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whether acute or chronic, we suspect that intra-ocular hæmorrhage must be a not unfrequent attendant on the operation of opening the cornea and snipping out a portion of the iris in cases of that disease. In addition to the instance referred to by Mr. Cooper, in which both eyes of a glaucomatous patient required to be extirpated in consequence of intra-ocular hæmorrhage after iridectomy, we observe it noticed in the number for January, 1859, of the Ophthalmic Hospital Reports, p. 299, that

“One glaucomatous globe was excised on account of the severe pain which followed the excision of a portion of iris (some vitreous had in this case been lost); portions of the choroid near the entrance of the optic nerve were displaced inwards by blood, which had escaped from the outer choroidal surface, between the sclerotic and the choroid."

We would venture to suggest, if intra-ocular hæmorrhage is a common result of the operation of cutting up the living eye in glaucoma, that instead of assuring the patient that the operation is to restore sight, and adopting a proceeding which causes great sufferingso much so as to require excision of the eye for its relief—it might be better to remove the eye first, and to dissect it afterwards.*

* That relief to pain, and even preservation of sight, have followed iridectomy in some cases of glaucoma,

does not admit of dispute. That excision of a portion of the iris, however, has any share in producing the beneficial effects, is not proven ; on the contrary, the presumption is, that, as in the following instance, the benefit is owing to the preliminary part of the operation-namely, the opening of the cornea, and evacuation of the aqueous humour :

* A man, aged fifty, of a lax, bloated appearance, otherwise of sound constitution, came under my care," says a celebrated operator, "about three months ago, on account of inflammation of his right eye, which had troubled him for eight days. I found the eye watering much, intolerant of light, the conjunctiva red and chemosed, the great ring of the iris of a dull tarnished hue, the pupil fixed, dilated, and very turbid, and the power of vision so much impaired that the patient discerned only the movement of the hand, but could not count the fingers. He complained of a variety of subjective luminous sensations, and of violent pain in the right brow, temple, and side of the nose. I gave a very unfavourable prognosis, as the disease bore so undeniably the aspect of severe acute glaucoma. The patient was placed in a dark room, an energetic antiphlogistic and derivative treat. ment adopted, and a powerful opiate given in the evening. The inflammation was thereby considerably reduced, and the pain almost completely removed ; but the sight was improved only so far that the patient could slowly count the fingers at the distance of some feet, while the field of view was extremely limited. The pupil continued very obscure, depending, as is common in acute glaucoma, on a diffuse muddiness of the aqueous humour, and a deposit over the posterior surface of the cornea.

* In a disease like this, which almost always mocks the influence of treatment, it is an imperative duty to make trial of some new remedy. No doubt we frequently see the symptoms of acute glaucoma subside, and after the use of antiphlogistics and mercurials, and especially after large doses of opium, an improved state of vision ensue ; yet the hopes based thereon give way on a more extended experience, inasmuch as either the inflammatory attacks are repeated, leaving each time a more contracted field of view, or a continued loss of sight (with centripetal diminution of the field of view), gradually takes place, without any new attack of inflammation. Sufficient and sad experience of these results determined me to strike into another plan of cure for the above patient. As the amaurosis which arises in the course of acute glaucoma is in a great measure propor. tionate to the increase of the internal pressure, denoted by hardness of the bulb, anæsthesia of the cornea, paralysis of the iris, &c., although yet deeper changes, probably in the bloodvessels, form the original cause, I determined powerfully to bring into play the means of diminishing pressure. After having with this view employed atropine without effect, I proceeded to paracentesis of the anterior chamber. Immediately after the first evacuation of the aqueous humour, the iris and pupil appeared much clearer, so that proof was furnished how far the diffuse muddiness of the aqueous humour had contributed to the dull appearance of the eye. A corresponding improvement in sight also instantly took place, so that the patient could count the fingers at the distance of seven, in place of



The following is an example of artificial oplıthalmia coming under Mr. Cooper's observation :

“ An inmute of an orphan school was placed under my care at St. Mary's Hospital, by one of the governors, who took an interest in her forlorn condition. She was suffering apparently from chronic inflammation of the right eye, with slight haziness of the cornea. Week after week elapsed without amendment, notwithstanding a variety of treatment, and suspecting that there must be some cause for this, I took the girl into the hospital, and desired that she should be watched. All I could learn was, that although always complaining of her eye to me, she never at any other time seemed annoyed by it. This convinced me that she in some way irritated the eye, but she was not detected, and after a month she was re-transferred to the out-patient's department, the eye remaining much the same.

"A few days after this, I met the girl a short distance from the hospital, on her way to it to appear before me. I stopped her, and without speaking, drew down the lower lid of the affected eye. The mystery was at once cleared up! A chip of wood had been cunningly placed between the lid and the eye, and was of course always removed when the eye was to be looked at. The chip was quite sodden with mucus, having evidently served this purpose for a long time.“ (p. 291.)

