THE

BRITISH AND FOREIGN

MEDICO-CHIRURGICAL REVIEW.

OCTOBER, 1819.

PART FIRST.

Analytical and Critical Reviews.

ART. I.

1. Traité Théorique et Pratique des Maladies des Yeux. Par L. A. DESMARRES, M.D., Professeur de Clinique Ophthalmologique, &c. Avec 78 Figures intercalées dans le Texte.-Paris, 1847. 8vo, pp. 904. Theoretical and Practical Treatise on the Diseases of the Eyes. By Dr. A. L. DESMARRES, Professor of Clinical Ophthalmology, &c.

2. Die Operative Chirurgie von JOHANN FRIEDRICH DIEFFENBACH. Zweiter Band.-Leipzig, 1848.

The Operative Surgery of J. F. DIEFFENBACH. Second Vol. (Chapters XCIV to CXX inclusive.)

We have here placed together the works of two men, the most opposite in character and pursuit,-the one the type of the special, the other of the universal surgeon ;-the one a young man writing to make a reputation, the other a veteran imparting the fruits of long experience;-the one, surgeon of a large public hospital, frequented by numbers of students continuously watching, recording, and verifying his practice and statements; the other, professing and teaching clinical eye-surgery in a small room on the third floor at the back of a dirty house in one of the smallest streets in Paris. In stating this fact, we do not wish to disparage Dr. Desmarres; but in judging of a book, something should be known of the author. We should know what opportunities for observation he has enjoyed, and be careful that, in matters of authority, a Parisian professor of clinical ophthalmology should take a lower position than a surgeon of a British eye-hospital, containing many beds, and attended by numerous students. In Paris, there is nothing which approaches to our eye infirmaries. M. Sichel, some years ago, commenced giving gratuitous advice to persons suffering from diseases of the eyes; and students, who paid him ten shillings a quarter, were allowed to witness his practice. After a time, he added three or four beds to his establishment, and supported it by the

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fees of the students; as such it still remains. M. Desmarres was one of M. Sichel's pupils, who quarrelled with him, imitated him, and is becoming a rival. It is astonishing, considering the small means of MM. Sichel and Desmarres, how much they have done. The results of their labours have been far greater than those of many surgeons among ourselves, who have been placed under far more favorable circumstances; but still, in considering practical books, we must not shut our eyes to the true position of the author, or forget that those who are watching his practice seldom do so for more than a few months.

We need not say much as to the value of the work of Dieffenbach; it is the most perfect book on operative surgery which has ever been published in any language. We purpose shortly to give a close analysis of the volume before us. At present we shall merely select from the chapters on the operative surgery of the eye such practical remarks as are likely to be useful to our readers, or appear to illustrate the statements of Desmarres. Dr. Desmarres' work is a systematic treatise on the diseases of the eye, nearly on the same plan as the treatises of Lawrence, Mackenzie, and Jones. The work opens, like that of Jones, with an Ophthalmoscopie, or rules for examining the eye in a state of disease. The rest of the work is divided into three parts, comprehending diseases of the eyelids, diseases of the globe of the eye, and diseases of the lachrymal apparatus. The diseases of the conjunctiva, semilunar membrane, and caruncula lachrymalis, as well as those of the muscles of the eyeball, are considered in the second part. No notice is taken of the diseases of the orbit—a material omission.

General plan. The first part of Dr. Desmarres' work is divided into four chapters, which treat of congenital and acquired deformities, inflammations, tumours, and syphilitic affections of the eyelids. The second part contains fifteen chapters, embracing diseases of the conjunctiva, cornea, sclerotica, anterior chamber, iris, crystalline capsule, crystalline, vitreous body, ciliary body, and retina; general diseases of the globe of the eye, functional affections of vision, diseases of the muscles of the eye, and diseases of the semilunar membrane and caruncula lachrymalis. The third part consists of three chapters, embracing diseases of the lachrymal gland, puncta and lachrymal canals, lachrymal sac, and nasal duct.

Had this work been an English one, or one likely to be translated into English, we should have pointed out evident faults in this arrangement, and the difficulties and inconsistencies into which it has led the author; but we need not occupy our readers' time by doing so. We think it better to make such an analytical and critical survey of the book as shall enable us to convey to our readers the most important practical information it contains, comparing the views of the author with those of Dieffenbach, and making some additions of our own.

