Lectures ON SOME PRINCIPAL DISEASES OF THE EYE.

MAY 21, 1853. of the cornea, the iris being bare, the pupil open, the capsule and lens transparent, and preventing, by their pressure against the ON iris, the escape of the vitreous humour. This state of course only lasts for a few days, till the capsule bursts, or becomes covered, OF together with the iris, by an indelibly opaque cicatrix. The principal points of similarity and of distinction between THE EYE. this disease and catarrhal ophthalmia are these : In the first Delivered at Guy’s Hospital. stage purulent ophthalmia resembles catarrhal in the sensation as if extraneous particles were lodged between the conjunctival sur. BY JOHN F. FRANCE, ESQ., faces ; in the incipient inflammation displayed upon the palpebral SURGEON TO THE EYE INFIRMARY. portions of conjunctiva ; in the glutinous, opaque, mucous, secretion, which clogs the cilia and canthi, and in the feeling of stiffness in the motions of the lids. It stands distinguished by the pain which accompanies it, (and this is a very important LECTURE IV. feature,) by the violence of the inflammatory action, the rapid (Concluded from page 403.) advances it makes, the early commencement of chemosis and PURULENT ophthalmia in the adult is variable in severity and tumefaction, and the quick transition of morbid secretion from termination, yet presents the same type, whether produced by opaque mucus to fully formed pus. the direct contact of gonorrbceal matter, or reproduced in a second There is another disease which I have known mistaken for individual by the ocular discharge of one affected in that manner, purulent ophthalmia-viz., acute inflammation of the cellular or arising altogether independently of any venereal poison. Within tissue of the orbit. The latter complaint is much less common than my own experience the disease has generally arisen in the two purulent ophthalmia. I have seen perhaps four or five instances, former ways. But the causes which have operated more exten- and in fact, at the moment of writing these lines, have one sively in its production in military practice have been-exposure under my care which will serve to illustrate the distinction. The to atmospheric vicissitudes (especially to those great alternations man presented himself with opaque muco-purulent secretion between the diurnal and nocturnal temperature which occur in hot1 loading the cilia, and chemosis of considerable amount accomclmates); exposure to an atmosphere loaded with moisture, or panying conjunctival inflammation. The cornea and other with sandy particles ; confinement in a vitiated atmosphere, as textures of the globe were unaffected ; there was severe pain. that of an overcrowded batrrack or hospital, particularly one So far the case resembled closely an early one of purulent ophthronged with the subjects of this very disease. Most of these thalmia. The points of difference indicating the true nature of circumstances, you will observe, involve the condition of a local the case were these:-Tbe history afforded no ground for supirritant being actually applied to the conjunctiva. posing that the mischief had arisen from contagion or unusual When arising from these latter causes, it would appear (de- exposure; but the man attributed all to the effects of a blow reo structive as the complaint has been) that it is essentially only a ceived a few days before. The tumefaction of the lids and the severe form of catarrhal ophthalmia; but when produced, as we morbid secretion were not proportionate to the degree of chemosis ; most commonly find it in civil practice, from the specific con- but, on the other hand, the effusion in the deeper cellular tissue tagion of gonorrhoea, it differs widely from that disease. It com- around the globe was far more than proportionate to the tumemences, however, with sensations bearing much resemblance to faction, the chemosis, or the conjunctivitis. The immobility of the those which usher in catarrhal ophthalmia,-a feeling of irritation eye, and perhaps slIght protrusion of the organ proved this. By and itching about the eye, and a fallacious perception of sand or carefully investigating such a case, prescribing in accordance grit between the conjunctival surfaces. The secretions from the with the view suggested by the circumstances so elicited, and affected organ are augmented, tears flow in unusual abundance, watching for any further development of the symptoms assimiand the cilia and inner canthus become clogged with opaque, lating it to purulent ophthalmia, its real character is soon put adhesive mucus. The palpebral conjunctiva at the same time beyond doubt. This inflammation of the orbital cellular tissue displays the signs of inflammation. But the patient is seldom is apt to terminate in deeply-seated abscess. I have known it seen, in ordinary practice, at this early and brief stage of the connected with phlebitis, extending to the cerebral sinuses, and disease. Very soon severe pain is experienced in the eye, which terminating fatally. The treatment to be adopted for purulent ophthalmia in the may extend to the temple and forehead. The first sensation of stiffness about the organ gives place to one of fullness and ten- adult is as follows:-Should there exist evidence of exalted action sion ; the morbid secretion assumes a distinctly purulent charac. of the heart and arteries, if the pulse at all approach a full, incomter, and the ocular conjunctiva participates with the palpebral in pressible, bounding character, the tongue be coated with white fur, violent inflammation. This proceeds with remarkable rapidity, the skin hot, &c., blood may be abstracted from the arm to a suffia few hours, in some cases, sufficing for the completion of that cient extent to diminish the volume and firmness of the pulse, at least down to the level of the natural standard-perhaps a trifle melancholy career, which ends in extinction of sight. Purulent ophthalmia involves in a high degree the cellular below. Should such symptoms not be evinced, for constitutional tissue subjacent to the conjunctiva ; hence, as soon as that disturbance is exceptional and not habitually present, and the portion of the membrane, which covers the sclerotic becomes patient be a person of robust or of plethoric habit, blood may affected, the tissue referred to takes on morbid action, and (as I still perhaps be judiciously drawn to such extent as to reduce the described when speaking of the infantile disease) chemosis or pulse slightly below par. But in saying this I make the greatest admission which I can. sub-conjunctival cedema is the result. The mucous membrane in consequence becomes raised around the.comea in a cushion-like Most strongly and seriously do I deprecate those repeated exform, bagging oftentimes over its edge, and always rising consi- haustive bleedings which were formerly deemed at once justifiable derably above its level, so as to make the cornea relatively and necessary in the treatment of this disease. Certain it is that deeper than the conjunctiva which surrounds it. In severe cases such large abstraction of blood is far from protecting the patient the effused substance does not consist of serum only, but fibrine against destruction of the cornea-the real point to be dreaded; likewise exudes, causing the chemosed surface to feel firm and and no less unquestionably it entails upon him both greater resisting, instead of soft and yielding, as when serum only has liability to a chronic and protracted form of this very malady, been poured out. The palpebrse become reddened, swollen, tense, and likewise a strong predisposition to the manifold diseases, ophand shining, and present no tnfling obstacle to examination of the thalmic and general, of anaemia. Bacot, on Syphilis, says—’’ If globe. Meanwhile, the pain which had arisen shortly after the ever there was a disease in which blood may be taken away withonset of the disease continues, and the truly purulent secre- out limitation it is this." And I think the same author uses the tion escapes copiously from beneath the distended upper lid, expression-" The lancet should never be out of the surgeon’s which commonly overlaps the lower to a considerable extent. hands." So Desmarres (writing in 1847) recommended for puruThe changes thus set on foot quickly produce further lent ophthalmia venesection night atid morning, while the pulse mischief; for now the cornea suffers ; sometimes its superficies permits, besides leeching. But from these rules I totally dissent. becomes dull and hazy, sometimes ulcerated, sometimes opaque Deplete from the arm should the acuteness of the case combined and discoloured, and its more or less complete disorganization is, with plethora demand, or vigour warrant the measure-not in the last case, insured. It is a singular feature in the com- otherwise; and rather make one free bleeding which may suffice, plaint, that from the time when destruction of the cornea than by reiterated venesection pursue a practice pregnant with takes place, the violence of the inflammation subsides, the tension ulterior mischief. of the lids and entire conjunctiva is relaxed, the purulent The bowels should be cleared at first, and suosequently be discharge diminishes, and in short the convalescence of the maintained in a loose state, and the diet should be low. Partly patient may be reckoned from that hour. I have even known to make sure of the enjoined rule in this respect being observed, and partly for the sake of its peculiar depressing effect, consome degree of vision teporarily restored after the separation

