NOTES FROM A Course of Lectures

713 And MM.

Becquerel and Rodier, who give these particulars, state that the effect of bleeding in impoverishing the blood increases with every venesection. This is likewise well illustrated in many of the tables which accompany the work of MM. Andral and Gavarret.*" In their striking array of facts you will observe that the attenuation of the blood occurs almost exclusively at the expense of the corpuscles, the other constituents of the blood undergoing little change, in their proportion either to each other or to the entire mass. This law prevails in respect of all haemorrhagic affections, and of some exhaustive diseases besides. The albumen, for instance, you will observe, remains stationary, or nearly so. The physiological explanation of this fact appears to be as follows: - After the abstraction of a considerable mass of blood, the volame of the circulation is restored by an increased absorption through the veins : the materials absorbed consist of those which had previously been exhaled from the capillaries into the interstices of the several organs, and into the areolar tissue of the body, a flilid so nearly identical with serum, (differing only in its concentration,) that this constituent of the blood is soon replaced; but as the corpuscles can only be regenerated by a slower process of growth, each bleeding appears to have been made especially at their expense. But still there are certain drains or excretions from the system which occur chiefly at the expense of the serum of the blood, and by which the albumen is consequently much re duced in its proportions. Protracted and extensive suppuration, or the discharge from large cancerous sores, or continued serous evacuations from the bowels, would act directly in diminishing the albuminous contents of the blood, as well as indirectly interfere with the regeneration of its corpuscles. In Bright’s disease, where so much serum passes off with the urine, the same effect is observed; in three cases, where Andral analyzed the blood, he found that the organic matters of the serum had fallen from their normal proportion (72 in 1000) to 61.5, 60.8, and 57.9 respectively. The development of hydatids in the liver (as it occurs in the rot of sheep) is attended by a similar result as regards the albumen; and Andral, who first drew attention to the fact, states that sheep are liable to two distinct forms of ansemia, contrasted with each other in this particular: in the one form (analogous to ,chlorosis of the human subject) the corpuscles alone are diminished; in the other (that which depends on the parasitic growth) the albumen, equally with the corpuscles, undergoes a marked diminution. The attenuated condition of the blood, arising under any of these circumstances, produces an important secondary * Proportion ofthe severaL Ingredients of the Blood in Cases of Rheumatic Fever, illustrating the Changes effected by Bleeding.

worthy of notice. You know that naturally limitary membrane of the capillaries is a transudable tissue; that it lets a certain quantity of the liquor sanguinis sweat through it; and no doubt there is a definite proportion observed by nature in the construction of the body (according to its various local necessities), between the fluidity of the blood and the thickness and transudability of that limitary membrane, in the several organs where it is distributed. Now, in excessive attenuation of the blood this proportion is destroyed; the fluid is too penetrating for the tissue, and in consequence the membrane becomes too easily transuded by its effect which is

the

contents. Such is the origin of those effusions into the areolar tissue (oedema) and into serous cavities, which are apt to occur when the serum of the blood is much de-albuminised. They do not arise in cases (of haemorrhage, for instance, or of chlo rosis) where merely the corpuscles of the blood are relatively diminished; but only when the liquor sanguinis has undergone some considerable reduction of density by the loss of its dis. solved albumen. Their origin is purely physical : the animal membrane, under the same amount of pressure, suffering the partial transudation of its fluid contents with greater facility in proportion to the limpidity and low specific gravity of £ those contents. Of the composition of the fluids exhaled under these circumstances I shall have other opportunities of

speaking.

_

NOTES FROM

A Course of Lectures Delivered BY GILBERT

at

St. Thomas’s

Hospital.

MACKMURDO, ESQ., F.R.S.,

SURGEON TO THAT HOSPITAL, AND TO THE ROYAL LONDON OPHTHALMIC HOSPITAL.

(Reported by his Son.)

LECTURE VI.

