everts the upper lid so as fully to expose the palpebral conjunctiva, over the surface of which he paints with a camel's hair brush the solution of the nitrate of silver, taking care to apply it thoroughly to the reflection of conjunctiva which forms the oculo-palpebral fold. After waiting for about half a minute, he then, with a syringe, gently squirts over the granular surface a stream of cold water, or what is better a solution of common salt of about the strength of gr. x, ad aquæ 3j, to wash away and neutralise all the surplus nitrate of silver, so as to prevent its irritating the eye, or blackening the ocular conjunctiva, a misfortune I have seen occur when strong solutions of the caustic have been frequently used without taking these precautions.

GONORRHOEAL OPHTHALMIA is an acute specific inflammation of the conjunctiva of the lids and globe, induced by the inoculation of some gonorrhoeal matter into the eye. It is characterized by a profuse purulent discharge from between the lids, which is of a yellow colour, and exactly corresponds in appearance with that which flows from the urethra. disease is rapid in its progress, and very destructive; unless it is soon checked, the eye is lost.

The

Treatment.-A few years ago the treatment consisted in excessive bleedings from the arm, and in the use of strong depressing medicines. Experience has shown the error of such proceedings, and by now adopting a directly opposite course, a far larger proportion of cases recover with good and useful eyes. In gonorrheal ophthalmia the treatment must be constitutional and local.

Constitutional Treatment.-From the very commencement of the attack the strength of the patient must be supported by tonics, diffusible stimuli, and a liberal diet. The whole history of a gonorrhoeal ophthalmia is of a depressing character. The patient, generally suffering from gonorrhoea at the time the eyes become inoculated, is, from the nature of his complaint, and the treatment adopted to cure it, below the standard of health. The disease itself is also very exhausting; but the prospect of loss of vision, with the utter annihilation of all future prospects, adds to the sense of loneliness and despair. The fact that the patient is suffering from a severe urethral discharge, will not forbid the free use of tonics and stimulants. The danger of ulceration and sloughing of the cornea is increased as the vital powers are depressed. Having therefore first acted freely on the bowels by a moderate purgative, quinine in 2 gr. doses, or cinchona with the mineral acids, should be given every four hours. If there is much pain or irritability, opium should be prescribed, either in small quantities frequently repeated, or in one full dose at bed-time. When there is heat of skin, with thirst and a furred tongue, an effervescing mixture with ammonia may be advantageously ordered before prescribing the direct tonics. The diet should be one with meat or beef-tea, and with a certain amount of wine or brandy, according to the strength of the patient.

Local Treatment.-The best applications are nitrate of silver, lotions of alum, or sulphate of zinc and alum, and cold.

1. Nitrate of Silver.-This is best used in the form of solution, varying in strength from gr. x to gr. xxx, ad aquæ 3j, according to the severity of the case. The lids should be everted, and the conjunctival surfaces painted over with the solution, which should be allowed to remain a few seconds, so as to whiten the parts, and be then washed off in the manner described before.

This should be repeated once daily, and in very bad cases a second application may be necessary. When the lids are so swollen that they cannot be everted, two or three drops of a weaker solution of nitrate of silver, from gr. ij ad gr. x, ad aquæ 3j, may be dropped twice a day into the eye, after it has been first cleansed by syringing away the discharge with cold water.

2. Lotions of Alum.—Gr. vj, ad aquæ 3j, or of sulphate of zinc and alum, of the proportions mentioned at page 174, should be used at least once every hour to wash away the discharge as orten as it accumulates. The lotion should be gently injected over the surface of the globe with a syringe or india-rubber bottle, so as thoroughly to wash away all purulent matter at each application.

3. Cold is very grateful to the patient, and may be applied during the intervals between using the lotion, by placing a fold of lint, wet with iced water, over the eyelids, and changing it as often as it becomes hot or dry. The patient may also be allowed to wash away the discharge as fast as it exudes from between the lids with a piece of linen dipped in the iced water. By a steady perseverance in this line of treatment the best chance of saving the eye is afforded to the patient, but the disease is frequently of so virulent a character, that in spite of all remedies, and the most judicious management, the cornea sloughs, and the eye, for all useful purposes, is irretrievably lost. -Practitioner, Dec. 1868, p. 338.

