or lens, examine them by oblique illumination before going further. Many opacities in the cornea are so slight that you overlook them on naked-eye inspection, and also with the ophthalmoscope mirror, but find them directly by oblique illumination. Need I add that you must be very particular that your object-lens, when you use it, is quite clean. Any stains on it will be seen as if on the patient's retina.

3. Having completed your examination of the media, still proceed on system. The next duty is to estimate the length of the eyeball. A patient may come complaining that he is rapidly loosing his sight, and you may find that it really has become so defective that he cannot read the largest ordinary print. You hastily assume that he must have some disease of the deep parts, some form of amaurosis. You proceed to ophthalmoscopic examination, and again hastily employ both mirror and object-lens, and it is quite possible that you may overlook altogether the fact that the eyeball is much too short and the patient hypermetropic. In high degrees of hypermetropia, if sudden failure of accommodation happen to occur, the defect in sight may often be so great as to draw the attention quite away from the right scent. I have already described the method by which we ascertain whether an eye is abnormal as to length. For the benefit of the mere novice, I may, however, here add, that whenever without the object-lens, any of the details of the fundus-vessels, disc, patches, &c.,—are easily seen, he may be quite sure that the globe is either too long or too short, or that the lens is wanting. If these objects are seen very easily, and the image very bright and beautiful, then, in all probability, it, is an inverted image, and the eye is myopic. If only large trunks of vessels have been seen, and these not easily kept in view, then probably it is the erect image, and the eye hypermetropic.

4. Still proceed on system. Having ascertained that the media are clear, and that the eyeball does not materially deviate from its normal length in either direction, you may now examine in succession the optic disc and its vessels, the retina, and choroid near to it, the yellow spot, and lastly, the outlying districts. I must mention each of these separately.

5. The Optic Disc. Note its shape, its margins, whether definite or otherwise, its colour, and its level. Observe whether the vessels upon it are seen sharply or not, and look particularly as to how they conduct themselves, at its margin. Distinguish between artery and vein, and note the size of each. It is a common mistake with young observers to pay attention to the vein only. In the healthy state the disc should be round, and its choroidal rim distinct and sharp; the vessels on its surface should be seen with beautiful clearness, and the difference between vein and artery, as to size and colour, should be readily distinguished. In the centre, or near it, and close to where the trunks of the vessels dip back, there will be seen a bright white patch. This white patch may be large and very conspicuous in some eyes, and small in others, whilst still the eye is not in the least diseased. As regards the vessels, you must distinguish between the large branches of those destined to supply the retina, and the minute ones which give a general pink tint to the nerve itself. The latter may be much diminished, whilst the former retain their size.

Amongst the more common peculiarities displayed by the disc in a state of disease, we have

1st. The formation of crescents by its side, or of irregular circles around it in myopia.

2nd. A jagged condition of the choroidal rim, indicating either the commencement of crescents, or the previous occurrence of inflammation (neuritis).

3rd. A hazy semi-opaque appearance of the structures in which the retinal vessels run, by which the latter are in part concealed and rendered indistinct. In this state the margins of the choroidal rim are concealed, and the disc appears to be much increased in size, and to be limited by a shaded, indistinct edge. This "woolly" condition implies neuritis.

4th. The disc may be too red or too pale. The pallor sometimes amounts to absolute whiteness, sometimes it is blue-white, and sometimes it is a dirty grey tint. Sometimes the pallor affects the whole disc surface, and at others

only a part. If only a part, the third next to the yellow spot is that usually affected, and in commencing cases this is always the first to suffer. The pallor may indicate mere anæmia, with, perhaps, primary atrophy, or it may indicate an anæmia and atrophy which are secondary to inflammation. It requires much experience to decide this point.

5th. The disc, instead of being on the same level as the rest of the retina, may be pushed backwards, or cupped as it is called. This cupping will be recognised by carefully tracing the main trunks of vessels and observing whether they curve on passing over the choroidal margin. If the cup is well marked, the vessels will bend so much that they are lost sight of at the edge of the disc, to be found again on its surface, looking much smaller and paler than those in the retina, and requiring a little movement of the object-lens to bring them well out. Cups of this kind imply intra-ocular pressure, the characteristic of the disease known as glaucoma. With them pulsation of the vessels may often be observed.

