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COURSE OF LECTURES ON THE DISEASES OF THE EYE,
LONDON, SATURDAY, MARCH 21, be
COURSE OF LECTURES
[1839-40.
between the two textures, identical. If there the close resemblance these writers
some
analogy
yet they are by were
ON THE
1840.
no means
imagine, we might very reasonably expect that pustules would generally be found upon the conjunctiva, during AT THE an attack of variola. Such, however, is ROYAL SCHOOL OF ANATOMY AND MEDICINE, certainly not the case. In a great many cases the eye appears to be altogether MANCHESTER, exempt, not merely from pustules, but even By JOHN WALKER, Esq., Surgeon. from active inflammation ; and in ordinary cases, where ophthalmia does exist, it is not the pustular, but a much more severe form. LECTURE VII. of ophthalmia, viz., the catarrhal, which is THE OPHTHALMIA RESULTING FROM SMALLDISEASES
OF THE Delivered in 1839-40,
EYE,
appear to
observed. Some authors, indeed, deny that variolous THE next subject to which I have to reever do form on any portion of the quest your attention, is Ophthalmia Variolosa, conjunctiva. This opinion is entertained or the ophthalmia resulting from small-pox. by M. Guersent, Dr. Gregory, and Mr.. I have before stated, that during the pro- Marson. The contrary opinion, however, is gress of the various exanthemata, the inflam- generally considered to be the correct one, matory action is apt to be extended from either perhaps from want of proper examinathe cutaneous to the conjunctival surface of tion, or from taking it for granted that, bethe palpebrse. cause there are pustules on the cutaneous In such cases we generally find that, in surface of the lids, there must also be some addition to inflammation and swelling of the on the conjunctiva. The pustules, however, lids, a certain amount of conjunctivitis is when stated to be present, are usually present, either during the existence of the spoken of as if they never appeared any eruption, or after it has begun to decline, as where but on the surface of the cornea. No evinced by the redness of the conjunctiva, author that I have met with ever speaks of the intolerance of light, and the mucous dis- variolous pustules on the conjunctiva, either charge which collects upon the tarsal mar- of the globe or of the palpebrse. This, it gins, and causes them to adhere. Usually, must be confessed, is somewhat suspicious, in variolous cases, the ophthalmia is very since if it were really pustular ophthalmia. slight ; and in many the agglutination of that comes on during variola, pustules would the lids is probably caused solely by the be noticed elsewhere besides on the cornea ; matter from the pustules about their margins. so that, on the whole, it is very probable This agglutination of the palpebral mar- that the existence of variolous pustules, onL gins, as you are doubtless well aware, very any portion of the surface of the e3 e, is aloften continues for several days during the together an assumption, unsupported by progress of the variolous affection, and is facts. I have certainly never seen them usually of no importance, although we often myself. find such a condition spokn of by the friends I have said that when ophthalmia is exof the patient, as one of actual blindness ; cited during the progress of small-pox, it is in such instances the blindness is merely the catarrhal, and not the pustular variety such as would be occasioned by placing a which is ordinarily seen. I state this from handkerchief around the eyes. the observation of a few cases which have It is the custom of many writers on come under my care; and I have no doubt ophthalmic surgery to describe the conj unc- that, in some of the more severe cases, it is tival membrane as a direct continuation of the purulent variety which supervenes ; that the outer covering of the body. I remarked, the organ suffers from extension of the inin a former lecture, that although there may action to the cornea, occasioning POX.
If pustules
No. 864.
flammatory
938 The Treatment of Variolous Ophthalmia between its laminae, of it; and must be regulated altogether by the mildthat thus are produced the numerous sunken ness or severity of the attack. In slight eyes, staphylomatous projections, and in- cases, probably some simple unctuous sobdelible opacities, which are so often met stance, e. g zinc ointment, applied to the tarsal margins, might operate beneficially in with as sequelae of small-pox. The view I have taken of the character of allaying irritation and facilitating their variolous ophthalmia has been much strength- separation. The occasional use of warm ened by the perusal of a very able practical water may also be similarly useful. If it be correct to consider the ophthalpaper, by Mr. Marson, of the Small.Pox Hospital, a gentleman who has evidently mic affection as an extension of the inflam. paid great attention to this subject. Ac- matory condition of the palpebrse, which cording to Mr. Marson, the proportion, are always much swollen, and in a state among variolous cases, of those who suffer strongly resembling that which attends from a severe attack of ophthalmia, is 26 in purulent ophthalmia, it becomes a question 1000, or one in 39; and of these, 11 lost an whether proper applications to pustules on eye-about one in 100=precisely one and a the lids may not be useful for preventing tenth. "The attack begins, generally, on the extension of the inflammation to the conthe eleventh or twelfth day, or later, from junctiva, and thence to the cornea. In the first appearance of the eruption, and cases where pustules form on the tarsal When the pustules on every other part of margins, such extension is more likely to the body are subsiding. It comes on after happen, and, therefore, they should be early the secondary fever has commenced, with opened with a needle, and then touched rednegs and slight pain in the part affected, with the nitrate of silver-pencii. This and very soon an ulcer is formed, having its practice has been recommended by Velpeau, seat, almost invariably, at the margin of the with a view to prevent the deformity which cornea; this continues to spread with more is otherwise apt to result from their ulceraor less rapidity, according to the degree of tion and cicatrization. But I would advise secondary fever present; in the more vio- its adoption on higher grounds, viz., because lent cases an ulcer being formed on each I consider it would probably tend to preside of the cornea at the same time, showing vent the severe inflammatory condition of the disease to be advancing with great the conjunctiva and cornea, which so often severity, and presenting a tolerably certain results indication that the eye will be entirely lost. If, however, such inflammation have exThe ulceration passes through the different tended to the conjunctiva, and more particulayers of the cornea, until the aqueous larly if it have proceeded to the cornea, I humour escapes, extending itself too late- can have no hesitation in recommending rally, and, if the part of the cornea de- you immediately to apply the nitrate of stroyed be large, the iris will protrude silver freely to the conjunctival surface, through the opening. In the worst cases and to treat the affection in every respect as there is usually hypopion, and when the if it were a case of severe catarrhal or pumatter is discharged the crystalline lens rulent ophthalmia. If I have considered it and vitreous humour escape ; or the humours improper or unnecessary to practise bloodmay escape from deep and extensive slough- letting, or to administer mercury and the ing, in the first instance, without the forma- other usual antiphlogistic remedies in catartion of matter, this being succeeded, of rhal or purulent ophthalmia, when met with course, by the total annihilation of the form in ordinary circumstances, I am far less of the eye, as well as the sight." (LANCET, likely to recommend such treatment when either of these forms of ophthalmia occurs vol. ii. 1838-39, page 235.) After perusing Mr. Marson’s graphic after small-pox. Even the advocates of account of the symptoms and progress of antiphlogistic treatment think it improper this affection, I think but little doubt can to administer mercury in such circumbe entertained of its being either a severe stances, where sloughing is so liable to form of catarrhal, or of purulent ophthalmia, come on. To me it appears that bloodwhich he has described. The sloughing of letting, no less than mercury, must necessathe cornea Mr. Marson conceives to be rily tend to favour such a process. I would analagous to the same process which is so say for blood-letting, substitute quinine, and frequently observed to take place in the the use of wine and other tonics and stimucellular membrane in various parts of the lants. By the adoption of this treatment, I body. In the progress of variola, sloughing apprehend the patient will have a much of the celln lar membrane, of the scalp, palpe- better chance of recovering the function brae,aboutthebeardinmen,neck,elbow,and of vision unimpaired. A milder form of ophthalmia is also very dorsum of the foot, is still more frequently observed than in the cornea. Wherever it frequently observed to come on at the expioccurs, Mr. Marson justly ascribes the ration of one, two, or three weeks after the sloughing process to violent inflammation variolous pustules have disappeared. This is termed attacking structures of similar character.
