No. 1604.

MAY 27, 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 IV.

PU1’lÛent ophthalmia; symptoms; local ; results; measure ojseverity>’ treatment; fornaer laras; Mr. Tyrrell’s plan>’question of stimuli reasons for anxiety; constitutionaltreatment; question of mercury>’ tonics; case in point.PunÛent ophthalmia in infants>’ symptoms; si1n’ilar to

adults; measure of intensity; cause of loss of sight ; tI’eat-

1nent >’ local; successful if properly applied ; great import-ance of early and suitable treatment.

GENTLEMEN,—We pass by a very natural and easy transitionfrom the catarrhal to the purulent form of ophthalmia, forthough this latter is a most formidable disease as compared tothe former, the difference Ïs rather in degree than in kind. I

propose to class together purulent and gonorrhoeal ophthalmia,because I am not awafe of any important practical distinctionbetween the two, either as regards the symptoms or thetreatment. I will consider this disease, in the first place, asit is found in adults; and secondly, as it occurs in infants.The early symptoms very closely resemble catarrhal ophthalmia;one eye is primarily affected, and if the disease is the result ofgonorrhoea, it is often limited to the eye first attacked; itcommences in the conjunctiva lining the palpebrae, and rapidlyspreads to the ocular conjunctiva; the eyelids become of abright-red colour, much swollen, and closed; escaping frombetween the lids is some thick yellow pus, which flows outreadily and abundantly when the lids are separated. Thein ocular conjunctiva is swollen, infiltrated with serum, or

th1’! more severe cases with lymph, so that the cornea seemsburied and partly overlapped by its elevated margin, givingrise to that symptom known as "chemosis."

" Blood, as wellas serum, is extravasated beneath the membrane; this symp-tom is termed" ecchymosis." The condition I have now

’’

described may be very rapidly developed, even in as short aspace as twenty-four hours, or it may occupy some days.Generally about the third day the second eye becomes affected,and pursues the same course, though usually in rather a milderform. As the disease progresses, the cornea becomes involved,its surface appears hazy, then the layers are infiltrated withpus, become gradually disorganized, and give way; in lesssevere eases the cornea rapidly ulcerates, the ulcer usuallycommencing round the margin of the cornea, and graduallypenetrating its substance; the cornea then gives way, the

aqueous humour escapes, the iris and lens fall forward into theopening, and staphyloma is the result; the globe becomesflaccid; the swelling diminishes; the redness becomes of adeeper colour, and the disease rapidly loses its intense cha-racter, the integrity of the organ having been the price paidfor the subsidence of this truly formidable disease.During the development and acme of purulent ophthalmia

the pain is of a very severe and distressing character; there isintense burning and tension of the globe and eyelids, with con-stant irritation, as if a foreign body were in the eye, succeededby deep-seated throbbing, as if the eye would burst. These

symptoms are usually attended with considerable constitutionalirritation, a foul tongue, loss of appetite, dry skin, &c., andoften exhibit themselves in their most violent form in person.whose powers have been impaired by previous illness or intem-perate habits. With regard to the cause of purulent ophthal.mia, it is essentially a disease of hot climates, where it is verycommon and very destructive to sight, and where it probablyarises from some atmospheric poison, and spreads by contagion.In the years 1800-1-2 our troops suffered severely from thisdisease in Egypt, from which circumstance it has been calledby some "the Egyptian Ophthalmia."

" Those who wish fullyto investigate the history and symptoms of this disease, as ithas appeared at different epochs and in various localities, andas it has spread blindness and consternation through bottarmies and navies, will find an admirable digest of the subjectin Mr. M’Kenzie’s elaborate and most comprehensive work orDiseases of the Eye. My object is to confine myself as exclu-sively as possible to practical details, and to abstain from