Having carefully studied the disc, your attention will next be directed to the retina and its vessels. The retina ought to be almost perfectly transparent, but in dark eyes-and particularly in members of the dark races--a delicate haze, or bloom-of-plum appearance, may be observed in it, especially near to the yellow spot. You ought to be able to trace the retinal vessels with the greatest ease. If this cannot be done, then inflammation of some kind or degree is present. The grand characteristic of inflammation, as far as the retina is concerned, is opacity. This opacity may vary from the merest haze to that of the dense white or grey pellicle. By this haze the trunks of the vessels will probably be more or less concealed, but if the deeper layers of the retina are affected, their concealment may not be much. You will remember that the retina consists of three principal layers-that of rods and bulbs, which is close to the choroid, and probably fed by it, that of nerve cells, granular matter, &c., in the middle, and that of nerve-tubes (derived from the optic), &c., which is innermost. It is in the latter layer only that the arteria and vena centralis run these vessels have nothing to do with the deeper or outer layers. The inflammation may affect chiefly either the inner or outer layer, being in the one case, a neuro-retinitis, in the other a choroido-retinitis.

In some cases of retinitis, as in that which attends Bright's disease, hemorrhages are very common.

The yellow spot is recognised almost as much by its negative features as by any distinctive peculiarities. It is situate a little to apparent nasal side (inverted image) of the optic disc, and is exactly opposite the observer when the patient looks at the ophthalmoscope mirror. No large vessels cross it. It is more highly pigmented than the neighbouring parts, and also often looks rather hazy and indistinct. It is here that the deposits characteristic of Bright's disease are earliest seen.

The choroid is the tissue which gives colour and glow to the fundus. It may vary exceedingly within the limits of health, and its variations will cause apparent haze, or otherwise, in the retina. Before trusting yourself to any ophthalmoscopic descriptions whatever, examine carefully the differences in the eyes of fair and of dark persons. In the latter you will find the choroidal epithelium full of pigment, and showing dark mapped-out areas, which might easily be supposed to be morbid, whilst the vessels of the choroid are coucealed. In the fair-complexioned eye the leashes of vessels will be seen with marvellous brilliancy, and beauty, and the suspicion of atrophy will be suggested. It is much more common to see the results of inflammation in the choroid than to trace the early stages of such. The results are permanent, and very conspicious. The epithelium may be absorbed in large patches, usually with masses of black pigment remaining. The absorption may implicate deeper layers, and be attended by atrophy of the vascular rete and exposure of the sclerotic. The patchy condition in a case of choroiditis disseminata may be compared to that of a piece of well-marked tortoise-shell.

Inflammation of the choroid in patches is usually of syphilitic origin. Atrophy of the choroid, independent of inflammation, is frequent in advanced states of myopia.

Inspection of the outlying districts of the fundus is easily done, by making the patient look upwards, downwards, &c., strongly. It should never be omitted; for not unfrequently changes may here be discovered which will be the key to the case. It is here that the dots of pigment, characteristic of retinitis pigmentosa, will be first found. Here also, in syphilitic inflammation of limited degree, patches may be sometimes found when there are none in the central parts of the fundus.

Having mentioned some of the chief morbid conditions to be expected, I will now specify some of the errors into which novices with the instrument are likely to fall. Like all other instrumental aids-and the stethoscope is a prominent example-the ophthalmoscope must be expected to lead to many mistakes. It is difficult to use, and requires long experience before the observer can trust his own interpretation of what he has seen. Want of familiarity with the varying conditions which may be met in health, is a main cause of error. Thus a well-pigmented choroid in a dark complexioned person may be easily misapprehended. A very large physiological cup may be taken for "white atrophy," or for a glaucoma cup; a margin of black pigment at the edge of the disc may be attributed to disease; and alterations in size of vessels, which are peculiar to the individual, may be supposed to imply anæmia or congestion. It is possible, also, in a highly pigmented eye, to mistake the yellow spot itself for the remains of a blood clot. As to the common error of fancying the retina hazy when the appearances are due to opacity in one or other of the media, I have, I think, already said enough.

