LECTURES ON THE ANATOMY, PHYSIOLOGY, AND DISEASES OF THE EYE.

LECTURES ON THE

AND DISEASES OF THE EYE.

ANATOMY, PHYSIOLOGY,

BY MR. LAWRENCE.

London Ophthalmic

Infirmary, Moorfields.

LECTURE

VIII.

On the Treatment of Chronic Oplethalnaia.Of Orbital Inflammation.—Of Wounds

of the Eye. Gentlemen,

I STATED in the last Lecture, that I regarded chronic ophthalmia as differing

from acute inflammation of the eye, not in kind, but in degree, and as requiring a treatment founded upon the same principles, but less active. When you have arrested an attack of acute ophthalmia by active antiphlogistic treatment, you will do well to rest a little, and not proceed immediately to any other measures. Allow the natural restorative powers of the part and the system an opportunity for exertion ; it would be quite wrong to lay down the principle that we should be always doing something—that we should be keeping up an incessant fire of therapeutical artillery. Nature will not stand still, even if the medical attendant allow himself a little leisure; on the contrary, she will employ the respite from treatment in restoring the healthy functions of tlie part. If, in consequence of the long continuance of disease, or of the active treatment which it may have been necessary to resort to, the general powers of the system should be much reduced, it will undoubtedly be necessary to adopt measures for invigorating the patient.Strength is best promoted by nutritious diet, the moderate use of termented ligood air, and exercise ; these may be combined with the partial repose or Moderate use of the organ, which should be freely exposed to the air, and as much

quors,

No. 123

light as its remaining irritabiwill allow. If the debility should continue and seem to require, more particnlarly if the patient should think that it calls for, the aid of the materia mediC’(l, you must resort, I suppose, to the professional methods of giving strength, namely, the use of mineral acids and the vegetable tonics. The most troublesome cases of what is called chronic ophthalmia, are those iB which acute inflammation has been either totally neglected or very inefficiently treated. Cases of this kind are frequent among the lower orders, where the vessels seem to have become permanently enlarged, and changes of structure have occnrred on the surface of the organ from the long time which has been suffered to elapse without resorting to effectual means. This condition of chronic excitement, produced by the inflammation having been allowed to go on unchecked, kept np and aggravated by the patient probably pnrsuing his ordinary occupation and mode of living, is very difficult to remove, either by local or general treatment. Steady attention to diet, the regular use of aperients, repeated applications of leeches, combined with seton or issue on the temple, are the most essential points of treatment in such cases; I have met with cases which have long resisted this combination of means, and with some in which it has even ultimately so

to the

lity

failed.

The points which remain to be considered in the treatment of chronic ophthalmia are, the question as to the use of local stimulants and astringents, the time

and circumstances under which, if useful, to be employed, and the particular remedies of this kind which are preferable. When the eye is preternaturally red, when it is weak and irritable, when exertion of it, or exposure to light, causes watering and pain, though it may be easy while at rest, stimulants and are resorted to with the view of causing the distended vessels to contract, and thus removing what remains of inflammatory excitement. Of stimul-

they are

astringents

[Jan. 7, 1826.]

