of myriads of organised beings, infecting its atmosphere with miasmata and humidity. To this we must add the bad constitutions of our peasants, enfeebled by miasmata, by the pellagra, by insufficient and bad food, and damp dwellings. To these same causes must, I think, be attributed the erysipelas and hospital gangrene, which so frequently follow operations and wounds of the most ordinary and trifling description; and it is for this same reason perhaps that operations for hernia are more dangerous than in other more elevated provinces, and also autoplastic operations so commonly go wrong, and to these same causes which we see in this province of Italy may be attributed the more frequent recurrence of cataract than in other parts, a fact which has afforded me the opportunity of studying the subject on a large scale. We are now studying an entirely new modification of the operation for cataract, that of Professor von Græfe. The wound of the sclerotic is covered by the conjunctiva, and thus appears to offer a better chance of union. Whether this actually be so or not, is a matter we are at present submitting to experience. Ophthalmic Review, Oct. 1867, p. 371. 76.-FURTHER EXPERIENCE ON REMOVAL OF THE LACRYMAL [Before reading the following article, our readers would do well to refer to Mr. Laurence's previous one on the same subject in Retrospect, vol. liv., p. Mr. Laurence states that so far as his knowledge extends, the lacrymal gland has been removed twenty times for the cure of lacrymal disease, and with hardly an exception a permanent cure of the principal symptomepiphora-has resulted. Moreover, what is very remarkable, this result ensued whether the gland was wholly or only partially removed. A possible explanation of this is, that the excretory ducts being severed, the gland left behind atrophies.] The first question put to me by all those who have heard of my operations has been: Does the eye continue moist after the operation? It does, completely so. My experience in this point of view is corroborated by that of Mackenzie and of others, who have removed the lacrymal gland on account of tumours of its substance. Thus, Mackenzie states, 'the moisture and lubricity of the conjunctiva remain unaffected after extirpation of the lacrymal gland." In Dr. O'Beirne's case, in which the lacrymal gland was removed on account of its enlargement and induration, the patient suffered no inconvenience. Nor did Mr. Dixon's patient, who underwent the operation on account of traumatic obliteration of the canaliculi. These facts appear to show that the moisture of the globe is normally furnished by the Meibomian glands. What effect has the removal of the lacrymal gland on the abscess of the lacrymal sac? The study of my own cases has shown me that after a varying time the secretion of pus from the mucous membrane of the sac decreases, and finally disappears. Where this result does not progress favourably and spontaneously, it may be promoted by slitting up the lower canaliculus, in order the more efficiently to apply local remedies to the mucous membrane, either in the form of collyria or injections by Anel's syringe. Vin. opii, or weak solutions of argent. nitrat. (gr. i-iv. ad. 3j.), I find to answer best, applied once or twice a day, washing out the sac with injected water a few times during the day in the interval of the collyria. My conception of the mode of origin of the abscess of the lacrymal sac is that the sac, in the first instance, gets distended with tears, which are more or less completely pent up within its walls, according to the more or less complete imperviability of the nasal duct. The mucous membrane thus gets irri tated and congested, from its undue tension, and possibly from the circulation in its vessels becoming impeded. The tears themselves probably acquire acrid properties during their undue retention in the sac, from chemical changes which may be aggravated and accelerated by the subsequent admixture of the purulent secretion. This purulent secretion, after a time, reacts as a secondary cause of abscess, both by its adding to the distension of the sac and by its own intrinsic irritating properties-probably augmented, as in the case of the tears, by changes in composition from undue retention. Cystitis from an over-distended bladder, due to some obstruction to the flow of nrine-whether this be stricture of the urethra, enlargement of the prostate, or any other cause-appears to me to afford an excellent illustration of the mode of formation of lacrymal abscess. Not that I deny that exceptionally dacryocystitis may arise idiopathically in the same way that cystitis mayfor I have seen a few such cases myself. That over-distension of the lacrymal sac is the usual cause of its abscess, is indirectly proved by the observation which may be made daily, that watering of the eye from eversion or obstruction of the puncta lacrymalia never causes abscess of the sac. In one case, the watering of the eye ensued from a fibro-plastic tumour compressing the sac, and ceased after I removed the tumour. After what I have said, I think we should neither feel surprised, nor disappointed, that removal of the lacrymal gland does not cure the lacrymal abscess-which may, and