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A Course of Lectures ON DISEASES OF THE EYE,
JULY
15,
1854.
admitted that the effect is less favourable-that it is productivee of considerable pain, of increased inflammatory action, and of ON infiltration of matter between the corneal layers. This I havee chiefly observed amongst the old and feeble; but the happy DISEASES OF result that occurs in numerous cases, and the extreme urgency and threatening aspect of the symptoms, fully justify and even Delivered at the Medical School of the London Hospital. suggest the plan I am now advocating. I have usually observed that these ulcers occupy a considerBy GEORGE CRITCHETT, ESQ., F.R.C.S., able area; and if we are unable to arrest their progress, and SURGEON TO THE ROYAL LONDON OPHTHALMIC HOSPITAL; LECTURER ON SURGERY AT THE LONDON HOSPITAL, ETC. penetration occurs, the iris immediately falls forward, in contact with the opening, which, gradually enlarging, allows of its protrusion, and thus " prolapsus irides" occurs; the natural resisting power and elasticity of the globe is weakened, LECTURE VI. the prolapse increases, the anterior surface of the eyebulges Treatment of ulcer of cornea in its various stages; acute and and staphyloma occurs. It is very desirable, if forward, spreading glassy; vascular; adz’cctatage of issue.s; corneal possible, to obviate this latter result; and here, again, it has a Corneitis: its course: history; pacrsues definite oliacities. been to apply the nitrate of silver, in substance, to treatment; expectant; a severer form occasionally seen;its the suggested protruded part. The objection to this plan is, that it often symptoms: trecctitzent. causes severe pain, and is by no means uniformly successful, GENTLEMEN,—In my last lecture I described the principal and therefore I cannot recommend it. I much prefer either aspects under which ulceration of the cornea presents itself to puncturing the prolapse with a needle, which often causes it to our notice. I have now to consider the treatment best adapted contract and shrivel away, and thus to close up the corneal to each form or stage of this disease. In all cases in which you opening; or in case that fail, and the protrusion still increases, have ascertained with certainty the existence of an ulcer of to remove it entirely. Under the most favourable circumthe cornea, it is a good precaution to impress the fact on the stances, when disease has produced such results, the inmind of the patient or some friend, and to remind them that, tegrity of the organ is seriously compromised; but it is quite under the most favourable circumstances and the most judicious possible that sufficient space may be preserved for the formation treatment, a permanent opacity must be expected; otherwise, of an artificial pupil, and under any circumstances, it is most as the cure is accomplishing, they become dissatisfied, and the desirable to prevent the occurrence of a large staphylomatous blemish, which is to the surgeon the proof of success, may be protrusion. attributed to inefficient or improper treatment. If, however, In the glassy ulcer, there is very little to combat locally, the the partial eclipse be predicted, credit is rather gained than conjunctiva is very slightly injected, there is no surrounding lost when the prediction is fulfilled. During the first stage, opacity in the cornea, and no indication of any morbid action mentioned in the last lecture, that in which the ulcer is in in the part, except the loss of substance. Here we have process of formation, there is usually an excess of local action evidently an error of nutrition, and our chief efforts must be in the conjunctival membrane, and the usual symptoms of directed toward the constitutional condition of the patient. acute ophthalmia. Soothing applications, such as poppy We must endeavour to correct, as far as possible, the baneful fomentation or warm water, together with the local abstrac- influences to which such patients have usually been exposed, tion of blood by means of a few leeches to the temple, followed in the shape of impure air, small, ill-ventilated abodes, inup by counter-irritation behind the ear, are the most likely sufficient and unwholesome food; giving, at the same time, means of arresting the ulcerative process; at the same time, it such medicines as are calculated to assist in sustaining the may be necessary to sustain the general power, and counteract general powers of the patient. This object it is often very by constitutional treatment any abnormal state of system that difficult to effect. We suggest changes which poverty and may exist. Thus, in children, struma is often found in league ignorance are either unable or indisposed to adopt, and the with corneal ulceration. At puberty the menstrual function may debility resulting from a protracted exposure to these numerous be at fault; prolonged lactation is a fertile and very embarrassing sources of disease requires a very complete change and a very cause; and, later in life, a feeble, shattered, and physically long course of sanitary and medicinal treatment for its removal; depraved state of system, the result of constant and prolonged hence, one of the remarkable features in the transparent ulcer intemperance, gives rise to ulceration of the cornea. These is the very lengthened period during which it will remain various conditions must be combated with such means as we stationary, and unaltered in its size and other characters. The have; and we must ever bear in mind, if we would be suc- local treatment is comparatively unimportant, and should be cessful practitioners, that the most active and destructive of a very mild character. It has been suggested that the salts inflammatory and ulcerative processes are compatible with, of lead, in solution, should not be employed in ulcers of the and even dependent upon, a very feeble state of system, which cornea, on account of the tendency to a permanent deposit may require tonics, stimuli, and a very liberal dietary for their upon the surface. I have observed this on more than one This point I havealready insisted upon, but I hold it occasion, and it is quite in harmony with what occurs when cure. to be of such importance, and so very imperfectly recognised the acetate of lead is powdered over granular lids; and as by the profession generally, that I take every available oppor- there is no counteracting advantage to be gained by the use of tunity of urging it. I cannot but rejoice to find this view ably lead lotion, it is better to abstain from it altogether where developed and abundantly illustrated in the lectures delivered ulceration exists. Some cooling, unirritating collyrium, such last summer by Mr. Skey at the College of Surgeons. I very as rose water or elder-flower water, or a weak solution of early imbibed this opinion from my late teacher, Mr. Tyrrell; vinegar, is the best local application. Where the case is very subsequent experience has given me almost daily evidence of protracted, and the surface of the ulcer becomes irritable, it is its truth, and I cannot but hope that the eloquent appeal that sometimes advantageous to touch the surface lightly with the has been made from so high an authority, and to such an fine point of the nitrate of silver. I much prefer this to the audience, will result in the establishment of so important, so employment of a