498

opii, or vinous tincture antiphlogistic. Without any pnrticular of opium, has been much employed, both specification of case, he directs the vinum in this country and on the Continent, in opii to be dropped into the eye two or consequence of the recommendation of it three times a day, in conjunction with by the late Mr. Ware; I do not know other remedies. For my own part, I whether it was first introduced into prac- should never think of using it in acute tice by himself or his partner, Mr.Wathen. ophthalmia; in such cases it would rather The mode of employing it is to introduce increase the inflammatory disturbance, half a drop, a drop, or two drops, be.- though I must observe, at the same time, tween the patpebrae, so as to bring it into that it is not a very active remedy, and contact with the inflamed conjunctiva. that it cannot do very serious mischief. You may take it with a quill, or a direc- Its employment should be restricted to tor, and while the patient rests his head cases of chronic inflammation, in which back drop it into the internal angle of we have only to regret that its efficacy the eye, so that when he separates the should fall so far short of the vii-tties lids the fluid may diffuse itself over the ascribed to it. Having seen it often used, globe. The first effect is a sharp, smart- I har dly remember any case of a serious ing sensation, accompanied with a dis- or obstinate kind, in which it alone has charge of tears ; but, when this is gone been decidedly effectual in arresting the re(Iff, the patient generally says that he disorder. It may afford a feels relieved. The stimulus applied to lief to the patient, but I believe that if the distended vessels is supposed to pro- its use should be altogether abandoned, mote the constriction of them, and thus there would be no diminution either in facilitate the recovery of their natural the number of cures or in the time em. dimensions. It is employed once or twice ployed in effecting them. Weak brandy a day. The vinum opii is the tinctura and water is a popular remedy for bad thebaica of the old London pharmaco- eyes, and used without any discriminapoeias, the ingredients of which were-an tion of the nature or period of the affec. ounce of opium, half a drachm of cinna- tion. However, being applied externalfy, mon and of cloves, and half a pint of it is only to be considered as a cooling sherry wine. The opium and aromatics wash. You will frequently find the liquid lan. were macerated for eight days in the wine, and the tincture was then strained. danum of Sydeuham mentioned in foreil(l1. In more modern pharmacopoeias the tine- writers ; it is the old tinctura thebaica, tura thebaica was omitted, and a spiri- with the addition of half an ounce of saf. tuous tincture, the present tinctura opii, fron. Various astringent metallic salts are substituted for it. Mr. Ware ascribed a peculiar virtue to the combination of employed in chronic ophthalmia, in the ingredients in the old pharmacopeeia; he form of solution. Alum, in the pi-opor. thought the spirituous tincture had not tion of from four to ten grains to an the same effect, and he found that opium ounce of distilled water; sulphate of zinc alone, or wine alone, would not accom- and copper, from two to six or eight plish the purpose. I believe it was in grains ; nitrate of silver, one to six gr.; consequence of Mr. Ware’s recommenda- oxymuriate of mercury, one or two grains tion, and the general use of the remedy to the ounce of water. These solutions in ophthalmia, that the College of may be introduced between the palpebræ cians again introduced vinum opii into so as to come in contact with the istheir pharmacopoeia : but it is singular flamed surface ; in point of efficacy in that, as the efficacy of the remedy was common inflammation, they seem to be so pointedly ascribed to the precise com- entitled to about as much praise as the bination of ingredients in the old formula, vinum opii. In cases of purulent oph. it should have seemed fit to that learned thalmia they have a more decided effect, body to diminish the quantity of opium as I shall have occasion to mention hereone half. Mr. Ware informs us, in a sub- after. The liquor plumbi subacetatis, unsequent edition of his treatise, that this diluted, is used as an astringent. It new form of the remedy is just as effica- might seem at first that it could not be cious as the old, in which opinion I quite safely applied to the eye in an ondiiuted agree with him, If we were to rely on state, but it is by no means an irritating Mr. Ware’s representations, we should application, though powerfully astringent. suppose it to be a remedy of most sove- A French oculist, M. St. Ives, has proreign virtue. He seems to have used it posed a remedy which has’ been very indiscriminately in all cases of ophthal- much employed on the Continent under mia, both acute and chronic ; in acute, the name of lapis divinus. It is comcombined with leeches, blistering, purg. posed of a singular mixture of ingreing, and the treatment ordinarily called dients : an ounce of alum, nitre, and

lants, the vinnm

temporary

Physi-

499 are fused cessaries, but of the comforts and luxuries together in a crucible ; half a drachm ofof life, you should arrest inflammation by camphor is added towards the end of the active antiphlogistic treatment ; and then

sulphate of copper, respectively process.

