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known remedies, or merely a pseudo-syphilitic or mercurial complaint.
It is certain that it has generally occurred to those who had used mercury for a real or supposed lues; but I have seen three cases where that medicine had never been used, nor any venereal affection even suspected ; one of them was a married woman, who had three healthy children during five years that she suffered under it, and had submitted to every plan of cure that could be devised, by numbers of medical gentlemen to whom she bad applied. Like all others in this disease, mercury, in any shape or form, was to her invariably injurious.
In the only case I have seen prove fatal, the uvula and soft palate sloughed away from time to time. Little aphthous crusts formed on the back part of the fauces, falling off successively, and succeeded by round black ulcers, which gradually penetrated deeper and deeper, destroying great part of the nose and internal ears. She could not swallow solid food in this stage of the complaint, her hair fell off, debility and swellings in various parts supervened, and death at length terminated her sufferings.
In any of the cases I have seen, the constitution exhibited no characteristic mark of a scrofulous diathesis.
I do not think it necessary to enlarge on this subject at present, nor to enumerate what local and constitutional remedies had been tried, but shall probably, in a short time, submit a few cases of it to your readers, in a detailed manner; and in the mean time, hope that more light may be thrown on this matter by some abler and more experienced practitioner.
Belfast, 7th November 1815.
Case of Artificial Pupil. By Mr MOORE, Surgeon, Belfast.
UGH Quin, a labouring man, aged about 48, applied to me
in April last. When a boy, he lost the sight of the left eye by an accident. In September 1814 be struck the sound eye against the end of a stick, and ruptured the sclerotic coat above the cornea, to the extent of half an inch, in nearly a semicircular direction, with the concave part towards the cornea. A portion of the vitreous humour protruded, supported by its capsule, and the flap made by the wound, and formed a tumour
about half the size of a common bean. The eye was very much inflamed; there was a considerable discharge of matter like pus and mucus mixed ; and severe pain in the temples and forehead, occasionally shooting to the vertex. The pupil was closed in consequence of the continued inflammation, which had now lasted eight months, and the iris had that rugose appearance we often see in closed pupil, and was drawn upwards by its attachment to the ciliary ligament, which ligament was drawn upwards by the protrusion of part of the vitrcous humour. He could just discern light from darkness, at the clear light of a window or door.
On examining the eye, the following indications obviously presented themselves : Ist, To abate the inflammation in the eye, and relieve the pain in the forehead and temples. 2d, To remove or lessen the size of the tumour, as the friction of the upper eye-lid on it caused a considerable degree of irritation. 3d, To procure admission for light into the eye by an operation.
In order to fulfil the first, two grains of submurias hydrargyri were given at bed-time, and a drachm of pulv. jalap. comp. next morning. These were repeated twice a-week; and a solution of acetate of lead was very frequently applied to the eye by means of linen rags dipped in a large basinful of it. By continuing this plan a fortnight the inflammation was nearly removed, and the pain in the head and temples quite gone.
Then, wishing to remove the tumour, I punctured it with the cataract-needle, and squeezed out the greater part of its contents, which were of the consistence of jelly, and appeared to be the vitreous humour thickened. In a few days a little inflammation, that had been excited by pressing it, abated.
I then proceeded to the operation, in presence of Surgeon Macdonnell of this town, and assisted by Staff-Surgeon Latham. Having fixed the eye with a speculum, I pierced the cornea with the extracting knife, half a line from the sclerotica on the outside, and a little above the transverse diameter of the cornea, and continued the incision to its lower part, keeping at the same distance from the sclerotica. I then introduced a very small hook, and fixed it in the centre of the iris, carefully avoiding the lens; the iris being gently raised, the point of a fine pair of scissors was introduced behind the hook, and the raised part snipped off and brought out. There was a slight effusion of blood from the iris, which rendered the eye turbid. The antiphlogistic plan was continued, as above mentioned, and in about a week the effusion was absorbed, and the eye became clear. We then found the pupil in its proper place, and fully the natural size ; such as it usually is in a moderate light, and quite cir
cular, except the part near the external angle, towards which it was lengthened a very little, and the margin of that part not so smooth or well defined as the other part of the circumference. He could now discern colours, point out the different objects in a room, and the panes of a window, or the colour of people's clothes at the opposite side of the street. In a few days he went home to the country with a very useful degree of vision. It is now five months since the operation, and I have lately heard from him. He is able to follow his business as usual, and the sight of the eye is as good as before the accident, except that the pupil has not the power of contracting, and it is necessary to wear a shade over it in a strong light.
As this affection of the eye has not been much attended to, it may not be irrelevant to give a slight sketch of the different methods that have been practised for its relief, with a few remarks.