73.-ON THE TREATMENT OF GRANULAR OPHTHALMIA AND PANNUS BY INOCULATION.

By J. G. HILDIGE, Esq., Surgeon to the National Eye and Ear Hospital.

The following cases, treated at the National Eye and Ear Hospital, show the efficacy of inoculation as a remedy for the cure of the above diseases, when all other means had proved unavailing.

Case 1.-Ellen B., aged seventeen, of a healthy and tolerably strong appearance, applied for medical advice under the following circumstances: She stated that when she was four years of age her eyes commenced to be affected, and ever since that time, during a period of thirteen years, she had been almost continually under medical treatment, her sight being occasionally so bad that she was obliged to be led about. On examination I found the cornea of each eye extremely vascular, and so opaque that it was with difficulty she could discern large objects placed near her. The mucous lining of the upper eyelids was covered with granulations and much thickened; it also showed signs of long-continued treatment. She suffered considerably from pain in the eyeballs and temples, which from time to time became so severe, particularly at night, that sleep was completely banished from her pillow. As the usual remedies were followed only by temporary improvement, and as she had been suffering so long from the disease, I resolved to have recourse to inoculation, a remedy which I had seen elsewhere employed with the best possible results, and which was not contraindicated in this case. The pus was taken from the eye of an infant suffering from acute purulent ophthalmia, and was introduced by means of a camel hair-brush between the girl's eyelids. After the expiration of twenty-four hours considerable irritation, accompanied by pain, set in, and at the end of forty-eight hours both eyes were suffering from an acute attack of purulent ophthalinia. Active antiphlogistic treatment was employed, the disease ran a favourable course, and at the end of fourteen days the inflammatory symptoms had subsided, leaving both corneæ perfectly sound, and showing indications of commencing improvement. Three weeks later both corneæ had become so transparent that the patient could read large type; and at present, four months from the day of inoculation, her eyes are perfectly sound, and her sight so good that she can read small type and see distant objects more distinctly than ever she remembers to have done in her life.

Case 2.-Eliza S., aged fifteen, apparently of a healthy and strong constitution. She had suffered from granular lids and pannus of right eye for a period of three years, during the greater portion of which time she had been under medical treatment. The cartilage of the upper eyelid was hypertrophied, and its mucous lining, which was covered with granulations, was much thickened and altered in structure. The cornea was vascular and opaque, so that the eye was almost useless to her. The left eye presented no trace of disease, but the sight of it had become much impaired from sympathetic irritation. This patient was inoculated at the same time as the preceding one, the left eye having been previously bandaged; and after a period of three days acute purulent ophthalmia, accompanied by considera

ble constitutional irritation, set in. The disease ran its course in about fourteen days, leaving the cornea perfectly sound; and at the end of ten weeks she could read ordinary-sized type with ease and see distant objects.

Case 3.—Mrs. B., aged forty-five, of a somewhat delicate appearance. She had suffered from granular lids for several years; both cornea were, however, perfectly transparent. Her sight was extremely bad, owing to a lesion of the retina which had existed for some time, and which was slowly progressing. She was inoculated with pus taken from a patient suffering from blenorrhea. A slight attack of purulent inflammation followed after a period of fortyeight hours. At the end of three weeks the attack had passed away, destroying every trace of granulations, and leaving both corneæ intact.

Case 4.-John B., aged ten, of a strong and healthy appearance. He had suffered for six months from granular ophthalmia, complicated with hypertrophy and ectropium of the eyelids of both eyes. The corneæ were perfectly transparent. Not wishing to resort to inoculation before making a trial of other remedies, I excised a portion of the diseased membrane from the internal surface of each lid, and afterwards cauterized the parts with the solid nitrate of silver, a pad and bandage being placed on each eye in order to retain the parts in situ. This mode of treatment was continued for some time, but was not attended with any permanent benefit, so that I determined to treat the case by inoculation. A severe attack of purulent ophthalmia followed the application of the pus; it yielded, readily, however, to treatment, so that at the end of ten weeks every vestige of the disease had disappeared, the ectropium being completely removed and the boy's vision excellent.

I have treated other cases of opacity by this means, and with the same beneficial results; and I consider that it may be safely resorted to in every case of granular ophthalmia, except when it is contra-indicated by a strumous or syphilitic diathesis, in which cases diphtheritic inflammation would be the inevitable result.-Dublin Quarterly Journal, Feb. 1869, p. 78.

