ladies and gentlemen addressed themselves to work each other's ruin at cards. And if, with our better knowledge, and our more humanized manners, the fruits of our advancing civilization, we have changed all this, shall we not hope also our favourable change, as the time recedes when ardent spirits, ranking almost as a panacea, were judged supremely fitted to strengthen and to ease toil, to save from the effects of heat and cold, to repel the risk of infection, and to cure many forms of actual disease; and were esteemed besides the best of all means to cheer our gloomy hours and to adorn our happy ones? It became no wonder, then, that they were so lavished, that, as moderation was reckoned a mean and foolish asceticism, so conviviality was accounted a virtue, strength of endurance a triumph, and the want of it a provocation to contempt, while intemperance a laudable jollity, or, at the most, an amiable failing. The drunken excess which consistently followed on the prevalence of such notions, the fertile origin of an unceasing medley of drinking customs, was not more an insanity than religious persecution, or superstition, or rigour in our judges, or the point of honour, or gaming, each more unwise than the other, was an insanity. It was rather, like them, a prone and natural sequence, belonging to our manners, and preserving ever a due proportion to its cause. Already, as the influence of that cause sensibly declines among the higher classes, the intensity of the result as notably diminishes; nor have the lower classes, happily, failed to participate largely in the improvement.

Drunkenness, then, is but a trait left to us of a lower civilization. High civilization is not mere literary knowledge, or refinement of manners, or purity of morals. Any of these may exist separately, or with but little support from the others. It is the harmonious junction of all the three. As we acknowledge this the more, and as its realization advances the more among us, its boons will become extended. Let us strive towards these, in the issues before us, not by giving vogue to a fallacy, but by inculcating detestation of a vice. If we proceed otherwise, we shall have no enduring success, and we shall deserve none.

REVIEW II.

A Treatise on the Surgical Diseases of the Eye. By H. HAYNES WALTON, Surgeon to the Central London Ophthalmic Hospital, &c. &c. -London, 1861. 8vo, pp. 686.

THIS is a new edition of a work by Mr. Walton, published in 1852, under the title of Operative Ophthalmic Surgery; which was received by the profession as a good practical introduction to the study of those eye-diseases which more immediately call for surgical interference. In the truest sense it is a new edition. The history of ophthalmic surgery, which formerly occupied forty-six pages, has been omitted. Many of the chapters have been thoroughly revised, or recast. the use of chloroform in ophthalmic surgery, on affections of the excreting lacrymal organs, on strabismus, and on incision of the con

Those on

junctiva in purulent ophthalmia, have been re-written; while entirely new chapters have been added, on the use of the eye-douche, on sympathetic inflammation of the eyeball, on orbital and intra-cranial aneurisms, on iridectomy and other operations for the cure of glaucoma, and on the ophthalmoscope.

We purpose shortly to direct attention to some portions of Mr. Walton's work, bearing on subjects of great practical interest, on which new light has been shed by recent investigation, or on which our author has deemed it well to change from the views adopted in his first edition.

Our readers must be aware that, while every other means is in general found fruitless, two methods of treatment are available in cases of that insidious and very serious internal inflammation of one eye which results from previous injury of the other, and which has received the name of SYMPATHETIC OPHTHALMITIS. The one is free incision of the injured eye, with removal of a portion of its cornea, so as to give exit to any foreign body which may be concealed within its tunics; and the other, extirpation of the injured eyeball. On this important point of practice Mr. Walton expresses himself as follows:

"No general treatment, no local application, no dietary system, is of avail in checking unequivocal sympathetic ophthalmitis. Nothing of the kind can be depended on; and while I thus speak from my own observation, I endorse the statement of all trustworthy observers. The affection can be stopped, or subdued, only by surgical treatment. A portion of the eyeball must be removed, whereby the products which have set up the irritation, or the cretaceous or ossified tissue which has acted as a foreign body, may be got rid of, or extirpation resorted to. When done early, this practice works wonders. If adopted before the sympathetic action has induced palpable structural changes, it will be all-effectual. At later stages, it may arrest progress, and stay the destruction. Even when the pupil has become adherent to the capsule of the lens, and the iris dull, I have seen a check.

Removing a portion of the eyeball will generally suffice, as it is frequently in the anterior part of the eye that the centre of the morbid action is seated. I have very frequently found the vitreous humour healthy; this portion of the eye, therefore, not being spoiled. With the reduction of the eyeball only, the deformity is very much less, and the case is better fitted for an artificial eye; and, in the early years of life, the destined growth of the orbit is less interfered with.

