5

contraction in the muscular coat of the artery; and it is only asmaller and more transient degree of that anaemic atrophywhich the action of secale or any other morbid obliteration ofthe arteries might more permanently produce.No doubt it is by diminishing the access of nutrition to the

elements of an organ, that pressure acts so remarkably in pro-ducing atrophy. It not only, in all probability, quickens thewaste and removal of a tissue, but hinders it from being re-paired again. See, for instance, how the presence of an aneu-rism or other tumour causes the successive atrophy of the tis-sues against which it presses; and see, in a cirrhotic liver, orin a lung after pleurisy, how the contraction of fibrin willoperate in arresting the growth, and finally producing thestarvation of the part which it invests.But why do I say that, in these cases the pressure acts

doubly-quickening removal and hindering reparation ? Forthis reason, that if it only quickened the removal of the tissue,there would be hypertrophy for the consequence. Atrophyonly results from pressure when this is uninterrupted; and ifyou remit the pressure at intervals, you get hypertrophyinstead of atrophy as the result; because you then reducethe case to the analogy of those already described ; yourender it a case of simply increased waste in the part, whichis compensated for by an increased growth. Thus, instead ofa tumour pressing on bone, let a surgical apparatus pressthere-one which is discontinued at night-and you gethypertrophy as the result. " In Mr. Cheshire’s apparatusfor weakness of the spine, the weight of the head and trunk isthrown upon the h2.unch-bones and chin. A steel hoop restsupon the ossa ilii, from the middle of which a rod rises verti-cally behind the spine, higher than the head, over which itarches, terminating in a hook; a strap passing beneath thechin of the patient is suspended to the hook. In those withwhom this instrument has been used, the lower jaw, havingto sustain unusual pressure, generallv enlarges, throwing outa bony swelling at the part where the chin-strap tells."* OrI may give you a still more familiar instance of the influenceof remission on the effects of pressure, in reminding you of thepathology of corns. They are a hypertrophy of the cuticle,arising in intermittent pressure. Let that pressure be conti-nual ; as, for instance, on the foot of a man, whose fracturedleg has been put up in a slovenly manner; and the pressure,instead of making the skin hypertrophy, and producing acorn, atrophies it, and gives an ulcer.

I must not leave the subject of hypertrophy and atrophy,without alluding to those changes in consistence which so fre-quently accompany them - to hardening, namely, and to

softening. But these are so often compound processes, thatmy present notice of them may be brief. As a general, butby no means an invariable rule, hypertrophy is accompaniedby some solidification of the tissue, and atrophy (as I haveshown in the brain and kidney) with some rarefaction or

softening. For as a general rule (and I must repeat that ithas important exceptions) the larger outlines of an organ arethe last to alter: atrophy and hypertrophy are essentiallymolecular operations; and so the one diminishes, or the otherincreases, the number of molecules in a given area before thearea itself becomes wider or narrower. Before a muscleshrinks visibly with atrophy, you would find its specific gravityreduced, showing that its tissue becomes less in concentrationbefore it becomes less in size; and so with hypertrophy,before the muscle perceptibly swells in volume, you wouldfind its specific gravity increased as the evidence of greatermolecular accumulation. ’

The most striking exception that occurs to me is in respectof secreting surfaces-not glands, for they follow the rule Ihave just stated, but in respect of simple membranes wheregrowth takes place on a free surface. Here, as you mayespecially see on mucous and synovial surfaces, an overgrowthof epithelium is very generally accompanied by a softenedand almost diffluent state of the product. And, to give you a ’’,different sort of exception, there can be no doubt that many ’iatrophied organs ultimately become hard from absorption of z,their fluid matters and collapse of their fibrous tissue. Thus ’,I have already noticed the contraction and hardening whichensues in the last stage of Bright’s disease, when all the Iefficient parts of the kidney have perished, and the fibrousdensity of a breast which has never exercised its functions, or IIhas long ceased from their exercise. Other changes in con- isistence depend chiefly on serous infiltration, more or lessthan natural, between the constituent elements of a part;such, for instance, as we see when the brain or the lung is

* Mayo’s Outlines of Pathology.

rendered cedematous. Or softening of an organ may dependon the diffusion of pus through its textures; or hardening maydepend on the copious infiltration of fibrin, or on the depositof earthy material in its substance. Or either may depend oncertain post-mortem changes; such as the hardening of musclewhich occurs in the rigor mortis, or the softening of themucous membrane of the stomach and intestines after deathfrom the presence of a free acid in them.But all these are topics which do not now press for con-

sideration.