solution of lunar caustic, which irritates the vital a principle. conjunctiva, without acting so directly upon the ulcer, and In cases of acute and spreading ulcers, where penetration of often seriously aggravates the case. It is particularly imthe cornea is threatened, it becomes a matter of extreme im- portant, in the glassy ulcer, to apprise the patient or his portance to determine whether there is any means of arresting friends that an opacity of the cornea must be expected, otherthe progress of the ulceration. However judiciously the con- wise the symptoms are so mild, and the evidence of breach of stitutional treatment may be conducted, there is every fear that . surface so faintly appreciable to uneducated vision, that dispenetration may occur before a favourable reaction has time to credit may easily attach to the surgeon who is in attendance, take place; it, therefore, is an anxious question, whether we and, as the ulcer begins to fill up, an impression will be gained can, by any local application, bring about an altered action in that the case is retrograding, at the very time when it is the part, and avert the impending danger. It is in such cases drawing to an auspicious close. In cases of ulcer with a vascular membrane and organized as these that I have found the nitrate of silver, in substance, of great value; it should be finely pointed, and carefully limited deposit upon its surface, which is usually somewhat raised as much as possible to the ulcer itself; in order to effect this abovethe level of the rest of the cornea, and in which red object, glycerine should be dropped into the eye previously, so vessels may be seen travelling to supply it, the treatment is as to protect the remainder of the surface from the action of difficult. We have here new and organized deposit to combat the caustic. It seldom requires repeating more than once or with; diseased action seems to have established itself, and (if twice, and it will frequently be found that the ulcer will begin I may use the expression) to have taken up its abode in the to fill up and heal from that time. In other cases, it must be part, and this very much increases its power of resistingall
A Course of Lectures
THE EYE,
No. 1611.
24 remedial means, and its constant proneness to relapse or return Having now described those affections of the cornea which after apparent subsidence. I have had an opportunity of I believe to be secondary, and dependent upon an inflammatory observing several of these cases at the Ophthalmic Hospital; condition in the conjunctival membrane-viz., vascular opacithey usually apply after this condition has existed for a con- ties and ulcers, I pass on to the consideration of those morbid siderable time, and when a variety of remedial means have changes which are peculiar to the cornea. The term " corneitis"may, I think, with propriety and been exhausted upon them. They generally occur in young females about the age of puberty, or a little anterior to this, convenience, be applied to the disease I am now about to dealthough they are also found in young strumous children. I scribe, as it seems to be restricted in its effects to that strucbelieve them to be due, in the first instance, to a disturbed, ture, and to have all the characteristics, both in its history altered, or arrested function of some important organ in a and symptoms, of a specific malady, although we shall find feeble or strumous diathesis, aggravated by an active depleting that it differs considerably in the degree and in the extent, or plan of treatment, or by the injudicious and protracted use of rather depth, to which the layers of the cornea are implicated. strong local stimuli, particularly the nitrate of silver. The It is a disease of childhood and youth, very rarely, if ever, obvious inference is, that every available means must be taken occurring after the middle period of life; it usually develops to bring about and maintain the normal function of any organ in a few days, with little or no pain, and with scarcely any that may be at fault. This is particularly necessary as regards evidence of conjunctival inflammation, the slight pink dismenstruation ; at the same time I may add that I have fre- coloration seeming rather to be due to injection of the quently found the local disease, when thus established and sclerotic vessels-probably those vessels which are described organized, continuing in full force long after the constitutional as being specially dedicated to the nutrition of the proper vice to which it owed its origin has passed away. As regards layers of the cornea. That which usually first attracts the local treatment, I have usually found stimuli of all kinds in- notice of the patient is dimness of sight in one eye, accomjurious ; soothing applications are the best; sometimes one or panied sometimes with a slight dull, aching pain. On examintwo leeches, applied about every other day for a week or two, ing the eye, the cornea presents an uniform pale-white opacity, are of use, particularly where the vessels are rather numerous with just sufficient transparency remaining to enable you to and full, and the inflammation is in a sub-acute stage; but that see the iris and pupil, but not with such clearness as to show which has appeared to me to be of the most marked and essen- with certainty its colour and condition, although its activity tial service in this form of disease are issues inserted into the may usually be made out. The surface of the cornea, when temple, and kept there for many months. I usually employ a closely inspected, is found to be finely granulated; in fact, the small pea for this purpose, which must be changed daily. I state I am now describing is perhaps best represented by comam aware that some high authorities, and Mr. Tyrrell amongst paring the altered cornea to a thin layer of finely-granulated others, sweepingly condemn the use of issues in all cases of eye ground glass. The opacity is very generally and equally disease, on the grounds of the severity of the treatment, its diffused over the cornea, though usually rather thicker towards general inutility, and the subsequent deformity. I admit that the centre, but it is difficult to determine the extent to which these are objections in slight and transient cases; but they lose it penetrates and involves its layers, and in this respect there their force when we are considering a severe, obstinate, pro- is probably considerable diversity. The pain is very slight, tracted disease, liable to relapse, detrimental to sight, and sometimes altogether wanting, and there is no intolerance of effectually preventing all use of the organ while it remains un- light. One eye is almost invariably affected in the first subdued. It is for such cases that I would reserve the employ- instance, and the disease may be limited to the eye first inment of issues. A morbid action has become established in the volved; but more commonly, when it has existed some time, eye, and requires a prolonged discharge in its immediate and is subsiding or has just passed away, the second becomes vicinity, gradually to divert it from its original seat, and to similarly affected, and runs through the same phases. This is weaken the tendency to relapse-at least, such is the explana- by far the most common form of corneitis that we meet with: tion I am disposed to offer; but, whether correct or not, I