deposition of lymph
a or
ulceration,
or even
sloughing
939
Secondary Variolous Ophthalmia. It usually exhibits the milder symptoms ,,
........
noticed in the slighter
ophthalmia, but
cases of catarrhal uncommon to find
it is not
I could easily add to the number, were it necessary ; but they have been quite sufficient to illustrate and establish the principle for which I have contended. According to the arrangementI laid down at the I shall, in the next place,’ proceed to speak of the various
ulceration of the cornea supervening, more particularly in individuals of a strumous constitution. The treatment is to be conChronic Diseases of the Conjunctiva. ducted on the principles I have before laid down. These are, no doubt, more or less, the result of increased vascular although Of the Ophthalmia that accompanies the other some of them do not exhibitaction, the phenomena Measles and Scarlatina, mz., Exanthemata, viz., Meastes and Scarlatina,by which the presence of inflammation is technically named Ophthalmia morbillesa and usually indicated. Scarlatinosa, I need not say much. You will PTERYGIUM. always find that it is decidedly the catarrhal variety that exists during the progress The first of the chronic affections of the of these affections. Such we might expect, conjunctiva to which I shallallude is Ptery-
commencement,
à
priori, to
be the case, from the
epidemic gium.
character of the exanthemata, and of this This is a chronic vascular growth, affectform of ophthalmia. Dr. Frick has alluded ing, as is commonly supposed, the conjuncto the connexion between catarrhal ophthal- tival membrane, or, as Mr. Middlemore mia and another epidemic disease, viz., thinks, the cellular substance lying between the influenza, both of which affections he it and the sclerotica. consideis to be identical, and he states that It is most commonly observed at the inner
during the prevalence
of an epidemic influ- angle of the eye, where it arises from about enza, those persons who were attacked with the caruncula lacrymalis (with which, how-
catarrhal ophthalmia were exempt from the influenza. I have before alluded to the fact, that the exanthemata are very apt to excite ophthalmia in strumous individuals. In such cases, the ophthalmia is usually more protracted, and less manageable. I need, however, here only refer you to what I said when addressing you on that subject in my last lecture. I have now brought to a conclusion my
ever, it has no connection), with a broad base, and gradually tapers off as it proceeds towards and upon the surface of the cornea. Its shape is, therefore, triangular, and as it also somewhat resembles in appearance the wing of an insect, it has been named pterygium. The diseased structure is not usually very dense. In the slighter cases it seems to consist of little more than a thin membrane, in which is imbedded a considerable account of the various active inflammatory number of vessels, when it is termed pterystates of the eye in which the conjunctiva gium tenue; at other times it is more dense, is primarily and principally affected. And, and has a fleshy appearance, and then it is notwithstanding that I have occupied a named pterygium crassum. considerable period of time in the discusAlthough, as I have said, a pterygium is sion of what some may be inclined to con- usually noticed at the inner angle of the eye, sider as the affections of an unimportant yet this is far from being universally the case, portion of the visual organ, yet you will for sometimes it is met with at the temporal find, on referring to what has been already angle, and occasionally at the superior accomplished, that I have had occasion to and inferior portions of the globe. When speak of several of the most interesting and observed in the two last-named situations, really the most important affections to which I think it is often caused by a fold of the the eye is subject. You will further find, conjunctiva having become adherent to the that those affections are such as will most cornea, near its circumference, when in a frequently come under your notice when state of ulceration. Such, at least, has engaged in actual practice. The in more than one instance that has that I have advised you to adopt in the come under my notice, where the pterygium management of this class of affections, is occurred after’an attack of purulent ophthalconsiderably different from that recom- mia. I have also noticed it after ulceration mended by our best writers. I would only of the cornea from injury with lime. la further remark of it, that it is not the result these cases the paipebrw are usually closed of mere idle speculation as to what I should for a considerable time, and thus the tenmyself conceive, from a process of reason- dency to adhesion between the opposing ing, ought to be adopted for conjunctival surfaces is favoured. This kind of pteryinflammation ; on the contrary, I have fur- gium is more movable than the other, and nished you with an actual and literal de- readily admits the introduction of a probe scription of the practice that I am daily in under it,-acircumstance which clearly the habit of resorting to for its subduction. proves that this form of pterygium, at least, Of the success attending that practice, I is not connected with the subconjunctival have supplied you with a few examples. textures. 2 3 P
treatmenthappened
940 This morbid growth sometimes terminates margin of the cornea, but, if allowed to remain, it soon passes upon it and to its centre. Occasionally it happens that there are two or three of these growths, one arising from each angle, and both uniting in the middle of the cornea; and some authors state that they have seen one proceeding from each of the four sides of the globe, at the
uniting in the centre. Generally, pterygium
is confined to one eye, but sometimes it is noticed in each. The order of frequency, as respects situation, is described by Mr. Middlemore as follows :" First, the forma1i.on of a pterygiam upon one eye, placecl at the inner canthus; secondly, the formation of a pterygium upon each eye, arising from the inner canthus; thirdly, the occurrence of two pterygia upon one eye, one arising at the inner, and the other at the outer canthus ; fourthly, the formation of one pterygium alone, either at the outer canthus, or at the upper and lower part of the eyeball, but not at the inner canthus." My own experience on this point does not coincide with that of Mr. Middlemore. I have most frequently seen pterygium arising from the inner canthus of only one eye; and, next in frequency, I have observed the pterygium arising from under the superior lip, also in one eye. The experience of other surgeons will, probably, still further differ. great deal of speculation and some ingenuity have been expended upon the subject of this morbid growth, more particazlarly as to the cause of
A
Its
inxariably assuminga Triangular Shape.