NOTESFROM

A Course of LecturesDelivered at St. Thomas’s Hospital.

BY GILBERT MACKMURDO, ESQ., F.R.S.,SURGEON TO THAT HOSPITAL,

AND TO THE ROYAL LONDON OPHTHALMIC HOSPITAL.

(Reported by his Son.)

LECTURE VII.

Corneitis ; its Results, and Treatment.

GENTLEMEN,ņWe have to consider, this evening, the differentaffections of the cornea, and their treatment, together withthe results of inflammation in this all-important fibrous tissue.When I first briefly described to you the anatomy of the eye,I mentioned the laminated texture of the cornea, and that itwas described as being covered, anteriorly and posteriorly,by peculiar elastic laminae, and also in front by the epitheliallayer of the conjunctiva, and behind by that which has beenmore recently described as the epithelial layer of the aqueoushumour. I also told you, that anatomists differed -on these

points, and particularly as to the existence of this so-calledaqueous membrane, which had been for some years describedas lining the two chambers of the eye, and passing in frontof the iris. If you read the excellent lectures on this subject,published by my friend, Mr. Bowman, you will be well repaidfor your trouble. You will there observe, that what usedto be termed a hernia of the aqueous membrane, projectingthrough an ulcer of the cornea, is now stated to be the

posterior elastic lamina, presenting the form of a pellucidvesicle, and preventing, for a time, the escape of the aqueoushumour, and subsequent prolapse of the iris; but as it is notmy province to enter into minute anatomy, I shall contentmyself with again referring you to these interesting lectures,and now proceed to my subject. ,

The cornea very often suffers during attacks of ophthalmia,affecting the conjunctiva and sclerotic, as I have already hadto point out to you. We find it, under different circumstances, "covered with phlyctense or pustules, or suffering from ulcera-tions, or loaded as it were with pus between its lamellm afterlong-continued rheumatic or catarrho-rheumatic ophthalmia.Also suppurative inflammation of an acute or a chronic cha-racter may attack this tissue; but, more generally, corneitisis chronic in its character, and occurs most frequently inscrofulous subjects. The patient complains of a mistiness of £vision, with a dull and intermittent pain, and much tendernessof the whole eye, particularly at night. At first the corneais dull, hazy, and greyish; this is often only partial, and Ihave seen it without any pain being complained of by thepatient. In a farther stage, the conjunctival and scleroticvessels are injected, and each set present their peculiar anddifferent characters-those of the sclerotic exhibiting a circleof a brick-dust or lake colour around the cornea; and theconjunctival vessels, being also filled and distended, have pre-sented sometimes even bright red patches over the scleroticas they passed towards the cornea. Sometimes the vascularityis so great, that the appearance has been likened to red cloth(pannus); but this only occurs in protracted cases, and thenthe intolerance of light and epiphora become excessive. Wevery generally observe small rounded or oval opake spotson different parts of the cornea,-it is the epithelial layerw,hich is particularly affected,-and the appearance has beenwell compared to the effect which would be produced bytouching this tissue all over with the point of a pin, or it may

