department of Surgery. The former, though frequently unsuccessful, yet, being occasionally attended with advantage, justified their claim to superiority; whilst the subject was either miserably neglected, or only slightly investigated in this country. The present race of surgeons appear, however, to be fully aware of its importance; and the foundation of institutions for the reception of patients labouring under visual maladies, will, we trust, ere long, reclaim this neg lected branch of surgical study from the obscurity in which it has hitherto been involved. This will be more especially the fortunate result, if competent talent be called in to support them. Impressed with this hope, and with the gratifying prospect held out, we hail the appearance of the volume before us with pleasure, as affording a valuable addition to the small collection of good works which have been written upon the subject. We shall endeavour to give our readers a brief analysis of its contents, in order to afford them some idea of the value of the observations it contains, and to incite them to peruse the whole at length.

In his preface Mr. Gibson takes the opportunity to remark, that some practitioners may be disposed to doubt the veracity of his statement respecting the extreme insensibility of the iris, from its generally having been supposed to possess the contrary properties in a superior degree. These opinions are now, however, proved to be founded in error. The experiments and operations of Professor Scarpa, and the extensive practice of Mr. Gibson, have enabled these gentlemen to assert, as an incontrovertible fact, that the muscular fibres of the iris areendowed with a very slight proportion of nervous influence, and are little disposed to inflame on being irritated. The knowledge of this fact is of the utmost importance, as the ignorance of it has hitherto deterred many surgeons from interfering with the more complicated disorganization of the eyes, under the idea that the most dreadful symptoms might be expected to supervene, in consequence of a wound inflicted upon the iris.

The first section of this work is entirely taken up with a concise history of the operation, as it has been performed by different surgeons with different variations; but the author avoids giving an opinion with regard to the relative advantages of each. Our countryman, Cheselden, appears to have been the first who devised and executed any operation with the intention of forming an artificial pupil. After him Sharp, Wentzel, Janin, Scarpa, Mounoir, Demours, &c. proposed operations to effect the same object, each of them varying from the others, but all being liable to objections in a greater or less degree, and not adapted to the various derangements

rangements of the eyes requiring the operation under consideration. It has been Mr. Gibson's good fortune, by reasoning and experiment, to devise modes in order to supply the desideratum in question; and provide for every exigency. We shall proceed to a concise account of his operations, occasionally extracting from his volume.

"The mode of operation for forming an artificial pupil, it is obvious, must be varied according to the circumstances of the case. When there exists merely an opacity in the centre of the cornea without derangement in the internal parts of the eye; or, when the pupil is closed after the extraction, or depression of a cataract; in these cases the operation will be most simple. But if, along with central opacity of the cornea, the iris has formed adhesions to its inner surface, with, or without a corresponding diminution of the capacity of the anterior chamber of the aqueous humour, the operation becomes more complex. If again, along with opacity, and adhesions of the iris, the crystalline lens or its capsule be opaque, the adoption of still more complex expedients is necessary. The sarne may be observed of those cases, in which the pupil is totally obliterated, or nearly so, and the iris adheres to the capsule of the crystalline lens; for this rarely happens without an opacity of the lens or its capsule, or of both. Sometimes, however, a blow upon the sclerotic coat, particularly affecting the crystalline lens, and probably rupturing the edge of its capsule, is followed by an absorption of the lens, and leaves only the opaque capsule.

"In describing the operations, adapted to these cases, it is to be understood that the subjects of them were adults generally, who had either lost one eye, or had both eyes in similar circumstances of disease. I have never thought it of sufficient consequence to perform the operation where one eye was entire and perfect."

To accomplish the operation requisite to be performed under these circumstances, in addition to the cornea-knife and curved scissars, a small hook, a minute pair of iris-scissars, and a small pair of forceps, are necessary; the two last being of a peculiar construction, and devised by Mr. G. for-the operation.

Opacity in the centre of the cornea is the first state requiring the operation which he treats upon. In this case he supposes at least a third part of the cornea to remain transparent and situated either at the superior or inferior part, internal or external angle of the eye. The latter spot he prefers, or towards the inferior part, as the operation is less difficult here.

"The first step of the operation is to secure the eyelids, as in the operation for extracting a cataract. A puncture is then to be made in the cornea with a broad cornea-knife, within a line of the sclerotica, to the extent of about three lines. All pressure is now to be removed from the eyeball, and the cornea-knife gently withdrawn. The conse quence of this is that a portion of the aqueous humour escapes, and the

iris falls into contact with the opening in the cornea, and closes it like. a valve. A slight pressure must now be made on the superior and nasal part of the eyeball, with the fore and middle finger of the left hand, till at length, by an occasional and gentle increase of the pressure, or by varying its direction, the iris gradually protrudes, so as to present a bag of the size of a large pin's head. This protruded portion must be cut off with a pair of fine curved scissars, and all pressure at the same time removed. The iris will then recede within the eye, and the portion which has been removed will leave an artificial pupil more or less cir cular.

"It sometimes happens that the whole breadth of the iris, to the border of the natural pupil is protruded and removed in this way. This, I consider as rather an advantage, as it ensures a large pupil, though generally one which is oblong in its shape. I have found, however, the mere circumstances of shape to be of little consequence in this operation, and always to be sacrificed to the object of size. It may also be remarked that the opening has no disposition to close, when, in forming the artificial pupil, the border of the natural pupil is divided.

"It occasionally happens, also, that as soon as the knife is removed, the muscles of the eye-ball act with violence, and propel a small staphyloma or bag of the iris through the incision. If this bag be not large enough to form the new pupil, the iris must be further protruded by gentle pressure.

