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ST. MARY’S HOSPITAL.(OPHTHALMIC DEPARTMENT.)

CASES OF PURULENT CONJUNCTIVITIS IN NEWLY-BORN

INFANTS; METHODS OF TREATMENT;CLINICAL REMARKS.

(Under the care of Mr. ERNEST HART. )THERE is no disorder more commonly met with in the range

of ophthalmic practice than purulent conjunctivitis in infants.And in hospital practice not only is the frequency of the dis-ease very fully exemplified, but the disastrous consequences ofits intensity and of the want of proper attention are witnessedin many cases of total blindness from resulting opaque staphy-loma, where the eyeball itself has become involved in thedestructive inflammatory action.

Several cases are now under course of treatment in the oph-thalmic department of St. Mary’s Hospital, under charge ofMr. Ernest Hart; and the most painful results of some pastattack are seen in a, child admitted under the care of Dr. Alder-son in the Victoria ward for other diseases, but wholly blindby double and complete opaque staphyloma from an attack ofpurulent conjunctivitis, which destroyed both eyes. