ROYAL LONDON OPHTHALMIC HOSPITAL, MOORFIELDS.

386 ROYAL LONDON OPHTHALMIC HOSPITAL, MOORFIELDS. Melanoais of the Globe of the Eye; Removal; Recovery. (Under the care of Mr. CRITCHETT.) WHEN passing in review the heterologous growths to

the human frame is subject, we find melanotic offering a very striking and inexplicable peculiarity : namely, the absence of blood-vessels. Breschet injected such growths with a very subtle fluid, and did not succeed in discovering any vascular structure. How, then, does a melanotic tumour grow and increase in sizeIs it by new matter deposited by the vessels of the neighbouring healthy tissuesIs there any analogy between the growth of a melanotic tumour and that of a nail or claw!4 Is such a tumour composed merely of colouring matter, which by a sort of error loci accumulates in certain localities!s Why should melanotic growths so frequently spring from the choroid coat, which is characterized by its deep black colour ! These are interesting queries, and worthy of arresting for a moment the pathologist’s attention; for it would seem as if a nearer approach to a knowledge of intimate structure could be obtained touching melanosis, than is likely to be gained regarding other heterologous growths. This will appear probable when we consider that the melanotic mass bears some analogy to coagulum of blood; and it maybe conjectured that the transformation of the vital fluid, which is necessary to give rise to melanosis, is less complicated, and passes through fewer phases than that which precedes other maligIt nant growths, such as encephaloid tumours, scirrhus, &c. will probably one day be made clear that what are called heterologous growths (presenting, as is well known, structures to which there is no analogue in the healthy frame) are the result of a series of changes, commencing at normal nutrition, and ending by gradual transformations, or rather perversions, in an apparently new material. On this hypothesis it would be easy to understand that the tendency, once established, may manifest itself in various parts of the body, and at different periods; and as tendencies are undoubtedly transmitted from parent to child, the hypothesis would harmonize with the hereditary development of the disease. But we must leave the field of speculation to return to the sober consideration of facts, and especially to the propriety of removing malignant growths. This is a subject of vast interest, upon which we shall soon have ample opportunities of dilating, for we have before us, in several charitable institutions, extremely instructive examples of rapid recurrence of malignant disease. What is the surgeon to do when cases of malignant growths are presented to him !t Always refuse to operate? This course would be quite sound in theory, but, could hardly be carried out in practice. The large majority of cancerous, diseases, for which operations are encephaloid, or performed, recur. This is an undoubted and patent fact; and yet look at our operating theatres: count the number of which are constantly being recancerous lips, breasts, &c., moved ; notice the limbs which are amputated for encephaloid growths: and are all these surgeons in the wrongt Certainly not. They are acting in opposition to certain principles which would make it a law to turn away all patients who are affected with malignant disease; but they justly found their practice upon the fact, that here and there, when the disease has been extirpated in the early stage, it has not returned, and they give their patients the chance of ranking among the lucky few. At the same time, even in the event of a recurrence, months and years of comfort are procured to the patients, where they might have remained for the same period a prey to intense suffering and agony. The only doubt which has sprung up in many a surgeon’s mind has referred to the possibility of hastening the hour of death by the interference of the knife. On this head we have no opinion to offer, and though we possess some facts bearing on the question, they are but very few. Confining our attention for the present to melanosis of the globe of the eye, we find that in the second volume of this journal for 1849, we reported, p. 617, a case operated upon by Mr. Fergusson at King’s College Hospital; the globe was extirpated, and as the patient has not presented himself again these two years, we may harbour the hope that the disease has not returned. Mr. Critchett’s patient, whose case we have this day.to narrate, has certainly some prospect of permanent benefit, as the disease had taken but little extension. In this supposition we are strengthened by the following words oj Mr. Lawrence:-" In the early stage of melanosis, when you

which

tumours

-

melanotic

can be confident that it does not extend beyond the original seat of the eye, there seems to be a chance of permanent cure

by removing the disease." The particulars of the case treated by Mr. Critchett run as follow: Early in July, 1851, a person, thirty-six years of age, of a highly sanguine temperament, applied to Mr. Critchett, at the Royal London Ophthalmic Hospital, on account of a dark irregular lobulated tumour of the right eye-ball. This tumour projected through the sclerotic just on the outer side of the cornea, to such an extent as to raise and protrude the lids, and had all the appearance of melanosis. It seems probable that the disease commenced about two years previous to admission ; the first symptom the patient observed was dimness of vision, which gradually increased to total blindness, before