A solution is made

contain- there will be

no chronic stage, but tne structure and functions will be to restored by the natural powers of the

grains of the mixture in six ing ounces of water,thestrength of which is ten

healthy

be increased according to circumstances. system. In older and feebler subjects, especially Such a mixture cannot of course have any effect differing from that of simple solu. in females, in those whose constitution is tions of the metallic salts. A German debilitated by excessive labour, by scanty writer, Conradi, has recommended a col- unwholesome nutriment, exposure to cold, lyriam, which is often mentioned, com- and deficiency of clothing, by a want, in posed of one grain of oxymuriate of mer- short, of the domestic comforts of life, cury, six ounces of rose water, and halt’ you should be more cautious in depressing a drachm or a drachm of the liquid lau- the general powers of the system; a milder antiphlogistic treatment should danum of Sydenham. It may be observed gererally, with re- be resorted to, and when you have put a spect to all these proposed remedies, that stop to the inflammatory excitement, you if active treatment be resorted to in the should invigorate the by a better first instance, and followed up steadily, diet, by the moderate use of fermented they are never wanted ; and if insufficient liqnors, if possible, by a change of air, means have been employed, so that a and to these means may be added the use state of chronic inflammation is produced, of tonic medicines and local astringents. this is a complaint which it is often ex- You must bear in mind, however, thac tremely difficult to remove, and which is very active local inflammation may take not likely to yield to the vinum opii, or place in weak states of constitution. In old and feeble females, you will often any remedies of that class. There are other local applications re- meet with such a degree of ophthalmic commended by those whose authority is inflammation, as will require very consi. deservedly high on this subject, which I derable depletion. In many cases it have not mentioned, and which, indeed, seems as if the depression of the general are not deserving of mention. The Ger- powers of the system rendered the local mans use a variety of vegetable sub- disturbance more obstinate. The observations which I have now stances, and herbs in a dried form, which they inclose in muslin or linen bags, and made, are applicable to the subject of apply to the eye; and they are in the ophthalmic inflammation generally ; there habit of varying these herbs at different are two or three remarks respecting the stages of the complaint, according to particular affection which I first detheir supposed properties, or the effect scribed, which it is necessary to subjoin, which they are desirous of producing. I that you may have a complete view of am really at a loss to conceive how indi- the treatment of these cases. vidnais, who entertain just notions with In inflammation affecting the whole respect to many parts of pathology should globe, the internal tunics are involved. It will be necessary, after the employpersist in such ridiculous trifling. In Scarpa yon may read of ponltices of ment of antiphlogistic means, to resort to bread and milk, with saffron, and the the use of mercury with views, and in a Lord knows what. I cannot conceive manner which I shall have occasion to any thing more inapplicable to an in- point out more particularly when I come flamed eye than a poultice ; nor can I to the subject of internal inflammation of regard bueh a practice with any greater the eye. I mentioned that suppuration of the respect, than the vulgar one of plastering up the eye with conserve of roses, which globe is one of the consequences of inis quite as scientific and judicious. If it flammation of the whole organ. When were worth while to resort to any thing this takes place, the evacuation of the of this kind, the popular application of matter, by making a free opening into the the pulp of a roasted apple would be the cornea, will anticipate the period of ease best. It is the lightest substance in the to the patient, and put a stop to his sufpulpy form, and retains heat and mois- ferings, which would be greatly protractture very well. ed if you allow the matter to make its If I were to sum up generally the di- own way out through the firm textures ot rections for treating ophthalmic inflam- the sclerotica and cornea. As the eye mation, 1 should say, that in the young must inevitably be lost, you need not be at,d strong, in persons of full habit, and deterred from adopting this course by any in those individuals whose circumstances considerations of injury done to the form give them a command not only of the ne- of the organ.

system

’