often has, existed, off and on, for years-so soon as we could wish; that a purulent fluid exudes from the puncta, on firm pressure over the sac, not unfrequently for months after the operation. The removal of the lacrymal gland removes the primary cause of the abscess, but it neither removes the inflamination of the mucous membrane nor its disposition to secrete pus, which, as I have endeavoured to show, acts as a secondary cause for the continuance of the abscess; this, having become established as an independent condition, may take more or less time to disappear -moreover that this is greatly promoted by the removal of the continuous irritation of the mucous membrane by the pent-up tears, is a fact, I can, from repeated observation, most positively affirm. In three cases [Cases 9, 11, and 19] in which the lacrymal gland was removed, acute abscess of the sac followed the operation, but soon subsided, and, indeed, seemed to expedite the cure of the preceding chronic abscess. In my own two cases the perviability of the nasal duct was remarkably restored after the operation. I do not know how to explain this fact, but it would induce me in other cases to obliterate the sac after removal of the gland, should the abscess not yield to milder measures, such as those which I have previously indicated. I shall now describe the method of operation which I adopt. The instruments required are--a long narrow scalpel; blunt-pointed scissors; a small, sharp, double hook, such as used to be employed to evert the globe in the old operation for squint; a pair of bulldog-catch long forceps; needles and silver wire. Chloroform is administered to tolerably perfect anæsthesia. The skin immediately below the upper and outer third of the orbital ridge is divided with the scalpel. In this step of the operation the skin may be made tense by drawing it from side to side with the fingers; but it being very movable at this spot, care must be taken not to draw it up or down, otherwise the incision will fall over the frontal bone, or too far beneath the edge of the orbit, and as the lacrymal gland is in close contact with the roof of the orbit, there may be some difficulty in finding it. After the skin has been divided, the fascia connecting the periosteum of the orbit with the upper edge of the tarsal cartilage is cut through, and the orbital cavity is gradually entered by successive cautious strokes with the scalpel. After a sufficient cavity has been made into the orbit, the gland is felt for on the roof of the orbit by the fore or little finger of the left hand. After a little experience it may be recognised by the touch as a hardish, smooth, round body. In feeling for the gland, care must be taken not to push the finger too forcibly back into the orbit, otherwise the gland may, from its very loose attachment to the periosteum of the orbit, be dislocated from its normal situation, and pushed back into the orbital cellular tissue, or left attached to the fascia covering the eyeball, and its discovery and excision be rendered difficult, or as I, in one or two cases, found impossible without making an unwarrantably large opening into the orbit. Should there be any difficulty in feeling the gland, it is better to, at once, divide the external commissure of the lids by an horizontal incision outward, made to meet the outer end of the first incision. A triangular flap will be thus formed with its apex outwards; this flap is then thrown inwards, and the outer and upper angle of the orbit is thus freely exposed, when the gland will be much more readily reached, and may, in such cases, be found more in contact with the outer surface of the eyeball than with the roof of the orbit. Before making either of the above two incisions, I always feel for the pulsation of the temporal artery, so as not to wound it; and this has never occurred in any of my operations. After I have assured myself of the exact position of the gland, I pass the double hook along the side of the finger of my left hand, as a guide, keeping its points along my finger; I then half-rotate the handle of the hook, so as to bring the points of the hook towards the gland, which I firmly transfix with these points, draw it forwards, and carefully sever it from its connections with the end of the scalpel. After removing what I consider to be the gland, I invariably make a section of it, in order to assure myself that what I have removed is really the gland and not portions of the orbital cellular or fatty tissue. The section of the lacrymal gland is firm, dense, of a tawny colour, and of the usual lobular structure of racemose glands, and with the slightest care cannot be confounded with any other of the orbital tissues. As I have before said, although it is desirable to remove the entire gland, it is by no means a sine quâ non for the success of the operation; so that it is wrong unnecessarily to extend the limits of the operation, no good end being thus attainable, but on the contrary, certain untoward consequences may ensue, to which I shall, shortly, more particularly allude. After the gland has been thus removed, pretty sharp hemorrhage generally ensues, an artery of the orbit (probably the lacrymal branch of the ophthalmic) being