Scarpa is the only author who is supposed have offered anything like a correct explanation of the circumstance. " The constancy of this fact," says this eminent writer, "ought to be referred, in my opinion, to
cornea.
It does not
explain the triangular
figure of that portion of the diseased mass affecting the conjunctiva scleroticæ, and we know that it is not merely that portion upon the cornea which exhibits this peculiarity of shape, but that it is quite as strongly marked upon the sclerotic portion. Nor does Scarpa’s statement offer any solution of the question, why a pterygium never passes the centre of the cornea, since it can scarcely be supposed that the mecha. nical resistance, at that point, is absolutely so great that it may not be overcome. In truth, Scarpa’s attempt at explanation amounts simply to this-that the resistance to the progress of a pterygium upon the cornea, is owing to the increasing adhesion between the conjunctival covering and the cornea itself, and that, on its arriving at the centre, the mechanical resistance is so excessive that it cannot be overcome, and that thus the further progress of a pterygium is stopped. I quite agree with Mr. Guthrie in thinking that Scarpa’s hypothesis,"al. though it may appear sufficiently plausible, is so unsatisfactory, that the problem is still open for the exercise of further ingenuity." It is an admitted fact, that the adhesion of that portion of the conjunctiva which covers the cornea, to the subjacent tis. sues, is exceedingly firm ; whilst that of the sclerotic portion, it is well known, is quite the opposite. This firm adhesion, I readily grant, will sufficiently explain the slow pro. gress of any vascular growth under the conjunctival surface of the cornea; but that it has anything to do with determiningthe figure of that growth, or of stopping its progress at a certain point, I can by no means admit. On the contrary, if this adhesion increases, as it is considered to do, towards the centre of the cornea, and the pterygium has this increased mechanical resistance to contend against, supposing its progress to be uninfluenced by other causes, it might be expected to proceed around the margin of the cornea, where the resistance is so much less, rather than towards its centre, as it always does. But the entire subject, in my opinion, requires and admits of an explanation of a more
to the adhesion of the lamina of the conin proportion as it advances from the circumference towards the centre of the cornea. For in consequence of such structure and different degree of cohesion, which actually exists in the sound eye, it must necessarily follow, in the first place, that the progress of the comprehensive character, which shall equaJ1y pterygium ought to be in every case of such apply to the condition of both conjunctiva disease much slower upon the coruea than and cornea. A proper explanation of this peculiarity upon the white of the eye ; secondly, that from the greater resistance which it always attending the growth of a pterygium, cannot, meets with, in proportion as it exteuds to- I conceive, be arrived at without reference wards the centre of the cornea, it must, being made to the vascular supply of the from mechanical necessity, assume a than- conjunctiva. The conjunctival vessels, then, are, to a gular form, the base of which corresponds to the white of the eye, the apex to the certain extent, to be considered as indecentre of the cornea." pendetot of each other. They pass into the Now, if the explanation given by Scarpa substance of the membrane at four distinct were, as far as it goes, correct, it is still points, one at each angle, and at the superior open to the objection that it explains only and inferior portions of the globe. This is one.half of the case, viz., only that half the case both with the palpebral and muswhich hols reference to the conjunctiva of the cular arteries. By this arrangement, it
juiietiva becoming stronger,
941 will be perceived that the vascular supply sides of the globe, must necessarily of the
conjunctiva covering the globe
is
a
assume
triangular figure. This figure results, as have said, from the limitation of the mor-
derived from four distinct sources, and that I each set of vessels is destined to the nutri- bid action to the vessels which are distrition of one-fourth of the conjunctival mem- buted to one of the four sections of the conbrane. junctival covering of the globe, as will be Now, in acute conjunctivitis, as I for- evident from the annexed diagram. Here the large circle may be supposed to merly stated, the conjunctival vessels are usually all involved in the increased action, represent the periphery of the conjunctival and, therefore, the whole surface of the surface of the globe, and the smaller one membrane is more or less loaded with ves- the margin of the cornea. If morbid action sels. But it frequently happens that these be confined to the vessels of one of the four vessels are only partially affected ; for ex- divisions, it will be seen the morbid strucample, those of the inner or of the outer ture must necessarily assume a triangular angle alone become affected in this way,-a figure. condition to which the term ophthalmia an- The origin of the thin membranous pterygularis has been applied. The same is gium is somewhat obscure. Frequently it often noticed, too, in pustular ophthalmia; arises without any obvious cause. Usually a single pustule is observed at the inner or there is considerable vascularity attends its outer margin of the cornea, and a fasciculus growth, although it cannot be said, in any of vessels is seen running from a correspond- case, to amount to inflammation. As it ing angle of the eye to the pustule. In these most commonly affects the inner angle,—a instances, the morbid action is confined to portion of the conjunctiva which is, perone or another of the series of vessels to haps, more vascular and more irritable than which I have alluded, and the figure they the rest,-it is not unlikely that it may often present always more or less resembles that be excited by irritation from external of a triangle. causes, such as foreign substances, which In cases of corneitis, too, we find the are always propelled towards this point by vessels creeping slowly from the margin the winking motions of the lids. Bell has towards the centre of the cornea, and never remarked that stone-masons, who often get proceeding around its circumference. In fragments of calcareous matter into the eye, these cases, when the vascularity of the are most liable to pterygium. The other cornea has only been partial, I have often variety of pterygium (p. crassum), I have noticed that the vessels have assumeda already remarked, is’ frequently the result shape similar to that which they exhibit it of adhesion between a fold of the conjuncpterymium. tiva and an ulcerated portion of the cornea. In like manner, in the case of pterygium, I have likewise observed the fleshy pterywhich is a morbid growth, unattended by