ference from the one I have just described. The first I shall refer to was describled by Prof. Von Hebra in the Wein. Med. Wochenscrift for January, 1878. In this article he suggests the use of an instrument in acne rosacea made after the form of a lancet needle, with cutting edges on both sides, and provided with a stop so it may not penetrate too deeply into the derma. He adds that the perpendicular punctures are made for the purpose of destroying the blood vessels, and that the bleeding can be easily arrested by compressed wadding. In addition to the above-named instrument, which has been used successfully by Prof. Von Hebra in acne rosacea, another has been invented by Mr. Balmanno Squire, of London, called the multiple scarifier. It consists of a number of needles attached to a handle, and arranged parallel to one another with a curved shield on either side. Mr. Squire maps out the diseased patches with a solution of black sealing wax, freezing the surface with an ether spray, and then applies the multiple scarifier. Should the scarifier be too broad for some of the smaller patches he advises that they be operated on at a subsequent sitting with a single scalpel. He also states that the bleeding, which may be copious, may be immediately arrested by pressure with the fingers, a layer of wet blotting-paper being interposed between the fingers and the skin pressed upon.

I have briefly described the instruments recommended by these distinguished gentlemen in order to prevent confounding the purpose they set forth, with the object of the method I have alluded to in this paper.

I make no application to deaden the pain before the operation, for I believe it always tends to increase the congestion of the part. In using the needle-knife I allow the point to penetrate to various depths, according to the thickened condition of the integument. In some points of the diseased patch, simply erythema may be present, while in others delicate capillaries, tubercles, and excessive hypertrophy may exist; consequently the former will necessitate very slight punctures, while the latter will require deeper incisions according to the hypertrophic growth. In this manner I reach all the larger and smaller patches.

During the operation I hold the needle-knife in the right hand and rapidly apply it to the parts, while with the left I sponge the surface with warm water in order that it may bleed freely. By sponging the surface, the poured-out blood will be absorbed, and will not, therefore, obscure the operation. It will also prevent the blood from clotting in the incisions and arresting its flow. I aim not to obliterate the capillaries, but to relieve the congestion and

stagnation of blood in the vessels, to enlarge and equalize the circulation, and to awaken the action of the absorbents so that the deposits may be carried off.

It will be seen that the method I have employed differs materially from both that have been recommended by Von Hebra and Squire. I have treated rosacea in the past most unsatisfactorily with soaps, tar, sulphur, and other stimulating applications, without in the least benefiting my patients. Feeling that my efforts were of no avail, I adopted the plan of relieving the engorged capillaries and then soothing the hyperæmic skin. I have in this manner obtained quite a number of remarkably good results during the past two years.

In obstinate cases, in addition to the copious blood-letting, the cure is often facilitated by brushing collodion lightly over the surface; it frequently splints the vessels and thus lessens their calibre. The vapor bath is likewise of great assistance in hastening the absorption of the tubercles and rendering the skin soft and smooth. If these applications are persevered with in rosacea, it will be found that they will be attended with the happiest consequences in the form of diminution, and finally disappearance of the redness and hypertrophic growth.

ON SYMPATHETIC OPHTHALMIA.

By E. DYER, A.M., M.D., HARVARD.,

OF PITTSBURG.

THE recognition of sympathetic ophthalmia presents few difficulties. In the first place, an inflammation, more or less severe, of the eye first affected is always present, and offers certain peculiarities. The most prominent and constant is a state of irritation or inflammation of the ciliary region, just behind the cornea. This is always tender and sensitive to the slightest pressure upon it by any hard substance, as a penholder or probe. The eye may be in any stage of inflammation, from the highest degree of plastic irido-cyclitis or choroiditis to a comparatively low state of chronic irritation in an atrophied bulb. Vision is destroyed either from idiopathic disease, or by an injury. Sympathetic ophthalmia never immediately follows the injury, and is rarely excited under two weeks, generally in from five to six weeks, while after a lapse of twenty years, an eye which has been destroyed, and may be in any state of preservation as to shape or size, may, from more or less frequent attacks of irritation, or even from some slight violence, by which the position of an encysted foreign body or displaced lens is altered, give rise to this most serious affection.

Sympathetic ophthalmia exhibits itself in the second eye under two distinct forms, the inflammatory or organic, and the functional or subjective. The first is almost always fatal, the last offers one of the most brilliant results of modern surgery. The inflammatory form is ushered in by asthenopia, photophobia, and lachrymation, tenderness on pressure, and pain in the ciliary region. Soon dimness of vision is noticed, and at the same time the ophthalmoscope reveals a cloudiness of the vitreous humor, and to the naked eye the same condition is apparent in the aqueous. Fine points are seen on the inner surface of the cornea and on the capsule of the lens. The pupil is contracted, and the iris discolored from the condition of the aqueous humor. The rosy ring around the cornea becomes more injected, and the pain is intensified. A plastic exu

dation is thrown out by the iris, especially from its posterior surface, and it becomes adherent to the lens. As the exudation becomes more abundant, it collects in masses behind the iris and bulges it irregularly forward in little nodes. The pupil is closed with lymph, the eyeball grows soft, the vitreous shrinks, the retina and choroid become detached and the eyeball atrophied. This is called plastic irido-cyclitis. It is very slow, never acute, and almost always fatal to the eye. After irido-cyclitis is once established, enucleation of the other eye, iridectomy, or any other means has rarely been known to arrest it.

