No. 1606.

JUNE 10, 1854.

A Course of LecturesON

DISEASES OF THE EYE,Delivered at the Medical School of the London Hospital.

BY GEORGE CRITCHETT, ESQ., F.R.C.S.,SURGEON TO THE ROYAL LONDON OPHTHALMIC HOSPITAL; LECTURER ON

SURGERY AT THE LONDON HOSPITAL, ETC.

LECTURE V.Renzote eects of lJW’ulent ophthalmia; gramilc(1’ lids 2·aseulaa·

opacity of coavzecc; bulging of cornea>’ various forms of thegranular condition otlaer causes of vascular C01’nea ta?-ioits]Jlolls of t)-cat))e22t; probable durationJ’ rulesf01’ selection ofstimuli ; inode of applying thQI)1, 2cnfavorcr-able symptoms.Ulco’s of the cornea >’ fow’ conditions appearance of each.

GENTLEMEN,—I have already hinted that, in addition to themore immediate effects of catarrhal and purulent ophthalmia,there are a remote class of changes, resulting from the pro-longed existence of these diseases, that produce an alteration inthe secreting surface of the conjunctiva, and as a consequenceof this more or less serious damage to the cornea. After the.severer symptoms of the primary disease have passed away,and when the cornea is still bright and clear, some sensation ofgrittiness is complained of, particularly as night approaches,and some thick secretion, though to a much smaller extentthan before, of a puro-mucous character, still glues the lids,collects at the inner canthus, and sometimes smears the cornealsurface. If this state is allowed to continue unchecked forsome time, the conjunctiva, particularly of the lids, acquires avelvetty and raisecl appearance. The villi thus raised andenlarged may become still further, and somewhat irregularlydeveloped, so as to resemble the granulations of an ulcer, inconsequence of which this condition has been termed "granularlids," though it must be borne in mind that this change occursin the villi, and is entirely due to hypertrophy of these littlebodies. It occupies many weeks and even months in its de-velopment, and when allowed to pursue its own course is verypersistent, and even gradually increases. If the disease limiteditself to this structure it would be of little importance, butsuch is seldom the case; by degrees the vessels in the ocularconjunctiva become enlarged, particularly those correspondingto the upper lid, and from thence they creep down over thesurface of the cornea, gradually covering its upper half, andproducing the appearance of a thin, delicately-organized falsemembrane overlaying the transparent tissue of the cornea.,

This is a slow but almost sure result of granular lids, andwhenever the one is found the other may with certainty beprognosticated. This opacity may gradually increase, both inits superficies and in its density, until two-thirds of the corneais covered more or less thickly. The vessels organizing thisnew product may all be traced as coursing down from above,except in very severe and protracted cases, when I have ob-.served the surface of the cornea to be one uniform mass oforganized lymph. In all these extreme cases I find the originaldisease has been contracted in tropical climates; it is termed"vascular opacity of the cornea." A condition somewhat re-sembling the above is occasionally found without any well-marked granular condition of the conjunctival surface ; itoccurs about the age of puberty, and results from a strumouscondition of system. It may be distinguished from the form Ihave just described by the fact that the vessels encroach uponthe cornea from all sides instead of from above only. Theyalso appear to involve more deeply the corneal tissue, and notto be limited so entirely to its surface; and as a result of thisthe resistant power of the cornea becomes diminished, and itsconvexity increased, and its refraction so much augmented, asseriously to interfere with vision, even after transparency is re-stored. The size, shape, and colour of the villi in the enlargedstate vary much, according to the severity of the primary dis-ease, the treatment then adopted, and the constitution of thepatient. They are sometimes large, loose, flabby, and pale;at others they are small, round, red, and highly organized, andbetween these two extremes there are many shades of diffe-rence, depending upon the time the disease may have existed,the state of the constitution, and the previous treatment. Thecauses of this curious change in the mucous surface may betraced to severity in the original disease, to insufficient localtreatment, or entire neglect, or very active constitutionalmeasures, and to a diseased state of the digestive organs.Some of the most marked and obstinate forms of this disease