74.-LACRYMAL OBSTRUCTION.

By ROBERT B. CARTER, Esq., Consulting Surgeon to the Gloucestershire Eye Institution.

It is well known to practitioners that lacrymal obstructions depending upon stricture of the nasal duct, below the sac, are often of a very obstinate character. In some cases, when the canaliculus has been slit up, and Bowman's largest probe passed through the stricture, the difficulty is soon Overcome. In others, and I think they form a majority, the stricture soon closes again, and the malady becomes as troublesome as ever. All manner of devices have been tried in vain; and such patients become a source of unmixed weariness at the hospital, and of weariness mitigated by guineas, in the consulting-room. Cat-gut probes, laminaria probes, injections of all sorts and in all quantities, styles to be worn temporarily, and styles to be worn permanently, form only a few of the resources that have been tried, sometimes successfully, but yet with frequent failure even in skilful and practised hands. And, if these probings and manipulations were ever performed unskilfully, it could scarcely be expected that benefit would be derived from them.

Nearly at the same time, Dr. Ulrich Herzenstein, of Vienna, and Dr. Stilling, of Hesse Cassel, put forth the suggestion that the difficulty in these cases was due to the fact that the instruments in common use were not large enough to dilate the nasal duct effectually. The bony channel of the duct is about three times the diameter of the largest of Bowman's probes; and hence this probe can scarcely be an efficient dilating agent within its walls. Both Herzenstein and Stilling sought for improved resources in the modern methods of treating stricture of the urethra. The former adopted the plan of splitting; the latter, the plan of internal incision. Herzenstein's instruments are, on a small scale, like those of Mr. Bernard Holt for the

urethra; and their employment is said to have been attended with success. I have no practical knowledge of them; but the method by internal incision I have now used sufficiently often to form some estimate of its value.

Dr. Stilling has contrived a knife (made by Weiss and Son) for his operation, somewhat resembling a small tenotome, rounded at the point, with a sharp cutting edge and rounded back, the blade about three quarters of an inch long, rather wider at the heel than at the point, and inserted into an ivory handle by a steel stem of such a length that the ivory handle is above the canaliculus when the point rests on the floor of the nose. This knife may be used to slit up the canaliculus, and may then be carried on in the same way as an ordinary probe; or the probe may be used first, to ascertain the position and measure the resistance of the stricture. The knife being fairly in the nasal duct, and its point on the floor of the nose, the resisting structures in the duct are to be freely divided, up to the bony wall, in three or more directions, until the blade is felt to be free in the duct, and can be turned round or moved up and down, without encountering resistance. The knife may then be withdrawn, and the fact of its having been in the nose may be tested by a probe; but generally there will be sufficient bleeding from the nostril to remove all doubt upon the point.

According to Stilling's experience, no other treatment than this is required. The incisions will be followed by a little swelling of the parts cut, so that the passage may be occluded for a time. But in the course of a day or two this swelling subsides, and no disposition to contraction remains. I have now performed the operation on four patients; and, with regard to three of them, sufficient time has not yet elapsed thoroughly to test its effects, although they are so far satisfactory. But in the case of a gentleman who had been suffering from obstruction for a long period, and for whom a probe had been passed at regular intervals, with only temporary benefit, a radical cure appears to have been brought about by the single operation. The probe now glides into his nose without encountering any obstruction, the tears pass away freely, and there is nothing left to remind him of the malady that was once a source of daily and hourly annoyance.— Practitioner, Jan. 1869, p. 24.

75.-UPON AN IMPROVED METHOD OF EXTRACTION IN CASES OF CATARACT.

By Dr. CHARLES BELL TAYLOR, Surgeon to the Nottingham and Midland Eye Infirmary. [In the year 1865 Dr. Taylor drew attention to a method of extraction in cataract, which he had found successful in several unpromising cases. (See Retrospect, vol. li., p. 284.) ]

The instruments that I employ are a pair of sharp forceps that pierce the sclerotic, a very light speculum (a modification of Von Grafe's), and two knives, a line in width and bent at an angle similar to the ordinary iridectomy knives, one with a sharp point, and the other with a blunt or bulbous extremity.

