 



Fig. 2. is a section of the eye of a woman, 
aged 46, which was extirpated by Mr. Astley 
Cooper, at Guy's Hospital, in August last. 

Two years before that time, the cornea of her 
left eye became opaque from chronic inflam- 
mation. 

In this state, after a severe attack of fever, the 
surface of the eye began to throw up a vascular 
fungoid tumor. On her admission it was of the 
diameter of a shilling, covering t.hp cornea and 
a part of the sclerotica, and protruding between 
the eyelids. It was slightly tabulated, of a dark 
purple color mingled with red j it sometimes 
bled, but was never painful. She is the mother 
of nine children, and her health had been gene- 
rally good. She recovered speedily from the 
operation. 

Dissection of the Eye. 

The tumor is situated without the globe ; 
it appears pulpy, vascular, and of an un- 
equal dark color. It is of a square figure, 
formed of various lobes separated by delicate 
fibrous bancls, and adheres to the sclerotica and 
the margin of the cornea. These two mem- 



OF PLATE VI. 41' 

branes could be traced entire beneath the tumor. 
The globe being divided, the vitreous humor 
escaped in a liquid state and of a yellow color. 
The lens had disappeared. Within the globe 
and opposite to the outer tumor, is another and 
smaller morbid growth which has no commu- 
nication with the former, and is of a softer 
and very vascular substance. It occupies the 
lower and anterior part of the globe, raises and 
compresses the retina, and is distinctly situated 
between the layers of the choroid coat; the 
venous layer on the outside is thickened ; it can 
be traced backwards, and is firmly adherent to 
the sclerotic Coat, from which it io separated with 
the help of a needle. The arterial, (ruyschiana) 
is thickened, but much less so than the venous 
layer ; it forms a tumor within and behind the 
morbid mass, which thus produces a complete 
separation between the two layers of the choroid 
coat. The retina, though displaced, is entire and 
adhering to the ciliary body, the whole of which 
is beginning to change into a similar morbid 
mass, covered with pigmentum nigrum. The 
processes are only in some places slightly dis- 
tinguishable. The uvea is also changed. The 
iris preserves its color, though imperfectly ; it is 
adherent at its centre to the cornea. The optic 
nerve is not diseased, but thinner than in health, 
All the points of situation and figure are dis- 
tinctly and faithfully exhibited in the engraving. 



E E 



418 EXPLANATION 

I beg leave to offer a few additional observa- 
tions on the several specimens of fungoid disease 
exhibited in Plate II. Figures 2. and 4 : Plate 
III. IV. V. and Plate VI. Figures 1 . and 2. The 
first of this series is unique in my experience. 
In the explanation, I have stated my opinion that 
the seat of the disease is the cellular texture 
connecting the conjunctiva to the cornea. I 
find no other texture degenerated, nor other- 
wise affected than the contiguity and extent of 
the disease explains. It was not characterized 
by any symptom of malignity; neither pain in 
the ball or in the head worthy of notice, nor 
any affection of the constitution. The defor- 
mity and the fear of its increase were the in- 
ducements to the operation, which was done 
about a twelvemonth ago. This was attended 
by no untoward symptom, and up to this time 
the subject of the disease has continued well. 

In its fresh section the tumor nearly re- 
sembled that described in Plate VI. Figure 2. ; 
in its situation it is not very dissimilar; the 
cornea supports the former, the sclerotica the 
latter; but in the latter the covering membrane 
is not traceable ; and I have little doubt that 
the conjunctiva gave origin to the fungus in 
both instances. The internal tumor, however, 
gives a more complicated and formidable cha- 
racter to the disease depicted in the last plate. 