Conjunctivitis Scrofulosa, or Phlyctenular Ophtlialmia; Pustular Ophthalmia; Ophthalmia Morbillosa; Scarlatinosa Variolosa; Rheumatic Ophthalmia and Catarrho-rheumatic Ophthalmia. GENTLEMEN,-From the name assigned to the affection of the eye which comes next under our notice, you will at once perceive that it is an affection of that organ in persons of scrofulous constitutions. This term, scrofula, so objectionable to the world, has been described as signifying a peculiar set of diseases in a constitution, which, from its particular characters, is likely to suffer from such diseases under circumstances calculated to call them forth. The chief symptoms of this form of ophthalmia are, great intolerance of light, small elevations over the cornea, termed phlyctense, in the epithelia layer of the conjunctiva, which I have sometimes seen opposite the very centre, but more generally nearer its circumference, or at a little distance from it over the sclerotic; the under surface of the eyelids generally present patches of a reddish colour, but the membrane over the eyeball is not very red at first. The phlyctenæ are in some cases clear vesicles, and at other times they are white and opaque. Frequently we observe a number of small vessels, distended with blood, directing their course towards one of these elevations at th edge of the cornea, or on its surface. The lids are spasmodically closed by the orbicularis muscle to protect the eye from the light, which is most distressing in these cases. The

eyebrows are contracted, and the muscles of the face are called into excessive action, giving a very peculiar appearancQ to the patient. He will seek the darkest corner of the room, or bury his face under the bed-clothes, or when brought out for examination, he will cover his face with his hands, and resist violently your attempts to examine properly his eyes. Very generally excessive sneezing accompanies this affection; the tears will gush down the cheek violently when the lids are opened by the surgeon, the eyelids become swollen, and frequently excoriation of the cheek, and even a pustular eruption, as crusta lactea, will follow from the irritation of the tears, and from the child rubbing its eyelids and face on aocount of the itching produced by the flow of tears. The photophobia has generally been considered to result from a sympathetic affection of the retina, but not from absolute disease of the nerve. Very generally there is but little

714 pain present, and not any when the patient is allowed remain in the dark and in perfect quiet, but any motion of his eyes seems to cause him much pain. It is supposed that the distribution of the lacrymal nerve to the gland, orbicularis, and conjunctiva, explains the strong sympathy between these parts. You will generally have numerous other symptoms of scrofula present, as thick and swollen lips, and an irritable condition of the mucous membrane lining the nose, with much discharge, sore ears, enlarged glands, affections of the joints, tumid belly, and disordered bowels, with general debility, and a flabby skin; generally the patient is relieved towards the evening, but he does not sleep well, and he will wake suddenly (and if a child), scream out with pain, and after a little time, and when he has had a copious discharge of tears, he will go off to sleep, and perspire profusely towards the morning. In most cases both eyes are affected, but not always, and they will sometimes suffer alternately. Cold and moisture, when combined, produce very frequently severe attacks of this disease, and thus peculiar localities are more likely than others to excite it ; insufficient diet, confined residences, sedentary occupations, hard study, also eruptive disease, teething, &c., in children, are all so many causes of it in feeble subjects. Your prognosis ought always to be a very guarded one, and you should strongly impress on the friends the absolute necessity of their obeying your directions for a considerable time after the child has apparently recovered, for relapses easily and frequently occur. During the treatment of a case you will sometimes be told that the patient had suddenly and very unexpectedly entirely recovered for a short time, and that the disease had as suddenly reappeared. I have seen this very frequently. You must therefore prepare the friends for these occurrences, as children liable to these attacks may suffer regularly once or twice a year throughout their childhood. The effects of prolonged attacks of this disand the progress of the complaint ease are often very serious, is very insidious. The cornea may be affected in various ways. You may see a thickened whitish portion of the conjunctiva over it, with some red vessels passing to it, and you will not eventually be able to get rid of this opacity, or ulcers may succeed the phlyctenæ and produce mischief of various kinds; adhesions of the iris, or protrusions of it through A permanent thickening of the the cornea, may occur, &c. eyelids, especially the upper one, is a very common and very unsightly result of protracted attacks of this disease; and some patients who have suffered thus frequently for many years have their sight permanently much impaired, also from the long disuse of the eyes; and I have often seen confirmed strabismus in children, whose eyes had been perfectly straight previous to their suffering from strumous ophthalmia. If the cornea is clear when a patient is brought to you, or even if there should be only a superficial opacity, or an interlaminar deposit, you may expect that the eyewill recover; but if there are opacities, such as cicatrices after ulceratio , or a prolapsus iridis with adhesion, you must not expect that the cornea can be perfectly restored, although even in these cases absolute 0

together with an improved diet, and the proper topical remedies, have restored the eye, and sometimes to an extent far surpassing my most sanguine expectations. The different preparations of iron, and the sulphuric and nitric acids, in some of these instances, have benefited the patients