Lectures

SOME PRINCIPAL DISEASES

No.1551.

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466 nausea should be maintained by ipecacuanha or tartarized the majority of instances in which the cornea suffers, ulceration antimony; three or four grains of the former, or a quarter of a rather than sloughing is the agent in its destruction. It had long been customary to scarify the chemosed conjunctiva, grain of potassio-tartrate of antimony being given every six or four hours, according to the influence exerted. One or two mainly with the view of adding another to the various methods grains of calomel must be combined with each dose of the nauseant; of depletion it was the usual practice to resort to. On a prinit contributes powerfully to check the progress, and promote the ciple difficult to understand, the chemosed conjunctiva over. reduction of the chemosis, and should be continued so as gently lapping the cornea was also occasionally snipped away with to touch the gums. These, then, are the constitutional remedies scissors, a proceeding which, if the theory explained above be in to be relied upon: moderate bleeding, if demanded; low diet; any degree true, must have rendered the adequate supply of the cornea with blood still more precarious. nauseants, and mercurials. The new plan of procedure suggested by Mr. Tyrrel consists The local treatment is equally important. Cupping to the temple must be employed, and should be repeated, if necessary, in scarification of the conjunctiva in radii diverging from around within moderate limits; for arterial blood constituting the prin- the cornea. The object is to relieve the tension of the con. cipal supply of the cupping-glass, an extravagant expenditure by junctiva, and the pressure exerted by it upon subjacent structures; this method is likely to be of still greater eventual injury than to allow the effusion confined in the meshes of the reticular tissue the abstraction of a similar quantity from the arm. You may to escape; and to permit what remains to expand without injury may perhaps be surprised at my laying so much stress upon the to the vascular net-work around. I have myself frequently tried this operation, and am convinced point of not carrying depletion to too great an extent. The quotations just made, however, from authors of consideration may of its propriety in cases of purulent ophthalmia, with chemosis, show how theoretically the opposite plan has been enjoined; and threatening the integrity of the cornea. The idea upon which it I have myself witnessed years ago that plan pursued so far in is founded possesses great claims to attention; for besides the practice, and with such results,as to make me exceedingly solicitous high authority of its promulgators, many circumstances in the to guard against its future prevalence. From eight to twelve history of the disease lend it support; but whether the theory be ounces of blood, therefore, I should state as the full limit of a admitted to the full or no, certainly this method of scarification single cupping; and this quantity should not be withdrawn more holds out advantages rendering it well deserving of general adop. than twice, or at most three times, and only upon urgent occa- tion. The mode of performing division of the chemosed consion, and in vigorous subjects, so often. Leeches may be liberally junctiva is as follows :-An assistant elevates the upper lid with resorted to; but no very marked benefit is to be anticipated from a wire speculum, and supports it against the superciliary ridge, their use in this violent disease. at the same time depressing the lower lid upon the orbital edge of Puncturing the swollen palpebrse, where tension of the surface the superior maxillary bone. Thus, the cornea, surrounded and is great, will sometimes be found beneficial, as it often is in ery- overlaid by the swollen and distended mucous membrane is exsipelas ; and, again, relief is given under the same circumstances, posed as fully as practicable. The extremity of a small sharpby dividing the external canthus, and so taking pressure off the pointed bistoury or of a cataract-knife is now inserted beneath Great care should be observed in procuring by means the overlapping fold of conjunctiva, which, together with the cornea. of fomentation, and by injections between the palpebrse, if neces- submucous cellular tissue, is freely divided in a direction radiating sary, a free outlet for the purulent secretion, which, however, is from the cornea. One or two such radiating incisions are to be generally too abundant to sustain confinement for more than a made over the interval between the several recti muscles-that is few minutes.Still careful and assiduous syringing, or sluicing, to say, one or two outwards and upwards between the levator with warm water or poppy water, is of essential service by alto- oculi and adductor, one or two upwards and inwards between the gether preventing accumulation of the discharge, which, from its levator and abductor, and the same below on either side of the