6

appear as if it were covered with fine sand; in other cases prevent the iris forming any unnatural adhesions, and to renumerous depressions are seen on it. The proper smoothness lieve, in some measure, the dull, aching pain which occurs inand polish of the cornea is temporarily lost, or lymph may be these cases. I have occasionally seen vesicles on the cornea,deposited in various quantities, and then the opacity is more -the epithelial membrane is raised, and a clear fluid is con-dense and white. We find as the case advances, the photo- tained between it and the cornea; the patient complains of se-phobia increases, from the sclerotic becoming implicated; vere pain, and of feeling generally unwell: they will not beargeneral headach and more pain, and a sensation of tightness active treatment. If we correct their secretions, and orderin the eye, with some fever, are complained of as the case them to take a warm bath occasionally, we shall do more forproceeds, although very generally the progress of the inflam- them than by any local applications, although we are alwaysmation is slow and tedious, and the constitutional symptoms expected to order some topical remedies. A peculiar form ofare not strongly marked. In cases of long standing, the inflammation of the cornea also occasionally accompaniescornea occasionally becomes conical, and the anterior chamber puerperal fever: the eye is very irritable, and the conjunctivais distended by the increased secretion of the aqueous humour. much injected with blood; there may or may not be simulta.-As in strumous ophthalmia, so in corneitis, the young are the neously rheumatic or catarrhal symptoms present; numerousmost liable to be attacked, and particularly young females little vesicles arise on the conjunctiva; very soon the corneawho are harassed by irregular and defective menstruation, is severely affected, and agonizing pain in the globe and orbitor those who suffer from cutaneous disease, and these patients is complained of; suppuration quickly follows between thewill be thus affected after exposure to damp or cold. laminae of the corneae, and the matter will find its way intoWith regard to treatment, our first purpose must be to the anterior chamber, and occasion hypopium; great debility

relieve the sufferings of the patients, and to arrest the deposi- and lassitude precede and accompany this affection, also it oc-tion of lymph and subsequent adhesions; but we have to bear curs frequently during prolonged lactation. A nourishingin mind the peculiar constitution of such patients, and we diet, some medicines, and slight counter-irritation, togethertherefore administer mercury with great care. A few leeches with the removal of the child, if the party is suckling, are theare sometimes necessary, but not often. The hydrarg. c. proper treatment. When a conical abscess bursts posteriorly,creta, with the compound antimony powder, may be given in we see generally a prolapse of the iris: this may protrude en-the proportions indicated by the condition and age of the pa- tirely through the cornea, if the anterior laminae are also de-tient. General diaphoretics, Dover’s powder at night., with stroyed, or it may remain as a partial prolapse, in which casewarm pediluvia. Sometimes it is advisable to affect the the aqueous humour does not escape. The iris then becomes

