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in very suddenly, yet in a large number of cases the outbreak has been foreshadowed by a train of premonitory symptoms. These are: occasional dimness of sight, often towards evening, shooting pains in the eyeball, muscæ, and a gradual diminution of the field of vision. Graefe has drawn particular attention to this last point. The outbreak may be followed by a remission, only a temporary improvement, for fresh paroxysms will occur, and blindness inevitably result. In the advanced stages sclerotic staphylomata are apt to occur, mostly behind the insertions of the recti tendons. Chronic glaucoma differs from the acute chiefly by the insidiousness of its course, which is unmarked by those violent symptoms which characterize the outbreak of the acute form. It is quite as intractable as the acute form. The retinal veins are turgid, and the retina is sprinkled with hemorrhagic spots, just as in the acute form. Sometimes in the same person, one eye is attacked by acute, the other by chronic glaucoma. These facts favor the supposition that acute and chronic glaucoma are only different forms of the same disease. Graefe has called attention to a peculiar form of amaurosis, in which the optic papilla is excavated. This affection must be carefully distinguished from glaucoma, which may be done by observing that the globe is not tense, and the other signs of hyperæmia are also absent.

Morbid anatomy of glaucoma.-The small blood-spots which are sprinkled over the inner surface of the retina are small spots of capillary hemorrhage. This condition was first recognized in glaucoma, by actual dissection, by Mr. Bowman. The bleeding proceeds from capillaries in the inner layers of the retina, and the blood either spreads laterally amongst the elementary structures of the retina, or, bursting through the hyaloid membrane, it forms small clots in the vitreous humor. The retinal capillaries are irregularly dilated and studded with small fusiform and globular enlargements-little aneurismal pouches. These dilatations do not occur on the large vessels. The pouches and the vessels communicating with them are usually crammed full with bloodcorpuscles. In the hemorrhagic spots the retinal tissues are infiltrated with blood-disks, which have escaped by the bursting of some of these little aneurismal pouches. Excepting the changes described above, the retinal capillaries have a healthy appearance, and do not present traces of fatty or atheromatous degeneration. The coats of the arteries are hypertrophied. The vitreous humor sometimes has a yellow tinge, which is derived from the coloring matter of the effused blood. It often contains blood-disks and delicate fibrinous webs; and sometimes also small blood-clots, which can be clearly seen with the unaided eye. The vitreous humor has a very remarkable degree of consistence, and does not quickly flow off when the eyeball is cut across. Viewed by transmitted light, the glaucomatous lens has a yellow tint like the vitreous humor, and which is probably acquired from the same source-viz., the coloring matter of the effused blood. The relations of the lens and the vitreous humor favor this supposition. In none of the dissections were any morbid changes found in the choroid, unless when staphylomata were present. Corresponding with the staphylomata, the choroid, retina, and sclerotica preserve their native relations to one another, and are not separated by any effusions. The choroidal pigment is irregularly distributed; the tissues seem opened out. The subsequent changes in the retina and choroid, in the advanced stages of the disease, have an atrophic character. The dilated retinal capillaries and their contents have been found dark and granular, in a state of fatty degeneration, and the contiguous parts of the retina participate in these changes. The symptoms, the ophthalmoscopic signs, and the structural changes which take place early in the disease, all point to a state of great vascular excitement in the retina, and a greatly increased internal pressure upon the walls of the globe. It is this pressure which causes the blindness in the early stage of the disease, and the fixed dilated pupil, for when the pressure is relieved by operation, sight and mobility of the pupil return.

ART. 88.-New Operation for Artificial Pupil. By Mr. CRITCHETT.

(Medical Times and Gazette, May 3, 1858.)