It is a question of great interest, what are the tissues which being injured in the one eye, are likely by sympathy to give rise to inflammation in the other. It is thought that sympathetic ophthalmitis “is most apt to be excited if the wound has produced a protrusion of the iris, and such a cicatrix as keeps the remainder of the iris perpetually on the stretch, and that it is especially liable to occur if the Tetina has been divided or lacerated.” (p. 301.) In addition to what is here stated, we believe that it should be mentioned that such injuries as implicate the annulus albidus of the choroid, or in other words, the choroid muscle and the ciliary nerves, are more apt than others to be followed by sympathetic ophthalmitis. The presence, also, of fragments of iron, percussion-caps, and the like, within the injured eye, is a cause which should be particularly noticed, as apt to give rise to disease in the opposite eye.

“ There is this curious fact,” continues our author, " that so far as I am aware, sympathetic inflammation is not a consequence of the operations for cataract or artificial pupil, though extensive wounds are thereby inflicted on the cornea and iris, and in many cases the iris is involved in the cicatrix. four feet. This evidently arose from the removal of the turbid aqueous humour, which had disturbed vision by its absorption and dispersion of the light. The chief effect of the paracentesis consisted, however, not in the immediate, but in the gradual improvement which was observed in the course of the next day, so that the patient was able to make out large type; this being plainly attributable to some change in the internal circulation of the eye.

Some days later, as the aqueous humour again appeared somewhat turbid, the paracentesis was repeated, and this even a third time. Although the patient has now a dilated and nearly motionless pupil, and the iris has changed colour, he congratulates himself on possessing very good sight, so that, with convex glasses suited to his presbyopia, he rends the print No. 3 of Jäger's book, and hesitates only at the most difficult words of No. 1. Besides, the field of view is laterally completely unimpeded—that is, the extent and sharpness of excentric vision is normal, a circumstance which, since I have employed exact and appropriate means of measurement, I have never before observed in any case of glaucoma which had run its course."

Such is the important testimony of Dr. Von Gräfe (' Archiv für Ophthalmologie,' Erster Band, Abtheilung ii. p. 302, Berlin, 1855), in favour, not of any new treatment for glaucoma, as he seems to suppose, but of one long ago advised and found useful in that disease, and for which it is to be hoped that iridectomy will speedily be abandoned.

Again, gun-shot wounds, though generally destructive to the eye, comparatively seldom excite sympathetic inflammation.(Ibid.)

Mr. Cooper explains, that in the treatment of sympathetic ophthalmitis by operation, we have the choice of two proceedings, the one consisting in excising a portion of the eye originally injured sufficient to allow of the escape of its contents, and the other extirpation of the globe. He confesses that though the former has its advantages, he leans to the latter as the more likely to save the eye threatened with sympathetic disease. (p. 304.)

In the operation of extirpation, according to O'Ferrall's method, Mr. Cooper directs the conjunctiva to be divided “at the point of reflection.” (p. 310.) It is better, however, to remove as little of the conjunctiva as possible, as the more of it that is left, a better cushion will be formed for the application of an artificial eye. The conjunctiva, therefore, should be divided as close to the cornea as possible; the membrane should then be pressed aside, and the recti divided one after the other.

In all cases in which an artificial eye is to be worn, it is important, no doubt, to apply it early, so as to prevent the eyelids from contracting, and sinking it upon the stump. We should doubt, however, if the time specified by Mr. Cooper for the introduction of an artificial eye after accidental evulsion of the eye, will be sufficient-namely, “about a week.” (p. 228.) A month, or a couple of months, will generally be soon enough.

After removal of the globe in O'Ferrall's method, it might be supposed that nothing would be easier than the successful adaptation of an artificial eye.

“When the eye has been excised in the manner described, the muscles being left, form in the process of healing a solid projecting mass, admirably adapted,” says Mr. Cooper, " for supporting an artificial eye.

Not only is the orbit åt to receive it in from four to cight days after the operation, but by raising and supporting the flaecid lids, it affords positive relief.” (p. 311.)

As to the successful adapting of an artificial eye after extirpation of the globe, we have found it easier said than done; and we observe that Mr. Gray, & well-known artificial-eye-maker, states that

" When the globe has been excised, it is still a desideratum that some artificial support for the artificial eye should be found. Mr. Moon, the late housesurgeon of the Royal London Ophthalmic Hospital, suggested artificial eyes with the edges inverted. Such eyes succeeded in removing the sunken appearance, but in the course of time caused irritation and accumulation of discharge."

Dieffenbach, it is well known, went the length of transplanting a flap from the temple into the orbit, in order to form a cushion for an artificial eye after extirpation of the globe.



The perusal of Mr. Cooper's work affords abundant proofs of the necessity of more attention being paid to eye-diseases in the education of the general practitioner. He refers to many cases in which injuries

Ophthalmic Hospital Reports, Jan. 1859, p. 305.

of the eye had been wofully mis-treated before coming under his care, or that of some other well-informed surgeon.