its cause is involved in much obscurity. I have endeavoured entertain no doubt whatever of the power and value of the in vain to attach it to some special abnormal condition of remedy. I have succeeded in completely and permanently system, or to exposure to cold or some other noxious influence. curing several cases of this kind-by the prolonged use of issues Some high authorities always apply the term " strumous" to when they had baffled all other means for many months and this morbid change, and I do not deny that it may be comeven years, and when the constant irritation and necessary plicated with this diathesis, like most forms of ophthalmic confinement were casting a gloom upon what would otherwise disease; but I have frequently seen it in young persons from be the brightest period of life. It seems to me that, to obtain the country, about the period of puberty, and a little past that emancipation from such a condition, a small scar on the temple age, having every appearance of health, and in whom I could is but a slight penalty, and one most freely paid by the not find the faintest trace of struma, and therefore, where it is observable, I regard it rather as an accidental concomitant sufferer. When the cicatrizing process is going on favourably, the only than as a cause. This disease is rather to be regarded as an practical point we have to consider has reference to the opacity example of altered or diseased nutrition, which in a less delicate remaining in the cornea; this is often a cause of great anxiety structure would scarcely be noticed, but which becomes imon the part of the patient, on account both of the deformity and portant by disturbing the function and changing the appearthe dimness of vision resulting from it, and its removal is ance of a transparent tissue. With regard to treatment, I have taken some pains to invesfrequently sought. I believe time will effect much in this respect, as we find, in other scars, a gradual contractile tigate and follow out the natural history of this disease in a process goes on for a considerable time, and the surrounding great number of cases, and I have come to the conclusion that deposit entirely passes away, so that a very decided diminu- it has its definite period of development, that it remains in full tion of the opacity ultimately takes place. Much confidence force for a given time, varying from two to four or five months, is expressed by some in the action of various local stimuli in and then gradually passes away, clearing from the circumference promoting the absorption of such opacities; thus, solutions of like a vanishing cloud, and ultimately leaving no trace behind, the nitrate of silver, of zinc, of iodide of potash, calomel, and the cornea resuming its perfect original transparency, although various other stimuli, are each of them in high favour with the central opacity will often linger in a patchy state for some different observers. It is extremely difficult to estimate the time after the circumference of the cornea has become quite value, either positive or relative, of any of these means, when transparent. I was first led to take this view of corneitis, from we know the natural tendency is towards a gradual absorbent finding that, whilst I was pursuing various kinds of treatment, action. It is impossible to avoid the conclusion that, whilst and at the very time that the disease appeared to be subsiding it may be the result of our application; it may also be irre- most favourably under the plan I was adopting, the same train spective of, or it may even be in spite of, the means employed; .of symptoms would suddenly manifest themselves in the second and, I must confess to some degree of scepticism in regard to eye, would pass through the same stages, and subside in about the efficacy of any of these stimuli in removing opacities; at the same time as the eyeprimarily affected; thus, for example, the same time I am quite aware that in practice it is often on several occasions, I instituted a mild mercurial course, in necessary to employ something of the kind. I generally use a accordance with the recommendation of Mr. Tyrrell, and solution of the iodide of potash-five grains to an ounce of during the time that there was direct evidence of mercurial distilled water-dropped in three times a day. It does not action in the system, I have seen the disease commence and run through its course in the second eye. I have also observed cause pain-, and its action is gently stimulating and absorbent. I think the nitrate of silver objectionable, because I have seen the opacity remain quite stationary during the prolonged several cases in which its prolonged use has caused a perma- influence of this medicine, and only subside when the period nent stain in the conjunctiva. If we do employ it, care must seemed to have arrived at which the disease had run its be taken not to continue it for any lengthened period; cer- course; thus, by degrees, I became in a great measure extainly not above five or six weeks at a time. pectant, and with a result quite as satisfactory as when I used
25 active constitutional and local means, and probably much more Such cases would give an easy triumph to the administrator of If my view of this disease be correct, and I have taken infinitessimal doses if he should be working his miracles at that much pains to test it by repeated and close observation, it phase of the disease. Such cases form an interesting section of attached follows that the management of this affection is very simple. pathology, not only on account of some special All local stimuli are quite useless, and may be injurious, by to them individually, but because they are highly suggestive giving pain, by increasing vascularity, and by irritating a and instructive. They show how important it is to know the membrane previously scarcely involved in the disease. Some natural history of disease in estimating the power and value of very mild collyrium must be used, and, if any constitutional any plan of treatment, and how rationally the success of various suitable means that exert no real effect upon the system is explained, error can be detected, it must be treated with medicine. Thus children affected with this disease are often So protracted and apparently hopeless are some of these cases, weak and strumous, and improve in health under the influence that it requires great confidence in our pathology, and a large of steel, cod-liver oil, or iodine; at the adult period, tonics amount of uniform experience, to venture to promise a favourable issue in such a case; nevertheless, I have attended seem most frequently to be indicated, and any suitable treatment may indirectly tend to shorten the period of duration of some very severe forms of the disease in which patients have the disease by restoring the system to a condition of health; remained dark for many months, where, upon the strength of beyond this point art can effect nothing, and the rest must be former observations, and without any reliance upon any method left to the "vis medicatrix naturæ"—that constant friend of of treatment, and in the face of so considerable a morbid change in the cornea that it seemed to an ordinary observer as if it our profession on many trying occasions, and who, in this form of disease, I have rarely if ever known to fail. Hence it follows could never resume its transparency, I