roof of the orbit, it could be felt that the projection at the angle was due to an enlarged and tortuous coil of artery, and that the artery was tortuous and dilated along the roof of the orbit. Here, then, was a case of arteriovenous aneurism, with the cirsoid dilatation of the artery, and probably also of the vein, which commonly accompanies that disease. In such a case there is no roughened sac; the arterial blood passes by a smooth aperture into the vein and these are conditions under which it is almost hopeless to expect that indirect pressure will effect a cure-almost hopeless, but not quite. I felt it right, therefore, to employ digital pressure on the carotid during three weeks, organizing for the purpose a staff of three persons, who maintained intermittent but complete pressure during several hours daily for that period. It was very easy to stop pulsation in the projecting tumour by pressure on the carotid, and the arrest of the pulsation always afforded the visible sign that the pressure was complete. In cases of true aneurism, some surgeons have thought it desirable that the pressure should be continuous and incomplete, allowing a small stream of blood to flow through the tumour and deposit its fibrin. In arterio-venous aneurism I have no doubt that it should be intermittent and complete; for here the object is, by stopping the flow of blood from the artery into the vein, to seal in the first instance the aperture of communication. If this complete pressure be not intermittent, faintness follows from the interference with the circulation of the brain. This boy always bore fifteen minutes of pressure very well. At first we all thought there was a marked improvement; and the boy said that he did not suffer so much in the head. However this may have been, at the end of three weeks there was much the same state of things as before. After some consideration I resolved to tie the common carotid artery, as offering the best means of cure.

In March, I operated, in the presence of Mr. Erichsen, Mr. T. Holmes, Mr. Walter J. Coulson, Dr. B. W. Richardson administering the chloroform. The operation lasted but a few minutes, and neither the vein nor nerve was seen. The ligature of the common carotid immediately caused the flattening of the pulsating tumour, and an entire cessation of its beat. On recovering from the chloroform, the boy was calm and sensible; there was no perceptible change of temperature in the heart, or in the eye, or in the neck He slept well that night, and the most remarkable point in all the after-progress was the total absence of any symptoms which could have led to the supposition that the great artery of the neck had been tied, or that anything had been done to interfere with the circulation of the brain. The ligature fell on the eighth day. The patient was seen during his convalescence by Mr. Erichsen and Dr. Richardson. The only point to be noticed was, however, the absence of symptoms.

Looking to the frequency with which ligature of the carotid has produced the gravest symptoms of brain disorder, and the occasions on which it has been followed by softening of the brain, paralysis of the opposite side, and death, I was disposed to think-and it was also the impression of Mr. Erichsen-that this boy had a great advantage in that the collateral circulation had been developed previously by digital pressure, and the sudden diversion of the blood was hence attended with little or no shock to the brain. It was in this hope that I persevered in the use of digital pressure before the operation, after it was evident that it was not likely itself to effect a cure. I think it may perhaps be recommended that this preliminary measure should in future always be adopted, if only with that view.

The final result of the ligature has, in this case, been satisfactory. There is not, at the present time, any trace of the tumour, or pulsation at the angle of the eye. The sight is perfect. He has no pain or noises in

the head; he runs and plays about, and is clever at his book. There may be heard, by applying a stethoscope to the head, a whizzing bruit. This has been noticed in other cases after cure, but it has not affected the permanency of the cure. I attribute it to the retrogressive dilatation of the arteries which had occurred during the progress of the disease. This slightly cirsoid condition will probably remain.

In the following table may be seen a list of the recorded cases of intraorbitar aneurisms treated by ligature of the primitive carotid, with the result:

THE

Herpin
Pétrequin
Brainard

Do.

1845

1852

Death.

Unsuccessful.

Successful.

Successful, sight gone.

Successful.

Successful.

Curling
Nunneley

1854

1852

1856

Do.

1858

Death.

Do.

1859

Bowman

1859

Death.

It will thus be seen that the statistical results of the operation are not unfavourable, considering the magnitude of the vessel ligatured, and its importance to the nutrition of the brain. Out of the twenty cases which are here tabulated, in three cases the ligature of the common carotid was followed by death. In two the success was incomplete. In a sixth case the pulsation of the tumour was unabated by the operation. There remain fourteen successful cases out of twenty.