"Mr. Critchett has recently adopted at the Moorsfield Ophthalmic Hospital, a mode of operation where it is wished to displace the pupil, which is, we believe novel. Instead of drawing out and snipping off a portion of iris, he draws it out and secures it by a fine ligature from slipping back. It may, perhaps, at the first mention, seem that the result must be nearly the same as if the scissors were used, since the portion included in the ligature will slough away. There is, however, another point in Mr. Critchett's proposal which indeed constitutes its main feature. It has long been an aim with ophthalmic surgeons to discover some mode of operating by which the natural pupil should be simply displaced to the elected position without laceration of its margin. This was the end sought to be obtained by the ingenious suggestion of a surgeon of Nantes, to remove a small portion of cornea near its circumference, and then allow the iris to bulge and become adherent to the cicatrix. This latter mode of operating has been frequently adopted of late by Mr. Bowman and other English surgeons, and we have seen some excellent pupils obtained by it. It is, of course, the substance of the iris near its circumference which bulges into the wound, not its pupillary edge. Now, Mr. Critchett aims to exactly imitate this process, with the advantages that no portion of the cornea is excised, and that the result is much more certain. Having made an incision close to the corneal edge sufficient to admit of Leur's forceps, the iris is seized just within the opening (that is, very near to its attached border), and is gently drawn out until enough is prolapsed to allow of the application of the ligature. The ligature prevents all chance of the return of the iris which might otherwise follow. Mr. Critchett has now performed it in four instances, and last Friday, Mr. Bowman also adopted it in a case under his care. It is, of course, best adapted for cases of leucoma, &c., where the iris itself is not diseased. If the pupil have strong adhesions, one or other of the numerous older methods would be better suited."

ART. 89.-On the Operation of Iridectomy. By Mr. T. WHARTON JONES, F. R. S., and Dr. MACKENZIE.

(Medical Times and Gazette, April 3, 1858.)

This paper is a criticism on the operation of iridectomy, or excision of a piece of the iris, as recommended by Dr. Graefe, of Berlin, as a means of cure in various diseases of the eyes, especially chronic iritis, irido-choroiditis, and glaucoma. The writers are altogether at variance with Dr. Graefe. "Dr. Graefe's practice of iridectomy," they say, "appears to us so opposed to the plainest principles of surgery and common sense, and so little supported by its results, that we must confess our surprise at its having been so eagerly imported into this country. We have no doubt, however, that in a short time iridectomy as a means of treating glaucoma will be abandoned; while the attention of practitioners having been redirected to the effect of taking off the intraocular pressure which plainly exists-not, however, as the primary, but as one of the secondary phenomena in glaucoma-the practice will be revived of more frequently puncturing the cornea and sclerotica in this disease."

ART. 90.-A Peculiar Disease of the Retina. By Dr. BADER.

(Ophthalmic Hospital Report, No. 2, Jan., 1858.)

Dr. Bader's chief object is to show that the retina is the seat of a special form of disease, in which the other textures of the eye do not participate, except secondarily and remotely, and to separate it from the vague class, Amaurosis. I should propose to name it, "Softening of the Retina." Once familiar with the peculiar appearance of the optic nerve entrance, the disease can be recog nized in its earliest stages, and is open to treatment. The objective symptoms are, when far advanced, well marked; but for the diagnosis, I believe the ap

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pearance of the optic nerve entrance to be sufficiently characteristic. The more advanced the disease, the more marked is the grayish-blue appearance, and the less is the supply of blood; and the more do the vessels give the impression of being bent over the edge of the optic nerve entrance. The pulsation not unfrequently seen in the vessels may be caused by the blood overcoming the resistance it finds at the bend.

Another feature, though not constant or peculiar to these cases, is the distinctness with whh the insular arrangement of the hexagonal pigment is seen on the red choroidal field. It may be owing to a change of position of the rods, produced by the disease in the nerve-cell layer of the retina; the last of the above cases shows how complete the retinal transparency remains to the ophthalmoscope while the destructive changes are progressing in its substance. Mr. Bowman, I believe, first discovered the change of position of the bluishgray crescent in the optic nerve entrance, on movements of the eye. This symptom will be understood by considering the shadow thrown by a movable, concave, light reflecting surface.

The disease, when far advanced, causes opacity of the lens, and similar changes consequent on pressure in the cornea and sclerotic, and in the ciliary circulation. If we add pain, sudden increase of hardness of the globe, and other active inflammatory symptoms to the above sketches of the exterior of the eye, then we have what is called "Acute Glaucoma."

The present surgical treatment of these cases, as employed by Mr. Critchett and Mr. Bowman, tends to decide which cases will be improved by excision of part of the iris. Acute cases have decidedly been improved, not so chronic

ones.

The ophthalmoscope recognizes the above disease in its earliest stage. Will the surgical treatment be more successful when applied early? or is it only serviceable when inflammatory symptoms join the chronic state? or is acute glaucoma a different disease altogether? The marked difference of success of the surgical treatment, as applied to apparently the same class of diseases, leads to the above questions. Cases similar to the above, and accessible to the ophthalmoscope, will, I believe, be the most favorable to allow of accurate and conclusive experiments.