have reiterated my conthat a most important part of our treatment, and one that we viction that sight would be restored, and I have never known may very confidently and advantageously administer, (pro- my opinion prove incorrect. And this promise has been the one vided only that we make a correct diagnosis,) is the assurance slender hope to which the poor, half-blind sufferer has held on of a complete restoration of sight; for in the milder form of the through many a dark and anxious month, and it has required disease that I am now describing, I can scarcely call to mind a no little faith on the part both of the patient and the surgeon, before that faith has been once more merged in restored sight. single exception to this favourable result. It occasionally happens that corneitis manifests itself under I have usually observed that the antecedents of this disease and severer form, and, though probably differing only have been of such a character as to enfeeble the system,-conanother in degree, spreads deeper, produces more formidable results, siderable labour, great mental anxiety, some constant drain and more seriously interferes with vision, from the circum- upon the system, improper and insufficient food; but I have stance that it usually involves the second eye before the first not been able to trace any direct or immediate effect upon the has recovered its transparency. The corneal opacity, instead disease by the removal of these unfavourable circumstances. of being uniform, exhibits one or more patches of a reddish- After what I have stated, but little remains to be said on the brown colour, not on the surface, but between the layers of the subject of treatment; the great point is not to be induced to On a superficial view these appear like small masses do too much by the severity of the disease. I am quite concornea. of extravasated blood; but if carefully examined, and especially vinced, after repeated trials, that mercury will not’absorb the when subjected to the dissecting power of a magnifying glass, organized deposit; I therefore now carefully abstain from its they are found to be made up to a great extent of minute use. I simply limit myself to the employment of such means vessels, and to be in fact masses of highly-organized lymph. as will restore power to the system, but without anticipating Sometimes there is only one small patch of this kind, the re- any favourable result to the disease, except indirectly, hoping mainder of the cornea presenting the appearance of ground merely that it may run its course more speedily when the glass, as in the milder form I have before described; but I system is in a healthy condition. Local means are useless, and have seen some few cases in which the entire cornea has pre- if stimulating, injurious; if I made an exception in favour of sented one nearly uniform organized mass. In this severe type any kind of local treatment, it would be the use of issues. I of corneitis there is much more evidence of increased vascu- think I have observed that the disease has been favourably larity ; the conjunctiva is considerably injected; the deeper modified by their employment, and that the eye, secondarily vessels are involved; there is both lachrymation and some affected, has run a less severe and protracted course than intolerance of light; patients also complain of a dull, aching the first. It is quite in unison with all my observations, that pain. It is very important not to confound this disease with issues act favourably wherever new organized deposit exists in the vascular opacity of the cornea, which I have described in a the cornea, but to produce any effect, they must be persevered former lecture as the result of a villous state of the conjunctiva in for a considerable time. There is one point that I feel pretty in strumous subjects. In this latter, the vessels lie chiefly on confident about in reference to this very formidable disease, the surface of the cornea, and are distinctly and individually which is, that unlike most affections of the eye, it very rarely visible with the naked eye; whereas in vascular corneitis, as I returns. term the disease I am now dwelling upon, vessels can only be seen through the aid of a magnifying glass, and the reddishON THE brown patch is placed between the corneal layers. This may, perhaps, appear to some rather a minute and unnecessary divi- USE AND ABUSE OF POTASSA FUSA AND sion of diseases that closely resemble each other; yet, inasmuch POTASSA CUM CALCE as they differ most essentially in their origin and cause, in the IN THE effects they produce, in their prognosis and treatment-in fact, TREATMENT OF UTERINE DISEASE. in their entire history, it is surely very desirable clearly to mark the distinctions between the two; and I am the more BY J. HENRY BENNET, M.D., anxious to insist upon this point, because it is quite evident PHYSICIAN-ACCOUCHEUR TO THE ROYAL FREE HOSPITAL, ETC. that even so acute and accurate an observer as the late Mr. Tyrrell has confused the two diseases together, as will be seen IT is now more than nine years since I introduced to the by his placing Cases 33 and 34 in his work under the head of "Corneitis" instead of "Vascular Opacity," to which they profession, in the first edition of my work on ’’ Uterine Inflammation," potassa fusa and potassa cum calce as valuable reevidently belong. The disease I am now describing never produces ulceration medies in the treatment of some chronic and intractable forms of the cornea, or abscess between its layers, nor does it ever of uterine inflammation. Since then these agents have been soften the texture so as to cause it to yield, and thus to increase adopted by many practitioners at home and abroad, a fact of its convexity; its effects are limited to the general dulness of which I have ample evidence in my own practice, as I am conthe cornea, and the organized deposit between its layers. This stantly consulted by patients in whom this means of treatment disease is exceedingly distressing to the patient, on account of has been resorted to. In some of these cases I have found that the great dimness of sight that it produces usually invading the caustic potash has been incautiously used, so that lesions the second eye before the first has recovered its transparency, of the vagina and partial occlusions of the cervical canal have and thus producing a condition very closely bordering on been produced, notwithstanding the careful and minute directemporary blindness. It may occur in children, but the worst tions which I have given for its employment. As I cannot forms of it that I have seen have been in adults between thirty but consider myself to a certain extent responsible for the use and forty years of age. It is very protracted in its duration, of a remedy which I have introduced in this country, I am and, as far as I have seen, resists every kind of treatment, but anxious, in the present paper, to lay down precisely the rules ultimately gets quite well, when perhaps every plan has been which ought to regulate practitioners when they resort to so tried and abandoned in despair; and much unmerited and powerful on agent. Potassa cum calce was first used in the treatment of chronic unexpected credit may be gained by the fortunate individual who happens to be in attendance at the time of its subsidence. inflammation of the cervix uteri by M. Gendrin, the enso.