system rapidly with mercury; and at other times the case will adherent at the one point to the cornea, and the pupil will benot bear this medicine at all, until the powers have been closed or not, accordingly as different parts of the iris havesomewhat sustained. The barks, with bitter infusions, in one advanced towards the opening in the posterior part of theset of cases, and steel in some of its varied forms, in others, cornea. It is in these cases, as also in the posterior ulceration,will be required, and generally at once-that is, if the case is that belladonna, freely applied, seems to be very instrumentalof the chronic form, and if there are not any acute inflamma- in saving the eye, and in keeping sometimes the iris quitetory symptoms present. I have tried iodide of potash, but away from the opening in the cornea. If, however, therehave not generally liked its effects in these cases. I men- should be much destruction of the cornea throughout itstioned that we sometimes see, in protracted cases, an increased laminse, the aqueous humour will escape, the iris will protrude,convexity of the cornea, and the patient becomes myopic; also and adhesions will be formed, and permanent staphylomatousI said that suppuration might occur of an acute or chronic prominences will remain: but of this part I shall have tocharacter. The first form is generally traumatic, and I have speak again in discussing the affections of the iris.known accidents, apparently very trivial, set up acute corneitis, In some few cases the chronic abscess of the cornea will offollowed by suppuration and destruction of the organ. The itself burst anteriorly. If this takes place in a favourableSymptoms are those of general and acute ophthalmic pain, point, and not opposite the pupil, the eye may be saved by judi-heat, intolerance of light, a sensation of tension of the cious support, and the avoiding all depletion. I have seen thisglobe, swollen and firmly-closed lids, great vascularity of the occur without the patient being aware of it-a convincing proofconjunctiva and sclerotic, the cornea dull, and there may of the absence of severe pain or excessive action. That whichgenerally be seen a dense white or yellowish spot. I need is usually spoken of as hypopium, is the presence of pus in thescarcely tell you, that this condition requires immediate and anterior chamber; it generally arises from affections of the irisvery active treatment, and occasionally it becomes absolutely or cornea, and is mostly situated at the bottom of the chamber,necessary to puncture the cornea, and let out the interlaminar and if we change the position of the patient’s head we see thepus, which has by its pressure caused the greatest suffering to matter shift its position also, and it will still present a cre-the patient; but the sight is seldom preserved after such scentic form, with its convexity downwards. This is the caseoccurrences. I had recently a young lady under my care, only where the matter is quite fluid, but as disease goes on, ifwith acute corneitis. She was of a strumous habit of body, unchecked, the chamber will be more or less filled with pus,and excessively weak; yet she had all the symptoms of the which is then thicker, less moveable, and does not gravitateacute form of corneitis, apparently having arisen from expo- with the inclination of the head sideways. In some instancessure to cold. She had previously lost one eye under a similar we observe, as the result of slow inflammatory action, depositsattack, treated antiphlogistically, and I thought it right at of earthy matter in different parts of the cornea; these areonce to pursue a different course. I gave her a single grain of various as to number, and they differ much in size, and appearcalomel and five grains of Dover’s powder, at night; bark first, like so many elevations. I have seen them accompanyingand then steel; slight counter-irritation and warm pediluvia, corneitis, with ulceration of a low character. The late Mr.tonic ale and the most nourishing diet, and her eye, which Tyrrell first drew my attention to the fact, and as it had beenhad been considered to be in a hopeless condition, very considered that they were the results of the application of thesoon began to improve. She has now a clear cornea and saturnine lotion leaving deposits in the eye, we treated suchgood vision, although, when I first saw her, there was a con- cases at the Ophthalmic Hospital for a considerable time withsiderable quantity of pus between the laminae of the cornea. warm water, and we still found that these deposits presentedThe chronic form of suppuration of the cornea takes place themselves. We removed them with a fine needle, and

generally in young scrofulous children, or in elderly persons, washed the eye well, and yet again and again the patient re-and in these often after operations for cataract, or accidental turned with fresh deposits formed. It is when we have gotbut slight injuries to the cornea. I have seen this occur after rid of much of the inflammation, and thereby of a nebulousAsiatic cholera. Onyx is the word generally used when we condition of the cornea, that we observe these deposits. Aspeak of this interlaminar pus when it lies at the bottom of weak solution of vinegar-and-water,or a lotion of very dilutedthe cornea, on account of its similarity in appearance to the muriatic acid, have seemed to be useful in checking this affec-white mark at the root of our finger-nails; and we see this tion. As one of the results of inflammation we have to treatappearance in the chronic form rather than in the acute form ulceration of the cornea, and this may be inflammatory or in-of suppuration of the cornea. The patients thus affected re- dolent, superficial or deep.quire a generous and sustaining diet, and seldom bear any de- The superficial form sometimes embraces a considerablepletion. If the matter continues to increase in quantity, the portion of the surface-it often results from slight injuries,corneal laminae become more separated, ulceration takes and occurs generally in weak and rheumatic persons. Theplace towards the posterior surface, and the matter falls into deep ulcer is circular; it penetrates through the laminae onethe anterior chamber, and forms what has been termed a by one, and presents a funnel shape, and if unchecked, thefalse, in opposition to the true, hypopium, which I shall here- aqueous humour will escape, and staphyloma will result;after describe. It is important in all these cases to apply the edges are ragged, and of a dull, greyish colour, but some-the extract of belladonna freely around the eye, in order to times perfectly clear; its other characters will depend much