at once,

much. It has been well remarked, that the friends of scrofulous patients, and even their medical advisers, havetoo often (acting on the idea that the disease was one of mere debility) given the patients too stimulating a diet. They will not bear this well. True it is that they require nutrition, in the proper sense of the term, and not stimulants, as such; let them then have a mixed but a thoroughly wholesome diet. I need not enter into their details further here. Tepid washing, or even warm baths, will occasionally be useful; warm clothing, and regular exercise in a pure air, are essential; but persons thus affected cannot sustain the glare of the sea, or of chalk cliffs, such as Brighton, &c. Early hours, particularly as regards the retiring to rest, are necessary. A shade should be worn, and the ventilating spring shade is very superior to that which is tied closely round the head, and which keeps the part hot and uncomfortable. Warm poppy or chamomilefomentagenerally preferred by the patients, but even evapotions are rating lotions are grateful to others. If cold applications are used, the patient soon afterwards complains of increased heat in the parts. In some cases I have given relief, by allowing the patient, during the night, to have a thin bread poultice, with plenty of well-washed lard in it, and enclosed between two folds of muslin, placed over the eye, although, as a general rule, I do not like the application of poultices to the face. Sometimes I order one drachm of liq. opii sedat. Battlei, and one ounce of water. A small quantity of this may be introduced between the eyelids. Counter-irritation is very frequently required, either behind the ear or to the nape of the neck, or by a seton or issue being applied or made in the upper arm. Some surgeons prefer rubbing the tartar-emetic ointment on the neck, considering that they thus get rid of the photophobia. As soon as it is practicable you should use the nitrate of silver drops, in proportion of one to four grains to ounce aquse, or the sulphate of zinc or copper lotions, or the wine of opium. Whenever you order the nitrate-of-silver drops, you ought to require your patient to visit you, or have his eyes well examined by some medical friend very frequently. As these drops occasionally stain the globe of the eye, and the under surface of the lids, if persisted in too long,-and I know of no effectual method of getting rid of these stains, although many have been proposed,-it has been recommended that nitrate of silver, in substance, should be applied along the outer surface of the upper lid, to remedy the photophobia. Others have recommended us to apply the tincture of iodine. I have tried each- plan fully, and I have succeeded with each applica tion, in some cases, but I have often been baffled. The latter application appears to me much preferable, on many accounts. You must, of course, not repeat it daily, if the skin becomes inflamed, which will occur sometimes. Belladonna rubbed on some vision is frequently preserved. the temple, as an ointment, around the eye, will often assist With regard to the treatment of this form of ophthalmia, us; or it may be applied in the form of vapour. There is a you must bear in mind what I told you at the commencement form of strumous ophthalmia, called pustular ophthalmia, of this lecture-viz., that it is inflammation attacking the eyes which differs in some few points from that which I have been of scrofulous individuals; consequently, I need scarcely advise last describing. The late Mr. Morgan used to call it aphthous you to refrain from lowering the powers of your patient. It ophthalmia. It has been considered as an intermediate link may, in some cases, be advisable to apply a few leeches, but between strumous and catarrhal ophthalmia. There is little these instances are rare. Your patients will more frequently or no intolerance of light present. The redness is more require support directly after you have attended to the con- general and reticular, and sometimes you will see spots of dition of the liver, stomach, and intestines, &c. This you ecchymosis present. You will observe generally one, two, may affect with a moderate dose of calomel, with rhubarb, or or several, aphthous elevations, much larger than the phlycjalap, or scammony, according to circumstances, and you tense. They discharge a clear fluid when they burst, and not may have to repeat them twice or thrice; and you may any pus. They are situated around the edge of the cornea, in also, in some cases, when there is any feverish action, much very various numbers. This occurs in older subjects than the relieve your patient by giving him an emetic of ipecacuanha, last-named disease; and from ten to eighteen or twenty years or of tartarized antimony, at intervals; afterwards occasional of age it is not an uncommon affection. The treatment should doses of mercury with chalk, with antimony and compound be simple. A brisk aperient should be given at once, and decoction of aloes, will be most beneficial; but in almost every afterwards carbonate of iron, or iron and quinine conjoined, expedite the cure very materially by commenc- or such other tonics as may appear in the particular cases to case you will ing early with a tonic, such as the sulphate of quinine, or be necessary. Zinc, sulphate of copper, or nitrate of silver the liq. cinchonae cordif. of Mr. Battley. Children will lotions, or Goulard lotion, if there should be much action, to take well one grain of the former rubbed up with sugar, admit of the astringent at once; in such cases a few leeches, or in solution, or four, six, or eight drops of the latter, or a blister or two, may be necessary. When children have twice or three times a day in water; and adults will, had measles or scarlet fever they frequently suffer from slight of course, require larger doses. I have frequently had ophthalmia, with phlyctenula present, and sometimes ulcerachildren brought to me with interlaminar deposits, with tion of the cornea occurs. After the measles a severe form hazy and nebulous cornese, or even with ragged ulcers of catarrhal ophthalmia will occasionally trouble the patient from strumous ophthalmia, and who were in imminent for a considerable time. The patients will require tonic treat. danger of losing their eyes speedily; whereas, the bark given ment and astringent applications, with occasional aperients.