digressions, however curious and interesting. In this countrythe cause of the severer forms of the disease is the contact ofgonorrhoeal matter; it may also arise from the accidental in-trusion of matter from an abscess, an instance of which cameunder my own observation in the case of a medical man; itmay result from atmospheric influence in a constitution proneto its development; also from severe injury to the eye. Symp-toms very closely resembling those I have now described occa-sionally follow the operation of extraction. It must not besupposed that the disease always produces the extreme resultsI have mentioned; it may be arrested at any stage, and theresult, though usually more or less damaging to the eye, is re-gulated by the period at which the disease is checked. Thusit was found that the epidemic which committed such ravagesin the army in Egypt did not in the onset always involve anyother structure but the conjunctival membrane. The result ofthis severe and protracted form of inflammation was in mostcases found to be an alteration in the surface, an enlargementof the villi, and a condition to which the term " granular con-junctiva" is applied. This becomes a serious and constantsource of irritation to the cornea; by degrees its surface be-comes dull, and covered with red vessels, and thus a "vas-cular opacity" of the cornea results, seriously interfering withvision, and giving rise to more injurious consequences than thepurulent attack in its early and acute stage. Many of oursoldiers were invalided and sent home in this state, and suchcases still occasionally present themselves in this condition atthe Ophthalmic Hospital. In other cases more or less damageis done to the cornea; it not unfrequently happens that oneeye is staphylomatous, and the other presents a dense opacityand adhesion, more or less complete, of the iris to the cornea,leaving some chance of restoring sight through the medium ofan artificial pupil; and a few cases occur in which permanent,hopeless blindness is the result of this disease. The severityof i,he attack may be measured by the extent of the swellingand redness of the lids, the colour, thickness, and quantity ofthe discharge, and the condition of the cornea.We may now consider the question of treatment; as you may

readily imagine, all the most powerful agents,both constitutionaland local, have been brought to bear at different intervals, andby different leading authorities, in the hope of controlling thisdangerous and often destructive disease. Thus, formerly,patients at the Ophthalmic Hospital have been bled to syncope,and as the local inflammation progressed, this operation hasbeen repeated again and again, and, combined with it, anti-mony and mercury have been freely administered, so as toaffect the system quickly and thoroughly; but each and allthese means, though pushed to the utmost that the patientcould bear, were found signally to fail, and rather promoted,on the contrary, the fatal progress of the disease; thus to theloss of sight was superadded more or less permanent damageto the constitution. Free scarification of the conjunctiva, andremoval of portions of the chemosed membrane have been re-commended ; local stimuli in their several forms have beenemployed. Thus the solid nitrate of silver has been freely andrepeatedly rubbed over the surface both of the lids and theocular conjunctiva. The late Mr. Tyrrell, whose early ex-perience of this disease was very discouraging, was during thelatter period of his life strongly of opinion that the loss ofvitality in the cornea was due to mechanical pressure upon thevessels from the chemotic condition of the conjunctiva. Actingupon this hypothesis, he recommended and frequently practisedthe free division of that raised portion of the conjunctiva sur-rounding the cornea. This he effected by means of a series ofincisions with an ordinary cataract-knife, radiating from thecornea towards the circumference of the globe in every direction,placing the back of the knife on the surface so as to divide theconjunctiva without injury to the cornea or sclerotic. In this

way he believed that he relieved the circulation of the part,and allowed the cornea to receive its usual nutrition, and re-cover its threatened vitality. In his truly practical andvaluable work, he cites some remarkable instances in whichthis treatment was attended with very marked success in hisown practice, and where he was able to stay the progress of thedisease just at the critical moment when vision was in eminentdanger. The correctness of the hypothesis seems very doubtful,and the treatment founded upon it has not been so successfulin other hands as the experience of its originator might haveled us to hope and expect.