It appears that Cheselden was the first to perform the operation ; and from his manner of doing it, he must only have considered that closure of the pupil which succeeds extraction or depression. He introduced a couching-needle, having a cutting edge only on one side, through the sclerotic, a line and a half from the cornea, and, pushing the needle through the iris near the external angle into the anterior chamber, and carrying it nearly as far as that side of the iris next the nose, he then turned the edge backwards, and withdrew it, so as to make a transverse section of the iris.
This operation has not succeeded in the hands of other surgeons; and it is evidently not adapted for a case of closed pupil where the lens is in its place, as it must be injured by introducing the needle into the posterior chamber. Besides, the incision of the iris is apt to unite again, and render the operation useless.
The method proposed by Janin, by making an incision the same as in extraction, and, with a fine pair of scissors, making a perpendicular division of that part of the iris next the nose, is better than Cheselden's, but I think is liable to two objections. The incision in the cornea is too large ; one half the size or a little more is sufficient; and by carrying the incision farther than the lower part of the cornea, the flap is apt to be elevated by the lower eyelid, and prevented from adhering, and part of the iris is apt to protrude. The other is, cutting the iris perpendicularly on the part next the nose. In this way it will admit a portion of light, but the sight would be more extensive and better if it were in the proper
axis of vision. Scarpa has recommended to separate the iris from the ciliary ligament, by introducing a needle through the sclerotic, two lines from the cornea, and tearing the iris from the ciliary ligament, at the part next the nose.
He has practised this method in a few instances successfully; but that eminent surgeon only takes into consideration the case of closed pupil after extraction, or depression, or where the lens has been absorbed by solution. He informs us, that there is great pain attending it; and also that it was a month and sometimes more before the blood effused in the aqueous humour has been absorbed. He has a great objection to cut the cornea after extraction, or depression ; thinking that it will excite great irritation. The pain and irritation, however, is much less in opening the cornea, and cutting the iris in its centre, than piercing the sclerotica and tearing the iris from the ciliary ligament. Besides, the pupil is not in its proper place, where we ought always to endeavour to make it ; unless there is some particular objection, such as an opacity of the cornea ; and in that case we are obliged to make it opposite to whatever part may be transparent.
The late Mr Gibson of Manchester punctured the cornea, so that part of the iris might protrude, and with a fine pair of scissors snipped off the protruded part, so as to form a pupil. This is a safe method, and is adapted for those cases where there is but part of the cornea clear, and the natural pupil sound, but obscured by the opacity. In puncturing, or making an incision in the cornea, it requires one of a considerable size to permit the iris to protrude; and when the pupil is made in that manner, it is behind the scar (or very nearly so) left by the incision, which may cause some obscurity in the sight; and I think it probable, that the iris and cornea may adhere, as we sometimes see after extraction.
Sir William Adams practises a method different from either of the foregoing. He introduces a small knife with one cutting edge only, and makes a transverse incision in the centre of the iris of a proper size for a pupil, and at the same time cuts up the lens, (as it must be wounded in making the pupil) in order that it may be dissolved in the aqueous humour, and absorbed. The patient may obtain a tolerable degree of sight no doubt ; but it must be still imperfect, owing to the loss of the lens; and it may be sometimes necessary to break down the lens repeatedly before the solution is completed. Where I have seen it performed, there was a considerable degree of inflammation, and the cure was very tedious Probably we may not always be able to save the lens; but I am induced to believe, that most surgeons would attempt it, and that there is a reasonable prospect of success
In performing the operation as described in the case related above, the only risk is, that of injuring the lens with the hook, when raising the iris to snip it with the scissors; but in the hands of a surgeon of tolerable steadiness, and accustomed to operate on the eye, there is very little danger. The hook I used is very fine, the curved part not being more than two lines, or two and a half in extent, and sufficiently curved to keep its hold until the piece was cut out. Raising the iris is of the greatest service, as it enables us to cut out a piece nearly circular ; which makes a good pupil, and prevents it from adhering again, which it generally does, if there is only an incision made in it. The scissors used are somewhat concave, such as are used in cutting a piece of skin from the external part of the eyelid, in cases of inversion ; and, I think, they make the pupil more circular than straight ones would.
From the foregoing, it appears that we may divide the cases that require the operation for artificial pupil into three species.
1st, Where the pupil has closed in consequence of the removal of the lens by an operation.
2d, Where the pupil has closed in consequence of inflammation from an accident, or some other cause, and where the lens is in its natural place.
3d, Where there is an opacity of the cornea before the natural pupil, that prevents vision, and there is some other part of the cornea clear.
In the first, either the operation practised by Scarpa, or the one described in the preceding case, may be adopted at the option of the surgeon. I have stated some reasons above for preferring the latter.
In the second, the operation used by Sir William Adams, or the one described in the foregoing case, may be adopted. I have also stated some reasons in favour of the last.
In the third, it is obvious we must make the pupil opposite whatever part of the cornea may be clear.