OF PLATE VI. 419 

Plate III. with the exception of Figure 7. 
exhibits the various appearances of the medul- 
lary sarcoma in its several stages, in the eyes of 
a child who was under my observation from the 
commencement of it to the termination. In 
one eye (Figure 2.) the disease seems to have 
begun in the interstitial texture of the choroid; 
the sclerotica is also affected on its outer sur- 
face, and both the nerve and the vitreous humor 
have undergone a kindred change. In the 
other, (Figure 6.) which had advanced to an 
ultimate state of disorganization, both surfaces 
of the sclerotica, the interstitial texture of that 
membrane, and the adipose memrmme of the 
orbit, are loaded with the diseased growth ; and 
by after-dissection the choroid too was distinctly 
ascertained to have partaken of the same action, 
as is seen in the preparation in my posses- 
sion. In Plate IV. Figures 1. and 2. shew 
the disease affecting the integral texture of 
the sclerotic and choroid coats, and optic 
nerve. In Figure 1. the vitreous humor is evi- 
dently the basis of the disease. In Figure 2. 
the retina retains its character, and what re- 
mained of the vitreous humor was, it is pre- 
sumable, fluid. In Figure 4. the vitreous and 
crystalline humor are still marked, notwith- 
standing the displacement, reduced bulk, and 
total deterioration of the former. The sclero- 
tica is not specifically affected ; the irregularities 
of its figure are owing to the several protrusions 

E E 2 



420 EXPLANATION 

of the morbid mass, deeply stained in parts, 
as in Figure 1. with the pigment of the choroid, 
by which tunic it is formed. Figures 3. 5. and 
6. have a common character; they are speci- 
mens of the genuine fungus heematodes in its 
acute form. This, in my belief, is not the cha- 
racter of either of the preceding, or of the 
figures in Plate V,\ but as the last- mentioned 
were not subjected to dissection, I cannot speak 
of them decidedly. 

Figure 1. of Plate VI. is a rare disease:— a 
child was lately brought to the hospital with a 
large and rapidly increasing tumor upon the 
forehead, just above the orbit, and depressing 
the upper eyelid. The eye was free from dis- 
ease. The swelling had a firm but elastic feel, 
and was immoveable. The child was irritable, 
and of an unhealthy aspect. The disease was 
concluded to be a medullary osseous fungus. I 
am disposed to think that this disease had a simi- 
lar origin, and that the bony parietes of the orbit 
have been absorbed, and by its increase the eye- 
ball protruded and disorganized in the manner 
represented. 

Figure 2. shews conclusively the proper inter- 
stitial origin of the disease in the choroid; it is 
separated by the outer layer of this membrane 
and the healthy sclerotica, from the similar 
fungoid degeneration of the conjunctiva. 



OF PLATE VI. 421 

If the reader will compare with these the 
specimens delineated and described in Mr. 
Saunders's Treatise, Plate II. and Mr. Ward- 
rop's Essay on the Fungus Haematodes, Plates 
II. and ///. a striking analogy will be obvious 
to him in the seat and texture of these diseases. 
They appear to me to substantiate the observa- 
tions at page 222. that the disease is not pecu- 
liar to any individual texture, but in turn affects 
nearly all of which the organ is composed. 

1. The cerebrum, optic nerve, in its medul- 
lary and neurilemmatous texture; the sclero- 
tica, choroides, and its appendages; the iris, 
retina, tunica hyaloidea, and vitreous humor; 
the muscles, cellular and adipose substance, and 
the tunica conjunctiva, are all susceptible of it. 

2. The cornea and crystalline lens are alone 
insusceptible. These structures are least vas- 
cular, being naturally impermeable to red blood. 

3. The choroid is the most strongly disposed 
to assume it, the retina least so. In Mr. Saun- 
ders's Plate II. Figure 4. this tunic intimately 
involves, and is indeed assimilated in texture 
with the morbid secretion occupying the vitreous 
humor. 

4. Some of these diseases appear to be chro- 
nic ; those, for example, which have a dense, 



422 EXPLANATION 

firm, and semi-organic character. The pulpy 
or brain-like are also slow by comparison with 
the highly organized or hematoid species. The 
latter is sometimes engrafted on the medullary, 
but it is as often primary. They frequently co- 
exist in distinct parts of the same structure. 

5. The comparative firmness and rapidity of 
growth seem to depend on the texture from 
which the growth proceeds. Speaking gene- 
rally, the sclerotica and sheath of the nerve 
degenerate into the dense and firm sarcoma, 
sparingly organized ; the cerebral substance 
and the medullary part of the nerve into the 
pulpy or curd-like matter, which is the secre- 
tion also of the vitreous cells ; the haematoid 
fungus is, I believe, the production of the 
choroid and its appendages. While the disease 
is confined to the sclerotica, or to the vitreous 
cells, it is slow ; when the choroid partakes of 
it, it is luxuriant, increases rapidly, and bursts 
up the containing textures. 