that have come under my care at the Ophthalmic Hospitalhave occurred in men who have served in the Indian army,where the original disease is probably due to atmospheric in-fluence, and where we find that all diseases of mucous membranesare severe, intractable, and prone to lapse into this hypertrophiedstate, and so to continue for an indefinite period. I have neverobserved this condition in infants even after the most acutepurulent ophthalmia. As may readily be imagined, the exist-ence of even a thin vascular layer over the surface of thecornea very seriously interrupts vision, and the worst casesonly allow perception of light, and a dim outline of objects, andit becomes an anxious question to what extent the brilliancy ofthe cornea can be restored by suitable treatment. In forminga judgment upon this point, what we have especially to noticeis the direction of the vessels-whether they creep down fromabove only, or whether they encroach from all sides-as uponthis circumstance depends the fact as to whether the vascularopacity is entirely due to the granular condition, or to someinherent vice in the conjunctiva and cornea, and in the generalstate of system. If we can satisfy ourselves that the disease ispurely local, and due to the mechanical change of the con-junctiva, we are justified in giving a favourable opinion as tothe result. Our treatment must be exclusively directed to theremoval of the granular condition. If we can succeed in this,the subsequent vascularity, which is a consequence of it,spontaneously subsides, and leaves a clear cornea. Variousplans have been suggested for their removal. Thus, excisionby means of curved scissors has been recommended It has,however, this serious objection, that if it be only partially andsuperficially done, it has the effect of pruning, the granulationsare reproduced, and usually to a greater extent, or, if they aredeeply and thoroughly removed, they leave an irritating,irregular cicatrix, that keeps up the disease of the cornea, andmay cause entropium, and is worse than the original condition,since it is irremediable. Frequent scarification has been

suggested, and is now sometimes had recourse to. My ownexperience is unfavourable to it, and I have seen cases whereit has been employed by other surgeons for many monthswithout advantage, and it seems improbable that a slight andtemporary unloading of the vessels, by small punctures or

cuts, should remove, or even diminish, these growths; theyirritate, but do not cure. The treatment that is most

uniformly recommended, and that which I have found the mostvaluable, is the application of some powerful astringent orstimulant to the surface of the enlarged villi. This should bedone by everting the upper lid, and applying the remedy freelyover the surface. The principal stimuli for this purpose arethe solid nitrate of silver, or a strong solution; the sulphate o{copper; the acetate of bad, alum, zinc, &c. In the selectionof a stimulus, attention must be paid to the condition of thegranulations, their size, amount of org-.ti:.Li2fLti6rL, nervous

sensibility, and the time they have existed. In the morerecent cases, where they are small, round, vascular, andsensitive, the stimulus must be mild, as, for instance, a solu-tion of the nitrate of silver or the sulphate of copper, aboutten grains to the ounce of distilled water; in the large, pale,insensible forms, the solid nitrate of silver may be freely andfrequently applied. As a general rule, and in an average case,my own experience leads me to prefer the sulphate of copperto any other application; it may be rubbed freely over thesurface, and repeated either daily or every other day, accordingto the effect produced; it is far less painful and irritating thanthe nitrate of silver, and except in very indolent cases producesa sufficient effect. Recently, the acetate of lead, in powder,has been much recommended. I have tried it in some cases.

It appears to incorporate itself with the tissue, and by degreesforms a sort of permanent enamel over the surface. I havenot been able to trace any favourable effect in diminishing thevilli, but I have no doubt it renders them less irritating to thecorneal surface, and may be conveniently and advantageouslyemployed when other means of acting upon them have beenexhausted. I have no doubt the ointment recommended byMr. Guthrie is very useful in these cases. Whatever causticor astringent is selected, it is desirable to limit its effect asmuch as possible to the part to which it is applied, and toprotect the rest of the conjunctival surface. This is more par-ticularly necessary when the nitrate of silver is employed insubstance. The best mode of effecting this object is to put alittle glycerine into the eye previous to applying the caustic,and also to keep the eyelid everted for some little time afterthe application. Although caustics and powerful astringentsare the only reliable means in these cases, it is only whenapplied carefully to the part, and at stated intervals, thatthey are of service. Used in weak solutions, as drops or

