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powerfully stimulates the contractility of the pupil, and thus the iris may be drawn back; this failing, we may with the utmost gentleness endeavour to replace the protruded portion with the rounded extremity of a probe; but if the aperture be small, and the portion of iris tightly girded like a strangulated hernia, such attempts will seldom succeed, and it is better to snip off the protruded portion with scissors. This may be done without much difficulty when the wound is quite recent, but after the lapse of some hours the eye will become irritable, intolerant of light, and unable to bear the necessary exposure; the iris, too, will then more easily resent any pressure. According to my experience, prolapses are very seldom overcome by belladonna, and I believe that the simplest, and on the whole the best, mode of proceeding is to bring the patient under chloroform, and to remove with scissors the extruded portion; the wound will then unite, and a tedious confinement and much neuralgic suffering be averted." (p. 113.)
"I am quite sure that it is not safe to use too great endeavours to return a prolapsed iris into the eye; it may be pushed back, but again and again will it protrude, and the unavoidable bruising with a probe will be very likely to excite iritis and all its attendant evils; it is far safer in such a case to snip off the prolapse as close to the wound as possible." (p. 114.)
We believe the plan to follow in such cases is, first, to act on both irides by dropping the solution of two grains of sulphate of atropine to the ounce of water into each eye, and painting the eyelids and eyebrows with moistened extract of belladonna; secondly, to bring the patient under the influence of chloroform, which at once favours the dilatation of the pupil, enables us to examine the eye composedly, and prevents the patient from opposing by any motion of his eye or head the manipulations necessary for returning the prolapsus; thirdly, by gentle continued friction of the eye with the upper eyelid, to endeavour to return the protruding portion of iris; fourthly, should this fail, by cautious pressure with the blunt end of a small probe to replace the iris, the probe serving to displace the aqueous humour, which swells out the prolapsus like a little bag, but which, on being emptied in this way, will often shrink into its natural place; fifthly, if the wound of the cornea is very small, so that the prolapsed bit of iris is firmly girt, and the small probe cannot enter, to enlarge the wound with the iris-knife, and repeat the attempts at reduction; sixthly, should none of these means succeed, to puncture the prolapsus, so as to allow the aqueous humour within it to escape, when it will fall into a flaccid state, and may in general be replaced; lastly, even this means failing, Mr. Cooper's advice may be followed, and the prolapsed bit of iris be cut off.
The tendency noticed by Mr. Cooper for the iris, once pushed into its place, to protrude again, is much diminished if the membrane has been brought fully under the influence of atropine.
Snipping off the prolapsed portion causes great deformity of the pupil, and ought not to be had recourse to unless all attempts at replacement have been unsuccessful.
Wounds of the crystalline are carefully considered by our author. We shall quote two of the cases related under this head:
"F. M., aged eight, was brought to St. Mary's, July 19th, 1858. On the previous day he was looking into the muzzle of a toy-gun, which he had
charged with a piece of wood having a needle stuck in it, when the gun accidentally went off, and the needle entered the right cornea near its centre, where it remained until pulled out. When I saw the eye there was a general sclerotic blush, and the iris, naturally grey, had a greenish tinge; a hazy point on the cornea indicated the seat of the wound, and corresponding therewith was a hazy point in the capsule of the crystalline lens, close to the margin of the contracted pupil. Simple treatment was adopted, and on July 26th the eye was quite free from inflammation, the iris of a natural colour, but adherent to an opaque spot in the capsule; the lens was perfectly clear, and I thought the case would be one of those exceptional instances in which the lens escapes opacity, but I was mistaken; after the lapse of a month the sight became impaired, and an unmistakeable grey film occupied the pupil. This I watched, and saw it gradually increase in opacity, but very slowly, so that three months clapsed before traumatic cataract was fully developed; the opaque spot in the capsule remained unaltered; the pupil was disengaged by atropine." (p. 118.)
"T. W., aged eight years and a half, was brought to St. Mary's, July 31st, 1858. A fortnight previously he was looking through a keyhole, when a boy on the other side thrust a pin through and wounded his right eye. There was much pain, and the eye was poulticed with a mess in which bruised snails formed an ingredient. The cornea now presented a wound near its centre, still open, and surrounded by a considerable haze; the iris, naturally hazel, was dark reddish brown, and in contact with the cornea; the capsule of the lens was opaque, and the pupil, reduced in size, and of a narrow crescentic form, was adherent to it. There was much venous congestion of the conjunctiva and sclerotica, and a purple zone surrounded the cornea.
"The child was feeble, and not in a condition to bear powerful treatment; two leeches were applied, and grey powder, with sesquioxide of iron, administered twice daily; the eye to be frequently fomented with a belladonna lotion, and the brow to be rubbed with extract of belladonna and opium. At the expiration of a week great amendment was visible; the vascularity had diminished, and the iris had to a considerable extent recovered its natural hue; mercurial was after a time suspended, and quinine with iron substituted; the eye gradually lost the inflammatory condition, but the pupil remained closed." (p. 119.)
