On the division of the ciliary muscle in the treatment of glaucoma, as compared with iridectomy / by Henry Hancock.

  • Hancock, Henry, 1809-1880.
Date:
1860
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Credit: On the division of the ciliary muscle in the treatment of glaucoma, as compared with iridectomy / by Henry Hancock. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    The Lancet,] LONDON HOSPITAL MEDICINE AND SURGERY. [October 6, 1860. aeration, it is only n of ad- eyeballs, of a fact Mr. Hulke’s microscopical examinations, therefore!, cannot be admitted as at all conclusive or of much value against my proposition, “that the ciliary muscle exercises considerable influence in maintaining and aggravating the glaucomatous condition,” and still less against my operation for the, division of this muscle. They only prove that in certain casks of ad- vanced glaucoma, in which an operation is admitted to be rarely successful, the ciliary muscle may have undergone atrophy with the rest of the tissues; but they by iio means prove that this is the case in all or even in average instances, as we cannot for one moment imagine that any surgeon would extirpate a glaucomatous eye capable of relief by o unless under very peculiar circumstances. I presume recently that Mr. Hulke has discovered this conditic vanced atrophy of the ciliary muscle in glaucomatous otherwise he would scarcely have omitted all mention of so much importance in his paper upon the “Pathdlogy and Morbid Anatomy of Glaucoma,” read before the Royal Medico- Chirurgical Society in December, li>57. On the other hand, my friend and colleague, Mr. Hogg, has kindly furnished me with the particulars of two glaucomatous eyeballs, extirpated at an advanced period of the disease, in which his microscopical examination demonstrated the ciliary muscle as highly developed, and anything but in a state of atrophy. I do not, however, advance these cases as of them- selves sufficient to controvert Mr. Hulke’s assertion—their number is too small; but, at the same time, they afford pretty conclusive proof that the ciliary muscle is not atrophied in all cases even of advanced chronic glaucoma. Neither can I admit that the success of my operation in any way depends upon, much less is solely due to, the drawing away of some of the superabundant fluid; or that it is a peculiar mode of paracentesis, to be classed with the operations of “ paracentesis sclerotica^” of Middlemore and Desraarres. I think I have succeeded in showing that, according to Mr. Hulke’s own statements, there is no superabundance of fluid in those cases most likely to be benefited by the operation ; therefore the drawing-away theory falls to the ground, and is still further negatived by cases Nos. 15 and 16, appended to this paper. The object of applying the term paracentesis sclejroticae to my operation, and classing it with the procedures of Middle- more and Desmarres, is transparent enough. Paracentesis of the cornea and sclerotica, as practised by these two surgeons, has not met with any great amount of success. If, therefore, the profession could be impressed with the notion that my operation was nothing more than one or the other of these proceedings, and that any transient good which it might be the means of effecting was due to the mere evacuation and draining away of fluid, it would be looked upon as deficient both in value and originality, and would, as a matter of course, fall into dis- repute, and proportionately give greater prominence to the operation iridectomy. It is true that the word paracentesis means, literally, a “piercing through,” but its application in surgery has hitherto been restricted to the operation of tapping. If we were to attempt to describe the operation of tenotomy in club-foot as “a peculiar mode of paracentesis” of the leg, or of the foot, or if we were to designate the operation &r the ’ex- traction of hard cataract as “a peculiar mode of paracentesis” of the cornea, we should expose ourselves to the charge of pedantry; yet the name may with equal propriety be applied to these operations, or even to iridectomy itself, as to my ope- ration for the division of the ciliary muscle. Hence the term as applied to this operation by Mr. Hulke is a misnoiher. The operations of Middlemore and Desmarres wire intro- duced for the avowed purpose of relieving intra-ocullr tension by the evacuation of fluid. My operation, on the cohtrary, is introduced for the avowed purpose of relieving the constriction of the several coats of the eye by division of the ciliary muscle. J An increased quantity of fluid may or may not be present, and, when present, some may flow by the side of the knife; but this is merely a coincidence, not by any means the primary object of the operation; for mere evacuation of fluid without division of this muscle is quite incapable of affording permanent benefit. In my former paper I pointed out the variety of opinions entertained by the supporters of iridectomy in this country as to the modus operandi of the operation. I would here ven- ture to suggest another. I believe it will be found in the course of time, that the element of success is the same in iridec- tomy as in my operation—viz., “the division of the ciliary muscle.” That, from the situation in which Von Graefe makes his first incision, he at the same time cuts it through, and I 338 have very little doubt it Ayill ultimately be found that the extent of this incision may be advantageously curtailed, and the tearing away of the iris altogether dispensed with. (To be continued.) % Sfo OF THE PRACTICE OF MEDICINE AND SUEGEEY IN THE HOSPITALS OF LONDON. Nulla est alia pro certo noscendi via, nisi quam pluvimas et morborum et dissectionum historias, tam aliorum proprias, collectas habere et inter se com- pavare.—Mohgagni. Dc Sed. et Cans. Morb., lib. 14. Procemium. RING’S COLLEGE HOSPITAL. CHRONIC EMPYEMA, WITH A FISTULOUS OPENING INTO THE CHEST; ALBUMINURIA; DEATH FROM RAPID (EDEMA OF THE LUNG; AUTOPSY. (Under the care of the late Dr. Todd.) The subjoined two cases were both primarily attacks of acute pleurisy of the right side, followed by effusion and intercostal bulging. In the first (for the brief notes of which we are in- debted to Dr. Edmund Symes Thompson, when house-physician to the hospital), absorption of the fluid went on, leaving a small, circumscribed empyema, pointing externally. This was opened, and continued to discharge matter for many months. The disease now became complicated with renal dropsy and albuminuria, which mainly influenced the final result. In the second case, thoracentesis was performed four times, with an exit of serum on the first two occasions, and afterwards of pus. The pleura was washed out regularly, with considerable relief, but, as we have now witnessed several times, it proved but temporary. John B , a healthy London tradesman, aged twenty- seven, had an acute attack of pleurisy on the right side in December, 1856, followed by much effusion, with bulging of the side. During the three following months, the fluid underwent gradual absorption, except that there was dulness on percussion below the axilla over a space three or four inches in diameter. Subsequently, a fluctuating prominence formed in this situation, into which an incision was made, in the fourth intercostal space, when about an ounce of matter escaped. After a few days the patient left the hospital, the wound still discharging a small quantity of pus. He was readmitted into King’s College Hospital in April, 1S59, under the care of Dr. Todd. Several ounces of purulent matter were discharged daily from the aperture in the side. There were considerable ascites and oedema of the legs. (Seven months before his second admission he had an attack of acute renal dropsy.) The opening in the chest, being small, was dilated by the introduction of sponge tents. The quantity of discharge diminished under this treatment up to a certain point, the dull space proportionately decreasing. He left the hospital, much improved in health; but was again admitted in the following November, with general dropsy, and scanty and highly albuminous urine. About eight ounces of pus were discharged in twenty-four hours from the thoracic opening. The patient was carried off, a few days after admission, by the rapid supervention of oedema of the lungs. At the autopsy, the right lung was found to be adherent to the pleura costalis, except in the interval between the second and fifth ribs, where the two pleural layers were separated by several ounces (perhaps fifteen) of purulent fluid, contained in a sac, formed externally by the partly bared ribs and inter- costal muscles, and internally by the thickened pleura. Liver large ; kidneys large and fatty. EMPYEMA AND HYDROTHORAX ; THORACENTESIS FOUR TIMES ; DEATH. (Under the care of Dr. Budd.) The brief details of this case were kindly furnished by Mr. Huxley, late clinical clerk to Dr. Budd.