the main source of the bleeding; but this has, in all my cases, without exception, always stopped on the application of a stream of cold water from a sponge. The wound should not be closed till the bleeding has stopped, otherwise shortly after the operation the upper lid may become enormously distended by blood extravasated into its loose cellular tissue-a result which I have in a few of my cases witnessed, when I had closed the wound without sufficiently attending to the above precaution. The wound may be closed by silver wire sutures, and care must be taken to place the parts in accurate apposition, more especially if the external commissure of the lids has been divided in the operation. In this case, the suture which requires the most accurate adjustment, is that which fastens the outer apex of the triangular flap to the skin of the temple. The wound may then be treated on general surgical principles: cold water-dressings, followed by warm ones, and even poultices, should any inflammatory action set up. In by far the greater number of my cases union has taken place by the first intention, and after a few weeks little or no trace presents itself of an operation which at the time of its performance appeared one of considerable severity. It is now incumbent on me to state certain unwished for results which may follow the operation. In most cases slight conjunctivitis ensues; this, in one case, ran on to inflammation of some of the deeper structures, which however gradually subsided under appropriate treatment, without, however, inflicting any permanent injury to the eye. But by far the most serious result which may follow the operation is ptosis of the upper eyelid. This was, in almost every case in which I observed it, of purely inflammatory origin and gradually subsided spontaneously, but in a few instances it was apparently due to a partial division of the levator palpebra. In Case 10, I am afraid that, owing to a free use of the knife, I must have divided or bruised some of the muscular nerves; for the ptosis was at first complete, although it subsequently became less, and the lateral movements of the eyeball were so paralysed as to give rise to considerable binocu lar diplopia. Ever after this case I have been particularly careful not to prolong the orbital incision of the operation either too far inwards or too deeply backwards. Indeed, in two instances in which the difficulty of removing the gland without a dangerous extension of the limits of the operation appeared to me impossible, I considered it a more surgical procedure to close the wound without removing the gland at all. It surely exhibits a very puerile feeling, besides a want of moral courage, to sacrifice the welfare of a patient to one's own false pride. Many years ago I saw a remarkable instance of this in another branch of surgery-a hospital surgeon would not be " foiled" in his attempt to introduce a catheter-within four-and-twenty hours the patient had a shiver, and shortly afterwards died from purulent infection. I have not, as yet, met with any other untoward effects from the operation than those which I have mentioned.-Ophthalmic Review, Oct. 1867, p. 361. 77.-EPILATION AS A CURE FOR OPHTHALMIA TARSI. By JONATHAN HUTCHINSON, Esq., Surgeon to the London Hospital. Ophthalmia tarsi, or tinea tarsi, consists essentially of a chronic inflamination of the hair-sheaths of the eyelashes, and of their proper glands. In bad cases the inflammation involves adjacent structures, the skin, mucous meinbrane, &c. The discharge adheres to the roots of the lashes, and forms a crust which prevents remedies from gaining access to the inflamed part. By far the quickest mode of cure is by the careful and complete removal of the hairs. The hairs usually come out with their sheaths adhering, showing that the lining membrane has been loosened by inflammation. In bad cases, two or three removals, at intervals of two weeks between each, are necessary. The hairs grow again very quickly, and in about six weeks attain their normal length.— Clinical Lectures and Reports of the London Hospital, 1867–8, p. 220. 78.-ON SOME OF THE ANOMALOUS EFFECTS OF ATROPINE ON THE EYE. By GEORGE LAWSON, Esq., Assistant-Surgeon to the Royal Ophthalmic Hospital, Moorfields. Atropine is chiefly used in ophthalmic practice to procure dilatation of the pupil, and to act as a sedative in various forms of inflammation of the eye. The preparation which is generally prescribed is the sulphate of atropia, this salt being preferred to the alkaloid, on account of its greater solubility, for whereas the sulphate is readily dissolved in distilled water, atropia is soluble in water in the proportion only of 1 in 500 parts. In an ordinary healthy eye, where the retina possesses its normal sensibility, and the iris acts freely, I have never known atropine fail to dilate the pupil; but as a sedative to the eye, I have, on a few occasions, seen it not only fail, but act as a direct irritant, and in two cases which I have to relate it caused the most acute and troublesome symptoms. In speaking of the anomalous symptoms produced by atropine, I would state my belief that they are entirely exceptional, and that whilst it is well to be aware that they