stant

we may well believe to possess The fomenting liquid should be between the lids by six grains of alum to the ounce of fluid. A mild ointment may be advantageonsly applied between the palpebroe to prevent cohesion, especially at night. Added to these remedies, and one of the most important of all, is the strong nitrate of silver solution made in the proportion of from six to eight grains to the ounce of water. It should be instilled between the lids four or five times in the day. For an important accessory in the treatment, directed especially to the immediate object of saving the cornea, we are indebted to the late Mr. Tyrrel. Mr. Travers, in his Synopsis of the Diseases of the Eye, had pointed out incidentally, many years ago, what he considered the true pathological cause of the destruction of that membrane. Adopting the theory thus thrown out by his predecessor, Mr. Tyrrel argued that if’ sloughing of the glans penis in paraphymosis results from obstruction to the circulation of the part, and is obviated by relieving the constriction-if sloughing of the cellular membrane in phlegmonous erysipelas of an extremity results in great measure from the unyielding tension of the affected integuments, and is averted by timely longitudinal incisions-then, to attain a similar end, analogous means must be put in operation in purulent ophthalmia, if a corresponding condition is found to arise in its progress. That the state of inflammatory chemosis constituted such condition was the belief of the accomplished surgeons just mentioned, who came to the conclusion that the destruction of the cornea in this disease is the result of mechanical impediment to its sanguineous supply, and is not due merely to inflammatory action in its immediate vicinity. They believed that in consequence of the extreme distention of the sub-conjunctival tissue the bloodvessels passing through and beneath the conjunctiva towards the cornea are in part so forcibly compressed against the scleroticin part so acutely bent upon themselves at the anterior margin of that structure, where the chemosis abruptly terminates-that the flow of blood through them cannot continue with the requisite freedom. The cornea therefore perishes, they concluded, like a gl1ns penis constricted by unrelieved paraphymosis -like a hsemorrhoid ligature by the surgeon-or an extremity, the main artery of which has been torn through. This very ingenious rationale of the circumstances attending

morbid agency upon

inferior rectus. The conjunctiva thus divided no longer confines the effusion in the cellular structure beneath, and the vessels proceeding to supply the cornea are relieved from compression. The reason of selecting the intervals between the recti is, that vessels of considerable moment to the conjunctiva and cornea pierce the tendons of those muscles, and would be endangered by incisions made in any other situation. It often happens that the tumefaction of the palpebrse is so great as seriously to obstruct exposure of the globe, and impede the performance of the operation just described. It is then necessary to begin by dividing the external commissure of the eyelids. This step has the double advantage of facilitating proper scarification, and at the same time of preventing that counter-pressure which the superior palpebra must ever exert upon the globe when (as in the disease now under consideration) parts enclosed by the eyelids are materially augmented in bulk. There is good ground, too, for believing that the pressure of the tumefied upper lid upon the cornea has no inconsiderable share in producing the destruction of that tunic; for it is obvious that this pressure must greatly contribute towards the strangulation of the vessels, while it is often the central and consequently most prominent portion of the cornea which suffers most. I unhesitatingly, therefore, advocate the use of these combined measures, feeling assured that, in adopting them in conjunction with the other remedies already specified, you will succeed in saving the cornea (upon which recollect the preservation of sight entirely depends) in a far larger proportion of instances, and with less call upon the constitutional power, than by resorting to the fearfully debilitating treatment formerly in vogue. After the acute stage of the disease has subsided, the purulent discharge has ceased, and both inflammation and chemosis are diminishing, you may employ a weaker solution of nitrate of silver, or substitute a solution of alum, of sulphate of copper, or of zinc, for the strong collyrium at first necessary. I have known very marked good effect result from a collyrium composed of eight minims of the solution of diacetate of lead, two drachms of Battley’s solution, and six drachms of rose water, even before the complaint could be considered to have fallen into the absolutely chronic state. As the violence of the disease more and more declines, especially if the subject be weakly, he will derive benefit from tonic medicine and tonic diet. The strong solution purutent ophthalmia has led to a great improvement in treating nitrate of silver may again be used, and even the caustic be the disease ; yet I cannot acquiesce in the universal or momentarily applied in substance, if an indolent ulcer be creep. general truth of the above theoretic views on this subject, as in ing on slowly, to open the anterior chamber ; or, having done so, a