gium to result from the application of lime active inflammation, but always evincing a to the conjunctiva, where ulceration had considerable degree of vascularity, there ie not occurred. The Treatment of Pterygium a’partial affection of the conjunctival vessels. These vessels, at whichever of the fou) must be regulated according to the greater sides the disease happens to be developed or less development of the morbid growth. proceed from that portion of the peripher3 In the incipient stage, when it is s!ill inof the conjunctival surface of the gtobe, auc considerable in size, and does’ not extend pass on towards and upon the cornea to it! upon the cornea, it is probable that the use centre, beyond which it never extends- of some stimulant or escharotic substance, thus occupying and being limited to one more particularly the nitrate of silver-pencil, fourth of the conjunctival surface, and may be sufficient to arrest its progress. Dr. Mackenzie states that he has known the therefore, possessing a triangular shape. disease to be removed by the use of a solution of nitrate of silver, or of vinum opii. When these do not succeed, he advises scarification of the diseased mass, or snipping a portion of it away. Mr. Lawrence has a great aversion to the use of stimulating and escharotic substances; and he even supposes that, by their use, a case of ordinary pterygium may be converted into something of a cancerous or malignant character, although he admits that he has never witnessed a case of malignant pterygium. I do not conceive that there is the slightest Thus, I think, it will be obvious that anydanger of such an event taking place from morbid action, particularly one of so chro--a well-regulated use of proper substances nic a character as pterygium, which is con-of this kind. Such applications, however, fined to the vessels of any one of the fourr are more particularly adapted to the thin
942 membranous pterygium, where the cornea is unaffected. CLINICAL LECTURES The fleshy pterygium will certainly not ADDRESSED TO THE yield to the use of stimulants and escharotics, and therefore it is best at once to pro- STUDENTS OF THE MIDWIFERY CLASS ceed to remove it by excision. The patient AT THE ROYAL SCHOOL OF MEDICINE, being properly placed in a chair, and the an who palpebrae separated by assistant, BIRMINGHAM, stands behind the patient and supports his BY head, the surgeon lays hold of the diseased J. T. INGLEBY, M.D., structure with a slender forceps ; by this process it is raised from the surface of the Fellow of the Royal College of Physicians, Edin. globe, and with a pair of curved scissors is LECTURE V. easily removed, by first detaching its corneal, and afterwards its sclerotic portion. CASE OF PLACENTAR PRESENTAIt is not advisable that the excision TION, TERMINATING FATALLY. should be effected quite at the base of the pterygium, because it occasionally happens GENTLEMEN :-The specimen now exhibitthat a firm cicatrix or band results, which ed to you is the uterus at the full term of materially interferes with the motion of the pregnancy, having, as you plainly see, the eyeball. This has been noticed, at least, at placentar attached to the body, neck, and the inner angle of the eye, and has been mouth of the organ. You already know, found to a certain extent to prevent abduc- that in all such cases artificial delivery is tion. To prevent this, Scarpa advises that essential, in order to preserve the life of a very small portion only of the sclerotic either parent or child. The natural powers portion of the diseased growth should be have certainly, in very rare instances, been excised, viz., about a line in breadth from equal to the delivery of the placentar first, the margin of the cornea. Mr. Guthrie is and then the child; and such may occur once, in the habit of removing about one-half of perhaps, in fifty or sixty cases. This is, that portion of the pterygium which lies however, never to be expected, and, forupon the sclerotica,-a proceeding which tunately, the resources of art, when timely he states has always been successful in interposed, are equal to the emergency. I am acquainted with three or four such occuring the disease. In the course of a few days after the currences, but I have only seen two, one of performance of the operation, the conjunc- which I will presently tell you something tival covering becomes renewed, and the about. The case which is connected with disease in some instances will have dis- the specimen before you may be related in appeared. It is exceedingly apt, however, a few words. The patient had several attacks of hæmorto return, and sometimes needs a frequent of the during the last few weeks of her rhage repetition operation. Some authors speak of this operation as pregnancy; but, I believe, with the excep. if it were always attended with success. tion of the last attack, the haemorrhage was It will be best, however, for the surgeon not particularly severe, and yet there must not to be too sanguine on this point, for his have been a material draining going on, for efforts will occasionally be frustrated ; and oedematous swellings had appeared; the if he succeed in removing the morbid last attack of flooding terminated her exist. growth, and preventing its re-formation, still ence. Her medical attendant, finding the the change it has induced in the texture of exhaustion death-like, feared to deliver at the cornea will be usually of such a nature the instant, and sent to request my attendthat a permanent opacity remains. " The ance. I was at home, and lost no time, young surgeon, therefore," as Scarpa re- but ere I reached the patient life had marks, " should not suffer himself to be ceased. Prompted by feelings of curiosity imposed upon by the specious relations of I passed my finger to the uterine orifice, and those who assert that they have removed it was so little open as barely to permit two pterygia by the knife, and completely re- fingers to enter. The attachment of the stored the cornea to its original natural placentar, around the orifice of the womb, is transparency. The cornea certainly appears too obvious to require describing. Such, less opaque at that part than before ; but it in brief terms, is the history of this melanalways remains dark, and clouded by an choly case ; and what inferences can we indelible, though superficial cicatrix." The deduce from its consideration? We learn opinion of Mr. Middlemore is in accord- this important fact, that a haemorrhage may ance with that of Scarpa, and he judiciously go on to the destruction of life, whilst the os remarks, that " if this view be correct,, uteri is almost closed. The coincidence may then an early operation becomes necessary,be an unfrequent one, but the states are perwith the intention of preventing thosefectly compatible with each other. An imchanges in the textures of the cornea whichportant question now arises, viz., did the uterine orifice possess dilatability ? for ill are apt to arise if the disease remain."