any external evidence of a tumour could be detected. About five months after the dimness was first noticed, pain came on; this was of a very severe and lancinating character, and occurred periodically, lasting usually from twelve A.M. to three r.M., and attended with slight conjunctival redness. In twelve months from the time the dimness was first noticed, the sclerotic began to look dark; during the last six months the tumour has increased very rapidly, and the pain has continued with the same intensity and periodicity until the day the patient applied at the hospital. The case had been in the first instance treated as amaurosis, a course of mercury was administered, and it was only when the discoloration of the sclerotic became visible that the real nature of the affection was suspected. The patient was seen by Professor Jager of Vienna, Mr. Dalrymple, Mr. White Cooper, and others; and, with their sanction, Mr. Critchett determined to remove the globe, the following reasons being the principal in favour of the propriety of the operation: 1. The disease, though probably malignant, and increasing rapidly, seemed to be limited to the organ in which it took its origin. 2. The various viscera were healthy, and the general state of system good, considering the constant and severe suffering, which circumstance was of itself a strong argument in favour of the operation. 3rd, and lastly. The patient himself, after the various considerations pro and con had been fairly explained to him, was anxious to have the eye removed. Accordingly, on Friday, the llth of July, when the patient had been thoroughly placed under the influence of chloroform, Mr. Critchett proceeded to perform the operation in the following manner:-Taking a rather strong pair of scissors, with blunt, rounded extremities, such as are used for strabismus, and an ordinary pair of forceps, he opened the conjunctiva at the inner canthus, and near the sclerotic, as if he were going to operate for strabismus. Mr. Critchett then divided the internal rectus near its ocular attachment, and sweeping the scissors round the upper part of the globe, readily divided the superior rectus and the superior oblique, together with the conjunctiva of that region. A similar mancauvre below separated the inferior rectus and the inferior oblique; the globe was then readily drawn forwards and outwards, and the optic nerve cut through by the same instrument, leaving the external rectus and the outer part of the conjunctiva only to be divided. The globe of the eye was now turned out of the orbit, and being held in the fingers and thumb of the left hand of the operator, the remainder of the attachments were easily divided, and the globe and tumour came out almost as cleanly as if dissected. (See the annexed engraving, taken from beautiful coloured drawing by Mr. White Cooper.)

The advantages of this mode of operating, when practicable, in lieu of the ordinary method with a scalpel, are-first, the very slight haemorrhage, the vessels being divided after they have ramified into small branches; secondly, the orbitar nerves, particularly the larger trunks, escape injury, and the subsequent constitutional irritation is thus much diminished; thirdly, the operation is more easily, quickly, and cleanly performed, and with far less pain, if the patient has not been narcotized; fourthly, and lastly, so much of the soft parts of

387 the conjunctiva remains, that artificial eye can rest.