points
15,
1854.
admitted that the effect is less favourable-that it is productivee of considerable pain, of increased inflammatory action, and of ON infiltration of matter between the corneal layers. This I havee chiefly observed amongst the old and feeble; but the happy DISEASES OF result that occurs in numerous cases, and the extreme urgency and threatening aspect of the symptoms, fully justify and even Delivered at the Medical School of the London Hospital. suggest the plan I am now advocating. I have usually observed that these ulcers occupy a considerBy GEORGE CRITCHETT, ESQ., F.R.C.S., able area; and if we are unable to arrest their progress, and SURGEON TO THE ROYAL LONDON OPHTHALMIC HOSPITAL; LECTURER ON SURGERY AT THE LONDON HOSPITAL, ETC. penetration occurs, the iris immediately falls forward, in contact with the opening, which, gradually enlarging, allows of its protrusion, and thus " prolapsus irides" occurs; the natural resisting power and elasticity of the globe is weakened, LECTURE VI. the prolapse increases, the anterior surface of the eyebulges Treatment of ulcer of cornea in its various stages; acute and and staphyloma occurs. It is very desirable, if forward, spreading glassy; vascular; adz’cctatage of issue.s; corneal possible, to obviate this latter result; and here, again, it has a Corneitis: its course: history; pacrsues definite oliacities. been to apply the nitrate of silver, in substance, to treatment; expectant; a severer form occasionally seen;its the suggested protruded part. The objection to this plan is, that it often symptoms: trecctitzent. causes severe pain, and is by no means uniformly successful, GENTLEMEN,—In my last lecture I described the principal and therefore I cannot recommend it. I much prefer either aspects under which ulceration of the cornea presents itself to puncturing the prolapse with a needle, which often causes it to our notice. I have now to consider the treatment best adapted contract and shrivel away, and thus to close up the corneal to each form or stage of this disease. In all cases in which you opening; or in case that fail, and the protrusion still increases, have ascertained with certainty the existence of an ulcer of to remove it entirely. Under the most favourable circumthe cornea, it is a good precaution to impress the fact on the stances, when disease has produced such results, the inmind of the patient or some friend, and to remind them that, tegrity of the organ is seriously compromised; but it is quite under the most favourable circumstances and the most judicious possible that sufficient space may be preserved for the formation treatment, a permanent opacity must be expected; otherwise, of an artificial pupil, and under any circumstances, it is most as the cure is accomplishing, they become dissatisfied, and the desirable to prevent the occurrence of a large staphylomatous blemish, which is to the surgeon the proof of success, may be protrusion. attributed to inefficient or improper treatment. If, however, In the glassy ulcer, there is very little to combat locally, the the partial eclipse be predicted, credit is rather gained than conjunctiva is very slightly injected, there is no surrounding lost when the prediction is fulfilled. During the first stage, opacity in the cornea, and no indication of any morbid action mentioned in the last lecture, that in which the ulcer is in in the part, except the loss of substance. Here we have process of formation, there is usually an excess of local action evidently an error of nutrition, and our chief efforts must be in the conjunctival membrane, and the usual symptoms of directed toward the constitutional condition of the patient. acute ophthalmia. Soothing applications, such as poppy We must endeavour to correct, as far as possible, the baneful fomentation or warm water, together with the local abstrac- influences to which such patients have usually been exposed, tion of blood by means of a few leeches to the temple, followed in the shape of impure air, small, ill-ventilated abodes, inup by counter-irritation behind the ear, are the most likely sufficient and unwholesome food; giving, at the same time, means of arresting the ulcerative process; at the same time, it such medicines as are calculated to assist in sustaining the may be necessary to sustain the general power, and counteract general powers of the patient. This object it is often very by constitutional treatment any abnormal state of system that difficult to effect. We suggest changes which poverty and may exist. Thus, in children, struma is often found in league ignorance are either unable or indisposed to adopt, and the with corneal ulceration. At puberty the menstrual function may debility resulting from a protracted exposure to these numerous be at fault; prolonged lactation is a fertile and very embarrassing sources of disease requires a very complete change and a very cause; and, later in life, a feeble, shattered, and physically long course of sanitary and medicinal treatment for its removal; depraved state of system, the result of constant and prolonged hence, one of the remarkable features in the transparent ulcer intemperance, gives rise to ulceration of the cornea. These is the very lengthened period during which it will remain various conditions must be combated with such means as we stationary, and unaltered in its size and other characters. The have; and we must ever bear in mind, if we would be suc- local treatment is comparatively unimportant, and should be cessful practitioners, that the most active and destructive of a very mild character. It has been suggested that the salts inflammatory and ulcerative processes are compatible with, of lead, in solution, should not be employed in ulcers of the and even dependent upon, a very feeble state of system, which cornea, on account of the tendency to a permanent deposit may require tonics, stimuli, and a very liberal dietary for their upon the surface. I have observed this on more than one This point I havealready insisted upon, but I hold it occasion, and it is quite in harmony with what occurs when cure. to be of such importance, and so very imperfectly recognised the acetate of lead is powdered over granular lids; and as by the profession generally, that I take every available oppor- there is no counteracting advantage to be gained by the use of tunity of urging it. I cannot but rejoice to find this view ably lead lotion, it is better to abstain from it altogether where developed and abundantly illustrated in the lectures delivered ulceration exists. Some cooling, unirritating collyrium, such last summer by Mr. Skey at the College of Surgeons. I very as rose water or elder-flower water, or a weak solution of early imbibed this opinion from my late teacher, Mr. Tyrrell; vinegar, is the best local application. Where the case is very subsequent experience has given me almost daily evidence of protracted, and the surface of the ulcer becomes irritable, it is its truth, and I cannot but hope that the eloquent appeal that sometimes advantageous to touch the surface lightly with the has been made from so high an authority, and to such an fine point of the nitrate of silver. I much prefer this to the audience, will result in the establishment of so important, so employment of a solution of lunar caustic, which irritates the vital a principle. conjunctiva, without