Symblepharon. Dr. Desmarres notices the usual distinction of total and partial symblepharon; also, that variety which may be called insulated, round which a probe may be passed, and that in which the morbid union, dipping into one or other of the conjunctival sinuses, is, in all its extent, continuous with the conjunctiva, except at its exterior edge, and round which, therefore, the probe cannot be passed. He takes no notice of the attempt of Ammon to bring two totally different sorts of diseases together, under the name of symblepharon, calling the one anterior, and the other posterior; the posterior being nothing else than the contracted

state of the sinuses of the conjunctiva, which generally accompanies xeroma; while his anterior symblepharon is the disease commonly known by this name, and which consists in an union, more or less complete, of the eyelids to the eyeball, the consequence of ulceration.

It is an important fact, which does not appear to have attracted Dr. Desmarres' attention, that total symblepharon is sometimes complicated with staphyloma of the cornea and iris. When this is the case, it becomes necessary to extirpate the staphyloma, in order to relieve the patient from very severe pain caused by the distension of the eye, pent in by the adherent eyelids. No attempt should ever be made to separate the lids from the ball of the eye with the knife, unless it be for the purpose of removing a staphyloma. In a singular case, which we have had occasion repeatedly to see, of total symblepharon, a fistulous communication exists between the staphyloma and the cellular tissue of the upper eyelid. From time to time, the upper eyelid becomes greatly distended, and the whole organ painful. The surgeon is then called to puncture the swelling, which he does with a narrow bistoury, giving issue to a large quantity of aqueous humour. This relieves the patient till the fluid again accumulates; and, no doubt, temporary relief might be afforded, in a similar way, to the more common cases, in which there is presented to our notice a simple combination of symblepharon and staphyloma, without any fistula of the cornea. Insulated symblepharon is always cured by simple division of the morbid band of connexion; but it is otherwise with continuous symblepharon, how narrow soever the adhesion may be. Whatever care is taken to prevent the reproduction of bands of adhesion, and a gradual reapproach of the disunited parts, these events are almost sure to follow, so that the patient is generally left just in the same condition as when he submitted himself to the knife. Tearing open the bottom of the wound day after day with a pin, so as to destroy the pyogenic membrane, as Amussat recommended for the permanent extension of cicatrices, will, we fear, prove in general inefficacious in cases of symblepharon, although it might succeed in keeping open an artificial coloboma palpebræ, were such a thing required, or an artificial slit of the prepuce, for the cure of phymosis.

On account of the difficulty of remedying symblepharon by operation, we have long felt inclined to think those oculists right, who tell the patient just to put up with the inconvenience he suffers. If the union is of small extent, the drag on the eye is slight, and scarce worth thinking about; if more extensive, the union is sure to return, just as the cure seems finished, and the cicatrization of the wound made in the operation comes to a completion. Let alone, the adhesions gradually become elongated, and the eye more mobile. Cut into, they become more solid, and the eye more confined. Ammon and Dieffenbach, however, men not to be beaten, invented each an operation, of a curious and artificial kind, for symblepharon; which we have not observed noticed in any English work.

In Ammon's operation, nothing is done in the first instance to the symblepharon; but by two incisions, meeting at an acute angle, the adherent lid is divided in its whole thickness, so as to form a triangular flap, having as its basis the edge of the lid, and including the symblepharon. Over this triangular flap, the two remaining portions of the lid are then stretched, and brought close together by the twisted suture. They unite

to one another, but not to the subjacent flap, on the inside of which is the symblepharon. At the end of fifteen or twenty days, when the union is consolidated, the second part of the operation is performed, which consists in dissecting out the triangular flap, which has been left adherent by the symblepharon to the globe of the eye. After each division of the operation, compresses wrung out of iced water are to be applied over the eye to moderate the inflammation.

He

Dieffenbach's operation consists in folding in the eyelid, so that its cuticular surface is brought into contact with the globe of the eye, after the morbid union is divided. If it is the lower sinus of the conjunctiva, for instance, which is affected, he proceeds in the following manner. makes an incision from the inner angle of the eye along by the side of the nose, and another, equally vertical, from the outer angle to the lower-outer edge of the orbit. He then detaches the lid from the globe of the eye by dividing the symblepharon, and shaves away the cilia. He next folds in the quadrilateral flap upon itself, so as to produce a complete entropium, and fixes it in this position by sutures. Four are generally required. They are supported by strips of adhesive plaster, and the parts are covered with a fomentation. When the globe of the eye is once cicatrized, the artificial entropium is to be removed, and the flap fixed again in its original situation by sutures.

We doubt much whether the deformity, which must result from such operations, will not greatly counterbalance the gain accruing from the cure of the symblepharon.