COURSE OF LECTURES
[1839-40.
between the two textures, identical. If there the close resemblance these writers
some
analogy
yet they are by were
ON THE
1840.
no means
imagine, we might very reasonably expect that pustules would generally be found upon the conjunctiva, during AT THE an attack of variola. Such, however, is ROYAL SCHOOL OF ANATOMY AND MEDICINE, certainly not the case. In a great many cases the eye appears to be altogether MANCHESTER, exempt, not merely from pustules, but even By JOHN WALKER, Esq., Surgeon. from active inflammation ; and in ordinary cases, where ophthalmia does exist, it is not the pustular, but a much more severe form. LECTURE VII. of ophthalmia, viz., the catarrhal, which is THE OPHTHALMIA RESULTING FROM SMALLDISEASES
OF THE Delivered in 1839-40,
EYE,
appear to
observed. Some authors, indeed, deny that variolous THE next subject to which I have to reever do form on any portion of the quest your attention, is Ophthalmia Variolosa, conjunctiva. This opinion is entertained or the ophthalmia resulting from small-pox. by M. Guersent, Dr. Gregory, and Mr.. I have before stated, that during the pro- Marson. The contrary opinion, however, is gress of the various exanthemata, the inflam- generally considered to be the correct one, matory action is apt to be extended from either perhaps from want of proper examinathe cutaneous to the conjunctival surface of tion, or from taking it for granted that, bethe palpebrse. cause there are pustules on the cutaneous In such cases we generally find that, in surface of the lids, there must also be some addition to inflammation and swelling of the on the conjunctiva. The pustules, however, lids, a certain amount of conjunctivitis is when stated to be present, are usually present, either during the existence of the spoken of as if they never appeared any eruption, or after it has begun to decline, as where but on the surface of the cornea. No evinced by the redness of the conjunctiva, author that I have met with ever speaks of the intolerance of light, and the mucous dis- variolous pustules on the conjunctiva, either charge which collects upon the tarsal mar- of the globe or of the palpebrse. This, it gins, and causes them to adhere. Usually, must be confessed, is somewhat suspicious, in variolous cases, the ophthalmia is very since if it were really pustular ophthalmia. slight ; and in many the agglutination of that comes on during variola, pustules would the lids is probably caused solely by the be noticed elsewhere besides on the cornea ; matter from the pustules about their margins. so that, on the whole, it is very probable This agglutination of the palpebral mar- that the existence of variolous pustules, onL gins, as you are doubtless well aware, very any portion of the surface of the e3 e, is aloften continues for several days during the together an assumption, unsupported by progress of the variolous affection, and is facts. I have certainly never seen them usually of no importance, although we often myself. find such a condition spokn of by the friends I have said that when ophthalmia is exof the patient, as one of actual blindness ; cited during the progress of small-pox, it is in such instances the blindness is merely the catarrhal, and not the pustular variety such as would be occasioned by placing a which is ordinarily seen. I state this from handkerchief around the eyes. the observation of a few cases which have It is the custom of many writers on come under my care; and I have no doubt ophthalmic surgery to describe the conj unc- that, in some of the more severe cases, it is tival membrane as a direct continuation of the purulent variety which supervenes ; that the outer covering of the body. I remarked, the organ suffers from extension of the inin a former lecture, that although there may action to the cornea, occasioning POX.
If pustules
No. 864.
flammatory
938 The Treatment of Variolous Ophthalmia between its laminae, of it; and must be regulated altogether by the mildthat thus are produced the numerous sunken ness or severity of the attack. In slight eyes, staphylomatous projections, and in- cases, probably some simple unctuous sobdelible opacities, which are so often met stance, e. g zinc ointment, applied to the tarsal margins, might operate beneficially in with as sequelae of small-pox. The view I have taken of the character of allaying irritation and facilitating their variolous ophthalmia has been much strength- separation. The occasional use of warm ened by the perusal of a very able practical water may also be similarly useful. If it be correct to consider the ophthalpaper, by Mr. Marson, of the Small.Pox Hospital, a gentleman who has evidently mic affection as an extension of the inflam. paid great attention to this subject. Ac- matory condition of the palpebrse, which cording to Mr. Marson, the proportion, are always much swollen, and in a state among variolous cases, of those who suffer strongly resembling that which attends from a severe attack of ophthalmia, is 26 in purulent ophthalmia, it becomes a question 1000, or one in 39; and of these, 11 lost an whether proper applications to pustules on eye-about one in 100=precisely one and a the lids may not be useful for preventing tenth. "The attack begins, generally, on the extension of the inflammation to the conthe eleventh or twelfth day, or later, from junctiva, and thence to the cornea. In the first appearance of the eruption, and cases where pustules form on the tarsal When the pustules on every other part of margins, such extension is more likely to the body are subsiding. It comes on after happen, and, therefore, they should be early the secondary fever has commenced, with opened with a needle, and then touched rednegs and slight pain in the part affected, with the nitrate of silver-pencii. This and very soon an ulcer is formed, having its practice has been recommended by Velpeau, seat, almost invariably, at the margin of the with a view to prevent the deformity which cornea; this continues to spread with more is otherwise apt to result from their ulceraor less rapidity, according to the degree of tion and cicatrization. But I would advise secondary fever present; in the more vio- its adoption on higher grounds, viz., because lent cases an ulcer being formed on each I consider it would probably tend to preside of the cornea at the same time, showing vent the severe inflammatory condition of the disease to be advancing with great the conjunctiva and cornea, which so often severity, and presenting a tolerably certain results indication that the eye will be entirely lost. If, however, such inflammation have exThe ulceration passes through the different tended to the conjunctiva, and more particulayers of the cornea, until the aqueous larly if it have proceeded to the cornea, I humour escapes, extending itself too late- can have no hesitation in recommending rally, and, if the part of the cornea de- you immediately to apply the nitrate of stroyed be large, the iris will protrude silver freely to the conjunctival surface, through the opening. In the worst cases and to treat the affection in every respect as there is usually hypopion, and when the if it were a case of severe catarrhal or pumatter is discharged the crystalline lens rulent ophthalmia. If I have considered it and vitreous humour escape ; or the humours improper or unnecessary to practise bloodmay escape from deep and extensive slough- letting, or to administer mercury and the ing, in the first instance, without the forma- other usual antiphlogistic remedies in catartion of matter, this being succeeded, of rhal or purulent ophthalmia, when met with course, by the total annihilation of the form in ordinary circumstances, I am far less of the eye, as well as the sight." (LANCET, likely to recommend such treatment when either of these forms of ophthalmia occurs vol. ii. 1838-39, page 235.) After perusing Mr. Marson’s graphic after small-pox. Even the advocates of account of the symptoms and progress of antiphlogistic treatment think it improper this affection, I think but little doubt can to administer mercury in such circumbe entertained of its being either a severe stances, where sloughing is so liable to form of catarrhal, or of purulent ophthalmia, come on. To me it appears that bloodwhich he has described. The sloughing of letting, no less than mercury, must necessathe cornea Mr. Marson conceives to be rily tend to favour such a process. I would analagous to the same process which is so say for blood-letting, substitute quinine, and frequently observed to take place in the the use of wine and other tonics and stimucellular membrane in various parts of the lants. By the adoption of this treatment, I body. In the progress of variola, sloughing apprehend the patient will have a much of the celln lar membrane, of the scalp, palpe- better chance of recovering the function brae,aboutthebeardinmen,neck,elbow,and of vision unimpaired. A milder form of ophthalmia is also very dorsum of the foot, is still more frequently observed than in the cornea. Wherever it frequently observed to come on at the expioccurs, Mr. Marson justly ascribes the ration of one, two, or three weeks after the sloughing process to violent inflammation variolous pustules have disappeared. This is termed attacking structures of similar character.