Dr. Bader relates three cases, of which the following is one :

CASE.-History.-October 9th, 1857. W. F, æt. 34, gardener, observed, nine years ago, on stooping, a dimness appear before both eyes. The dimness increasing, he underwent various medical treatment, comprising blistering, cupping, leeching, mercury, and tonics, during which, at the end of twelve months, vision was reduced to mere perception of light; this state continued up to April 22d, 1857, when the patient came under the care of Mr. Critchett; he then had perception of light, most in the left eye, but not sufficient to enable him to find his way about. Periodically he saw more light, especially in the mornings and evenings. Before and during this eye-disease the patient enjoyed good general health, and at no period of his life had had either inflammation or pain in the eyes or in the head.

Present symptoms.-Both eyes. October 9th, 1857. Slight external strabismus; the globes a little harder than normal, the sclerotics of a dirty grayishwhite color, large veins emerging from the ciliary region, general slight haziness of the cornea, the iris of a clear brown color. Both pupils irregularly dilated and immovable, their area slightly misty. April 22d, 1857. The corneæ transparent and the area of the pupils clear.

Ophthalmoscopic examination.-Both eyes. April 20th, 1857. The media transparent, the choroids of a deep red, with many brown pigment-islands, the entrance of the optic nerve too well defined, with a dotted bluish-gray watery appearance of its surface, most marked at its outer edge. At the upper part of the periphery of the left optic nerve some irregularly defined white patches dotted with pigment. Three very small vessels pass through the centre of the right optic nerve, and disappear at its periphery. Four veins returning from the retina, of normal diameter and color, pass out of the eye close to the periphery of the entrance of the optic nerve. Through the left optic nerve four thin vessels pass and spread over the retina, and two large veins terminate

abruptly, as in the right eye. October 9th, 1857. Right eye. The haziness of cornea and lens prevents the light from entering the depth of the eye freely. On a dimly red field the dirty bluish-gray well-defined surface of the entrance of the optic nerve is seen, with two thin vessels passing through its centre, and disappearing at its periphery. Left eye. The cornea and lens slightly misty, the state of the parts behind, as on the 22d of April. A good sketch of the entrance of the optic nerve, and the neighboring parts, may be seen at the hospital.

Treatment.-From April to October, tonic treatment. October 9th. Graefe's operation was performed by Mr. Critchett on the right eye. November 19th. The patient thought he saw more light with the eye operated on. The case is still under treatment.

ART. 91.-The Cataractous Eye Compressor: a new instrument for facilitating the extraction of Cataract. By JAMES VOSE SOLOMON, F.R.C.S., Surgeon to the Birmingham and Midland Counties Eye Infirmary.

(Lancet, Nov. 7th, 1857.)

In the removal of hard cataract from the axis of vision by extraction, after the section of the upper half of the cornea has been completed (in the right eye), and the capsule of the lens has been sufficiently opened, the operator, in order to dislocate the cataract through the pupil, raises the upper lid with the forefinger of the left hand, and with the "curette" in his right, makes pressure with the spoon end of that instrument upon the globe, at a point about midway between the lower margin of the cornea and the insertion of the inferior rectus muscle.

It will, however, sometimes happen, notwithstanding the corneal and capsular incisions have been properly executed, that the cataract does not come forward, but slips behind the iris, or perhaps sinks more or less deeply into the vitreous humor. Under these circumstances it is usual, and a very good practice, to get an assistant to harpoon the lens with a small and sharp hook, and then gently withdraw the cataract through the pupil and the corneal incision, care being taken not to avert the flap to such an extent as shall favor an escape of the vitreous. This manipulation to be safely performed, requires that it shall be executed by the steady and delicate hand of one who has been practically instructed in the operation under consideration. But such a one is not always at hand. I have therefore been led to devise and make use of the instrument, which consists of a cup of thin metal, with four elastic ribs attached to it, which fits on the end of the second finger; to the centre of the cup is riveted a curved stem, something less than half an inch in length; this stem terminates in a transverse bar, which is concaved, and set on at such an angle as will render it easy of adaptation to the globe of the eye.

Either silver or steel may be used for the cup and ribs. Each rib should be hollowed, so as to give it strength and elasticity.