cushion is left, whereon

ture, and the train of fearful symptoms sets in and leads to a fatal issue with terrible rapidity. In the case now described, only a few drachms of blood Can the experienced physician, by his previous study of the were lost, and the after-pain was so slight, that the patient signs of disease, distinguish in a given case the peritonitis could with difficulty be persuaded that the operation had been excited by perforation and effusion, from the same inflammaperformed. Wet lint was then applied between the lids and tion arising from other causes? We think this hardly over the orbit; this came away easily as suppuration became possible; not only because peritonitis may arise from so many established, and on the third day the patient was able to get pathological states or lesions, but also because the symptoms up. In three weeks from the time of the operation, he left of perforation are in general extremely obscure. It is in the hospital, with the parts perfectly healed, and much im- considering questions like these, that the importance of the study of semeiology becomes forcibly evident; and it becomes proved in general health. On making a section of the globe, the tumour was found clear that the mere searching with the scalpel for morbid perfectly black, about the size of a small walnut, and situated alterations, without intimately connecting these investigations between the choroid and sclerotic. The retina and humours i with the signs and symptoms, fades into utter insignificance in of the eye appeared healthy, though somewhat compressed, a practical point of view. The anatomo-pathological school, which in our days has and the increase had chiefly taken place at the expense of the sclerotic, which was much expanded and thinned. Under established itself so firmly on the ruins of the theories which it the microscope, the disease presented abundant evidence of has demolished, attaches perhaps too great a value to patholomalignancy, being chiefly made up of nucleated cells, some gical changes; and its disciples do sometimes overlook the allcaudate, and exhibiting rapid reproductive action going on important end of post-mortem examinations; viz., the framing within them. The patient has remained up to this day in of practical rules for the diagnosis and treatment of disease. good health, and is at least so far relieved from a very painful It is especially with respect to the various pathological states to which the abdominal cavity is liable, that this reproach is and rapidlv increasing- tumour. The severe pain is an unusual feature in the early stage of ’, most merited; and we might among these mention the this disease; it was probably due to the tension of the globe, tumours so often observed in that region. Here the diagnosis though it is difficult to offer any rational explanation of its is ever obscure; and ought we not, after the many autopsies periodicity. It is likewise important to notice how thoroughly, which have been made, to know more about these tumours than at the first development of the melanotic growth, the disease is actually the case? In order to render post-mortem inquiries profitable, it may simulate simple amaurosis. This circumstance should be remembered, and have due weight, when we are endeavouring would be requisite that each inspection were accompanied, as to form a correct diagnosis in cases of loss of vision, unac- far as possible, by a minute history of all the patient’s sensations, from the very dawn of the affection; that the progress companied by any sensible lesion of the organ. As the patient was anxious to wear an artificial eye, Mr. were carefully noted, the external appearances accurately Critchett, as stated above, directed his incisions in such a described, and all the symptoms duly recorded. Fifty manner as to obtain a spacious orbital cavity of a regular conautopsies, thus supported,would go far to enable the zealous formation, and where the conjunctiva in cicatrizing might cultivators of medical science to frame comparative data, offer a sufficient support to the enamel substitute. The which, in a diagnostic and therapeutical point of view, would latter was furnished by M. Boissonneau, who has been parti- be of the greatest value. We offer the following case, not cularly successful in this branch of art, and who, in this as fulfilling these requisites, for the history was obscure, and the symptoms deceptive; but it will nevertheless afford a very instance, obtained admirable resultats. We find that this artist obtains a remarkable degree of fair amount of practical utility. The notes were carefully mobility for the artificial eye, when the lost organ is reduced taken by Mr. Frederick Hall. W. H-, aged twenty-six years, a waterman, of spare by one-fourth or one-third, as he adapts the artificial substitute to the exact shape of the more or less regular and dimi- make, pale complexion, and of industrious and temperate nished organ. Mobility is naturally somewhat less in cases of habits, was admitted, June 16, 1851, under the care of Mr. Luke. He complained of much pain in the abdomen, which extirpation; but even here M. Boissonneau succeeds in beau- he embraced with his hands; his countenance was anxious, tifully imitating nature, as the remaining conjunctiva and he passed urine with great diffieyelids impress a sufficient amount of movement to the and heatmoaned very much; enamel eye. It is therefore a great mistake to suppose that culty, long intervals and in small quantity, although there an empty orbit is favourable to the introduction of an artifi- was a constant desire of evacuating both the bladder and cial eye: the more bulb is left, (provided it do not exceed the rectum. The patient could not assign any cause for his illness, exsize of the sound eye,) the better. We make the remark because many are under the impression that no artificial eye cepting that a day or two before admission he had had an attack of diarrhosa, and suffered much from tenesmus while can be worn, except the organ deprived of vision be removed at stool. He had taken a small dose of castor oil on the preby a surgical operation. We would finally direct attention to the extreme sim- vious day, but the stomach had rejected it. For the last few plicity which Mr. Critchett has introduced in the extir- weeks there had been much irregularity of bowels, and the pation of the eye. His armamentarium consisted of a pair of present illness had come on suddenly. He was placed into a warm bath, and afterwards into a scissors and forceps; and with these we saw him excise the eye in the way described above, without any apparent effort, warm bed; and when seen, in the space of an hour, expressed and in a very expeditious manner. We must confess our himself as much easier, and conversed cheerfully. On making partiality for instruments free from complexity; and we are an examination, the abdomen was found tense, and resonant inclined to believe that the tendency existing in our days to on percussion, the sound being loud along the course of the and transverse colon. Firm pressure gave some simplify operations, will be attended with beneficial results. ascending degree of pain in the right iliac and lumbar regions, and a

an

deep-seated

LONDON HOSPITAL. Ulceration and Perforation of the Appendix Vermiformis;

Peritonitis; Death. (Under the care of Mr. LUKE.) AMONG the various causes which may give rise to peritonitis, perforation of some portion of the alimentary canal by ulceration is one which claims more than ordinary attention. The symptoms of peritonseal inflammation are in general so sudden, and the progress of the ulceration may have been so concealed and unnoticed, that it is but seldom that the real nature of the disease is at once recognised. Indeed, it may happen that an ulcer (either arising in the course of continued fever, or in the midst of apparent health) may destroy by gradual extension all the coats of the intestine or stomach, rio barrier but the peritonseal investment being left against the effusion of feculent matter into the abdominal cavity. A slight effort, a trifling blow, may suddenly complete the rup-

uneasiness was felt about the umbilicus.

The

experience relief from the pressure in some parts, and never objected to it. Pulse full and strong, beating about 90; tongue moist, and slightly coated in the centre. patient seemed

to

Mr. Luke ordered five ounces of blood to be taken from the right lumbar region by cupping, and a gentle dose of castor oil to be administered. The night was restless; the legs were drawn up in the morning, and the bowels still constipated ; the oil had been rejected, and only two or three’. ounces of high-coloured and turbid urine had been passed. Saline medicine was now ordered; but as no amelioration took place on the next day, eight leeches were placed on the lower part of the abdomen, and a full dose of laudanum administered. This treatment was continued, and two days afterwards the patient seemed much better; he wished for some beer, and to be allowed to rise. Vomiting recurred soon after this, but several stools were passed, and the tension and resonance of the abdomen diminished. These favourable symptoms were not, however, of

long duration;

the

patient became gradually worse; all the

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