Degrees of vascularity are especially difficult of satisfactory comparison. You will hear one authority assert that the disc or retina is congested, when another will declare that they are quite normal. Let me warn you against the diagnosis of "congested retina." In four out of five of the cases in which the words "hyperamic retina" are used, they are probably employed in error. Both in the optic disc and in the retina, the size of the vessels may differ widely and be still within the bounds of health. Just as one person may have a florid cheek and red ears, and another pale ones, yet both be in good health, so may the colour of the optic disc and the size of the retinal vessels differ. The conditions of the circulation in the retina are such as to make any condition analogous to erythema of the skin simply impossible. If you find the retina visibly reddened, be sure that it is not simply "congested,' but stained by effusion, in fact, inflamed. The individual arteries are too far apart to give any general red colour to the whole. The interpretation of congestion must rest on the enlargement of their trunks only; and this, which is a comparative question, is very difficult to estimate. The old notions as to active congestions preceding inflammation, must be abandoned for the retina, as elsewhere. We now know that cell changes are the essential factors in inflammation, and that it is these that induce vascular changes. I do not by any means deny that the optic disc and retina may in some cases contain too much blood, and yet show no trace of inflammation; but I feel sure that these conditions are far less frequent than they are thought, and I warn the beginner against the fatal facility of explaining amblyopia by discovering congestion. Clinical Reports of London Hospital, 1867-8, p. 182.

75.-ON SCLERONIXIS: A CLINICAL LECTURE DELIVERED AT THE UNIVERSTIY OF PAVIA.

By Professor A. QUAGLINO, Lombardy.

[These remarks of Professor Quaglino are chiefly valuable as applicable to all such damp situations as he describes at the end of his paper. The thirst after novelty at any price has led us to forget those older operations which form the best inheritance our ancestors have bequeathed to us. It must be remembered that the basis of all the new operations for cataract are extraction and depression, or scleronixis.]

Simple lateral depression with the needle for hard cataracts; simple division, LVIII.-13.

or associated with linear extraction, for cataracts of cheesy or milky consistence, are the operations I prefer.

[The author then gives a table of twenty-eight cases of depression of cataract, twenty-six of which were successful, one only unsuccessful, and one required a secondary operation. Are not these results worthy of comparison with those of extraction?]

I must give my reasons for resorting more frequently to this method than to any other.

I had, for some time past, observed that extractions were too frequently followed by suppuration of the flap. This sometimes commenced by a disintegration of the cicatrix; and, moreover, generally just by the time I had come to regard the success of the operation as certain. Suppurative aquocapsulitis, prolapse of the iris, distorted pupil, or even a closed one, synechiæ, secondary cataract, and often, atrophy of the eye, were among the sad results of this extraordinary form of suppuration. What astonished me the more was, that I had very rarely observed such an occurrence in my practice at Milan, either in private or at the Fate bene Sorelle Hospital. This recalled to my mind the precepts of my predecessors Scarpa, Flarer, and Panizza, who at this very same clinic operated for cataract almost exclusively by scleronixis, and only exceptionally by extraction.

Being as warm a partisan for extraction as any of the modern ophthalmic surgeons, I with but bad grace resorted to depression-a method which the physiology of the eye seemed to have undoubtedly stamped as inferior to that of extraction.

Nevertheless, after what you have seen of scleronixis, should we be right to disregard this method, and to condemn it to the exile and oblivion a distinguished writer of the present day would insist on?

I am surprised to see brought forward, and there and then extolled to the skies, new operations, which possess far greater disadvantages than the old ones, and which are much more dangerous; thus banishing almost entirely a method much less exposed to such disadvantages, and which can boast of its solid successes.

We are, I believe, too much in the habit of allowing ourselves to be led away by the spirit of innovation, and of too readily accepting the dicta of authorities in place of following in the experimental path which our predecessors have traced out for us.

No doubt, to obtain favourable results from depression, we must attend to certain points, both in the operation itself and in its after-treatment. Before proceeding further, I shall quote a few à propos words of Scarpa :

"Impartial observation and experience," he says, "the great arbitrators of all such matters, appear to have declared themselves in favour of this old operation (depression); for it is easier to do than extraction; it is applicable to all kinds of cataracts, whether hard or soft; the consecutive accidents are less serious and less dangerous than those which follow extraction; and lastly, should the operation, in consequence of some accident, fail, it can be repeated twice or thrice, without danger, on the same eye.'