Andreæ remarks* on Dieffenbach's operation, that it would be simpler, instead of an artificial entropium, to have recourse to an ectropium, after the two vertical incisions were made; and to keep the lid everted, till the wound made in dividing the symblepharon was healed.

Entropium. The account given by Dr. Desmarres of entropium extends to twenty-one pages. He gives a figure, illustrative of a method of operating for entropium, by the extirpation of a vertical fold of skin, which, it seems, was long practised by a surgeon of Lyons, of the name of Janson; remarking that it is suited to the more serious cases. We have great doubts, however, whether chronic entropium, with morbid changes in the texture of the tarsus and conjunctiva, can be cured by any operation consisting merely in the removal of a piece of skin, or even in sections and partial extirpation of the orbicularis. Clipping out a transverse fold of integument is always sufficient for the cure of acute entropium. Dr. Desmarres observes, that a transverse excision of the skin will not always succeed in reducing an entropium, when it goes to a great degree, and especially when the palpebral opening is narrow. A vertical loss of substance, he says, has the double advantage over the transverse, that it acts more powerfully upon the inverted lid, and that, after the cure is accomplished, it does not increase the vertical diameter of the palpebral opening. It must not be forgotten, however, he adds, that the vertical cicatrix is more apparent than the transverse, the latter being concealed in the natural folds of the skin.

To perform the operation for entropium according to the method of Janson, the surgeon lays hold of a vertical fold of the skin of the inverted lid with his finger and thumb, or, what is preferable, with a pair of

* Grundriss der gesammten Augenheilkunde, vol. ii, p. 73. Leipzig, 1846.

entropium forceps, and extirpates the fold with curved scissors, taking care to let the extirpation extend close to the cilia. The wound is to be brought together with stitches, or, what is better, with the twisted suture, introducing three or four pins, and leaving them till they fall out of themselves. In this way, three or four small transverse wounds are produced, which contribute along with the vertical section to draw the edge of the lid into its natural direction. In some bad cases, several vertical sections may be had recourse to, at some distance from one another. Lisfranc sometimes denuded almost the whole lid. Segon made a crucial wound, combining the method of Celsus with that of Janson, and approaching the plan followed by Acrel of a lozenge-shaped wound. Dieffenbach does not describe the operations for entropium in this volume, having treated the subject in his first volume, in the section of Plastic Surgery.

Trichiasis. When only a few cilia are turned towards the globe of the eye, and evulsion has been repeatedly tried without permanent effect, Dr. Desmarres recommends a small fold of the skin, as near as possible to the edge of the lid, to be raised by means of a small double hook, and removed with a cataract-knife. Some drops of blood are discharged, and next day, he says, the upper edge of the wound (if the lower lid is the part operated on) inclining towards the lower, carries with it the misdirected cilia, and removes them from contact with the eyeball. The operation may be performed at several points of the same eyelid, if necessary. (p. 88.)

Dr. Desmarres does not give a favorable opinion of Carron du Villards' plan of cauterizing the bulbs of the cilia. This plan consists in pushing into each bulb, in the direction of the corresponding eyelash, an entomologist's pin, to the depth of at least a line and a half, and when all the pins are implanted, uniting them by a noose of well annealed silver wire. The group of pins is then to be laid hold of with a pair of curling-tongs, heated to a white heat. The pins immediately grow white, and the bulbs and their produce are destroyed. That the eyeball may not suffer in this process, several folds of brown paper, dipped in water, are to be applied over it, and held there with a wooden spoon.

This process, which Dr. Desmarres tells us he has tried with all possible care, is far from being so easy of execution as its author seems to hint. It causes much pain, and, if any considerable number of pins requires to be inserted, it throws the patient into a state of great excitement. The pins, besides, are not easily kept in their places, and it often happens that one or more escape at the very moment when the operator is trying to connect them together with the silver wire. Another inconvenience is, that the operator cannot appreciate the degree of heat which he directs against the diseased parts, so that a great extent of tissue may be destroyed in the vicinity of the edge of the eyelid, which then presents inequalities more or less deep. One patient had a relapse, and, what was worse, a coloboma. (p. 91.)

Dieffenbach describes three methods of operating for the cure of trichiasis and distichiasis; plucking out the cilia, removal of the ciliary margin of the lid by the knife, and turning the margin outwards by excision of a portion of the skin of the eyelid. The second plan is recommended by Jäger and Berlinghieri, but Dieffenbach does not approve