715 You will, then, read of ophthalmia morbillosa, ophthalmia because it is a fibrous tunic; and, as a simple affection, it is scarlatinosa, and so, also, of ophthalmia variolosa, and ophthal- much more rare than catarrho-rheumatic ophthalmia. I mentioned that there is generally some dimness of vision mia erysipelatosa; the third of these, that which accompanies the small-pox, has its peculiarities. You will generally see in these cases, and that it depended on the condition cf the small-pox pustules on the surface and edges of the lids, and cornea, but likewise you will often observe a contracted

cases, the lids are so swollen that the eyes become pupil and a sluggish iris. Even when there is no distant the eyes are much irritated by the confine- iritis, which does not often occur in sclerotitis, the* absence of ment and incrustation of the secreted matter, and the patient all secretion over the eye in these cases occasions at first a remains, as it were, blind for some time; but, eventually, it is painful sensation of dryness, but subsequently this symptom generally found that his eyes were not injured. The cilia are is lost sight of, and tears are plentifully secreted. There is often destroyed, and the lids are otherwise disfigured, and the not any great degree of intolerance of light, but there is genelacrymal apparatus having been much irritated, chronic blen- rally considerable restlessness and febrile action, and the norrhoea often remains. Much benefit has been derived by tongue is furred and whitish, and the skin hot and dry; there the application of a finely-pointed stick of caustic to the pus- is very little appetite for food, constipated bowels, and the tule, or any part of the lids; also others have pricked them, whole alimentary canal seems out of order. The treatment must in each instance depend on the peculiar and let out the matter, and then applied tepid applications of milk-and-water; any bland application is useful in allaying feature of the case. Plethoric patients, with hard and full the irritation. We sometimes see pustules on the cornea: pulse, will require bleeding from the arm; in milder cases, this is followed by ulceration, and the most serious conse- cupping or leeches will suffice; follow it up with calomel and quences, generally. When the patient’s eye is closed, and he colocynth, with Dover’s powder as an aperient, and afterwards complains of severe pain, heat, dryness, and other symptoms give diaphoretic medicines; a warm bath, or foot-bath, and of severe ophthalmia, you must anticipate the worst results; when the tongue is clean, colchicum, with an alkali and a bitter but if the eye is easy, though shut, you would not en- infusion at intervals, but this latter medicine must be carefully tertain any fear. Authors describe a secondary variolous watched as to its effects. Sometimes we give calomel-andophthalmia; it occurs about the twelfth or up to the opium, at night, until the mouth is sore, with great advantage, twentieth day, when the pustules have dried and fallen off: a and afterwards the Dover’s powder, at night, freely. Dry, whitish circular spot is noticed on the cornea; it is generally warm applications contribute much to the comfort of the very small, and the nebula thins off, as it were, at its edges, or patient. Opiate, friction, or belladonna may be applied; also it may join a second spot, and so on, and thus completely ob- a hop pillow or hot chamomile flowersin a bag,infeeble persons; The sclerotic also suffers frequently, and a generous diet, without acids, should be adopted; fermented scure the cornea. onyx appears at the lower edge of the cornea, and there is liquors should be forbidden. Bark and soda, in the propormuch lacrymation on exposure to light. This is supposing, tion of five grains of each, may be given three times a day, however, that the patient has not been properly treated. The with advantage, together with Plummer’s pill, or the calomeland-opium at night. Belladonna should be continually apremaining sight would depend on the size and situation of eventual opacity of the cornea. I have seen these variolous plied, so as to keep the pupil under its influence. Catarrho-rheumatic ophthalmia is a very common and a very pustules in the cornea of patients at our Ophthalmic Hospital, and therefore I do not hesitate to speak of them here, although dangerous disease. Here we have the conjunctiva and scleI am well aware that great authorities on eruptive diseases rotic simultaneously affected, and we have both sets of symptoms presented to our notice. Frequently there is more or deny their existence. The last ofthese forms, the erysipelatous ophthalmia, arises less chemosis; there is mucous discharge present, but not in after blows, exposure to draughts, sudden change of weather, excess; great photophobia, especially where corneitis co-exists. The patient complains of tension in and The daily pain of conjunctivitis, and the nocturnal pain of stings of insects, &c. around the eye; there is a pale redness of the conjunctiva, sclerotitis, are both present; a superficial ulceration of the and reddish straw-coloured vesicles of considerable size arise cornea and interlaminar effusions of pus frequently occur. around the cornea-these have the appearance of tears, and The pus in these cases is seldom absorbed. The cornea the bystander is deceived thereby. If it is unchecked, a livid ulcerates over the onyx, and the pus escapes; but when the redness appears, also spots of extravasated blood between the ulcer destroys the surface of the cornea, the aqueous conjunctiva and sclerotic, the vesicles enlarge; now there is humour escapes, and the iris falls forward, and much mischief much lacrymation, and a free secretion of white mucus; the ensues. Hypopium sometimes occurs; very generally the secreeyes become firmly agglutinated together during the night; tions require correction. This disease occurs chiefly in elderly there is a dimness of the cornea, but this only results from persons, and is in most cases the result of atmospheric influthe mucus on its surface. The disease gradually subsides ence. The treatment must partake of the characters of that under a proper management, and a very simple treatment will which I have recommended for catarrhal and for rheumatic suffice. In addition to the usual plans previously mentioned, ophthalmia, varied as the case may indicate; but it should be you should prick these large vesicles with a lancet, and admi- borne in mind, that in this affection the patient is generally nister a gentle diaphoretic and tonics afterwards, with astrin- elderly and feeble.