7

-on the strength of the patient; for if there is much power,there will be a corresponding inflammatory action, numerousred vessels will be directing their blood towards the ulcer orulcers, (for there may be several,) and any lymph that mayhave been effused will be opaque and red; whereas, on theOther hand, if the ulceration has occurred in a weak indi-vidual, it is termed indolent; no lymph or red vessels will beseen, and there will be an appearance, as if a portion of thecornea had been cut out, and there had been left only clearcut surfaces, of various shapes. These two extremes call for

opposite plans of treatment; but you may also see a patientwith an ulcer on the cornea, which presents neither of thesecharacters, and which will not require active treatment ofeither kind; there is in such a case a slightly nebulous conditionof the ulcer, and a moderate effusion of lymph in it, sufficientfor its reparation, or there may be only one vessel passing toit. I need scarcely tell you that these three forms of ulcera-tion indicate for themselves totally different treatment; forthe inflammatory and deep ulcer, moderate antiphlogisticremedies; for the indolent ulcer, tonics must be given, withappropriate alterative medicine,in accordance with the peculiarcondition of each patient; for the third form, very little is neces-sary. Nature is here working her part well, and we mustnot check the healing process by stimulus on the one hand,or depletion on the other. The cornea of patients of a stru-mous constitution, who have repeatedly suffered from low in-flammation of the cornea, will in after life present a curiousappearance, as of a crystal bevelled off at several points;these parts are generally quite transparent; pustules had ex-isted in some, indolent ulcers in others, and I have generallyobserved that their vision is not correct.In acute cases of ulceration, warm fomentations with or

without poppies relieve the sufferings of patients considerably;but where there is not much increased action, weak solutionsof the sulphate of zinc or copper, or nitrate-of-silver drops,or even the bichloride’of-mercury lotion, of which I haveoften spoken to you, will each in their turn be useful. I havefrequently watched patients for a considerable time, who hada hernia of that which we have generally called the aqueousmembrane, but which is now said to be only the posteriorelastic layer of the cornea; and I have known the eyes ofelderly feeble persons presenting this appearance for somemonths. We have given them every kind of support, medicinaland dietetic, and we have simultaneously applied astringentlotions. In some cases, after a lengthened period, a littleaction has been set up in the cornea, and some lymph hasbeen effused, and the ulcer has gradually healed, so that theeyes have been saved; but in others the protruded laminahas at length yielded, and prolapsus iridis and synechia tovaried extents have occurred. One case which had interestedus much at the Ophthalmic Hospital proved the great powerof resistance that this elastic lamina possesses. An oldwasherwoman was treated for this hernia for many months;notwithstanding all our efforts, we scarcely gained any ad-vance towards a healing process, and we were accustomed topoint out the case to the pupils as one well worthy of theirattention. At length (and certainly six months had elapsed),a slight haziness was seen, and a little lymph was apparent.Now we thought we had at last triumphed by our perse-verance ; everything promised well, and we thought the eyewas safe, when, lo! one morning the poor woman was led upto mv desk, having had a severe blow on the forehead by thehandle of her mangle; the eye itself had not been struck, butthe mischief had been effected; the membrane had given way,the aqueous humour had escaped, and the iris presented itselfin the opening in the form termed myokephalon, inasmuch asit resembled the head of a fly. Thus she lost her eye, and weour interesting case. When this prolapse occurs, if the irisdoes not seem likely to advance farther than it has at oncedone, adhesive inflammation is quickly set up, and the ulceris healed, under soothing applications at first, and astringentones afterwards; but if the iris is inclined to protrude in alarger mass, it is better to touch it with the fine point of apiece of lunar caustic. This, however, must be done withcare and delicacy, and it is always better to avoid applying itif there is any possibilitv of doing without it.