"When the entire eyeball is disorganized, posteriorly as well as anteriorly, especially when there is general enlargement, extirpation is the course to be adopted." (p. 115.)

Extirpation of the eyeball within the ocular sheath. . . . is what would be called a more brilliant proceeding than abscission. Yet I am quite sure that, if the patient's ultimate welfare be considered, its adoption should be the rare exception. Even a button of collapsed tissues is far better than none, and a slightly reduced eyeball is vastly superior to an empty orbit; and I think it better that these should be secured, if it be even at the expense of longer time.

"But will abscission confer advantages equally lasting with extirpation, is a question likely to arise in the mind of the practical man. Answering from my own experience, I say, Yes. In no cases in which I have selected it as the proper operation have I been disappointed." (p. 116.)

The latter part of Chapter IX. and the whole of Chapter X. are devoted to PULSATING DISEASE in the ORBIT (till lately deemed aneurysmal), a subject of great interest; on the pathology of which new and important light has been breaking in, while much remains to be investigated.

Most of our readers are doubtless acquainted with the cases recorded by Mr. Travers in the second, and by Mr. Dalrymple in the sixth volume of the 'Medico-Chirurgical Transactions,' which were regarded by these gentlemen as instances of aneurysm by anastomosis in the orbit, and which were cured by tying the common carotid. The possibility of an aneurysm by anastomosis in the orbit is not denied; indeed, a case in an infant of two months, under Mr. Walton's care, cured by ligature of the carotid, goes to establish the fact of its occurring as a congenital affection. Still, it has been distinctly shown, by recent observers, that all the symptoms once regarded as diagnostic of aneurysm by anastomosis in the orbit-such as the sensation of a sudden snap in the head, protrusion and tension of the eyeball, swelling of the eyelids, varicosity of the conjunctiva, throbbing of the orbital blood vessels sensible to touch and sight, pain in the region of the orbit, whizzing noise in the head synchronous with the pulse, obscurity of vision, aneurysmal bruit heard on application of the stethoscope, diminution of the exophthalmos on pressing back the eye, and cessation of the throbbing of the vessels by pressure over the common carotid in the neck—may arise from causes in which aneurysm by anastomosis, or aneurysm of any kind, has no part.

The facts and reasonings on which this important conclusion is founded are given in a condensed form by Mr. Walton, while reference is made to most of the original authors whose observations and dissections have led to the change from the doctrine of Travers and Dalrymple. This change the profession owes in a considerable measure to Mr. Nunneley, who, referring to the cases of those gentlemen, makes the following statement in a paper in the forty-second volume of the 'Medico-Chirurgical Transactions':

"In hardly one particular do these cases of disease in the orbit resemble aneurysm by dilatation, or enlargement of the small blood vessels in any other part of the body. 1st. It is very doubtful if aneurysm by anastomosis is ever developed unless it has a congenital origin. 2nd. Aneurysm by anastomosis does not appear suddenly; and when it is noticed, its increase is usually slow and gradual. 3rd. It is not caused by direct violence. 4th. All the bloodvessels in the neighbourhood of aneurysm by anastomosis appear to participate more or less in the increased action, as active agents, and not merely as passively dilated tubes. 5th. It is almost always, if not invariably, connected with the cutaneous or subcutaneous tissues. 6th. The result, where a single large distant artery has been tied in aneurysm by anastomosis, is not such as to lead to the supposition that all pulsation and tumefaction would instantly disappear on ligature of the carotid, if such a disease existed in the orbit; though a cure might follow, the effect would be gradual.”

Taking the whole that has been recorded into account, it seems to be established that exophthalmos with orbital pulsation, and bruit de forge, may arise from the following causes:

1. Congenital aneurysm by anastomosis. (Walton.)

2. True aneurysm of the ophthalmic artery; either spontaneous (Guthrie), or traumatic (Busk.)

3. Dilatation of the carotid where it issues from its canal in the temporal bone, with coagula around and within the dilated part, and an atheromatous and dilated state of the ophthalmic artery. (Nunneley.)

4. Inflammation of the cavernous and other sinuses of the dura mater, with coagula in their canals, and varicose enlargement of the ophthalmic vein. (Hulke.)

Which of these causes occurs most frequently, remains to be shown by future observation. We shall not be surprised if it turns out to be the last-mentioned; namely, obstruction to the return of the blood from the orbit through one or other of the veins or sinuses; a state of matters which will necessarily give rise to an increased quantity of blood in the orbit, an augmented pulsatory movement of the branches of the ophthalmic artery, and a thrusting forwards of the eyeball and eyelids.