Mr. Hart attaches great importance to the treatment by compression of the artery leading to the aneurism, and he cites two cases in which this plan was carried out most successfully. If this plan has not been earlier applied to the treatment of orbital aneurisms, the explanation must probably be found in the fact that continued instrumental compression of the carotid artery in the neck is a proceeding of almost insurmountable difficulty. Since Professor Vauzetti, of Padua, has perfected the application of digital compression, this difficulty no longer exists. Digital pressure was maintained in the case of R. T- without inconvenience. It failed to effect a cure, but it probably modified favourably the condition of the tumour, and developed usefully the collateral circulation of the brain. In the first case, that of Maria O—, treated by Professor Gioppi, of Padua, the cure was effected by compression for a few hours in four days; in the other case, that of Catharina B―, treated by Dr. Scaramuzza, of Verona, by inter

mittent compression occupying seven hours and twenty minutes in the course of eighteen days. It may perhaps serve to show how slowly the news of surgical progress may reach even the bestinformed quarters, that no reference whatever is made to these cases in Mr. Nunneley's paper in 1859, nor does this surgeon mention the possibility of effecting a cure by this simple means.

CASE I.-Maria O- aged 42, entered the clinique of the hospital of Padua, July 4th, 1856. She was of feeble constitution. Seventeen days previously, during an effort of childbirth, she felt as though her eye had started from the orbit. Four days afterwards the lids and globe of the eye were immovable, and there was complete blindness. On admission, the aspect of the patient was frightful. The eye lay motionless on the cheek; the pendulous lid was red and livid; the cornea infiltrated and opaque; blindness complete. There were pulsatory noises in the head, and the finger, when pressed back at the upper border of the orbit, felt an elastic aneurismal tumour thrusting forward the eye. Compression of the carotid very soon produced faintness, and Gioppi employed the method of Valsalva, fearing to use ligature. It failed. Digital compression was then employed for a minute or two at a time, suspending it when faintness threatened. This compression was effected with the finger by the patient herself, and some of the convalescents and others in the ward. The effect was of the happiest kind. On the following day there was already a diminution in the force of the pulsations; and at the end of the fourth day all pulsation had ceased. From that time all went well. Finally, the eye retreated within the orbit and sight returned, the patient remaining only somewhat myopic and with a dilated pupil.

CASE II.-Catharina B, of Verona, a washerwoman, aged 49, small and weakly, was admitted into the eye ward of the civil hospital of Verona on April 4th, 1858. She was weak in health and subject to palpitation. A few days previously, after a violent access of fever, she felt an acute pain in the left orbit and ear; something seemed to give way in the orbit; the eye became enlarged, and the patient could not distinguish light from darkness. On her admission, the left eye projected entirely beyond the orbit; the lids did not cover the ball; the eye red; cornea dull. The patient could hardly discern the light. There was pulsation and thrill over the orbit and left temple. She was the subject of dilatation of the heart and of the arch of the aorta. Digital compression of the carotid was therefore employed here very cautiously, for not more than five minutes at a time. Summing up briefly the carefully recorded details of the case, it may be said that during the eighteen days that the treatment lasted, the total space of time during which compression was used amounted only to seven hours and twenty minutes. The eye had then entirely entered the orbit, and pulsation had ceased. The cure was complete.

ART. 101.-On Inferior Section of the Cornea for the
Extraction of Cataract.

By Mr. ERNEST HART, Ophth. Surgeon to St. Mary's Hospital. (Lancet, Oct. 18, 1862.)

In the operation for the extraction of cataract, Mr. Hart prefers the inferior section of the cornea to the superior section. "My

own experience," he says, "and the observation of a long series of cases in the practice of my friend, Mr. White Cooper, prompt me to speak much more favourably of the inferior section than do some of our classical writers on ophthalmic surgery. From the results of a large number of cases of extraction, in rather more than half of which I have operated by the inferior section, I have great reason to be satisfied with that method. In a number of other cases which I have had opportunities of observing, the result has been as good.