After all that has been done and written on the subject of thisformidable disease, I believe all surgeons of experience mustfeel, in undertaking the treatment of such a case, muchanxiety, and many misgivings in regard to the result; theprogress of the disease is so exceedingly rapid, and the delicate

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transparent cornea so soon damaged, that it can rarely sustainunimpaired such acute inflammation of a membrane in its im-mediate vicinity, and from which some portion of its vitalityis derived. As I am unable to tell you how this disease canbe cured, I have dwelt somewhat upon the various methodssuggested for its relief, and I will now endeavour to indicatethe principles upon which the treatment should, according tomy own views, be conducted. We may consider the subjectunder the two-fold aspect of local and constitutional means.As the disease may arise from purely local causes, the localtreatment assumes considerable value and importance. The

plan I adopt when there is extensive chemosis, and swelling ofthe lids, and the cornea is threatened, is, in the first place,freely to divide the membrane by the method recommendedby Mr. Tyrrell, and, in addition to this, to endeavour to re-lieve the distended vessels by the application of leeches to theswollen lids. I also keep a piece of lint, dipped in cold water,constantly applied to the surface of the lids, and I direct astrong solution of the nitrate of silver, varying from five to tengrains to the ounce, to be dropped between the lids everyhour, or every two hours, as the patient can bear it. I thinkit verv important that the discharge should be carefully re-moved previous to the insertiun of the drops, so as to ensuretheir getting into contact with the surface of the membrane ;this can be best accomplished by means of a syringe and alittle luke-warm water; if the nitrate of silver occasions greatpain some other astringent may be advantageously employed;the sulphate of copper may be brushed over the surface, or astrong solution of alum may be substituted; but I place morereliance upon the nitrate of silver than on any other localmeans. If there is an ulcer threatening to penetrate, a finely-pointed piece of the nitrate of silver may be often advanta-areouslv aodlied to the ulcerating surface.As regards constitutional treatment, I am of opinion thatinternal remedies exert little or no influence over this form ofdisease, and certainly have no specific powers of controllingit. Mercury I have seen freely exhibited so as to produce itsfull constitutional effect without any benefit ; and in as far asit enfeebled the system with manifest detriment, all the mostsevere and rapid cases that have come under my observationhave exhibited symptoms of feeble power ; and although thecharacter of the poison is no doubt an important circum-stance in estimating the virulence of the disease, the condi-tion of system exerts no modifying influence. I should there-fore advise that while the vessels or the part are relieved bylocal depletion, the system be sustaineci in every possibleway. Tonics and diffusible stimuli must be freely administered.Decoction of bark with carbonate of ammonia, or a combina-tion of steel with quinine, in full doses, taking care at thesame time to act freely on the bowels. The diet must at thesame time be liberal and even stimulating-a full allowanceof good fresh meat and at least a pint of porter daily. Asthis disease may be the result simply of local contagion, ofcourse it is liable to occur in strong and plethoric persons,to whom the above remarks would not apply ; but even insuch cases, I should not advise general depletion, a healthycondition being that most favourable for the action of thoselocal means upon which successful treatment must mainlydepend. A case came under my care at the Ophthalmic Hos-pital some months ago, that so strongly illustrates and con- 1firms many of the above remarks, that though I am, as a gene-ral rule, unwilling to insert cases into these lectures, desiringthem to be regarded as the impressions left on my mind by alarge aggregate rather than as influenced by any solitary case,yet I am tempted to give it, because the disease I have beendwelling upon is fortunately so rare in this country that weare compelled to form an opinion upon very limited data.The young woman whose case I propose briefly to detail, had

lost her left eye during infancy. When I first saw her she hadbeen suffering for five days from a very acute attack of puru-lent ophthalmia in the right eye. The symptoms were in allrespects well marked ; the lids were much swollen and of abright-red colour, and closed ; the discharge was thick, yellow,and abundant; the conjunctiva was in a very chemotic state,and highly injected, and on the lower part of the cornea was alarge irregular ulcer, deep, and with well-defined edges, andnear the centre was a small transparent vesicle, indicating thatat this point the true corneal tissue was ulcerated through, andthat the aqueous humour was merely retained by the innerelastic layer. Collateral circumstances strongly indicated thatgonorrhceal inoculation was the cause of the disease. The pulsewas rapid, the skin moist and cool, the tongue foul but ratherflabby; great pain and restlessness were complained of, andthere was, as might be expected, great mental depression and

anxiety. She stated that she was a needlewoman, that herdiet was usually rather scanty, and that since her eye had beenbad she had lived lower than usual.My impression, on first seeing the case, was most unfavour-

able, and I entertained very slender hopes of saving any sight.In my treatment of the symptoms, I adopted, in all respects,the plans I have recommended above. My first and mosturgent anxiety and attention were directed to the ulcer whichthreatened every hour to penetrate. In the hope of preventingthis, I applied a finely-pointed piece of nitrate of silver to thesurface of the ulcer. I then divided freely the chemosis roundthe cornea in three directions. I ordered the eye to becleansed carefully with a syringe and luke-warm water, and adrop of a strong solution of the nitrate of silver, ten grains tothe ounce, to be put into the eye as often as it could be borne,and wet rags to be kept constantly on the lids : in combinationwith this local treatment I prescribed full doses of quinine, anda liberal meat diet, together with a pint of porter daily. Theresult was in all respects most satisfactory ; the ulcer healedwith a dense large white cicatrix, which obscured about halfthe pupil. The coiijuncti-47fi remained inflamed and villous fora considerable time, but by==means of repeated application ofthe sulphate of copper, this . as at length removed, and a <:on-siderable amount of useful visi was the result. The nitrateof silver appeared to act mos. Favourably in this case; itcaused but slight pain, and rapiu’v diminished the dischargeand the swelling of the conjunctiva and the feeling of heatand grittiness in the eye. The stretch of the solution that Iemployed was ten grains to the ounce -distilled water.We may now briefly consider this disease when it occurs in

infancy. The symptoms are very simila to hose I havedescribed as occurring in adults. but as 1t&Uuml; is bv no meansuncommon in infancy, and if neglected may bq=most destruc-tive to sight, it is of great importance that yt ’should fullyrecognise its leading symptom and understand t ’- principlesupon which it should be treated. This disease " st in-

variably shows itself on the third day after birth; ’. eyp,4are usually affected, though one often more severely 1 tother. The disease has been observed to exist a et LC

after birth, and a week or more may elapse before the dise comes on; but all the really severe cases I have seen have hathree days of incubation. There are two symptoms that manbe selected as a guage of the intensity of this disease as itoccurs in infants: the one is the condition of the lids; the otherthe colour and consistence of the discharge. If the lids are ofa bright-red colour, and much swollen, and if the discharge"is yellow and thick, and very abundant, it is a severe case, butonly in the first stage, and the eye is as yet probably safe; butif the lids appear of a bluish-red colour, and rather flaccid,the disease has most probably seriously damaged the eye.There is often considerable difficulty in examining the condi-tion of the sight in these little patients, on account of theswelling of the lids, the smallness of the palpebral aperture,and the amount and thickness of the discharge. On separa-ting the lids the space is immediately filled with water; thismust be carefully wiped away, and the lids reopened; thismust be repeated until no more discharge escapes, when thestate of the cornea may be ascertained. The rapidity and de-structive character of the disease are regulated by the nature ofthe morbid secretion that has been applied to the eyes, andalso by the constitutional powers of the little sufferer. Someof the worst cases I have seen have been in seven-monthschildren. The investigation of the causes of this disease isalways attended with difficulty, the mother being naturallyunwilling to admit that she has been the cause of her child’sdisease; nevertheless, I feel satisfied, from extensive inquiry,that leucorrhcea in the mother is a common cause of thedisease; and that, in the very severe and rapidly destructivecases that sometimes present themselves, gonorrhoea is thecause. I do not deny that the disease might arise from cold, butI believe this is rare, and that the symptoms are mild.From these remarks, it will be inferred that purulent

ophthalmia in infants varies much in degree ; the modifyingcauses being, as I have already said, the nature of the dis-charge and the constitutional powers of the child. It followsthat if the matter applied be gonorrhceal, and if the child beprematurely born or very feeble, the disease produces its dis-astrous results very speedily. I have, on several occasions,known it to destroy both eyes within a fortnight from its firstdevelopment, and I have known it to exist many weekswithout seriously damaging the eyes. It has been such casesas these latter that have no doubt lulled many nibdical meninto a false security with regard to the result, and into neglectof the case, or the adoption of most inefficient treatment. If

