patient was put to bed again, and kept there until the 7th of December, when he was allowed to get up, and the field was again mapped, giving practically the same result as Fig. 6, the area of retina in place being probably a little wider, and the vision amounting to. The patient was now allowed to be out of bed and around the ward, and up to the final measurement of the visual field-namely, January 31, 1894 (Fig. 7)-the vision remained as last recorded. A second scleral puncture was not performed, although there is reason to believe that it would have been followed by a good result.

This case is very interesting, showing an almost complete success,

so far as restoration of the field was concerned, while the patient remained flat in bed, speedy redetachment when he arose, although performing no more exertion than that of sitting and walking in the ward, and a final return to the primary condition of affairs, if we may judge from the two fields (Fig. 4 and Fig. 7), with, however, the preservation of central acuity of vision (2) far in excess of that which he had before the operation,-viz., movements of the hand in the lower part of the field.

CASE III.-Frederick D., aged fifty-six; American-born; a tinsmith by trade; gives the following history: the vision of the right eye failed two and a half years ago, that of the left eighteen months ago, neither of them suddenly, the dimness of the left eye starting as a cloud in the lower part of the field and lasting for one month before sight was practically obliterated. He was under treatment in the Wills Eye Hospital during April, 1893, with pilocarpine injections. His general health is good, and there is no account of excesses in his life. He never used glasses for close work.

The right eye sees vaguely the movements of the hand down and

out, but cannot count fingers. The disk is oval, gray-red in color, contains a small cup, and there is a huge detachment of the retina, almost complete, which floats upward into the vitreous. (Vide Fig. 8.)

On the 24th of November, 1893, two scleral punctures were performed, one between the inferior and the internal rectus and one between the inferior and the external rectus, each being followed by the escape of a small quantity of clear serum beneath the conjunctiva. No immediate ophthalmoscopic change was visible. The usual treatment of rest in bed and bandage was kept up until the 7th of December, without, however, any practical change either in the field or in visual acuity.

Although a distinctly unfavorable case, at the man's earnest request,

and as there had not been the slightest reaction, a third scleral puncture was performed. The incision, after consultation with my friend Dr. Charles Kollock, of Charleston, South Carolina, who was visiting the wards at the time, was made on the temporal side, just below the margin of the external rectus muscle. When the knife was turned and the wound made to gape, an unusually large quantity of clear, strawcolored fluid escaped, which formed a large bleb beneath the conjunctiva. The patient immediately stated that his vision was better. This, however, was probably an expression rather of his own anxiety that it should be improved than of what was actually the case.

The bandage, rest in bed, and the internal administration of iodide of potassium were continued until the 4th of January, 1894, when practically no change was visible with the ophthalmoscope, and the field of vision (Fig. 9) was obtained, which may be compared with the one originally found (Fig. 8), closely resembling it in all particulars.

Down and out the patient could distinguish the movements of the hand, but could not certainly count fingers. When the eye was last studied (on the 31st of January, 1894), there was practically as complete a detachment of the retina as there had been originally. The pupil was slightly pear-shaped, and, unless the rays of light were skilfully directed upon the small patch of retina still functionally active, the iris was immobile to the changes of light and shade.

Still hoping that his left eye might be benefited by a similar operation, and, curiously enough, insisting that his vision was better, although no improvement could be demonstrated, an operation was performed on this eye.

CASE IV. Frederick D. Left eye. The pupil was round, reacted sluggishly to light-impulse, the lens was slightly hazy, the disk was dimly seen as a vertical oval of gray-red color, and containing a small, sharp central excavation. There was extensive detachment of the retina, as is evident from the field of vision. (Fig. 10.)

Two scleral punctures, performed January 5, 1894, resulted in a moderate escape of straw-colored fluid, without, however, any immediate ophthalmoscopic change. One month later, after almost continuous rest in bed, during most of the time with eyes bandaged and continuously taking iodide of potassium, the patient was allowed to get up and the field of vision carefully mapped, resulting in the accompanying diagram. (Fig. 11.) This, when compared with Fig. 10, will show a slight improvement; so slight, however, that it is doubtful whether the improvement was the result of the operation, or whether, in a case so difficult to determine accurately the limits of the still functionally active retina, there may not have been some error in making the measurements.

It will thus be seen that in the case of Frederick D. there was practically no improvement (and also no harm), although in one eye there were three scleral punctures and in the other two, each of which was followed by the escape of subretinal fluid, in one instance in large quantities. This case belongs to what Hirschberg would call the unfortunate examples of total detachment of the retina which are not likely to be benefited by any operation or form of medication.

These four cases, or, to speak more accurately, three patients and four eyes, have been selected from a number because they illustrate the various results which are likely to follow an operation of this character, namely:

1. That primary relief or cure may be expected in idiopathic retinal detachment after scleral puncture, but that relapses are frequent, even while the patient is still in the hospital, and that they are almost sure to occur if, as in Case I., even some time after the operation, the subject of the disease performs work requiring special exertion.

2. That although the operation seems justifiable while there still remains light-perception, chiefly because, under proper precautions, no harm can result, it is extremely unlikely, even when it is followed by the free escape of serous fluid, that there will be any reattachment of the retina when the separation has been a practically total one, as, for example, in Case IV.

3. That occasionally, even when there has been a primary cure, so far as the restoration of the field of vision is concerned, followed by a relapse, the gain in central visual acuity seems to remain, although the field indicates that the redetachment has equalled the original separation, as, for example, in Case II.

Finally, I have brought these cases to your notice because all of them were exceedingly unfavorable, as all were detachments of long standing, and occurred in eyes which showed, in addition, other extensive degenerative changes. Therefore we may assume that in a similar series-which, however, should be very much more extensive if any safe conclusions are to be drawn-of favorable cases, fairly creditable results might be obtained; indeed, these, as you know from the statistics already quoted, have been secured.

Of course a very important point is to determine the suitable time for operation, and in the earlier cases on which this operation was performed, many years ago, it was claimed that the most advantageous results were obtained in recent cases. Graefe, however, maintained that the process of spontaneous descent of the retinal fluid should first be awaited, or, in other words, that at least six weeks should elapse

before operative interference was undertaken. Hirschberg, in the paper already referred to, coincides with Graefe's opinion, and believes that in an ordinary myopic retinal detachment at least eight or ten weeks should expire after the onset of the affection before scleral puncture should be performed. At the same time it does not do to wait too long, lest the perceptive power of the retina depreciate. In

Illustrating the changes produced by the instillation of a solution of eserine in a case of detachment of the retina.

closing his paper, Hirschberg states that an extended experience will have to decide these points and designate the best period for the repetition of the operation. This experience has come, in large measure, during the last ten or fifteen years, without especially modifying the principles he then laid down.

Were I to judge solely from my own experience, which is probably not different from that of many other operators, I should be inclined, after a thorough medicinal treatment, especially pilocarpine injections, iodide of potassium, and salicylic acid, to employ scleral puncture, with the understanding that after the operation the patient should remain in bed for at least six weeks with the eyes bandaged, and should then be