may possibly arise, yet I do not think they ought to prejudice the surgeon against the use of a drug which, when fitly prescribed, is, in the large majority of cases, most beneficial. That a solution of the sulphate of atropia will occasionally produce irritation has been noticed by several ophthalmic surgeons, and the reason of its acting in this irregular manner has been attributed to the presence of some free acid in the solution. The salt has not been neutral, and the solution has given a slightly acid reaction to litmus paper, and to this has been attributed its irritating effects. I think myself that the explanation is wrong, and that the free acid theory has but little, if anything, to do with the fact that a solution of atropine will occasionally give rise to very painful and troublesome symptoms. What amount of free acid can there be in the one or two drops which are dropped into the eye from a solution of the sulphate of the strength of gr. j. ad aquæ j. and yet when thus diluted I have seen it occasion great irritation. We use daily in ophthalmic practice salts which contain much more free acid than the sulphate of atropia, such as the sulphates of zinc and alumina, but I do not remember any instance in which they have caused the peculiar forms of irritation which, in exceptional cases, I have seen spring froin atropine. I believe that when atropine acts thus as an irritant, or produces peculiar and distressing symptoms, it is due to some idiosyncrasy on the part of the patient, which renders him intolerant of the alkaloid or of its salts, and, in some cases, of any preparation whatever of belladonna. In one or two patients in whom even a very weak solution of atropine has given pain to the eye, I have found that a solution of the extract of belladonna has been borne without even a feeling of annoyance, whilst in other cases the use of belladonna in any form whatever has seemed to act almost as an irritant poison. The anomalous symptoms which atropine may produce are 1st. A sense of smarting and heat in the eye, accompanied by redness and lachrymation. These symptoms may pass off in a few minutes, or they may extend over some hours, or even continue for many days. 2nd. An erysipelatous condition of the eyelids and surrounding integuments, with redness and chemosis of the conjunctiva. As an illustration of the first class of symptoms I will cite the following case-For a patient on whom I had ten days previously operated for cataract, I ordered a solution of atropiæ sulph. gr. j. ad aquæ 3j., to be dropped into the eye twice daily. The drops caused so much pain and redness of the eye that she was obliged to discontinue their use. On another occasion the same patient called at my house to have the eye which had not been operated on examined with the ophthalmoscope. Thinking that the irritation which had previously followed the use of the atropine might have been only an accidental occurrence, and due really to other causes, I dropped again into the eye some of the atropine drops. A little smarting was the immediate result, but the pupil becanie dilated, and I was able to examine the eye. By the time, however, she had reached home, the pain had much increased, and the eye shortly became acutely inflamed, and continued so for some days. This patient, I afterwards found, was able to use a solution of gr. v. of the extract of belladonna to the ounce of water without the slightest annoyance. I have frequently seen atropine produce a momentary sense of pain at the time of its being dropped into the eye, accompanied with a flushing up of the conjunctival vessels, but, as a rule, these symptoms have lasted but a short time. The next case is an example of the second group of symptoms which may be caused by atropine. At the beginning of this year I operated on a gentleman for cataract. The case at first progressed very well; but as there was a little soft lenticular matter in the pupil, I ordered a solution of sulphate of atropia (gr. j. ad aquæ 3j.) to be dropped into the eye twice a day. Soon after its application the eye became very painful, with the lids swollen, and on the following day there was a distinct erysipelatous blush over the lids, and extending down the face. As I had never seen erysipelas follow the extraction of an opaque lens, or the use of atropine to the eye, I regarded its occurrence as an accidental circumstance; but as the drops gave pain, they were stopped, and a lotion of the extract of belladonna was substituted. The erysipelas, however, increased, spreading over the head and forehead, and down the face. The belladonna lotion was shortly afterwards discontinued, as with the swelling of the lids it was not only useless, but it seemed to give pain. All the severe symptoms now abated, and the patient soon recovered, but with the pupil closed by opaque capsule. About six months afterwards the gentleman called upon me at my house, as I wished to examine the eye previous to performing a needle operation. In order to ascertain how much the pupil would dilate, I dropped into the eye two drops of a solution of atropiæ sulph., gr. ii. ad aquæ 3j. I had not at that time connected the erysipelas with the use of the belladonna, and was quite unpre |