It will be obvious to those accustomed to operate for cataract, that the upper lid can be elevated and fixed with the index finger, and pressure made upon the eyeball by the second finger of the same hand, arched in front of the eye, and having attached to it "the compressor." From the trials I have made with it, I believe that in the operation of extraction the surgeon will gain by its use an equivalent to a third hand. It is less painful to the patient than Daviel's spoon. The exact amount of pressure exerted is accurately appreciated through the tactile sensibility of the end of the finger. Moreover, by placing the stem of the hook held in the right hand just behind the upper part of the incision, a useful degree of counter-pressure can be made; and should the cataract not then come forward, or should any untoward accident threaten, the hook can be used to seize the cataract at the precise moment and in the exact mode that the operator may deem advisable. In fact, one mind will direct the whole of those manipulations, which demand skill and knowledge for their perfect execution.

P.S.-I have had made several instruments, which were modifications in detail, but not in the principle of the one delineated on this page, but prefer the

elastic ribs to a flat ring of metal, and the curved stem to a straight one set on obliquely to the cup.

ART. 92.-On Micropia produced by the Use of Belladonna.
By Dr. CORNAZ, of Neufchâtel.

(L'Echo Méd., and Dublin Hospital Gazette, March 15, 1858.)

Of late years, the medical journals have detailed several cases, in which a solution of belladonna, dropped into the eye, has caused a very curious phenomenon, making all objects appear very much smaller than natural. For this affection Donders has proposed the name of Micropia-one, certainly much more suitable than Microscopia, by which it has been hitherto called. This affection appears to be of very rare occurrence; for, not to mention the numerous cases of poisoning by belladonna-in none of which, as far as we are aware, has it been noticed-the solution of belladonna, or atropine, is daily used to examine the interior of the eye, and nevertheless, we cannot discover that micropia from mydriasis produced by the poison of the solaneæ has been described before 1851.

Without investigating the explanations hitherto given for this fact (which all fail in this-that if they were correct, this lesion ought to exist, at least more or less, every time that an artificial mydriasis existed) or dwelling on the line of treatment insisted on (which is only waiting until the belladonna ceases to act, or, at the most, applying cold lotions), we will detail here the particulars of some cases of this kind which we are acquainted with, because it is important that every surgeon should know exactly, not only the normal effects of every remedy which he makes use of, but those also which it may produce in exceptional cases.

CASE 1.-In some cases, objects appear smaller than they are in reality. The cause of this anomaly has not been clearly proved. It occurred once in a very decided manner, in my right eye, after a few drops of solution of belladonna, which has the effect of diminishing the refractive power of the eye, were dropped into it. In reading with both eyes, the left alone accommodated itself to the true distance, whilst the right, though open, interfered with my seeing clearly. When I closed the right, I saw perfectly; when I closed the left, I saw equally well at the distance of about a foot; but I had to make some effort to do so, and the letters appeared to me much smaller. When the belladonna had exhausted its action, this anomaly disappeared.-Donder's Nicropie-' Nederlandsch Lancet,' 1850-1, No. 10, Avril.

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CASE 2.-M. J. V- æt. 40, of good constitution, never ill before, was for some time annoyed with muscæ volitantes. The eyes showed nothing abnormal; there was no unusual vascularity; the pupil was moderately dilated, and very active; his present health perfect. There was no pain either in his eyes or head. The patient makes no complaint, except of the musca volitantes, which are attributed to slight congestion of the retina.

To allow of more complete examination of the organ, a few drops of a solution of extract of belladonna were dropped into the eye in the evening. He passed a very good night, and on walking was astonished to find that all the objects around him had assumed a new appearance. The newspaper lay on a table near him, and, on taking it up, it appeared to be composed of microscopic characters, which he could only decipher with great trouble, and thanks, he said, to his always having had excellent sight. However, objects appeared as clear as usual; they were not surrounded with a haze, or with luminous areola; their size alone was remarkably diminished. He rang the bell, and the servant who answered it appeared to him not taller than a girl of ten years old. He started up, more and more astonished. The clothes which he takes up are those of a child; however, he puts them on without any trouble. He goes down to breakfast, and instead of his wife and children seated around the table, he sees only a little dwarf and some dolls. His surprise and fright are extreme; he hurries off to his physician, but will not go alone, so great is his fright. The horses he meets appear to him dogs; the dogs rats. In a word, everything around him appears to him borrowed from the Lilliputian world

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