-

500

I have mentioned to you suppuration such circumstances the retina is rendered of the cornea, that is, deposition into its perfectly insensible to light. The pain texture of matter resembling pus only in intermits a little ; throbbing and rigors colour and external appearance, but, in are felt ; suppuration takes place, and all fact, thick and viscid. It is of no use to abscess is termed, without, however, any make a puncture, or cut into the cornea, material relief to the sufferings of the for no tluid would escape. patient, since the bony parietes of the cannot give way. Ultimately the organ Orbital Inflammation. matter makes its way to the surface, There is a very serious inflammatory either presenting at some part of the maraffection of the organs of vision, whichI gin of the orbit, or under the lid, pushing may as well mention iu this place; I al- torwards the fold of conjunctiva, which lude to inflammation of the orbital con- passes from the lid to the gtobe. Beer tents, of the soft parts contained in the has described this affection as involving bony cavity, independently of the globe, the globe of the eye as well as the snr. It seems that this affection may be coni- rounding soft parts. If this takes place, bined with inflammation of the globe; you will have, added to the symptom).! but this is a case of very rare occurrence, have already described, those denoting and I have never myself seen an instance inflammation of the external and internal of it. When we consider the peculiar tunics of the eye. The eye is thrust out, structure ot tne parts mvotveo m ttns 111- the scierotica becomes reu, the conjunctIammation, we may determine a priori, tiva is inflamed, the iris changes its cothe symptoms which attend it. It is, in lour, and the snfferings of the patient are fact, acute plilegnionotis inflammation in of course aggravated. Now what is to be done in a case of this the orbit, proceeding to snppuration, and ending in the formation of abscess. When kind ? If yon see it in an early stage, yon recollect the seat of this inflamma- the violent local pain, and the genera! tion, the highly vascular and nervous febrile disturbanceobviously point out the structures which compose the contents of necessity of the most vigorous and decided

close contiguity with the antiphlogistic treatment. When it ap. when you recollect further the the fluctuation that matter direct membranous continuation between has formed,Ishould recommend yon to the periorbita and the fibrous sheath of make an opening immediately into the the optic nerve on one side, and the dnra collection ; yon relieve the patient by this mater lining the cavity of the cranium on means and limit the extent of the local the other, you will not be surprised to mischief. When the symptoms point out find that inflammation of the orbital con- that the matter has formed, although yon tents is characterised by the most violent, do not absolutely feel any fluctuation, it deep-seated, and agonizing pain in the is better to make an opening by plunging orbit, extending over the whole of the a lancet or double-edged bistoury into the head, and accompanied by a sensation of part in which the matter appears to be tension and bursting, as if the parts indeposited, taking care to avoid injnring the orbit were too large for the bony capart consequence. Some time ago vity in which they are contained. As this I saw two instances of this affection, in bony cavity cannot give way to the swell- which the local and general symptoms ing of its contained parts, their tumefac- were characterised by a degree of violence tion pushes the globe forward towards which I have hardly ever witnessed in the front of the orbit, distending the lids, any other case. One was that of a young and making them unnaturally protube- man between twenty and thirty years of rant. The inflammation soon extends to age ; he came to me accompanied by hip who told me that he had sufferethe paipebrae, which become red on the surface, and swollen by cedematous effu- such agonising pain for the three or fon sion. The smallest attempt to move the preceding nights, that she was afraid h eye excites tile most acute pain, and tli( woua nave gone out OJ ms mind. JU cur therefore keeps the organ per case, matter was presenting just under th still. Tu conjunction with the local ridge ; after making a fre symptoms, there is violent inflammatory opening, a large quantity issued out, an fever ; the patient is delirious at night, upon putting in a probe it went to tli and continues so for several nights in bottom of the orbit. The other case oc succession. As the disease proceeds, all curred in a child between three and foii. the symptoms are aggravated to a pitcb, old ; the local and general sympwhich is almost intolerable. The globe toms were equally severe ; the matter of the eye is thrust further out, often be. presented between the lower lid and the yond the palpebrze, producing what is globe, but the quantity discharged on making an opening was not very consitechnically called exophthalmia. the