acting so directly upon the ulcer, and In cases of acute and spreading ulcers, where penetration of often seriously aggravates the case. It is particularly imthe cornea is threatened, it becomes a matter of extreme im- portant, in the glassy ulcer, to apprise the patient or his portance to determine whether there is any means of arresting friends that an opacity of the cornea must be expected, otherthe progress of the ulceration. However judiciously the con- wise the symptoms are so mild, and the evidence of breach of stitutional treatment may be conducted, there is every fear that . surface so faintly appreciable to uneducated vision, that dispenetration may occur before a favourable reaction has time to credit may easily attach to the surgeon who is in attendance, take place; it, therefore, is an anxious question, whether we and, as the ulcer begins to fill up, an impression will be gained can, by any local application, bring about an altered action in that the case is retrograding, at the very time when it is the part, and avert the impending danger. It is in such cases drawing to an auspicious close. In cases of ulcer with a vascular membrane and organized as these that I have found the nitrate of silver, in substance, of great value; it should be finely pointed, and carefully limited deposit upon its surface, which is usually somewhat raised as much as possible to the ulcer itself; in order to effect this abovethe level of the rest of the cornea, and in which red object, glycerine should be dropped into the eye previously, so vessels may be seen travelling to supply it, the treatment is as to protect the remainder of the surface from the action of difficult. We have here new and organized deposit to combat the caustic. It seldom requires repeating more than once or with; diseased action seems to have established itself, and (if twice, and it will frequently be found that the ulcer will begin I may use the expression) to have taken up its abode in the to fill up and heal from that time. In other cases, it must be part, and this very much increases its power of resistingall
A Course of Lectures
THE EYE,
No. 1611.
24 remedial means, and its constant proneness to relapse or return Having now described those affections of the cornea which after apparent subsidence. I have had an opportunity of I believe to be secondary, and dependent upon an inflammatory observing several of these cases at the Ophthalmic Hospital; condition in the conjunctival membrane-viz., vascular opacithey usually apply after this condition has existed for a con- ties and ulcers, I pass on to the consideration of those morbid siderable time, and when a variety of remedial means have changes which are peculiar to the cornea. The term " corneitis"may, I think, with propriety and been exhausted upon them. They generally occur in young females about the age of puberty, or a little anterior to this, convenience, be applied to the disease I am now about to dealthough they are also found in young strumous children. I scribe, as it seems to be restricted in its effects to that strucbelieve them to be due, in the first instance, to a disturbed, ture, and to have all the characteristics, both in its history altered, or arrested function of some important organ in a and symptoms, of a specific malady, although we shall find feeble or strumous diathesis, aggravated by an active depleting that it differs considerably in the degree and in the extent, or plan of treatment, or by the injudicious and protracted use of rather depth, to which the layers of the cornea are implicated. strong local stimuli, particularly the nitrate of silver. The It is a disease of childhood and youth, very rarely, if ever, obvious inference is, that every available means must be taken occurring after the middle period of life; it usually develops to bring about and maintain the normal function of any organ in a few days, with little or no pain, and with scarcely any that may be at fault. This is particularly necessary as regards evidence of conjunctival inflammation, the slight pink dismenstruation ; at the same time I may add that I have fre- coloration seeming rather to be due to injection of the quently found the local disease, when thus established and sclerotic vessels-probably those vessels which are described organized, continuing in full force long after the constitutional as being specially dedicated to the nutrition of the proper vice to which it owed its origin has passed away. As regards layers of the cornea. That which usually first attracts the local treatment, I have usually found stimuli of all kinds in- notice of the patient is dimness of sight in one eye, accomjurious ; soothing applications are the best; sometimes one or panied sometimes with a slight dull, aching pain. On examintwo leeches, applied about every other day for a week or two, ing the eye, the cornea presents an uniform pale-white opacity, are of use, particularly where the vessels are rather numerous with just sufficient transparency remaining to enable you to and full, and the inflammation is in a sub-acute stage; but that see the iris and pupil, but not with such clearness as to show which has appeared to me to be of the most marked and essen- with certainty its colour and condition, although its activity tial service in this form of disease are issues inserted into the may usually be made out. The surface of the cornea, when temple, and kept there for many months. I usually employ a closely inspected, is found to be finely granulated; in fact, the small pea for this purpose, which must be changed daily. I state I am now describing is perhaps best represented by comam aware that some high authorities, and Mr. Tyrrell amongst paring the altered cornea to a thin layer of finely-granulated others, sweepingly condemn the use of issues in all cases of eye ground glass. The opacity is very generally and equally disease, on the grounds of the severity of the treatment, its diffused over the cornea, though usually rather thicker towards general inutility, and the subsequent deformity. I admit that the centre, but it is difficult to determine the extent to which these are objections in slight and transient cases; but they lose it penetrates and involves its layers, and in this respect there their force when we are considering a severe, obstinate, pro- is probably considerable diversity. The pain is very slight, tracted disease, liable to relapse, detrimental to sight, and sometimes altogether wanting, and there is no intolerance of effectually preventing all use of the organ while it remains un- light. One eye is almost invariably affected in the first subdued. It is for such cases that I would reserve the employ- instance, and the disease may be limited to the eye first inment of issues. A morbid action has become established in the volved; but more commonly, when it has existed some time, eye, and requires a prolonged discharge in its immediate and is subsiding or has just passed away, the second becomes vicinity, gradually to divert it from its original seat, and to similarly affected, and runs through the same phases. This is weaken the tendency to relapse-at least, such is the explana- by far the most common form of corneitis that we meet with: tion I am disposed to offer; but, whether correct or not, I its cause is involved in much obscurity. I have