"As soon as the operation is finished, the eye is to be lightly covered with a few folds of fine linen, dipped in water, which may be cold in summer, and tepid in winter, and the patient is to be kept in an horizontal posture for a few hours. If pain should ensue, an opiate may be taken in the evening, and a saline purge the following morning. These medicines, however, are seldom requisite, but may be used as precautionary."

The puncture in the cornea ought not to be too large, and it is of importance to cut off the whole of the protruded portion of the iris with one stroke of the scissars; otherwise, on the escape of the aqueous humour, it recedes into the eye, and another opportunity for doing this, at the time, is not afforded. Should the artificial opening, as above mentioned, not appear sufficiently large to the operator, the iris may be drawn out of the eye, by means of the small hook, and divided, or (if it appear more easy) the iris scissars may be introduced into the eye, and the opening be enlarged, by cutting off a portion of the iris.

The subsequent inflammation in the eye is very slight. The aqueous humour is speedily regenerated (in an hour or two). Sometimes a slight cloudiness of this is perceptible, but the lapse of a few days serves to dissipate it. When the cornea is flatter than usual, and the wounded iris discharges, what may be termed, much blood, the case is rather unfavourable, the new pupil being much disposed to contract, This, however, may be prevented, we conceive, by the exhibition of the belladonna. The permanency of the newly

formed

1

formed pupil depends on its size, and the healthy state of the iris. If this be the medium size of the natural one, and, more especially, if it include its border, no contraction ensties; but, if the contrary to this be the case, an obliteration will occasionally take place. By means of this operation, a patient will be enabled to read a moderately small print, with properly adapted glasses. This new pupil does not possess the power of contracting and dilating, which the natural pupil has in an healthy state.

From the foregoing account, it will be evident that Mr. Gibson's operation has a decided superiority over all which have been hitherto recommended, as none of their projectors appear aware of the importance which attaches to leaving the capsule of the crystalline uninjured. We now know that the slightest wound inflicted upon this membrane will be succeeded by opacity, either of it, or of the lens: and, only one author who has written upon the subject has pointed out a mode, by which the risque may be avoided; but the operation is mentioned in very vague terms, its result not stated, and reasonable doubts may be entertained whether it was ever practised. "Ce n'est que d'après une tradition orale que notre illustre maître le Professeur Sabbatier a connu le procédé de Wentzel pere. Cette habile oculiste incisoit la cornée dans les deux tiers inferieurs de sa circonference; il saississoit avec des pinces et soulevoit le centre de l'iris pour en exciser une portion dont le defaut laissoit une ouverture indélébils.”* It does not appear that Sabbatier ever adopted this plan of operating†, and Wentzel describes a very diffi cult operation as the one which he and his father were in the habits of performing t. No other comment in particular is made upon the above quoted account by the writer Leveille, than that a Surgeon of Angers had performed a similar ope ration, substituting a hook in lieu of the forceps.

The second operation which Mr. Gibson describes is one, adapted to those cases in which there is "central opacity of the cornea, attended with adhesions between the cornea and iris, which include only an inner portion of the border of the iris."

"The consequence of considerable adhesions existing between the iris and cornea, is, that the iris frequently cannot be protruded through an opening in the cornea to a sufficient extent to form, by its removal, an efficient artificial pupil, as in the operation already described; the

* Vide Scarpa sur les yeux, trans. François par Leveille, Ed. 2d. tome 2, p. 169.

+ Vide Medecine Operatione, tome 3d.

Vide Treatise on the Cataract, &c. (No. 148.)

attempt,

attempt, however, may always be made, and the protruded part be cut off, however small it may be. If this expedient should not succeed, the next step must be to introduce the small hook though the part of the pupil, which does not adhere to the cornea, and to lay hold of the border of the iris. With a little care this membrane may generally be drawn out of the puncture in the cornea, and cut off, with the curved scissars. In doing this all laceration must be avoided." ،، Much, however, in these cases, must be left to the discretion and judgment of the operator. If, for instance, he should not observe any part of the iris, which can advantageously be drawn out with the hook, after making one attempt with that instrument, he will probably employ the iris-scissars, and enlarge the opening within the eye: or having clipped a portion of the iris, which now only adheres by a slight film, he will think the forceps the best means of removing it. Sometimes a slight point of adhesion between the iris and cornea may be advantageously separated by a cornea knife, at the time of making the puncture: or, the iris-scissars may be used for the same purpose, previous to using the hook; if it should be found impracticable to draw out the iris with the hook, on account of existing adhesions, the artificial pupil must be formed within the eye by the iris-scissars; which are to be used in the manner explained in the third operation."

Mr. Gibson's third operation is requisite in those cases where the adhesions formed between the anterior and inner edge of the iris, and the posterior surface of the lucid cornea, are very extensive, including the whole border of the iris, or nearly so. Here the attachments are to be partially divided by means of the cornea knife, at the time it is passed for the incision of the cornea. When this is effected, if the iris appear loose, the hook may be used to draw a portion of it out of the eye; but if this be not the case, the iris-scissars are to be introduced, and a portion of the membrane cut off.

We would recommend these two operations to the attentive perusal of our readers, the adhesion of the iris to the cornea being a frequent occurrence. It is often taking place in consequence of the evacuation of the aqueous humour through an ulcer which has penetrated the lamina of the cornea, producing irregularity and contraction of the pupil, which sometimes terminates in complete obliteration of sight.

Operation the fourth. Central opacity of the cornea, and total opacity of the crystalline lens, or its capsule ; with or without adhesions of the iris to the cornea. This state of the eye is not of frequent occurrence, but when it is met with, a more complex and arduous operation is requisite, than any of the above. Mr. Gibson details the various steps necessary to be adopted, by relating an interesting case which our limits will not allow us to transcribe. In the first place, an artificial pupil was formed, as related above. The opake crystalline, and its capsule, were then broken down (after the

lapse