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the disease in its severer forms be allowed to pursue its courseunchecked, the cornea gives way either by sloughing or byulceration, but most frequently by the latter, the iris prolapses,and either the globe becomes atrophied or staphylomatous.In milder cases ulcers form that leave dense central opacitiesthat are often very detrimental to sight. A curious result ofthese cases, even where the cornea remains bright, is a smallcentral white spot upon the capsule, which has probably beenprecipitated from the aqueous chamber during the time thepupil was in a state of extreme contraction. It remains duringlife, but is not detrimental to sight.The treatment of these cases is merely local; it is very

simple, and the result highly satisfactory. All that is requiredis the frequent application of some mild astringent or causticlotion to the surface of the conjunctiva. At the OphthalmicHospital we use a solution of alum, from five to ten grains to theounce; but a weak solution of nitrate of silver answers equallywell, and I think acts more rapidly. The essential point is, thatwhatever is used is well applied to the surface of the membrane.A frequent source of failure is to be traced to the neglect ofthis measure. The remedy has bep-i judiciously chosen, buthas failed for want of being propr ly applied. If a lotion isused, it should be frequently inje ced with a syringe betweenthe lids, so as to wash away thf discharge, and get well overthe surface of the membrane ; drops are used, the eye shouldbe first carefully cleansed. fhis plan of treatment, whenproperly carried out, is a1 iCst uniformly successful. Out ofmany hundred cases tha i have seen, I can scarcely recal asingle instance where si _t has been lost, if the treatment hasbeen commenced sufficiently early in the disease.Often as this plan df treatment has been urged, and unani-

mously as it has ,een agreed upon by ophthalmic surgeons;simple as it is i- its application, and certain in its results, yetpainful exper’ .ce proves that it constantly requires to bereiterated w’ increased emphasis. It is not unfrequentlyour pai "Luty to witness cases of this kind where sight isdamage nd even destroyed for lack of a little practicalknowli of this subject on the part of some of my profes-sional thren. If the despairing aspect and piteous cry ofbut oLe poor mother upon whose mind the sad truth suddenlybreaks in that her child is hopelessly blind, could image itself

to.. The sight and echo in the ears of those members of our pro-fession, it surely would arouse attention to the importance of.evoting a few thoughtful hours and some anxious care to thisdisease. So strongly have I been impressed upon this subjectrhen I have had a case brought to me hopelessly blind, and

have found that it has been under inefficient medical treat-ment, that I have felt that if it were permitted me to whisperbut one short sentence in the ear of every member of our pro-fession that should contain the essence of the greatest good tohumanity with which I am acquainted, the one I would select.in preference to all others would be-" Local stiiauli.37tould be,applied ew’ly, often, and thoroughly to the corljunetival surface&ugrave;. purulent ophthalmia of infants."

THE CHOLERA.

LETTER FROM DR. AYRE, OF HULL, TO THEPRESIDENT AND FELLOWS OF THE ROYALCOLLEGE OF PHYSICIANS.

(Continued from p. 538.)

IN your report there is an extract given from a returnmade by me as medical superintendent to the court of

guardians of two parishes, containing the number of the poorwho came under the treatment of the six appointed medicalattendants, with its results. Of these patients, of whom 725were in full, and 133 in impending collapse, making together858 persons, there were 474 recoveries; and Dr. Gull hascited these numbers as favouring his conclusion that calomel,however given, is inefficient in this disease. But that gentle-mau has omitted, and I presume has forgotten, to give theexplanation which I gave at an interview I had with him-namely, that three out of the six medical attendants declinedto employ the calomel treatment, as I found was noticedin a letter to THE LANCET of that year. To this disad-

vantage as affecting the result, I may add, that being engaged toattend the poor, the medical attendants had not unfrequentlypatients turned over to them in a condition wholly beyond the1!leans of ldief, and when I add that 2038 patients weretreated with calomel for the premonitory diarrhcea by twelvetnp.rlif"Q_l Qf:llilAnt.Q "U7th onlv RpVPTI &egrave;I’:"!t_+hQ Q.TBr1 F.h2f: +}U:lt. +.A+’l

