Three cases have occurred in my practice, presenting points in common, characteristic of this accident.

A sudden and most acute pain darts from the eye back into the brain, and is followed by a sensation of tearing, or dragging the eye from the socket. If the vessel gives way during or immediately after extraction, the vitreous humour will escape, and be followed by a flow of blood; but if some resistance is offered by union of the wound, the hyaloid becomes filled with blood, and the vitreous humour is lost sight of. The agonizing pain soon involves the brow and side of the head, and the eyelid is so exquisitely sensitive that it cannot bear the slightest touch; this adds to the suffering, the application of cold wetted rags to the eye being indispensable.

The first burst of pain is followed by faintness and nausea, often amounting to sickness, which nausea may continue many hours. The retching, however, does not prevent the stomach retaining small quantities of sustenance, and is best combated by soda-water, and by effervescing draughts containing dilute hydrocyanic acid; also by swallowing ice, either in lumps or as lemon ice. Cold jelly and cold beeftea are also grateful.

When the wound is sufficiently united to offer resistance to the immediate escape of the contents of the eyeball, the hyaloid becomes filled with blood; and when the wound is burst open, it gradually protrudes through the corneal section, and then between the lids, as a pouch filled with blood, represented in fig. 37. The retention of this increasing the suffering, it should be snipped off.

As the eyeball becomes distended with blood, the flap is widely opened, the upper lid thrust forward, and more or less œdema arises, commencing at the inner corner.

The blood is usually venous, oozing from the eye and

trickling down the cheek; there is every reason to believe that it is caused by disease of the choroidal vessels, and their

morbid condition prevents their ready contraction, nor probably does the bleeding cease till they feel the influence of the pressure caused by the coagulated blood within the

eye.

It was formerly supposed that rupture of the arteria centralis retina was the source of the bleeding, but that idea is now, I believe, generally abandoned. Mr. Walton mentions' a case seen by him at Moorfields, in which some time after extraction, the chambers of the eye filled with blood, which did not interfere with the success of the operation; but this was a piece of good fortune entirely exceptional.

Dr. Rivaud-Landrou,2 of Lyons, who has written upon the subject of intra-ocular hæmorrhage after extraction, is of opinion that it is caused by rupture of the small blood-vessels which pass from the choroid to the hyaloid, and is always a consequence of escape of vitreous humour.

The careful examination of four eyes in the museum at Moorfields is conclusive, to my mind, as to the seat of hæ

1 'Operative Ophthalmic Surgery,' p. 453.

morrhage. In one case, the eye was excised for intra-ocular hæmorrhage after extraction, being the second case in which excision was performed there for that occurrence. Two eyes were excised from one individual; in each, Graefe's operation had been performed for acute glaucoma, in each, hæmorrhage took place, and they were removed. In the fourth case a staphylomatous eye was ruptured by injury.

In all these preparations there is most distinctly visible the coagulum of blood lying between the choroid and sclerotica, pushing the choroid and retina inwards, or inwards and forwards, according to the magnitude of the clot. In not one did the bleeding take place from the inner surface, but in all clearly from the external surface of the choroid, probably from the vasa vorticosa. A precisely similar condition existed in another eye excised for hæmorrhage after extraction, the description of which is in the ninth volume of the Transactions' of the Pathological Society. I am therefore of opinion that intra-ocular hæmorrhage after extraction is due to a diseased condition of the choroidal vessels, that it does not arise from rupture of the central artery of the retina, and that it occurs irrespective of loss of the vitreous humour, though the sudden withdrawal of the support afforded to the weakened vessels by that body may be a powerful predisposing cause.

On June 13th, 1855, I performed extraction at St. Mary's Hospital, on the right eye of a female, aged 70. Some years previously she had suffered from deep-seated pain in the eyeballs, with muscæ, and had long been teased with irregular gout; the globes were hard and pupils nearly immovable, and it was with some reluctance that I performed the operation, as I did not think favorably of the case. section was completed with facility, the curette used, and with gentle pressure the lens escaped, a small quantity of

The

The flap

rather fluid vitreous humour accompanying it. being replaced, the lid was dropped, and I paused before taking a final look at the eye. After a few seconds the patient clapped her hand to her eye, and complained of sudden intense pain going back into her head. Removing her hand, I looked at the lid, and saw it rapidly becoming distended; raising it, I found the section gaping widely, and a large mass of hyaloid pushing through it. In a second or two a gush of blood issued from the eye, and flowed down the cheek. The bleeding continued for thirteen hours, notwithstanding the constant application of ice, and the free administration of gallic acid.

On the evening of the 17th, the patient being faint and low, a cordial opiate was administered; as the power of the circulation returned the bleeding recurred, but ceased in half an hour under the use of ice.

The application of cold was persevered in for two more days, when it was changed for poultices, as suppuration of the globe was commencing; liberal diet and wine were ordered, the suppuration proceeded favorably, and the eye gradually collapsed.

On December 6th, 1856, I performed extraction on the left eye of Anne Gale, a patient in St. Mary's Hospital. She was a feeble old woman, had been a great sufferer from rheumatism, and was so extremely deaf that it was with difficulty she could be made to comprehend a single sentence addressed to her. This infirmity made her very nervous, and from her restlessness the section was made with great difficulty, the iris being slightly wounded. The lens was extracted with facility and without any escape of vitreous humour. The patient was allowed liberal diet, and the eye not disturbed till the seventh day, when it was examined The eye was pale, cornea clear, but the section had not

united. The eye was therefore again closed for some days, and wine, with bark and ammonia, ordered. On the tenth day, the section being still open, and some serous chemosis existing, a weak solution of nitrate of silver was applied.

That evening the head nurse was suddenly called to the patient, and found a great protrusion hanging out from the eye, with blood trickling down the cheek. The housesurgeon was summoned, and applied ice and pressure. The hæmorrhage continued actively for an hour, when it gradually ceased and did not return.

The after-treatment was similar to that of the previous case; the eye suppurated and sank.

In the third case, the lady was 85 years of age, but of remarkably sound constitution; she had long been attended by Dr. Jervis, who kindly gave me his assistance in the trying after-treatment which became necessary.

ment.

This lady had long been the subject of hard lenticular cataract, and I performed extraction by the upper section, on the right eye, on Tuesday, November 2d, 1858. The operation was performed with facility, the lens escaped gently, and not a drop of vitreous humour followed. No case could progress more favorably; all pain ceased by the third day; there was not the slightest oedema of the lids, and speedy convalescence was anticipated. We were doomed to disappointThe patient was lying on the sofa quietly conversing with me on the evening of the following Friday, when blowing her nose rather briskly, she instantly exclaimed, "Oh, what a pang in my eye; it gets worse! it goes back into my brain! oh heavens, some one is dragging my eye out! the pain is intolerable!" There was nothing visibly wrong, and at first I attributed the pain to spasms, but as it increased I began to fear that intra-ocular hæmorrhage might be taking place. I bathed the eye with warm water for two or three minutes