In all cases of wounds of the eye, and especially in wounds through the cornea, such as those now quoted, the prognosis should be extremely guarded. Much depends on the force with which the instrument of injury has been propelled against the eye, much on its size and condition, whether sharp and polished or angular and rough, and much on the constitution and vulnerability of the patient.
One patient meets with a wound of the crystalline through the cornea, the opaque disorganized lens is extracted through a puncture of the cornea, in Mr. Gibson's method, an operation which has lately received the absurd name of linear extraction; no bad symptoms follow, the eye is, on the contrary, immediately relieved from the severe pain arising from the pressure of the lens against the iris, and as good vision is speedily restored as after the most successful operation for cataract.
Another patient meets with almost identically the same injury, the same operation is performed, but no relief to pain follows; the cornea next day appears hazy and flaccid, and speedily there set in all the symptoms of a violent ophthalmitis, under which the eyeball is pushed from the orbit, suppurates, bursts, and ends in atrophy.
"When the system," observes our author, "is in a bad state, a trifling wound of the eye will bring on violent general inflammation and suppuration of the globe; I have principally observed this in persons who had led irregular lives, and whose powers were low; soon after the injury violent pain attacks the eye, shooting back to the brain; the lids rapidly swell and assume a crimson hue; the eyeball itself enlarges, girded by the lids; and in a short time all natural appearance of the organ is lost, the cornea becoming first yellowish, then brown, the conjunctiva enormously chemosed, and more or less dry. . . . . There is little or no pus till the eye gives way, and then the pus flows from a small aperture, which gradually enlarges as the slough separates. The relief from pain is marked when the eye has given way." (p. 135.)
Mr. Cooper observes that he had "never known an instance in which a lens, rendered opaque from infiltration of the aqueous humour, has become clear." (p. 122.) He then quotes the following case from the Gazette des Hôpitaux,' in which such an event is presumed to have taken place:
"A countryman, whilst gathering chesnuts, was wounded in the left eye by one of the prickles of the outer husk. This sharp body had traversed the cornea, and implanted itself in the crystalline. Some days elapsed before M. Robert saw the case, and when he did so, the crystalline apparatus presented a uniform milky whiteness, of which it was impossible to determine the precise seat. M. Robert extracted the spine entire through an incision in the cornea, bled the man largely, and covered the eye with cold water dressings. The following day the opacity had greatly diminished, and forty-eight hours after had completely disappeared." (p. 122.)
It does not appear whether the following remark on this case belongs to M. Robert or to Mr. Cooper :-"The whiteness spoken of must have been either in the lens or the capsule, and in either case its rapid disappearance is marvellous." There can be little, if any doubt, however, that neither the lens nor its capsule had been wounded, and that the cause of the opacity must have been lymph deposited in the aqueous humour.
Contrary to the opinion of some authors, Mr. Cooper shows that danger attends small wounds of the retina-such as that which is sometimes from carelessness or ignorance made with the cataractneedle. He says:
"I have seen cases where the operation of solution was performed by puncture through the sclerotic, made rather far back to avoid the ciliary processes, in which no inflammation followed, absorption progressed, and the pupil became clear; but about six months after the first operation, and one month after the disappearance of the cataract, muscæ volitantes aud scintillations appeared, the sight began to deteriorate, and, despite of every treatment, permanent amaurosis from chronic retinal inflammation resulted." (p. 134.)
A very large proportion of Mr. Cooper's work is made up of cases, either original or selected from other authors. Some of the latter are really so astonishing as severely to tax our power of belief. The following is an example:
"The eye of an infant was wounded by two fragments of glass, of which one penetrated through the sclerotic and the other membranes to the bottom of the eye. A great quantity of vitreous humour escaped, and the anterior chamber was half filled with blood. The pieces of glass were extracted, the
lids closed, and ice applied. Antiphlogistic treatment, and the position of the child on its back, favoured the rapid healing of this wound, which was happily followed by no imperfection of sight." (p. 141.)
Our author occupies fourteen pages with the treatment, general and local, to be followed after the removal of foreign bodies from the interior of the eye, and after wounds of the globe. We shall extract a few passages from this important portion of the work, as both affording a fair specimen of Mr. Cooper's style, and of the judicious practice which he recommends.
"It may be laid down as an axiom, that if the eye receives an injury, the speedy recovery will depend far more on the state of the system of the patient than on the extent of the wound. A mere scratch will light up a flame that will destroy one eye, whilst another eye will bear with impunity the most severe laceration or incision.
"One patient will require support and stimulants to urge the sluggish powers to the reparation of the injury; whilst another will need the most rigid discipline and active depletion to keep the inflammatory action within reasonable bounds." (pp. 144-145.)