in

severe

completely closed;

the ’

posterior

gent applications.

I now pass on to rheumatic ophthalmia, and catarrho-rheumatic ophthalmia, which, like the catarrhal affection, generally arises from exposure to cold or damp. The sclerotic is a fibrous and inelastic tissue, and is the seat of the rheumatic affections, and the majority of cases occurs in persons of the middle age. There is in this form of ophthalmia a marked difference in the appearance of the eye from that which it presents under conjunctival inflammation. There is generally a dulness of the cornea, which interferes with distinct vision, the general redness is zonular, and deeply situated under the conjunctiva, but there is not so complete a zone as in iritis, nor is therethe reticular appearance peculiar to conjunctivitis. The vessels appear larger, and are more turgid, of a brickdust colour, or even purplish. There is generally slight conjunctivitis present, and also sometimes iritis, if the affection has lasted some time. Only one eye is generally affected, but sometimes both are affected, or there seems to be an alternation in this respect. There is not any increased secretion in the eye, nor any chemosis or inflammation of the palpebrae; the patient complains of a deep throbbing or stinging pain, chiefly around the orbit, temple, forehead, eyebrow, superciliary notch, and cheek, and his sufferings are worst during the night. Although termed rheumatic ophthalmia, I have often seen sclerotitis presenting the above symptoms in persons who have never suffered from rheumatism in any other form, and you may simply call it sclerotitis if you choose, as it only presents the above-mentioned symptoms

ON THE

PATHOLOGY OF THE CHRONIC FORMS OF OVARIAN DISEASE. By EDWARD JOHN

TILT, M.D.,

PHYSICIAN TO THE FARRINGDON GENERAL DISP ENSARY AND TO THE PADDINGTON FREE DISPENSARY FOR DISEASES OF WOMEN AND CHILDREN.

MICROSCOPICAL INVESTIGATION OF THE CONTENTS OF OVARIAN CYSTS.

THE pernicious influence of any agent stands in direct proportion to the advantages afforded by its judicious use. When inexperienced men look at nature through the microscopic lens, their eyesight is dazzled by the mass of objects presented to their view, they catch at the most salient points of some crystalline form, or other object, and then call on their imagination for the rest. If they are strongly impelled by the love of notoriety, they build upon their indistinct vision a scientific structure which soon falls to the ground like all

other edifices built on an unstable foundation. Many of these foundationless structures have been produced in late years, and if the headlong impetuosity with which the rising generation of medical men seeks to advance medical science by illdigested microscopical researches is not arrested, another generation will have much to do in clearing away heaps of

accumulated rubbish.