sound eye,

peculiarly irritating qualities. made astringent for injecting

evenof

467 in the India-rubber shops. I have reason to expect more from if repeated superficial sloughings of the cornea take place. At them than the administration of any drug. a yet later period, when cicatrization is slowly proceeding, merUnfortunately for the crew and passengers, the medical curial collyria, as the yellow or black wash, may be employed inspector allowed several cases of purulent ophthalmia to With great occasional benefit. proceed in the vessel, which disease, by the time sea-sickness Thus, then, to make a brief ré8nmé of the remedies upon was over, began to spread among the healthy. The congestion which we depend for the cure of purulent ophthalmia in adults. and inflammation of the conjunctiva ran very high in some. They are, in the early stage, before chemosis has become com- There being no leeches or cupping instruments, I was obliged to plete around the circumference of the cornea : Venesection to a have recourse to scarification both of the mucous membrane, as moderate amount in the rare cases wherein constitutional excite- well as the integument adjoining the external angle of the eye. ment demands it, or constitutional power may well sustain it; I sometimes opened the angular artery and got sufficient blood in evacuation of the intestinal canal by purgatives in the first in- this way. stance ; action upon the skin by diaphoretics, upon the hepatic Though this kind of practice was not very conducive to and other secretions by mercury, given briskly to affect the personal beauty, still it succeeded very well. What else could mouth; low, or at least restricted diet, according to the patient’s be done? The necessity for this rude kind of practice is owing vigour of habit; antimony or ipecacuanha in repeated nauseant to the authorities who make laws not insisting on their being doses, with the view of insuring obedience to the regimen obeyed. The local application I used with much benefit was a enjoined, of lessening excited action, and of determining to the strong solution of both nitrate of silver and sulphate of copper skin : Locally ·,-cupping to a moderate amount; leeching, or together. I must here remark that neither of these salts were puncture of the lids; assiduous fomentation with anodyne and sent in the medicine chest. Were it not that I fortunately had astringent fluid ; the use of the strong caustic solution every both in my pocket case, I fear many an eye would have been three or four hours, or as often as pain recurs, until the morbid lost (of course the surgeon would get the credit of it all.) The secretion is controlled ; anointment of the edges of the cilia with medicine chest afforded me some alum and sulphate of zinc for The extreme difficulty of getting hot some mild salve, to assist in preventing agglutination; and the lotions, and nothing else. maintenance of an elevated position for the head. water, and the great scarcity of washing utensils, prevented the For a case in the more advanced stage (wherein chemosis is amount of ablution so necessary in this filthy disease. Blistercomplete), to the course of remedies enumerated above must be ing the temples did good in some cases. As to the exhibition of added,-free scarification of the chemosed membrane in radii internal medicines, such as tonics, no drinking vessels being from the cornea, at the intervals of the recti muscles,-and divi- supplied by the ship-owner, (as far as I know,) and a solitary sion of the external canthus, to facilitate this operation, and to tin cup being possessed by each passenger. I would ask, how is obviate the pressure of the swollen palpebra upon the transparent a medical man in charge of such an establishment to manage? cornea. It was with difficulty that even a whisky bottle could be proLastly, when the duller aspect and diminished tumidity of the cured, when wanting to hold some fluid medicine in the way I palpebree, and the faded vascularity and relaxation of the chemosed was sometimes enabled to make up fluids. Powders md pills conjunctiva, and the less copious purulent discharge, all give are more manageable, though difficult to be made up with evidence that the disease is subsiding, tonic medicines and diet present accommodation. But still, from the scarcity of spoons may be given, and stimulant applications be gradually had re- and all the other various means in daily use on shore, when course to. Should the cornea have suffered, the various states administering medicine, great uncertainty must exist as to of ulceration, cicatrization, or nebula, must be treated according whether the dose is taken at all ; in fact I must state that I conto the rules to be more fully explained in a future lecture. side-r the sending a medical man on board such a craft, as almost As the contagiousness of this disease is certain, the utmost care a perfect humbug, as there is not a single law regarding the must be taken to prevent