61

lotions, I have often observed them to do harm by irritatingthe eye, without acting on the disease.In undertaking a case of this kind, it is important that the

patient should be made aware that, under the most favourablecircumstances, and with the most judicious management, theprocess of treatment must be tedious, extending over manymonths, and requiring great perseverance in the use of remedies.If the disease be limited to the upper half or even two-thirds ofthecornea, andifthe vessels can be all traced from above, you maydepend upon a, cure, provided the plan I have recommended bejudiciously carried out. The first result is the diminution ofthe villi, until by degrees the conjunctiva becomes nearly evenand smooth. During this time, the vessels running over thecornea gradually become smaller. looking at last like nne hairs;they then shrink away altogether, or leave so slight a changeat the upper margin of the cornea that vision is no longerinterfered with. No constitutional treatment seems to be

required, the object being to maintain as nearly as possible astate of health. There is a modification of this disease, towhich I have already briefly alluded, in which the vessels canbe seen encroaching over the surface of the cornea from allsides, and converging towards the centre. This conditionwould seem to depend only to a partial degree on a mecha-nical and local cause, to some extent upon the state ofthe constitution, and upon a diseased condition of the corneaitself. This morbid change is exceedingly intractable, andwill remain after the surface of the conjunctiva is restored to asmooth state. In these cases, the surface of the cornea is morethickly and uniformly covered with a highly organized falsemembrane; consequently, vision is more extensively interferedwith. Another more serious and fatN,l result of a continuanceof this form of disease is a certain amount of softening of thecorneal tissue, so that it no longer offers the same amount ofresistance, but yields to the pressure from within, so as tochange its shape and increase its convexity-a state of thingsthat seriously and permanently damages the sight even afterthe transparency of the cornea shall have been restored. The

management of this modification of vascular cornea is verydifficult, and the result usually very unsatisfactory. If thevilli are enlarged, the primary consideration is to restore asmooth surface to the palpebral conjunctiva; if the corneadoes not improve after this is accomplished, the cause will befound chiefly in the state of the constitution, and in someunfavourable sanitary conditions, as close, ill-drained, and ill-ventilatecl dwellings, improper and insufficient food, &c. Allthese disturbing and noxious influences must be carefullysought out, and as far as possible obviated. Tonics are useful,and sometimes a very mild but protracted mercurial courseseems to be of advantage.

I have observed that this disease frequently occurs in femalesabout the period of puberty; therefore attention must beespecially directed to the due performance of menstruation.The thorough establishment of this function is often attendedwith a very marked amelioration of the symptoms. As regardslocal means, so soon as the cornea is smoothed down, I havenever seen any good result from the continuance of stimuli,even in the form of weak solutions; they always seem to meto tease the eye without diminishing the vascular opacity.Neither havelbeen able to trace any advantage from dividing thevessels as they encroach upon the cornea,-a plan that has someadvocates amongst good authorities. During the prolonged localtreatment of the granular lids that these cases require, we some-times find that a subacute condition is set up, in consequenceprobably of some excess in activity or frequency of the stimulusemployed. Under these circumstances it is prudent to abstainfrom all irritating applications, to soothe the eye, and to waituntil it has subsided into a chronic condition before recom-mencing the treatment. When the surface of the conjunctivais brought into a smooth condition, I usually abstain from allfurther local stimuli, and trust chiefly to constitutional treat-ment. The only local treatment that I have found advan-tageous at this stage is the formation of an issue in the templewhich should be kept up for some months. It appears to be