deposition of lymph
a or
ulceration,
or even
sloughing
939
Secondary Variolous Ophthalmia. It usually exhibits the milder symptoms ,,
........
noticed in the slighter
ophthalmia, but
cases of catarrhal uncommon to find
it is not
I could easily add to the number, were it necessary ; but they have been quite sufficient to illustrate and establish the principle for which I have contended. According to the arrangementI laid down at the I shall, in the next place,’ proceed to speak of the various
ulceration of the cornea supervening, more particularly in individuals of a strumous constitution. The treatment is to be conChronic Diseases of the Conjunctiva. ducted on the principles I have before laid down. These are, no doubt, more or less, the result of increased vascular although Of the Ophthalmia that accompanies the other some of them do not exhibitaction, the phenomena Measles and Scarlatina, mz., Exanthemata, viz., Meastes and Scarlatina,by which the presence of inflammation is technically named Ophthalmia morbillesa and usually indicated. Scarlatinosa, I need not say much. You will PTERYGIUM. always find that it is decidedly the catarrhal variety that exists during the progress The first of the chronic affections of the of these affections. Such we might expect, conjunctiva to which I shallallude is Ptery-
commencement,
à
priori, to
be the case, from the
epidemic gium.
character of the exanthemata, and of this This is a chronic vascular growth, affectform of ophthalmia. Dr. Frick has alluded ing, as is commonly supposed, the conjuncto the connexion between catarrhal ophthal- tival membrane, or, as Mr. Middlemore mia and another epidemic disease, viz., thinks, the cellular substance lying between the influenza, both of which affections he it and the sclerotica. consideis to be identical, and he states that It is most commonly observed at the inner
during the prevalence
of an epidemic influ- angle of the eye, where it arises from about enza, those persons who were attacked with the caruncula lacrymalis (with which, how-
catarrhal ophthalmia were exempt from the influenza. I have before alluded to the fact, that the exanthemata are very apt to excite ophthalmia in strumous individuals. In such cases, the ophthalmia is usually more protracted, and less manageable. I need, however, here only refer you to what I said when addressing you on that subject in my last lecture. I have now brought to a conclusion my
ever, it has no connection), with a broad base, and gradually tapers off as it proceeds towards and upon the surface of the cornea. Its shape is, therefore, triangular, and as it also somewhat resembles in appearance the wing of an insect, it has been named pterygium. The diseased structure is not usually very dense. In the slighter cases it seems to consist of little more than a thin membrane, in which is imbedded a considerable account of the various active inflammatory number of vessels, when it is termed pterystates of the eye in which the conjunctiva gium tenue; at other times it is more dense, is primarily and principally affected. And, and has a fleshy appearance, and then it is notwithstanding that I have occupied a named pterygium crassum. considerable period of time in the discusAlthough, as I have said, a pterygium is sion of what some may be inclined to con- usually noticed at the inner angle of the eye, sider as the affections of an unimportant yet this is far from being universally the case, portion of the visual organ, yet you will for sometimes it is met with at the temporal find, on referring to what has been already angle, and occasionally at the superior accomplished, that I have had occasion to and inferior portions of the globe. When speak of several of the most interesting and observed in the two last-named situations, really the most important affections to which I think it is often caused by a fold of the the eye is subject. You will further find, conjunctiva having become adherent to the that those affections are such as will most cornea, near its circumference, when in a frequently come under your notice when state of ulceration. Such, at least, has engaged in actual practice. The in more than one instance that has that I have advised you to adopt in the come under my notice, where the pterygium management of this class of affections, is occurred after’an attack of purulent ophthalconsiderably different from that recom- mia. I have also noticed it after ulceration mended by our best writers. I would only of the cornea from injury with lime. la further remark of it, that it is not the result these cases the paipebrw are usually closed of mere idle speculation as to what I should for a considerable time, and thus the tenmyself conceive, from a process of reason- dency to adhesion between the opposing ing, ought to be adopted for conjunctival surfaces is favoured. This kind of pteryinflammation ; on the contrary, I have fur- gium is more movable than the other, and nished you with an actual and literal de- readily admits the introduction of a probe scription of the practice that I am daily in under it,-acircumstance which clearly the habit of resorting to for its subduction. proves that this form of pterygium, at least, Of the success attending that practice, I is not connected with the subconjunctival have supplied you with a few examples. textures. 2 3 P
treatmenthappened
940 This morbid growth sometimes terminates margin of the cornea, but, if allowed to remain, it soon passes upon it and to its centre. Occasionally it happens that there are two or three of these growths, one arising from each angle, and both uniting in the middle of the cornea; and some authors state that they have seen one proceeding from each of the four sides of the globe, at the
uniting in the centre. Generally, pterygium
is confined to one eye, but sometimes it is noticed in each. The order of frequency, as respects situation, is described by Mr. Middlemore as follows :" First, the forma1i.on of a pterygiam upon one eye, placecl at the inner canthus; secondly, the formation of a pterygium upon each eye, arising from the inner canthus; thirdly, the occurrence of two pterygia upon one eye, one arising at the inner, and the other at the outer canthus ; fourthly, the formation of one pterygium alone, either at the outer canthus, or at the upper and lower part of the eyeball, but not at the inner canthus." My own experience on this point does not coincide with that of Mr. Middlemore. I have most frequently seen pterygium arising from the inner canthus of only one eye; and, next in frequency, I have observed the pterygium arising from under the superior lip, also in one eye. The experience of other surgeons will, probably, still further differ. great deal of speculation and some ingenuity have been expended upon the subject of this morbid growth, more particazlarly as to the cause of
A
Its
inxariably assuminga Triangular Shape.