Among the vast variety of subjects to which the medical student's attention is directed, there is some danger of the object of all his study, namely, the practice of his profession, and the cure of disease, being well nigh overlooked. The essential thing to teach the student is the business of the medical and surgical practitioner, so that he may be able to treat according to just principles the common cases of injury and disease which will come before him. To this all his education should directly point. The dissecting-room and the hospital are the places where his studies ought chiefly to be carried on, and nowhere, we should say, is knowledge more improving or useful to be obtained than in an extensive and well-conducted eye-hospital, with such a work in the student's hand as the very valuable one of Mr. Cooper, which we have now reviewed. It is an excellent practical book, abounding in most interesting facts, and proving the careful observation and the sound practice of the author, with no nonsense or extravagant pretence, and well worthy of a place in the library of every practitioner.

The illustrations—both the coloured lithographic figures and the woodcuts--are extremely good.

REVIEW V. Klinik der Leberkrankheiten. Von DR. FRIED. THEOD. FRERICHS,

Professor in Breslau. Erster Band. Mit einem Atlas von 12 colorirten Stahlstichtafeln und zahlreichen in den Text einge

druckten Holzschnitten.-Braunschweig, 1858. 8vo. pp. 409. A Clinical Treatise on Diseases of the Liver. By DR. FRIED. THEOD. FRERICHS. Vol. I. Accompanied by an Atlas of 12 coloured

engravings on steel, and numerous woodcuts.
The ancients considered the liver to be the central

of the

vegetative functions. Plato, in his Timæus, styles it a Opéuua ñyplov, to indicate its importance in relation to vegetative life as distinguished from animal or spiritual. Galen regarded the liver as the origin of animal heat; from the liver sprung the veins ; in the liver chyle was transformed into blood. The doctrine of yellow and black bile outlived the rest of Galen's pathology, and even the opposition of Vesalius (1542), based upon his anatomical researches, failed to produce any immediate effect. It was not until Aselli (1622) had discovered the chyliferous vessels, and Pecquet (1647) had for the first time demonstrated the thoracic duct, that the ancient opinions on the liver and its functions were modified or abandoned. Bartholin and Glisson (1653 and 1665), maintained that the portal vein and liver had no share in conducting the chyle and assimilating it to blood. This view met with great favour at a time when, through the discovery of Harvey, a new physiology had been introduced. The opposition of Riolan and De Bils only afforded food for the humour of Bartholin, who after having "buried the liver,” now doubted the possibility of its “resurrection,” and wrote an epitaph, announcing the end of its

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reign. Swammerdam once more enunciated the ancient doctrine, but with so little effect that Boerhaave remarked : “ Dudum in meliori parte Europæ obsolevit haec sanguificatio nunquam ab eo viscere expectanda." The opinion became prevalent that the function of the liver is limited to the secretion of bile.

Whether it was that Galen was more lucky in his imaginations than Bartholin would admit, or that he was more experimental than the relics of his works, in garbled editions, permitted an inexpert mental age to perceive ; it came to pass that the nineteenth century found reason to revive much of the Galenic doctrine on the liver, and Magendie, Tiedemann, and Gmelin showed that a share of the digested contents of the gastro-intestinal canal makes its way to the blood through the portal vein and liver. The liver again came to be regarded as the seat of important changes in the composition of the portal blood (Lehmann). It was perceived that the hydrocarbons are in some way metamorphosed in this gland (Bernard). This discussion, which has for some time been carried on amongst a number of cotemporary physiologists, has not yet become a matter of history. Among some collateral functions of the fætal liver there now appears to be the production of blood corpuscles. The calorific result of the function of the liver has found another defender ; and thus it is, that the views of Galen, although modified, have risen juto fresh life and significance. The liver is once more the central organ of metamorphoses in the vegetative sphere of the animal economy.

Sensible as appears to us the view which the ancients held of the function of the liver, it did not serve them as the basis of their pathology. In diseases which admit of being easily referred to the liver, anatomically or functionally, the diagnosis of the ancients was as perfect as our own. Inflammation, abscess, obstruction in the liver were recognisable enough to them. But when the many obscure general distempers of the body had to be referred to a fons et origo, imagination was allowed free credit, and generally drew upon the liver. Sanguificatio vitiatar hepate vitiato. The responsibility of the liver became unlimited, and plethora, anæmia, cachexia, and dropsy were all and always debited to its account, upon the faith of the Latin flourish. Yellow and black bile, from the position of elementary ingredients of the organism, advanced to an etiological dignity, and either equivocally or at the call of some higher and still less known force, could assume a morbific agency. Through fourteen centuries few doubted the relation of yellow bile to acute diseases, accompanied by a febrile rise of the temperature of the body; and in selecting those diseases which they would attribute, on the other hand, to black bile, writers unconsciously poetic and figurative merely depicted the prospect that met their eyes when they contemplated those dark diseases, which, like convulsions and mental disorders, seem only to remind us of blackness and gloom.

The great advance in anatomy and physiology which signalizes the seventeenth century, had the effect of diverting the attention of physicians from the organ, which hitherto had enjoyed an unmerited



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