peculiarly applicable to those affections of the conjunctiva andcornea in which there is organized morbid deposit superaddedto the original healthy tissue. I have had an opportunity ofobserving and of treating many of these cases, especially inyoung females, some of whom have been inmates of our work-houses, who are tied to their hard lot by their incapacity forwork, the result of their defective vision, and who inheritmany of the disadvantages of the really blind without theircompensating advantages of an education suitable to theirbereaved condition. In many cases I have been quite success-ful in restorin a healthy condition of the cornea by persevering o,

for many months in the means above indicated; in others I

have failed in restoring goocl sight owing to the increased con.vexity of the cornea-a state of things quite irremediable.Some few cases have resisted all means of relief. A permanentchange of air, particularly to the sea-side, offers the bestchance of improvement under this unpromising state of things.A vascular condition of the cornea sometimes results from theconstant irritation of inverted ciliee; and in cases whereeversion has taken place, and the cornea no longer is protectedand lubricated by the upper lid, a still further changes takesplace, not only does the surface of the cornea become opaque,but by degrees it becomes dry. To this condition the term" cuticular cornea" is applied. The relief of these conditions,when dependent upon changes in the palpebra, will be mostconveniently considered with the diseases of the ocularappendages.you will perceive that I have been gradually led towards

the cornea in describing the granular condition of the conjunc-tiva, as being secondarily involved in this affection. I proposetherefore now to consider the various changes that occur in thecornea during diseased action. I have already described thevascular opacity of this tissue, and I pass on to consider someof its other secondary diseases under the head of " ulcers of thecornea." If the conjunctiva be inflamed beyond a certainpoint, or if the inilammation be prolonged at a certain heightbeyond a given time, and if there exist at the same time a.condition of constitution unfavourable to the subsidence ofmorbid action, the nutrition of the cornea becomes impaired,and its surface becomes at some time or other, (usually nearthe centre,) the seat of ulcerative absorption. On carefulexamination we find these ulcers in one of four conditions:1, in process of formation; 2, in a stationary condition;3, in a state of over-action; 4, in a healing or cicatrisingcondition. Therefore, the aspect that any particular ulcer mayput on, will depend partly upon the stage at which we happento examine it, partly upon the .degree of inflammatory actiongoing on in the conjunctiva, and partly upon the constitutionalpowers of the patient. An ulcer of the cornea during itsformation and progress may present an excavation of a circularor irregular shape, with defined edges, and often perfectlytransparent, as if a portion had been cut, or punched out, ortranspareht at one part, and opaque at another. In strumousulcers there is usually a considerable deposit preceding andaccompanying the process of absorption, resembling in thisrespect, a similar morbid action in other parts of the body.When this is the case, it requires some experience,and some careful observation to make out whether suchan ulcer is forming, or filling up. The time it has existed,and the appearance of the opacity will assist the diagnosis.If it be recent, and in process of development, the opacity israther deep, round, white, and well defined; whereas, duringthe healing process, the opacity is thinner, less defined, andmore delicately shaded off. The ulcerative process may bearrested at any point, or may proceed until it has penetratedthe entire substance of the cornea, giving rise to a small herniaof the elastic tunic, and when that yields to a hernia of the iris,again, it may form a very slight abrasion, scarcely perceptible,or a deep excavation. It may be situated at any part of thecornea, most commonly near the centre, particularly the glassyulcer; but it may invade the margin, especially in purulentophthalmia, as I mentioned in describing that disease.An ulcer sometimes attacks both surfaces of the cornea,

leaving the central layers unaffected. One result of thiscurious affection is the occurrence of hypopion, or pus inthe anterior chamber. When the ulcerative stage has ceased,the subsequent progress of the case will vary very much, andwill be regulated by the state of the system and the amount ofconjunctival inflammation, to which the ulceration owes bothits origin and its continuance. If the general health be goodand the case well-managed, the ulcer will be observed to begradually filled up with opaque lymph, until it reaches a levelwith the surface, when it will rapidly and perfectly heal, leavinga dense white cicatrix. In some rare cases I feel quite satis-fied, from personal observation, that ulcers heal with transpa-rent material; in others, when the ulceration is extensive, butshallow, it may heal over transparently, without filling up, soas to leave a flattened surface very detrimental to clear oraccurate vision. I have had cases of this kind in my ownpractice.When the general powers of the patient are at a very low

ebb the ulcer will remain in a glassy, transparent state, with-out any appreciable change of form or depth, for a consider-able time. The symptoms are usually, in such cases, verymild, and the conjunctiva but slightly injected; its veryexistence is often overlooked, and even to an experienced eyeit is only visible when the light falls in a particular direction.