endeavoured entertain no doubt whatever of the power and value of the in vain to attach it to some special abnormal condition of remedy. I have succeeded in completely and permanently system, or to exposure to cold or some other noxious influence. curing several cases of this kind-by the prolonged use of issues Some high authorities always apply the term " strumous" to when they had baffled all other means for many months and this morbid change, and I do not deny that it may be comeven years, and when the constant irritation and necessary plicated with this diathesis, like most forms of ophthalmic confinement were casting a gloom upon what would otherwise disease; but I have frequently seen it in young persons from be the brightest period of life. It seems to me that, to obtain the country, about the period of puberty, and a little past that emancipation from such a condition, a small scar on the temple age, having every appearance of health, and in whom I could is but a slight penalty, and one most freely paid by the not find the faintest trace of struma, and therefore, where it is observable, I regard it rather as an accidental concomitant sufferer. When the cicatrizing process is going on favourably, the only than as a cause. This disease is rather to be regarded as an practical point we have to consider has reference to the opacity example of altered or diseased nutrition, which in a less delicate remaining in the cornea; this is often a cause of great anxiety structure would scarcely be noticed, but which becomes imon the part of the patient, on account both of the deformity and portant by disturbing the function and changing the appearthe dimness of vision resulting from it, and its removal is ance of a transparent tissue. With regard to treatment, I have taken some pains to invesfrequently sought. I believe time will effect much in this respect, as we find, in other scars, a gradual contractile tigate and follow out the natural history of this disease in a process goes on for a considerable time, and the surrounding great number of cases, and I have come to the conclusion that deposit entirely passes away, so that a very decided diminu- it has its definite period of development, that it remains in full tion of the opacity ultimately takes place. Much confidence force for a given time, varying from two to four or five months, is expressed by some in the action of various local stimuli in and then gradually passes away, clearing from the circumference promoting the absorption of such opacities; thus, solutions of like a vanishing cloud, and ultimately leaving no trace behind, the nitrate of silver, of zinc, of iodide of potash, calomel, and the cornea resuming its perfect original transparency, although various other stimuli, are each of them in high favour with the central opacity will often linger in a patchy state for some different observers. It is extremely difficult to estimate the time after the circumference of the cornea has become quite value, either positive or relative, of any of these means, when transparent. I was first led to take this view of corneitis, from we know the natural tendency is towards a gradual absorbent finding that, whilst I was pursuing various kinds of treatment, action. It is impossible to avoid the conclusion that, whilst and at the very time that the disease appeared to be subsiding it may be the result of our application; it may also be irre- most favourably under the plan I was adopting, the same train spective of, or it may even be in spite of, the means employed; .of symptoms would suddenly manifest themselves in the second and, I must confess to some degree of scepticism in regard to eye, would pass through the same stages, and subside in about the efficacy of any of these stimuli in removing opacities; at the same time as the eyeprimarily affected; thus, for example, the same time I am quite aware that in practice it is often on several occasions, I instituted a mild mercurial course, in necessary to employ something of the kind. I generally use a accordance with the recommendation of Mr. Tyrrell, and solution of the iodide of potash-five grains to an ounce of during the time that there was direct evidence of mercurial distilled water-dropped in three times a day. It does not action in the system, I have seen the disease commence and run through its course in the second eye. I have also observed cause pain-, and its action is gently stimulating and absorbent. I think the nitrate of silver objectionable, because I have seen the opacity remain quite stationary during the prolonged several cases in which its prolonged use has caused a perma- influence of this medicine, and only subside when the period nent stain in the conjunctiva. If we do employ it, care must seemed to have arrived at which the disease had run its be taken not to continue it for any lengthened period; cer- course; thus, by degrees, I became in a great measure extainly not above five or six weeks at a time. pectant, and with a result quite as satisfactory as when I used
25 active constitutional and local means, and probably much more Such cases would give an easy triumph to the administrator of If my view of this disease be correct, and I have taken infinitessimal doses if he should be working his miracles at that much pains to test it by repeated and close observation, it phase of the disease. Such cases form an interesting section of attached follows that the management of this affection is very simple. pathology, not only on account of some special All local stimuli are quite useless, and may be injurious, by to them individually, but because they are highly suggestive giving pain, by increasing vascularity, and by irritating a and instructive. They show how important it is to know the membrane previously scarcely involved in the disease. Some natural history of disease in estimating the power and value of very mild collyrium must be used, and, if any constitutional any plan of treatment, and how rationally the success of various suitable means that exert no real effect upon the system is explained, error can be detected, it must be treated with medicine. Thus children affected with this disease are often So protracted and apparently hopeless are some of these cases, weak and strumous, and improve in health under the influence that it requires great confidence in our pathology, and a large of steel, cod-liver oil, or iodine; at the adult period, tonics amount of uniform experience, to venture to promise a favourable issue in such a case; nevertheless, I have attended seem most frequently to be indicated, and any suitable treatment may indirectly tend to shorten the period of duration of some very severe forms of the disease in which patients have the disease by restoring the system to a condition of health; remained dark for many months, where, upon the strength of beyond this point art can effect nothing, and the rest must be former observations, and without any reliance upon any method left to the "vis medicatrix naturæ"—that constant friend of of treatment, and in the face of so considerable a morbid change in the cornea that it seemed to an ordinary observer as if it our profession on many trying occasions, and who, in this form of disease, I have rarely if ever known to fail. Hence it follows could never resume its transparency, I have reiterated my conthat a