Part 29

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The operation of making an artificial pupil is far from being uniformly successful, and ought not to be had recourse to unless vision is entirely lost, or so much impaired as to be insufficient for the guidance of the patient’s steps. It is necessary on account of central opacity of the cornea—leucoma with entanglement of the iris—and entire closure of the pupil, or diminution of it, with concealment of the remainder by corneal opacity. It may be required after badly performed extraction of a cataract, the iris being entangled in the scar of the incision, at a distance from the junction of the cornea with the sclerotic; or on account of closed pupil from inflammation, when, perhaps, the cornea is all clear. The operation is varied according to the size of the anterior chamber, the presence or absence of the crystalline lens, the extent of sound cornea, and the condition of the iris. Interference is useless when disease of the retina is suspected, from the extent of the previous disease—from violent inflammation, with or without discharge of part of the contents of the eyeball. Three distinct methods of operation are pursued.

I. Simple division of the iris, or corotomia, may be practised when the iris is stretched, as after extraction. It is performed by introducing a small knife, like a needle, through the anterior or posterior chamber,—the surgeon being in this regulated by the size of the anterior chamber and the presence or absence of the lens,—pushing its point through the iris, or cutting that membrane vertically, horizontally, or both, to an extent sufficient for the transmission of light. If the anterior chamber be of its natural size, a small opening may be made in the cornea with a cataract knife, or a double-edged broad and thin one; and through this opening small scissors may be introduced for division of the iris.

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

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

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

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

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

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

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

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

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

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

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