number of deaths in the two parishes amounted to the largenumber of 1432 persons, or 1081 under other modes of treat-ment, it may well be believed that good service was renderedby the calomel, and that no warrant is afforded for the con-clusion to which the author of your report would conduct us.But to proceed. The first outbreak of cholera in this

country was, I believe, at Tooting, in Surrey, and few personscan forget the ravages it committed there. Out of 157 childrenthere were 108 deaths. Twenty-one of the children werebetween the ages of three and five, eighty-four between fiveand ten, and eighty-two from ten to fifteen. To these patientsDr Gull has referred, and informs us that 141 of them weretreated with calomel, (doses and frequency not given,) stimu-lants, ammonia, and brandy, were occasionally administered;the deaths were 80, recoveries 61. In giving this account ofthe treatment by calomel at Tooting, and the fatal resultswhich attended it, there is left to be conjectured what was thedose, and what the time of its repetition; yet the whole ques- .

tion hinges upon these two fundamental points of the treat-ment-the dose and frequency of its administration, andshould have been included in the account. This, however,has not been attended to in the report, and it is therefore incorrection of this most material omission that I must nowfurnish you with some details.The regular medical attendant in the Tooting Pauper

Asylum was Mr. Home Popham, who, in the number of THELANCET, Feb. 10th, 1849, thus writes;-" Dr. Ayre says, thatfor any benefit to be derived frona calomel it must be give;i everyfive minutes ...... I did not experience the same success in its useu.,3 Dr. Ayre, though 1 can readily attribute its partial failug-cto hating givezz the doses at too wide intervals, and I feel con-vinced that had it been administered at shorter intervals,the success would have been much greater. I gave HALF AGRAIN OF CALOMEL EVERY HALF-HOUR, with one-sixth Or one-fourth of a grain of opium, washing it down with a little

brandy-and-water." I shall make no remark upon this

ingenuous account by Mr. Popham, except to recommend toyou the perusal of that gentleman’s entire letter, as calculatedto afford the most important instruction as to what should andwhat should not be done in the treatment of this malady. Inthe cases which I have given from Dr. Shearman, as well asfrom many which I shall presently give, it will be seen withwhat facility the disease is subdued when occurring in children,and how readily they bear the calomel; and, I must also add,how rapid is their recovery, and how little more is needed forit than the calomel when properly administered.The next series of cases to which we come, are of eight

patients admitted into St. George’s Hospital. The details oftheir treatment, with which I have been favoured, are onlyvery briefly given, and accompanied by a notice, that no planwas followed-no limit prescribed. The doses and the intervalsdiffered in every mode, and the adjuvants were very various.The eight patients are incorrectly stated in your report to haveall undergone the same treatment by small and frequently-repeated doses of calomel. Five of these patients died, andthree recovered. The following is the account sent me:-

1. Ten grains of calomel twice, and afterwards two grainsevery two hours. Died.

2. Ten grains twice, and afterwards two grains every half-hour ; chloroform and camphor. Died.

3. Previously astringents; ten grains of calomel twice, twograins every ten minutes; quantity taken not named; chloroformand camphor. Died.

4. Four grains every two hours, with salines and stimulants.Died.

5. Twenty grains of calomel, astringents and morphia. Died.The following are the patients who recovered.1. Two grains of calomel every ten minutes, also with salines

and stimulants. Recovered.2. Ten grains of calomel, followed by two grains every

fifteen minutes, with stimulants. Recovery.3. After an emetic, twenty grains of calomel, followed by three

grains every five minutes; stimulants and warmth. Recovered.By this last patient, as my correspondent informs me,

"thirty-six grains of calomel were taken hourly for upwards oftwenty-four hours, and then continued until the third day atintervals of fifteen minutes. This patient was calculated tohave taken three ounces (1440 grains) of calomel. Prolapsusani, and tenesmus occurred as reaction commenced; but forthe first two days the stools were in a condition of black wash,without producing the least effect. Salivation very slightlyoccurred from it." .On the above cases I need scarcely remark, that the treat-

ment of the five fatal ones in no way resembled mine, and those