most important part of our treatment, and one that we viction that sight would be restored, and I have never known may very confidently and advantageously administer, (pro- my opinion prove incorrect. And this promise has been the one vided only that we make a correct diagnosis,) is the assurance slender hope to which the poor, half-blind sufferer has held on of a complete restoration of sight; for in the milder form of the through many a dark and anxious month, and it has required disease that I am now describing, I can scarcely call to mind a no little faith on the part both of the patient and the surgeon, before that faith has been once more merged in restored sight. single exception to this favourable result. It occasionally happens that corneitis manifests itself under I have usually observed that the antecedents of this disease and severer form, and, though probably differing only have been of such a character as to enfeeble the system,-conanother in degree, spreads deeper, produces more formidable results, siderable labour, great mental anxiety, some constant drain and more seriously interferes with vision, from the circum- upon the system, improper and insufficient food; but I have stance that it usually involves the second eye before the first not been able to trace any direct or immediate effect upon the has recovered its transparency. The corneal opacity, instead disease by the removal of these unfavourable circumstances. of being uniform, exhibits one or more patches of a reddish- After what I have stated, but little remains to be said on the brown colour, not on the surface, but between the layers of the subject of treatment; the great point is not to be induced to On a superficial view these appear like small masses do too much by the severity of the disease. I am quite concornea. of extravasated blood; but if carefully examined, and especially vinced, after repeated trials, that mercury will not’absorb the when subjected to the dissecting power of a magnifying glass, organized deposit; I therefore now carefully abstain from its they are found to be made up to a great extent of minute use. I simply limit myself to the employment of such means vessels, and to be in fact masses of highly-organized lymph. as will restore power to the system, but without anticipating Sometimes there is only one small patch of this kind, the re- any favourable result to the disease, except indirectly, hoping mainder of the cornea presenting the appearance of ground merely that it may run its course more speedily when the glass, as in the milder form I have before described; but I system is in a healthy condition. Local means are useless, and have seen some few cases in which the entire cornea has pre- if stimulating, injurious; if I made an exception in favour of sented one nearly uniform organized mass. In this severe type any kind of local treatment, it would be the use of issues. I of corneitis there is much more evidence of increased vascu- think I have observed that the disease has been favourably larity ; the conjunctiva is considerably injected; the deeper modified by their employment, and that the eye, secondarily vessels are involved; there is both lachrymation and some affected, has run a less severe and protracted course than intolerance of light; patients also complain of a dull, aching the first. It is quite in unison with all my observations, that pain. It is very important not to confound this disease with issues act favourably wherever new organized deposit exists in the vascular opacity of the cornea, which I have described in a the cornea, but to produce any effect, they must be persevered former lecture as the result of a villous state of the conjunctiva in for a considerable time. There is one point that I feel pretty in strumous subjects. In this latter, the vessels lie chiefly on confident about in reference to this very formidable disease, the surface of the cornea, and are distinctly and individually which is, that unlike most affections of the eye, it very rarely visible with the naked eye; whereas in vascular corneitis, as I returns. term the disease I am now dwelling upon, vessels can only be seen through the aid of a magnifying glass, and the reddishON THE brown patch is placed between the corneal layers. This may, perhaps, appear to some rather a minute and unnecessary divi- USE AND ABUSE OF POTASSA FUSA AND sion of diseases that closely resemble each other; yet, inasmuch POTASSA CUM CALCE as they differ most essentially in their origin and cause, in the IN THE effects they produce, in their prognosis and treatment-in fact, TREATMENT OF UTERINE DISEASE. in their entire history, it is surely very desirable clearly to mark the distinctions between the two; and I am the more BY J. HENRY BENNET, M.D., anxious to insist upon this point, because it is quite evident PHYSICIAN-ACCOUCHEUR TO THE ROYAL FREE HOSPITAL, ETC. that even so acute and accurate an observer as the late Mr. Tyrrell has confused the two diseases together, as will be seen IT is now more than nine years since I introduced to the by his placing Cases 33 and 34 in his work under the head of "Corneitis" instead of "Vascular Opacity," to which they profession, in the first edition of my work on ’’ Uterine Inflammation," potassa fusa and potassa cum calce as valuable reevidently belong. The disease I am now describing never produces ulceration medies in the treatment of some chronic and intractable forms of the cornea, or abscess between its layers, nor does it ever of uterine inflammation. Since then these agents have been soften the texture so as to cause it to yield, and thus to increase adopted by many practitioners at home and abroad, a fact of its convexity; its effects are limited to the general dulness of which I have ample evidence in my own practice, as I am conthe cornea, and the organized deposit between its layers. This stantly consulted by patients in whom this means of treatment disease is exceedingly distressing to the patient, on account of has been resorted to. In some of these cases I have found that the great dimness of sight that it produces usually invading the caustic potash has been incautiously used, so that lesions the second eye before the first has recovered its transparency, of the vagina and partial occlusions of the cervical canal have and thus producing a condition very closely bordering on been produced, notwithstanding the careful and minute directemporary blindness. It may occur in children, but the worst tions which I have given for its employment. As I cannot forms of it that I have seen have been in adults between thirty but consider myself to a certain extent responsible for the use and forty years of age. It is very protracted in its duration, of a remedy which I have introduced in this country, I am and, as far as I have seen, resists every kind of treatment, but anxious, in the present paper, to lay down precisely the rules ultimately gets quite well, when perhaps every plan has been which ought to regulate practitioners when they resort to so tried and abandoned in despair; and much unmerited and powerful on agent. Potassa cum calce was first used in the treatment of chronic unexpected credit may be gained by the fortunate individual who happens to be in attendance at the time of its subsidence. inflammation of the cervix uteri by M. Gendrin, the enso.
points