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This state of things is generally found in feeble, ill-fed people,particularly in children, not, however, of a strumous diathesis.It may be not inappropriately termed the "starvation ulcer."

AgcÜn, we find cases that are in all respects the antithesis ofwhat I have just described; here the reparative process is.carried to excess, the conjunctiva is highly injected, thesurface of the ulcer instead of being excavated is raised some-what above the natural level of the cornea, and one or twovessels, carrying red blood, may be distinctly seen passing overthe cornea to the lymph, filling up the ulcer. There is also,in such cases, a considerable amount of infiltrated opacity fromdeposit between the laminx of the cornea surrounding theulcer. There seems, in such cases, to be a false membrane,organized with red vessels, overlaying the ulcer in the cornea,and analogous to the membrane found after ulceration ofcartilage, and supposed, by the late Mr. Aston Key and z,

others, to be the cause of ulceration of this tissue, though nowknown to be the result. The usual condition, after an ulceris healed, is a dense white opacity, gradually shaded off intothe transparent cornea, the centre being the cicatrix of theulcer, and the margin interstitial deposit. The former isindelible but capable of diminution by a slow contractileprocess, the latter is capable of being absorbed. Each stageand condition that I have described requires some modificationof treatment, which will be dwelt upon in the next lecture.

CLINICAL AND CRITICAL CONTRIBUTIONS TOOBSTETRIC SCIENCE AND PRACTICE.

BY ROBERT BARNES, M.D. Lond.,MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN-ACCOUCHEUR

TO THE WESTERN GENERAL DISPENSARY, PHYSICIAN TO THE METRO-POLITAS FREE HOSPITAL, LECTURER ON MIDWIFERY, ETC.

I.ON UTERINE POLYPUS; ITS NATURE; EARLY

DETECTION AND TREATMENT.

THE cases I am about to relate, as the foundation for somemore general observations upon the nature and treatment ofuterine polypus, belong to a class not perhaps rare in theiroccurrence, but certainly sometimes escaping recognition, ifnot altogether, at least until long after the most favourableopportunity for treatment has gone by, and when the healthof the patient has been deeply injured. When polypus of theuterus has attained a large size, and has descended into thevagina, it commonly produces such symptoms as call impera-tively for a local examination. A digital exploration of thevagina, carried up to the os uteri, can scarcely fail in clearingup the nature of the case. But when. the polypus is still inthe early period of its growth, whilst it is still so small as notto have emerged from the uterus or the cavity of the cervix,although the most severe local disease and the most seriousimpairment of the constitution may be produced, the causethat entertains this local disease, and continues to exhaust thepowers of nature, may escape detection. One of the cases Iam about to relate supplies an illustration of this position, andpoints to the importance cf instituting a careful examinationof the uterus in every case of local disease attended by symp-toms which cannot be clearly referred to an intelligible cause.The other case not only illustrates the same point in practiceas the first, but also throws a clear light upon the nature andorigin of one form of uterine polypus. I also propose to offersome observations upon the classification of polypi, foundedupon a consideration of their structure; to seek to determinethe means of detecting the presence of polypi in the earlystage of their formation before they have cleared the os uteri;and to discuss briefly the method of treatment.CASE 1.-Catharine B-, aged forty-six, a single woman,