Scarpa is the only author who is supposed have offered anything like a correct explanation of the circumstance. " The constancy of this fact," says this eminent writer, "ought to be referred, in my opinion, to
cornea.
It does not
explain the triangular
figure of that portion of the diseased mass affecting the conjunctiva scleroticæ, and we know that it is not merely that portion upon the cornea which exhibits this peculiarity of shape, but that it is quite as strongly marked upon the sclerotic portion. Nor does Scarpa’s statement offer any solution of the question, why a pterygium never passes the centre of the cornea, since it can scarcely be supposed that the mecha. nical resistance, at that point, is absolutely so great that it may not be overcome. In truth, Scarpa’s attempt at explanation amounts simply to this-that the resistance to the progress of a pterygium upon the cornea, is owing to the increasing adhesion between the conjunctival covering and the cornea itself, and that, on its arriving at the centre, the mechanical resistance is so excessive that it cannot be overcome, and that thus the further progress of a pterygium is stopped. I quite agree with Mr. Guthrie in thinking that Scarpa’s hypothesis,"al. though it may appear sufficiently plausible, is so unsatisfactory, that the problem is still open for the exercise of further ingenuity." It is an admitted fact, that the adhesion of that portion of the conjunctiva which covers the cornea, to the subjacent tis. sues, is exceedingly firm ; whilst that of the sclerotic portion, it is well known, is quite the opposite. This firm adhesion, I readily grant, will sufficiently explain the slow pro. gress of any vascular growth under the conjunctival surface of the cornea; but that it has anything to do with determiningthe figure of that growth, or of stopping its progress at a certain point, I can by no means admit. On the contrary, if this adhesion increases, as it is considered to do, towards the centre of the cornea, and the pterygium has this increased mechanical resistance to contend against, supposing its progress to be uninfluenced by other causes, it might be expected to proceed around the margin of the cornea, where the resistance is so much less, rather than towards its centre, as it always does. But the entire subject, in my opinion, requires and admits of an explanation of a more
to the adhesion of the lamina of the conin proportion as it advances from the circumference towards the centre of the cornea. For in consequence of such structure and different degree of cohesion, which actually exists in the sound eye, it must necessarily follow, in the first place, that the progress of the comprehensive character, which shall equaJ1y pterygium ought to be in every case of such apply to the condition of both conjunctiva disease much slower upon the coruea than and cornea. A proper explanation of this peculiarity upon the white of the eye ; secondly, that from the greater resistance which it always attending the growth of a pterygium, cannot, meets with, in proportion as it exteuds to- I conceive, be arrived at without reference wards the centre of the cornea, it must, being made to the vascular supply of the from mechanical necessity, assume a than- conjunctiva. The conjunctival vessels, then, are, to a gular form, the base of which corresponds to the white of the eye, the apex to the certain extent, to be considered as indecentre of the cornea." pendetot of each other. They pass into the Now, if the explanation given by Scarpa substance of the membrane at four distinct were, as far as it goes, correct, it is still points, one at each angle, and at the superior open to the objection that it explains only and inferior portions of the globe. This is one.half of the case, viz., only that half the case both with the palpebral and muswhich hols reference to the conjunctiva of the cular arteries. By this arrangement, it
juiietiva becoming stronger,
941 will be perceived that the vascular supply sides of the globe, must necessarily of the
conjunctiva covering the globe
is
a
assume
triangular figure. This figure results, as have said, from the limitation of the mor-
derived from four distinct sources, and that I each set of vessels is destined to the nutri- bid action to the vessels which are distrition of one-fourth of the conjunctival mem- buted to one of the four sections of the conbrane. junctival covering of the globe, as will be Now, in acute conjunctivitis, as I for- evident from the annexed diagram. Here the large circle may be supposed to merly stated, the conjunctival vessels are usually all involved in the increased action, represent the periphery of the conjunctival and, therefore, the whole surface of the surface of the globe, and the smaller one membrane is more or less loaded with ves- the margin of the cornea. If morbid action sels. But it frequently happens that these be confined to the vessels of one of the four vessels are only partially affected ; for ex- divisions, it will be seen the morbid strucample, those of the inner or of the outer ture must necessarily assume a triangular angle alone become affected in this way,-a figure. condition to which the term ophthalmia an- The origin of the thin membranous pterygularis has been applied. The same is gium is somewhat obscure. Frequently it often noticed, too, in pustular ophthalmia; arises without any obvious cause. Usually a single pustule is observed at the inner or there is considerable vascularity attends its outer margin of the cornea, and a fasciculus growth, although it cannot be said, in any of vessels is seen running from a correspond- case, to amount to inflammation. As it ing angle of the eye to the pustule. In these most commonly affects the inner angle,—a instances, the morbid action is confined to portion of the conjunctiva which is, perone or another of the series of vessels to haps, more vascular and more irritable than which I have alluded, and the figure they the rest,-it is not unlikely that it may often present always more or less resembles that be excited by irritation from external of a triangle. causes, such as foreign substances, which In cases of corneitis, too, we find the are always propelled towards this point by vessels creeping slowly from the margin the winking motions of the lids. Bell has towards the centre of the cornea, and never remarked that stone-masons, who often get proceeding around its circumference. In fragments of calcareous matter into the eye, these cases, when the vascularity of the are most liable to pterygium. The other cornea has only been partial, I have often variety of pterygium (p. crassum), I have noticed that the vessels have assumeda already remarked, is’ frequently the result shape similar to that which they exhibit it of adhesion between a fold of the conjuncpterymium. tiva and an ulcerated portion of the cornea. In like manner, in the case of pterygium, I have likewise observed the fleshy pterywhich is a morbid growth, unattended by