"It has been objected to the inferior section that the edge of the lower lid is likely to become engaged in the wound, and so to retard union; and that by its position, being bathed in the tears of the inferior cul-de-sac of the mucous membrane, the healing of the cicatrix must suffer from that contact. I believe both these objections to be partly fanciful, and that they are not fully borne out in practice. I have never seen more rapid union than in the cases of inferior section, and the excellence of the ultimate result is greatly aided by the more favourable conditions which it offers for executing the operation to perfection. In employing the superior section, there are difficulties inherent to that method. These occur especially in the second and third stages of the operation. After the section has been made and the eye released, the ball turns upward under the lid so as to bury the incision, and the introduction of the cystitome, the expulsion of the lens, and the perfect clearing of the pupil are all infinitely more difficult than in the lower section. Practice teaches how to overcome these difficulties; but I am persuaded that the greater facility with which the pupil may be cleared and the parts adjusted has the effect of producing more perfect results from that operation. The accidents of operationand in these I include wounding the iris, effusion of blood into the anterior chamber, difficulty in extracting the crystalline lens, incomplete incision of the capsule, declension of the lens into the vitreous humour-may be almost wholly excluded from operation by the inferior section. By my own experience I am led to similar conclusions in respect to prolapse of the iris and synechia-two of the most troublesome accidents so far as the after-consequences are concerned. In one or two patients I have operated with the same degree of care by the inferior section on the one eye and by the superior section on the other, and the result has confirmed a preference for the former method. Thus, in Catharine B., who was lately under operation at the West London Hospital, the result on the left eye (inferior keratotomy) was perfect; in the right (superior keratotomy) the iris is adherent to the corneal cicatrix. The same has happened in two other of my cases lately. I know no more beautiful, simple, and successful operation than extraction by the lower flap."

ART. 102.-On Paracentesis of the Cornea.

By Mr. GEORGE LAWSON.

(Royal London Ophthalmic Hospital Reports, Jan. 1862.)

In this article Mr. Lawson relates some cases illustrative of the advantages of tapping the anterior chamber of the eye in cases of sloughing ulcers of the cornea, or of ulcers which refuse to heal under other modes of treatment, in cases of onyx, or of ophthalmitis with hypopion.

་

'The operation," he remarks, "is a simple one, and best performed by the manner usually adopted by the surgeons at Moorfields -viz., by passing a broad needle through the cornea at its lower margin, keeping the point well forward towards the cornea, to avoid wounding the lens, and then suddenly turning it on its edge so as to allow the aqueous to run off, and rapidly withdrawing it as soon as the iris approaches the cornea.

"The indications which call for this line of treatment may be briefly stated.

"1st. Increased tension of the globe. The eye, in any of the above-mentioned cases, may have its tension slightly increased, and this seems, in a great measure, to depend on an increased secretion of the aqueous, for the anterior chamber becomes deepened; and this is specially observable when contrasted with that of the other eye, and the iris, instead of presenting a plane surface, slopes backwards,

"2nd. Deep ulcers which threaten to perforate the cornea will often rapidly assume a healthy action after the tension of the cornea has been diminished by letting off the aqueous humour; and sloughing ulcers will, under the same treatment, derive similar benefit.

"That this benefit is often only transitory is true, but the operation is so simple, that it may be repeated an indefinite number of times, if the patient after each derives relief.

66

3rd. In cases of onyx, or pus between the lamina of the cornea, the relief of the tense state of the cornea promotes absorption and relieves pain, and so places the eye in a favourable condition for complete recovery. An onyx which threatens to burst backwards can be most safely combated by tapping the anterior chamber of the eye in addition to the use of other remedies.

"4th. This operation relieves pain, and, if carefully and properly performed, can do no harm. The relief of pain is so remarkable, that patients, on their next visit to the hospital, will, unasked for, relate the great benefit they derived from what had been done to the eye; but at the same time they will often state that after about twenty-four hours the pain was nearly as bad as ever. The truth being, that the aqueous had become completely restored, and that the tension which called for the first tapping was as great as ever. "The operation in such cases should be repeated."