"It appears to me, that the undoubted value of mercury as a remedial agent in iritis and some other inflammations of the eye, has led to an exaggerated idea of its necessity in cases of injury of that organ. It is too much the custom among young practitioners to begin with calomel and opium as soon as they undertake the management of a wound of the eye-a simple cut, for instance-and their reason is doubtless a not very defined notion, that as mercury cures iritis, so it ought to be given to counteract the effects of an injury; but a little consideration would convince them that their conclusion is premature. In a healthy subject a simple wound of the eye will heal with so little redness, pain, or disturbance of the organ, as not to deserve the name of inflammation; there is merely such an amount of vascular action as is necessary for the carrying out the process of union. . . . . . What are extraction of cataract, and artificial pupil operations, but severe wounds? Yet we never give mercury to enable these to heal! And the speedy and happy recoveries which take place under simple treatment should lead a reflecting mind to hesitate before deciding on a mercurial course for an injury, less severe, probably, than either of the operations referred to." (p. 146.)
"It was formerly the practice to deplete largely, and to confine to the most limited liquid diet, old persons who had undergone operations on the eye, or who were suffering from wounds of that organ; the phantom of inflammation. seems to have been ever present before our predecessors. This much is certain, that the opposite plan of treatment is generally adopted at the present day with the happiest results; and of those cases which take an unfavourable turn, for one patient who is attacked with acute inflammation after extraction, six or more suffer from non-union of the section from deficiency of power." (p. 148.) "The spirit-drinking, tobacco-smoking, ill-nourished artisan, who so frequently falls under our notice in this metropolis, is a bad subject for any injury of the eye; but it is less frequently acute inflammation which attacks him, than a low but scarcely less destructive form; there is great tendency in the cornea to take on suppurative action after wounds in such people, and the management requires much nicety; depletion they will not bear, and local irritants do more harm than good; it is very important to correct the secretions in the first instance, the tongue being generally foul and liver deranged."(p. 149.)
"If there be one thing more than another calculated to light up the flameof deep-seated inflammation, it is daily opening and examining the eye. L
cannot too often or too strongly deprecate such meddlesome proceedings. Another thing which often leads to mischief is carelessness or reckless exposure on the part of the patient; feeling no particular pain in the eye he presumes too much-reads, exposes himself to light and to cold draughts; a relapse is the consequence, and a heavy penalty is paid for the neglect." (p. 150.)
"If a delicate child be the subject of injury to the eye (and it is among children that serious wounds from forks and other pointed instruments are most frequent), the tendency to a strumous diathesis must be steadily borne in mind. The lowering, starving, and depleting system, would here entirely defeat its object." (p. 155.)
Mr. Cooper commences the consideration of Contusions and their effects with some remarks on ecchymosis under the conjunctiva and into the areolar tissue of the eyelids, a symptom which, he says, accompanies concussion of the brain. Of this we were not exactly aware. He says nothing of ecchymosis of the eyelids as symptomatic of counter-fractures of the orbit, an accident with which concussion of the brain, indeed, may be conjoined. After a fall or blow on the head, should extravasation of blood appear in the upper eyelid, without its having received any contusion, we are told that a counter-fracture of the upper wall of the orbit may be suspected; if in the lower eyelid, that the floor of the orbit is broken.
"Dans les percussions de la voûte du crâne sans contusion directe des paupières," say MM. Laugier and Richelot, "l'ecchymose de l'une ou l'autre est tellement caractéristique aux yeux des chirurgiens expérimentés, qu'elle suffit pour faire admettre sans autre signe, une fracture par contrecoup des parois de l'orbite."
It is stated that it is a character of such symptomatic ecchymoses that they increase during several days, and that they are not necessarily nor even commonly attended by any notable swelling of the eyelids; whereas direct contusions of these last are from the first accompanied by swelling and sanguineous extravasation. The symptomatic ecchymosis reaches the lids gradually, discolouring them more and more; while that which arises from direct contusion spreads, on the contrary, from the lids to the neighbouring parts.
The fact that extravasation of blood into the interior of the eyeball sometimes attends that which is external, and, unless a very careful examination of the case be made from the beginning, may not be discovered till the conjunctiva and eyelids begin to resume their natural colour, and the patient finds the sight of the injured eye seriously impaired or completely lost, seems also to be passed over without mention. In such cases ophthalmoscopic examination of the eye will occasionally reveal the existence of a clot within the sphere of the retina, or the signs of blood effused behind that membrane, or behind the choroid.
From page 159 to page 163, a very interesting series of observations is given, illustrative of the serious effects of apparently slight blows on the eye. Next follows the consideration of separation of the iris from its ciliary attachment in consequence of blows, the separation presenting every degree, from a minute chink to total detachment of