"It will be an interesting subject for future investigation," observes Mr. Walton, "to ascertain the signs by which intra-cranial and orbital aneurysms may be distinguished from each other, and from obstruction to the return of blood by the ophthalmic vein. It seems probable that, in the cases which most closely simulate aneurysm by anastomosis-as when the pulsation seems to spread beyond the margin of the orbit, or where it reappears after ligature of the carotid-the causes will be found to be venous obstructions, either from pressure on the ophthalmic vein or from disease in the cavernous sinus; and when the affection has a traumatic origin from blows on the head, it is more likely to be the carotid artery that is injured when in close relation with the bone in the cavernous sinus, than the ophthalmic, lodged in the soft tissues of the orbit, so that I should expect the intra-cranial origin of orbital pulsation to be by far the most frequent." (p. 238.)

Out of fourteen cases referred to by Mr. Walton, in which ligature of the carotid was performed, a cure appears to have been obtained in twelve. A fatal result followed the operation in two cases only; in one, from hæmorrhage; in another, from continued inflammation of the dura mater.

An important fact, not noticed by Mr. Walton, is, that a spontaneous cure has sometimes taken place. An instance of this, related by Dr. Fiske, of St. John's, New Brunswick, will be found in the 'Dublin Medical Press' for August 24, 1859, copied from the 'New York Journal of Medicine.' The patient was a female, aged forty; the disease, which affected the left orbit, began with the feeling of a sudden snap, followed by immediate protrusion of the globe, oedematous swelling of the lids, and loss of vision on the affected side; after three weeks a small pulsating tumour appeared under the superciliary ridge; it soon increased, and became so distinct as to be seen at several yards" distance. The patient had a constant whizzing noise in the ear. Pressure on the common carotid immediately arrested the pulsation of the tumour. The patient declined to have the artery tied. By and bye, some favourable changes took place; the angular vein, which had

1

been very turgid, became collapsed, and there was less thrill in the tumour. During the next four years, there was a slight increase in its size; but nothing of importance occurred, till Dr. Fiske was called one day in great haste to see the patient, as she was very ill. He found the pulsation had entirely ceased, and the distended veins had collapsed. The pain in the head, which was great, was relieved in a few hours, the whizzing sound ceased altogether, the pulsation never returned, and in the course of three months the tumour entirely wasted away. What for six years had been a great deformity, and a cause of much distress, had in a very short time, been entirely obviated, without the interference of art. The eye was restored to its natural position, and excepting the loss of vision in the affected organ, there were no remaining ill consequences.

Such a case appears to strengthen the conjecture we have already hinted at-namely, that pulsating disease in the orbit is probably in most instances the result of a clot-like deposit from the blood in one of the veins or sinuses leading from the eye towards the jugular: a cause undeniably of a dangerous nature, but not beyond the reach of a natural cure..

"When examining a vein which is plugged by a tough and adhering coagulum," observes Dr. Humphry, one can scarcely be persuaded that the circulation could ever have been re-established through it, if the patient had survived; yet there can be no doubt that this does take place, and that a vessel. may in process of time resume its functions, and be restored nearly, if not entirely, to its natural condition, after its channel has been completely or to a considerable extent blocked up by a clot." ... "The clots," he adds, "may soften and become intimately connected with the walls of the vessels, and may lead to the complete and permanent obliteration of their canals. More commonly, however, they are removed, or shrink into delicate bands or fibres, which offer little or no obstruction to the circulation."*

Substances which are known to possess an influence in retarding the coagulation of fibrine, such as ammonia, are exhibited in cases in which clot-like deposits are suspected to have taken place during life, in the hope that they may operate within the living vessela in a similar way to what they do when mixed with blood removed from the body. Much dependence cannot be placed on such medication. Still, the urgency of the disease vindicates a trial of every means which holds out a prospect of being of use.

The object in tying the carotid in pulsating disease of the orbit, is merely to reduce for a time the contents of the branches of the ophthalmic artery, not to obliterate these vessels. This object appears, in one instance, to have been accomplished artificially, without cutting down upon or tying the artery, for in a case of aneurysm of the ophthalmic artery, Professor Gioppi, of Padua, is stated to have employed digital compression of the carotid with success.† Tedious, painful, and uncertain as this means may prove, it is still worthy of

On the Coagulation of the Blood in the Venous System during Life, pp. 13, 23. Cambridge, 1859.

t Quoted from the Giornale d'Oftalmologia Italiano, in the Lancet, Sept. 17th, 1859, p. 286.