gium to result from the application of lime active inflammation, but always evincing a to the conjunctiva, where ulceration had considerable degree of vascularity, there ie not occurred. The Treatment of Pterygium a’partial affection of the conjunctival vessels. These vessels, at whichever of the fou) must be regulated according to the greater sides the disease happens to be developed or less development of the morbid growth. proceed from that portion of the peripher3 In the incipient stage, when it is s!ill inof the conjunctival surface of the gtobe, auc considerable in size, and does’ not extend pass on towards and upon the cornea to it! upon the cornea, it is probable that the use centre, beyond which it never extends- of some stimulant or escharotic substance, thus occupying and being limited to one more particularly the nitrate of silver-pencil, fourth of the conjunctival surface, and may be sufficient to arrest its progress. Dr. Mackenzie states that he has known the therefore, possessing a triangular shape. disease to be removed by the use of a solution of nitrate of silver, or of vinum opii. When these do not succeed, he advises scarification of the diseased mass, or snipping a portion of it away. Mr. Lawrence has a great aversion to the use of stimulating and escharotic substances; and he even supposes that, by their use, a case of ordinary pterygium may be converted into something of a cancerous or malignant character, although he admits that he has never witnessed a case of malignant pterygium. I do not conceive that there is the slightest Thus, I think, it will be obvious that anydanger of such an event taking place from morbid action, particularly one of so chro--a well-regulated use of proper substances nic a character as pterygium, which is con-of this kind. Such applications, however, fined to the vessels of any one of the fourr are more particularly adapted to the thin
942 membranous pterygium, where the cornea is unaffected. CLINICAL LECTURES The fleshy pterygium will certainly not ADDRESSED TO THE yield to the use of stimulants and escharotics, and therefore it is best at once to pro- STUDENTS OF THE MIDWIFERY CLASS ceed to remove it by excision. The patient AT THE ROYAL SCHOOL OF MEDICINE, being properly placed in a chair, and the an who palpebrae separated by assistant, BIRMINGHAM, stands behind the patient and supports his BY head, the surgeon lays hold of the diseased J. T. INGLEBY, M.D., structure with a slender forceps ; by this process it is raised from the surface of the Fellow of the Royal College of Physicians, Edin. globe, and with a pair of curved scissors is LECTURE V. easily removed, by first detaching its corneal, and afterwards its sclerotic portion. CASE OF PLACENTAR PRESENTAIt is not advisable that the excision TION, TERMINATING FATALLY. should be effected quite at the base of the pterygium, because it occasionally happens GENTLEMEN :-The specimen now exhibitthat a firm cicatrix or band results, which ed to you is the uterus at the full term of materially interferes with the motion of the pregnancy, having, as you plainly see, the eyeball. This has been noticed, at least, at placentar attached to the body, neck, and the inner angle of the eye, and has been mouth of the organ. You already know, found to a certain extent to prevent abduc- that in all such cases artificial delivery is tion. To prevent this, Scarpa advises that essential, in order to preserve the life of a very small portion only of the sclerotic either parent or child. The natural powers portion of the diseased growth should be have certainly, in very rare instances, been excised, viz., about a line in breadth from equal to the delivery of the placentar first, the margin of the cornea. Mr. Guthrie is and then the child; and such may occur once, in the habit of removing about one-half of perhaps, in fifty or sixty cases. This is, that portion of the pterygium which lies however, never to be expected, and, forupon the sclerotica,-a proceeding which tunately, the resources of art, when timely he states has always been successful in interposed, are equal to the emergency. I am acquainted with three or four such occuring the disease. In the course of a few days after the currences, but I have only seen two, one of performance of the operation, the conjunc- which I will presently tell you something tival covering becomes renewed, and the about. The case which is connected with disease in some instances will have dis- the specimen before you may be related in appeared. It is exceedingly apt, however, a few words. The patient had several attacks of hæmorto return, and sometimes needs a frequent of the during the last few weeks of her rhage repetition operation. Some authors speak of this operation as pregnancy; but, I believe, with the excep. if it were always attended with success. tion of the last attack, the haemorrhage was It will be best, however, for the surgeon not particularly severe, and yet there must not to be too sanguine on this point, for his have been a material draining going on, for efforts will occasionally be frustrated ; and oedematous swellings had appeared; the if he succeed in removing the morbid last attack of flooding terminated her exist. growth, and preventing its re-formation, still ence. Her medical attendant, finding the the change it has induced in the texture of exhaustion death-like, feared to deliver at the cornea will be usually of such a nature the instant, and sent to request my attendthat a permanent opacity remains. " The ance. I was at home, and lost no time, young surgeon, therefore," as Scarpa re- but ere I reached the patient life had marks, " should not suffer himself to be ceased. Prompted by feelings of curiosity imposed upon by the specious relations of I passed my finger to the uterine orifice, and those who assert that they have removed it was so little open as barely to permit two pterygia by the knife, and completely re- fingers to enter. The attachment of the stored the cornea to its original natural placentar, around the orifice of the womb, is transparency. The cornea certainly appears too obvious to require describing. Such, less opaque at that part than before ; but it in brief terms, is the history of this melanalways remains dark, and clouded by an choly case ; and what inferences can we indelible, though superficial cicatrix." The deduce from its consideration? We learn opinion of Mr. Middlemore is in accord- this important fact, that a haemorrhage may ance with that of Scarpa, and he judiciously go on to the destruction of life, whilst the os remarks, that " if this view be correct,, uteri is almost closed. The coincidence may then an early operation becomes necessary,be an unfrequent one, but the states are perwith the intention of preventing thosefectly compatible with each other. An imchanges in the textures of the cornea whichportant question now arises, viz., did the uterine orifice possess dilatability ? for ill are apt to arise if the disease remain."