As the danger, even if vomiting occurs, is very slight with the form of incision I am about to describe, I usually prefer to have the patient narcotised, and, as a rule, push the chloroform to full anæsthesia. The lids should then be kept apart by the speculum, and the globe gently depressed with a pair of ordinary forceps in the operator's right hand. Having got the eye into a favorable position, it should be fixed by the sharp forceps at about the junction of the upper with the middle third of the cornea. The pointed knife is then entered in the corneo-sclerotic junction, one or two lines from the forceps, at the summit of the cornea, pushed well into the anterior chamber, and, with a gentle sawing motion, the eye being steadied with the left hand, carried along the summit a distance of three lines. The aqueous will now escape, and if we wish to extract without iridectomy, or if the condition of the globe before and after incision, as regards tension, is such that

we have reason to fear excessive bleeding from excision of a portion of iris, it will be well at this stage to open the capsule carefully in its central and lower segments, a proceeding very much facilitated by the small size of the wound, the safety with which the globe may be manipulated, and a previously dilated pupil. If the cornea remains firm, if the lens is readily loosened on incision of the capsule, if the patient is perfectly quiescent, shows no tendency to vomit, and other circumstances prove favourable, we may extract without iridectomy, in which case it will be simply necessary to enlarge the wound in the manner hereafter to be described.

If, from the nature of the case, we have decided on associating an iridectomy with the extraction, and desire to derive the advantages of an iridectomy, so far as tension is concerned, the iris forceps should now be introduced into the wound, the blades opened, and the iris seized near to its pupillary border, drawn out, and divided at the right hand angle of the incision, carried over and excised at the left as in iridectomy for glaucoma. If, however, tension is quite normal, and the removal of a portion of iris is not likely to have a favourable influence on the after-progress of the case, a very small incision, or the merest slit in the constrictor fibres of the iris, will suffice to reduce the risk from bruising to a minimum, and still to some extent preserve the advantages of a natural pupil. If we have not found it necessary to open the capsule prior to iridectomy, it should now be rendered tense and carefully incised with the ordinary cystotome, the stem of which it is as well to have made either of platinum or soft steel, so that it may be bent in accordance with the projection of the patient's brow, or relative position of the eyeball. Having opened the capsule, and slightly loosened the lens, the eye should be seized to the right of the globe with a pair of ordinary forceps, and the wound enlarged to the left with the blunt-pointed knife (encroaching slightly upon the sclerotic to an extent that experience tells us, will, with a similar wound to the right, suffice for the ready exit of the lens); fixing the eye then with the left hand, the process must be repeated to the right. The incision is thus localized in a definite line, and its extent at any period of the operation is only limited by the will of the operator.

If the iris has been left intact, a comparatively large flap will be required, but if iridectomy has either preceded or is associated with the extraction, a very small shallow flap will suffice, one which yields readily to the advancing lens, while it is sufficiently slit-like and elastic to close without artificial apposition or external support, strong enough to resist protrusion by advancing vitreous, and too resilient to permit of accidental reflection.

The lens may now be extruded by slight pressure upon the globe, without passing any instrument into the eye, cortical fragments removed with ease, and any portion of capsule or lens matter likely to obstruct vision, be either torn across or removed with the sharp hook, canula forceps, or sucker.

If, from the existence of firm adhesions, the lens cannot be started by pressure, it should be dipped out with the wire-loop spoon, an instrument which from its extreme tenuity assists the exit of the cataract without adding to its bulk.

may

If it is desirable to extract by the lower section, the same form of incision be employed, and this is preferable in a few cases where the lens is superficially softened, as any pulpy cortical matter left behind in the eye will gravitate to the bottom of the anterior chamber, pass harmlessly through the coloboma iridis, and either undergo absorption, or be washed out with the aqueous. The risk of its lodging behind the lower segment of iris and setting up subsequent irritation is thus avoided, but the section is less sheltered, and the coloboma uglier and more disturbing to vision.

The operation completed, I apply a drop of solution of atropine in the corner of the eye, and cover the lids with a pad of fine cotton wool, dipped in, but not saturated with cold water. If sodden, the pad is heavy, irregular, unmanageable; but just moistened on the surface, it fits accurately into the orbital cavity, and speedily dries into a smooth film, closely bedded to the surface of the lids, absorbing moisture, insuring equable support, a regular