6. So also the color distinguishes the share 
which the choroid takes by the profuse morbid 
secretion of pigment. In the rich collection of 
specimens at St. Thomas's Hospital, to which I 
have been much indebted, is one in which, ex- 
cept the shell of the sclerotica, no traceable part 
of the organ remains but an immense flocculent 
mass, a sort of tomentum of black pigment. 



OF TLATE VI. 423 

It was extirpated some years ago by my la- 
mented colleague, Mr. Henry Cline. The pa- 
tient left the Hospital well, and has not since 
been heard of. It is probable then that the 
texture, color, and rate of progress of the dis- 
ease, vary according to the texture which is af- 
fected ; and probably a similar observation ap- 
plies to other organs according as they are 
more or less vascular. 

7. Cellular structure seems to form the com- 
mon nidus of the morbid deposit, whether the 
membrana adiposa, or the common connecting 
tissue, or that proper to an ui^an, as the vi- 
treous humor. Hence it is as often interstitial 
as superficial to the several tunics ; and often 
both in combination, as in some of the in- 
stances described. 

As regards the pathological history and rela- 
tions of these truly formidable and hitherto ob- 
scure diseases, much interesting information may 
be obtained by the perusal of Mr. LangstafFs 
valuable cases and observations in the VHIth 
and IXth Volumes of the Medico- Chirurgical 
Transactions. 

Unfortunately, in a practical view, our know- 
ledge of them does not enable us to say when 
they are, or are not (if ever not) constitutional ; 
when to anticipate success from an operation, 



424 EXPLANATION 

or the contrary, with sufficient certainty to 
afford us encouragement to be active, or a pre- 
text for doing nothing. I have said that certain 
morbid appearances in other parts should not 
always preclude the consideration of relief — 
much less the most advanced state of the malig- 
nant disease confined to one organ ; yet it has not 
unfrequently destroyed the patient when so con- 
fined; and after the operation, it often re-appears 
in a remote part. Mr. Cooper removed some 
years ago a fungoid tumor from the shoulder of 
a gentleman, who soon afterwards died of the 
disease in the eyeball. In another case he re- 
moved the fungous eyeball, and the patient 
died of the disease in the kidney. Unfortu- 
nately such instances are not rare. But on the 
other hand, there are not wanting cases to shew 
that the malignant disease in some of its forms, 
or in certain textures, may be strictly circum- 
scribed to a part and almost stationary during 
a period of years ; and, secondly, parts to all 
appearance so affected have been removed with- 
out any return of the disease, during a similar 
period of observation ; and these facts warrant 
the operation whenever the fungus js so placed, 
and the constitution so supported as to admit 

of it. 



Fig. 3. A fleshy pterygium. The subject of 
it was a female about 21 years of age and of a 



OF PLATE VI. 425 

scrophulous habit. She had experienced re- 
peated attacks of the scrophulous ophthalmia, in 
one of which the cornea gave way, and the iris 
prolapsed at the ciliary margin. A pterygium 
was then formed originating from beneath the 
whole base of the upper eyelid j it was of a trian- 
gular form, extending to the lower margin of the 
cornea ; of a sarcomatous density, about one 
line thick, and forming a fold when the eye 
was directed upwards. It was completely cured 
by the operation of dividing and detaching it at 
its basis. The patient recovered her sight, and 
ultimately no vestige of the disease remained. 

Fig. 4. A membranous pterygium. The 
subject of it was a girl sixteen years of age ; 
it supervened upon chronic ophthalmia, and re- 
sembled the former in size and shape, but was 
transparent so that the cornea and pupil appeared 
through it. This was likewise successfully re- 
moved. 



THE END. 






G. WOOOFALL, PRINTER, 
ANGFX COURT, SKINNER STREET, LONDON. 



Date Due 










































































































































Demco 293-5 



8a OT 



Accession no. 

JFF 

Author 

Travers, B. 
Synopsis of dis- 
eases of the eye. 

Call no.