orbit,

their

sensorium,

pears from

any

of

wife,

’patient fectly

superciliary

years

Under

501 derable in this case. In both instances the muriate of ammonia, or sal ammoniae the globe of the eye was very much pro- in the form of a wash, dissolved in a truded, but not actually thrust out ; and mixture of vinegar, spirit and water, is after the matter was discharged it rece- used for this purpose, and will do as much ded to its natural situation ; in the child good as any thing. The liquor ammonias vision was restored, but in the adult the acetatis may be used as a wash, alone or with rose water ; or the liquor ameye, although it had not been inflamed, mixed moniae mixed with soap liniment, may remained amanrotic. be rubbed on the part, as these stimuWounds of the Eye and Appendages. lating applications are supposed to be I have already observed, that inflam- capable of accelerating the process of mation is frequently prodnced by exter- absorption. There is a quack preparation nal injury, and it will be best to put calledpomade divine,’ composed appatogether in this place all I have to say rently of unctuous and aromatic ingrerespecting wounds of the eye and its dients, which is much used for this purappendages. The general principles of pose ; it an agreeable sort of salve, but I treatment are the same for all wounds. cannot say, from any experience of its Extraneous substances are to be removed, virtues, whether it is likely to promote the the sides of the wound approximated, disappearance of the spots produced by the patient must be kept quiet, and such ecchymosis. The conjunctiva is subject local and general means employed as are to ecchymosis from blows inflicted on the best calculated to prevent inflamma- eye ; it produces an uniform reddish tion. All these circumstances should be brown appearance ; as if blood were inattended to in wounds of the eye and its jected into its texture. This symptom

appendages even more carefully than in sometimes comes on spontaneously, being other instances, on account of the great the result of increased action in the caimportance of the organ, and its suscep- pillary vessels. The patient feels no pain from it ; the absorbents will generally tibility of inflammation. The eye-lids, the eye-brows, and the remove it in about ten days or a fortnight,

anterior surface of the eye, are liable to and I am not aware that we can do any ecchymosis. This effusion of blood into thing to accelerate its disappearance. I the texture of the part produces thosenever saw any instance of this discoloralivid black or blue marks in the palpebrse, tion remaining, or of its leading to any commonly termed a black eye. Muchanpleasant consequences. In incised or lacerated wounds of the loose cellular texture enters into the composition of the lids, and in many cases eye-brows and eye-lids it is ot consequence the effusion which takes place is very con- to bring the separated parts accurately siderable. Sometimes the palpebrse are together; for, if this be neglected, serious distended by a projecting convex swell- inconvenience and deformity may arise ing, and it often happens in pugilistic after the healing of the wound. In the contests that the eyes of the combatants case of a longitudinal wound of the palare in this way completely closed. On pebrae, I have seen a permanent slit in the such occasions the seconds are in the shape of the letter V, like a hare-lip, prohabit of performing a kind of chirurgical duced from negligence in this point. Inoperation, without having received any version or eversion of the palpebrae may diploma from the college ; they make an take place from the same cause, and ocopening in the skin with a lancet, and casion considerable deformity as well as squeeze out the blood, by which expedient serious inconvenience. I have seen a case they enable the combatant to see his way in which a horizontal wound of the upper a little longer. Ecchymosis is often oc- lid having been neglected, a sort of buttoncasioned by the application of leeches to hole was formed in the lid, from the parts the palpebrae; in whatever way these ex- not having been kept in apposition, and ternal marks are produced, individuals what was worse accretion of the conjuncare generally very desirous of getting tival surface of the palpebra to the globe rid of them, and you will be occasionally had taken place, and the lid hung so much to for this purpose. The question over the globe as to render the eye almost applied is therefore, whether we can adopt any useless. This shows the necessity of at. means to facilitate the departure of this tending to such wounds, however slight discoloration, produced by the effusion of and inconsiderable. I was consultei blood into the subcutaneoas.texture ? Ap- some time ago by a gentleman who had sorption will accomplish the purpose in a been thrown from his horse, and strnct certain time, and it is doubtful whether himself on the eye-brow, so that about we can abridge the time by using any of one-third of it, beinx the middte portion, those articles in the Materia Medica was detached and torn down towards the which are termed discutients. However lid. From inattention to the manage.