There is another form of sympathetic inflammation called serous cyclitis. This is very rare. The symptoms are much like those just described, but there is no plastic exudation. Early enucleation will perhaps arrest it.

The non-inflammatory form is fortunately the more common, and is always amenable to treatment. It is purely of a functional character. The patient complains of weariness in the eye after use, intolerance of light, and increased flow of tears. These symptoms may be so intense as to render it impossible to open the eye at all. In other cases there is a marked loss of sight, sometimes called sympathetic amaurosis. Laquer mentions a case occurring three weeks after an injury. Pagenstecher' has seen it increase or diminish as the other eye was better or worse. White Cooper and others report similar cases.

Another form is the interrupted loss of vision, while it is not uncommon to find more or less limitation of the field of vision. Sympathetic keratitis" and chronic kerato-conjunctivitis have also been observed.

In seeking for the causes of sympathetic ophthalmia, we find that injuries of the eye are the most frequent. Among these, the cases in which the presence of a foreign body has been detected have absorbed by far the most attention, but perhaps improperly So. It is true that among all injuries, those in which a foreign body has entered the eye and remained there are most certain to produce sympathetic ophthalmia. This perhaps occurs in more than ninety per cent. of these cases, whereby we have almost come to consider

Etude sur les Affections Sympathiques de l'Eil, p. 35.

2 Klinische Beobachtungen, s. 32.

3 On Wounds and Injuries of the Eye, p. 301.

4 Liebreich Klinische Monatsblätter für Augenheilkunde, 1863, s. 450.

5 Rheindorf: Sur l'Ophthalmie Sympathique, p. 11.

6 Warlomont: Transactions of the International Ophthalmological Congress, London, 1872.

sympathetic ophthalmia as implying the presence of a foreign body. This is far from correct. All punctured or lacerated wounds of the ciliary body or the sclero-corneal junction are peculiarly prone to induce this affection.

That we have not attached due importance to this fact is owing probably to the kindly healing of these wounds as a general thing, and the interval which may elapse before the sympathetic trouble is developed. Unfortunately ignorance of this has too often caused the loss of an eye from failure to recognize the nature of the disease in time.

An analysis of a large number of cases of sympathetic ophthalmia gives seventy-five per cent. as due to injuries, and of these only thirty-three per cent. can be traced to the presence of foreign bodies. Of the remainder, two-thirds were wounds, and one-third contusions.

A class of cases which might properly come under the head of foreign bodies is, where the lens has been depressed or reclined under the name of cataract operation, a proceeding which, happily, has been abandoned. The most remarkable report of these is given by an author, Mooren,' who, during ten years, observed twenty cases of sympathetic ophthalmia in which nine had resulted fatally from irido-choroiditis, the results of couching in the other eye.

4

Among the idiopathic causes are: cyclitis, irido-cyclitis, iridochoroiditis, retino-choroiditis," internal hemorrhages, cysticircus,5 intraocular tumors, detachment of the retina, staphyloma of the cornea, the operation of iridodesis, ankyloblepharon," prolapse of the iris," glaucoma,12 and, in short, any condition of the eye which

1 Ophthalmiatrische Beobachtungen, s. 144.

2 Stellwag von Carion: Augenheilkunde, Abt. I. s. 287. Mooren: Ueber Sympathische Gesichtsstörrungen, s. 38.

3 Graefe: Archiv für Ophthalmologie, Band XII. Abt. II. s. 149. Graefe: Klinische Monatsblätter für Augenheilkunde, Erster Jahrgang, s. 448.

5 Jacobson: Archiv für Ophthalmologie, Band XI. Abt. II. s. 164. Alfred Graefe Klinische Monatsblätter für Augenheilkunde, Jahrgang I. s. 264. 6 Pagenstecher: Klinische Beobachtungen, s. 59, 63.

7 Mooren: 1. c., s. 41.

8 Arlt: Handbuck der gesammten Augenheilkunde. Graefe und Saemisch, Band III. Erster Theil, s. 424. Mooren: 1. c., s. 40.

9 Steffan: Archiv für Ophthalmologie, Band X. Abt. I. s. 128.

10 Mooren: 1. c., s. 49.

"Critchett: Annales d'Oculistiques, Tome LI. p. 234. Klein: Klinische Monatsblätter für Augenheilkunde, Jahrgang XII. s. 334.

12 Graefe: Archiv für Ophthalmologie, Band III. Abt. II. s. 447.