Professor Flarer, my own master, held the same opinion; and, I must say, acted on it successfully.

The most permanent and brilliant results of depression are, we must acknowledge, obtained in the case of cataracts which are either soft or cheesy in consistence, in the fluid ones which occur in middle-aged people, and in those which occur in infancy. In hard, senile cataracts it may be adopted, but more exceptionally.

In every case, the precept of Scarpa must be borne in mind-that is to say, to open out widely the anterior capsule, without which a secondary capsular or membranous cataract may form. To effect this essential step, I depart somewhat from Scarpa's practice. Instead of making the incision of the capsule transversely, with a straight lance-headed needle (I do not employ Scarpa's curved one, which is much less easy to manage), at the same time as the lens is depressed, I prefer making at once two vertical incisions, which cross the capsule at each extremity of its transverse meridian, and then pushing the

middle of the capsule together with the lens proper, down into the vitreous by the flat side of the instrument. It is much more easy to lacerate the capsule at this stage of the operation, than it is after the lens proper has been depressed; for then it is almost impossible to make any further incision of the capsule, which yields to the least pressure of the instrument, be it ever so exactly directed. I make the first of my incisions before I have hardly well entered the anterior chamber; the second one on the nasal side I make by bringing the point of the needle towards the nose, penetrating the capsule de novo at its transverse meridian. Moving the needle from below upwards, tilting its handle, suffices to open out the vertical parallel incisions. This done, I proceed to the second step. This consists in depressing and sinking the lens, which I plunge into the vitreous humour, below and to the outer side, into a space bounded by the inferior and external recti muscles. In sinking the lens, a third incision is made in the capsule, the lower part of which is depressed, and so wide a breach of continuity is made in the anterior capsule as to render any kind of union of the portions of the capsule impossible, the danger of any secondary cataract being thus removed. By adopting the manœuvre I have just described, I have hardly ever had any secondary

cataract.

If the cataract is soft, or of a cheesy consistence, it may be broken up with the needle, the nucleus or any large particles sunk in the vitreous, and the rest of the cortex left to become absorbed, or, to hasten the cure, even brought forward into the anterior chamber, and then extracted by a curette through a simple linear incision in the base, and external periphery of the

cornea.

If the cataract is hard, of an amber colour, after the capsule has been lacerated in the manner indicated, the lens must be sunken to the side into the vitreous by a pretty quick, but delicate movement of the needle; so that it becomes buried in this humour, without, however, coming into contact with the bottom of the chamber, i. c., the inner coats, on which it would act like a foreign body.

This manœuvre is easy when the hyaloid has undergone atrophy, and the vitreous humour is more fluid than natural, but becomes more difficult when the vitreous is of normal consistence, and thus offers greater resistance to pressure and favours the rising up of the cataract to its old place. In the case of membranous or secondary cataracts division may still be practised with a straight needle, and it is well accomplished by the manipulation we have spoken of for lacerating the capsule.

The depression of the entire mass of the crystalline lens is hardly ever obtained. To effect this the zonule of Zinn must be cut through at its upper part, and the crystalline in its capsule must be dislocated downwards before depressing it; but this depression of the entire cataract, without lacerating its capsule, is not the practice we propose, nor is it desirable, inasmuch as its absorption is thus prevented. It thus always occupies the part of a foreign body in the interior of the eye, and ends by leading to atrophy of the globe after a series of more or less neuralgic and inflammatory symptoms on the part of the coats of the eye and of the ciliary nerves. In every case we must try to open up the capsule, so as to expose the substance of the lens to inhibition, to maceration in the aqueous humour, and to absorp tion.

If we compare the results with those of extraction and its various modifications, that is to say, with suppuration of the corneal flap, suppurative aquocapsulitis, iritis, prolapse of the iris and its consequences, finally panophthal mitis, we shall see that the results (successes) of scleronixis are perhaps not much below those of extraction; and, for our part we must acknowledge that they are superior, seeing that absolute loss of the eye hardly ever happens. But to what is this due? I think myself warranted in asserting that it depends entirely upon circumstances local and endemic entirely confined to this city, to this province, as it is to the whole of lower Lombardy, where the irrigation of the soil has been carried to its maximum for the cultivation of rice, and has thus converted the district into one vast swamp, productive