naturally healthy and robust, applied to me at the WesternGeneral Dispensary early in December last. I gathered fromher the following history :-She had menstruated easily, andwithout marked excess or deficiency in quantity, and hadsuffered no serious illness up to the age of forty-four. For thelast two years, however, she has suffered greatly from lumbar,sacral, and uterine pains, a sense of dragging and bearing-down, and pain in the left iliac region, extending down thethighs. All these pains were greatly aggravated at the periodsof menstruation; the flow became more abundant in quantity,lasting for ten, twelve, and fourteen days, leaving her veryweak * In the intervals between the menstrual periods therehas been a leucorrhcea.1 discharge, copious, sometimes gelatinous,sometimes muco-purulent, and sometimes, especially of late,tinged with blood. There has also been pain on passing stools,

and such irritation of the bladder as to give rise to a frequentdesire to pass urine. During the last year her general healthhas been suffering greatly; she has complained of loss of appe-tite, nausea, flatulence, cardialgia, and irregular action of thebowels. She has lost flesh, suffers from headache and giddi-ness. Her feet swell at times; her complexion has becomesallow; she is easily agitated by the slightest cause; any exer-tion produces palpitation, shortness of breath, and exhaustion.All these symptoms have been increasing in urgency within thelast few months. The loss of blood especially has been moreprofuse, frequently passing in clots, and she can no longer dis-tinguish the catamenial periods. The pulse is 90, feeble; thereis marked anaemia. She has undergone various kinds of generaltreatment, but without benefit. No local examination has beenmade.On Dec. 9th I instituted a careful examination. The toucher

caused great pain; the cervix was somewhat enlarged, lowdown in the pelvis, smooth and round; the os was open so asto admit the tip of the finger; in the centre was felt a softrolling body, of the size of a large pea; it did not project as faras the os. I at once recognised a small polypus. The speculumwas then used, and the cervix was seen to be highly inflamed;the internal surface of the os and the cavity of the cervix, asfar as it could be exposed by opening the valves of the specu-lum, was also intensely inflamed, a copious muco-purulent dis-charge escaping. The body which had been previously feltrolling under the finger was seen in the middle of the os; it didnot project so far as the margin of the os, and might haveescaped observation had not a bivalve speculum been employed.The appearance exhibited by the tumour when seen at thistime is represented in

FIG. 1.

I applied the solid nitrate of silver freely to the os andcervix, and admitted her into the Metropolitan Free Hospital,in order to remove the polypus.On the 16th, an examination was made; the inflammation

was diminished, but indications of approaching menstruationobliged me to defer the operation. By rest, astringent injec-tions, and salines, the inflammation subsided still more; but onthe occurrence of menstruation the loss of blood was great,and the inflammation returned. When the catamenia ceased,I again applied the nitrate of silver, and prescribed astringentinjections.On the 26th, the inflammation being in my opinion sufficiently

subdued, I removed the polypus by torsion, having first drawnit gently out of the cavity of the cervix, so as to enable myselfto grasp the pedicle firmly. When thus drawn out of thecervix it was found to consist of three lobes, and was very softand red. The operation was attended by a trifling loss ofblood, but some pain. On the second night after the operationsome hysterical excitement appeared; the pulse was 110; shecomplained of acute spasmodic pain in the region of the womb,with bearing-down; there was a moderate degree of febrilemovement, with sickness; a distressing cough came on.On the following day a small clot came away, and the symp-

toms were relieved, excepting the pain. Pressure behind thepubis seemed-to-cause pain, and she complained of great sore-ness on sitting up. By the use of emollient injections, seda-tives, with hydrocyanic acid, she got gradually better.On the 2nd of January, all febrile excitation having subsided,

as well as symptoms of acate inflammation, I ordered hermineral acids and lead inje ;tions.On the 9tb, an examination by speculum showed the cervix

in a more healthy condition; the vivid injection had faded, andthere was but little discharge from the cavity.On the 26th, I added sme tincture of iron to the mineral

acids. She had now recovered tolerable health; her appetitewas good; she could walk about without pain; the bearing-down had disappeared; the leucorrhaea was almost gone; shefelt strong and well. On examination now the os was foundperfectly natural, and the womb had ri3en to its proper placein the pelvis.