contact of the morbid secretion, either treatment of emigrants that is not evaded one way or another. with the patient’s sound eye, or with the eyes of any other person. The beneficial effect of sea air and change of life was exemStrict injunctions should therefore be given respecting the towels, plified in many cases of ophthalmia, a large number of the used by the subject of the malady; passengers being sent from a crowded workhouse, where that sponges, basins, linen, &c., and if the case occur in a barrack, or situation wherein numerous scourge had left many marks of its virulence. individuals are lodged in common, the affected one should by all Many persons, both male and female, were disfigured to a means be isolated, as completely as circumstances will permit. greater or less degree by staphyloma and leucoma. Few of The frightful ravages which purulent ophthalmia has heretofore those who had been attacked while in the workhouse escaped made in ill-ventilated and over-crowded habitations make this without having one or both eyes obscured by opacities. In most cases of long standing I found the mucous membrane point one of immense importance; and as the malady may break out in a workhouse, a public school, or on ship-board, as well as of the lids granular, and a gleety discharge proceeding from in the quarters of soldiery, the subject is one of extreme interest, them. How all this could have occurred to such an extent, in not only to the military surgeon, but also to the civilian. almost every case, is astonishing to any one who has observed the progress of ophthalmic disease in our metropolitan hospitals, where such deformities as a sequel to this disease are very rare. Notwithstanding the great attention which has been paid to the NORTH AMERICAN EMIGRATION, EMIGRANTS, condition of our poor in the workhouses, of late years, more particularly with regard to the amount of ophthalmia which has AND THEIR DISEASES. prevailed in the Irish Unions, the number of persons one both BY THOMAS WESTROPP, ESQ., M.R.C.S. sees and hears of, who have been either partially or totally deprived of vision, is very great, so as to lead us to conclude (Concluded from page 405.) that these cases must have been imperfectly cured. The many reports that have been made, and the number of printed circulars THE first evening after joining the ship, while we lay at that have been issued, containing ample directions as to the mode anchor in the river, I was called to see a girl, about sixteen yearsof treatment recommended by our best oculists, ought surely to of age. She was in bed, and appeared excited. I was told that leave no ground for the exense, that the disease is imperfectly she had violent spasms of the muscles about the neck, upper understood. I apprehend that the hospital department of our and lower extremities; she had turned her stomach during the workhouses, and the salaries of the attending surgeons, are day. This could not have been owing to sea-sickness, as the regulated by such economical principles, that the proper amount water was perfectly smooth. She appeared a likely subject for an of attention is not paid ; the consequence is, that many of our hysterical affection, I therefore gave her a draught, containing countrymen, whose means of subsistence depend on their daily aromatic spirit of ammonia and laudanum. This answered ex- toil, remain a burden to themselves and their country in these tremely well, she was much better the succeeding moaning, and, institutions. In one case of staphyloma, where from the fact of the patient after a repetition of the draught, ceased to complain. This: spasmodic affection was probably owing to the excitement ofbeing young and healthy, and the opacity of the cornea which attended it being of recent date, and at the same time a certain being associated with so many strangers in a ship. On getting outside the river, sea-sickness commenced sooner amount of vision remaining, such as being able to distinguish or later ; every one was laid low; Fome suffering more thant large objects indistinctly, I inferred that no disorganization of others. Few of the medicines usually recommended being ont the deep-seated structures of the eye had occurred. I therefore board, I did not think it worth while to attempt preventing or bad recourse to the mode of treatment recommended by Ritchter - wiz. the formation of an issue on the surface of the cornea even alleviating the sea-sickness of near 400 people. I think I have, personally, found the application of a tightk with some caustic. I was not very sanguine as to its success;- it belt around the abdomen useful in preventing sea-sickness on atcaused a good deal of pain at first. After repeating the applicaformer occasion. I hear that belts for the purpose are now soldl tion of the caustic several-times, at the end of a fortnight or so

the iris have prolapsed, and still the ulcer be indisposed to heal, or

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