I cannot too often impress on your minds the importance ofbelladonna in these cases; I mean, before any adhesive inflam-mation has been set up: it will, if possible, keep the iris apartfrom the cornea. Sometimes we have to treat sloughingulcers under various degrees of power, and each case will re-quire treatment varied accordingly. When I speak hereafterof injuries inflicted on the eye, I shall have to draw yourattention to the supposed power of the anterior elastic lamina

of the cornea, in holding firmly beneath it small foreign bodies,such as particles of iron, &c. &c., which had penetrated it, butwhich appeared to be lying quite on the surface of the cornea.A case has lately occurred, in which, after the cornea hadsloughed, the lens had remained in situ; as also the iris, whichhad become covered with yellow exudation at its outer part,but at the part nearer the pupil it retained its proper colour,but it was conical, being pushed forward by the lens, whichcontinued transparent. The case was under Mr. Bowman’scare. The iris became gradually covered with more lymph,and also the capsule of the lens; the healing processes gra-dually advanced, and the patient at length recovered. Rarely,but sometimes, we have to treat ulceration of the sclerotic:these ulcers occur in persons of low power, and must betreated accordingly.As results of corneitis, one often sees opacities of different

kinds as to their situation or density generally, but not always;the cicatrix of an ulcer is more or less opaque, but after in-dolent ulcers have healed, and when the process has beenslow, I have often seen the cornea quite clear, but it has notpreserved its proper shape at the parts where the ulcer hasbeen situated. We may have deposition of new matter, anddifferent names have been assigned to the different forms.Thus we speak of nebulse, speck, albugo, leucoma, &c.: the twofirst are superficial and slight, and result from a low degree ofinflammation; the third form, albugo, is generally used toexpress the result of effusion of lymph into the cornea; thefourth, leucoma, is more dense and less diffused than albugo;this last term is often given to the opacities after ulceration.The slighter forms will generally disappear during the treat-ment of the ophthalmia, or soon afterwards, by the use of astrin-gent lotions. Very varied applications have been used for thedense forms of opacities, and generally without much success;some of them have no vessels running towards them or overthem: in such cases it is self-evident what treatment is required.When the cornea, after partial or entire destruction of itshealthy structure, has become thickened, it presents generallya dense white projecting mass, like a small white marble; inthese cases, of course, the sight is lost; but sometimes theprojections are only partial, or they may be dense at thesuperfices, and clear behind. I shall have to speak in somefuture lecture of the different operations that are practisedfor the relief of patients under these conditions; and it is wellthat it is so, as I have exceeded my hour already. I maymention incidentally, that of late some patients whose caseswould have been considered hopeless have derived greatbenefit by the removal of the epithelial layer in front of thecornea, which had been thickened, and also of a succession offlakes from the anterior laminae of the cornea. This must bedone with great delicacy; the patients complain of considerablesuffering at the time, but in borne few cases their vision hasbeen restored to a useful extent.

[In the heading to our last lecture, (p. 713,) a semicolon is omitted b&bgr;4.tween the words scarlatinosa and variolosa; our readers are requested tqmark in the semicolon with a pen.]

CLINICAL ILLUSTRATIONSOF

CUTANEOUS SYPHILIS,HAVING ESPECIAL REFERENCE TO ITS PATHOLOGY AND TREATMENT.

BY ERASMUS WILSON, ESQ., F.R.S.(Continued from page 528, vol. i.)

IT is no part of my plan to seek out unnecessary distinctions,but where such distinctions manifestly exist, it is the duty ofthe scientific inquirer to observe and to note them. The dis-tinctions of appearance between the corymbose, the dissemi-nated, and the annulate forms of syphilitic lichen are tooobvious to be travelled over without a passing thought, a pass-ing reflection. It would be interesting, as it would be philo-sophical, to discover the cause of their differences; it may lienear the surface-it may be profound. It has certainly ap-peared to me that the differences were not merely confined tothe outward manifestation of the disease, but were also markedin the constitutional symptoms; if such be the case, the obser-vation of the surface would lead to deeper results, indeed tothe great end of all our pursuits and investigations to simplifytreatment and facilitate cure; to accomplish the heavenly shareof the duty of the medical ministry; to ease pain, and restorethe sick and suffering to health.While my foregoing papers have had for their object, at

least in principal part, to mark certain points of distinction