502

of the wound, the detached part of the brow healed below the level of the LECTURES rest; producing a remarkable and by no means becoming appearance. This genON THE tleman, who was handsome, rejected my advice of letting it remain as it was, and THEORY AND PRACTICE OF PHYSIC, wished me to adopt any proceeding for BY DR. CLUTTERBUCK. removing the deformity. I made a vertical incision on each side of the displaced Theatre, General Dispensary, Aldersgatepart, united the incisions transversely street. from and the dissected off portion above, its new situation, leaving it adherent below. Of the flap thus made I cut off LECTURE VIII. the upper portion, corresponding to the depth of the eye-brow; and then secured Gentlemen, AT my last lecture I was speaking of the remainder in its proper position by sutures. It adhered readily, and the the various ways in which diseases occaoperation seemed to have succeeded per-sionally prove fatal ; I remarked, that fectly, when the patient left England forsometimes death takes place in consea long absence on the continent. quence of some function, essential to life, being interrupted, and that it is on this In wounds of the brows and lids, adhe- account that diseases of the lungs, heart, sive plaster is not sufficient for keepingand brain are comparatively more danthe parts in exact apposition; it will begerous than others. Another way in which disease may necessary to unite them by sutures, suchi as will not irritate the parts, using small,prove fatal is, by the general irritation thin, sharp-cutting needles, with singlethat is excited by it ; of this we have but silk threads. You will employ such a num- a very indistinct idea. We find that disto eases occasionally prove fatal, although ber of sutures as may be unite the parts in their proper relation to they are seated in organs that are not each other. Lay over the part soft linen essential to life. I illustrated this by re. rag dipped in cold water, use this ap- ference to cases of extensive burns, where plication frequently, keep the patient the skin is the part injured ; such cases quiet, and attend to his bowels. You oftentimes prove fatal, and we ascribe may cut out the sutures in eighteen or the fatal termination to irritation, (which twenty-four hours; that time will be suf- is the intermediate cause,) withont being ficient to accomplish the purpose of pro- able to show how this effect is produced. moting accretion, as the edges of the The skin is not a part the functions of wound will be agglutinated either by co- which are immediately essential to life ; agulated blood or coagulable lymph.- death cannot, therefore, be produced by By removing the sutures you will avoid the interruption of its functions. The all irritation from that source, which brain, in these cases, appears to suffer, does not come on in so short a time. for in such as terminate fatally the stupor You will be surprised in many cases to and delirium that occur sufficiently ifldisee how speedily and completely the cate this organ to be affected. union of the parts is effected by adoptAgain, diseases may prove fatal by the ing these measures. The mode of pro- weakness which they indnce, and that in ceeding I have recommended’ is particu- different ways. Most diseases consist in larly necessary in wounds of the lid, in excessive, as well as disordered, action which it is more difficult to preserve an of the affected part ; and this excess of acaccurate adjustment than in wounds of tion, by degrees, exhausts the vital power. the brow. It is in this way that long continued diseases, of almost all kinds, gradually reduce the strength, so as at length to ERRATUM in Mr. LAWRENCE’s last Lec- prove fatal. In like manner, pulmonary consumption does not in genera) destroy ture. life, by absolute destruction of the hmgs, so as to render them altogether incapable Page 468, ten lines from the bottom, of carrying on their functions, (tbr a read proscribed. small portion of lung is sufficient to support life,) but by the continued state ot excitement that is taking place throughout the system, and consequent exhaustion of the vital power. Another caRse ment

necessary

for "prescribed,"

of weakness exists here, namely, th,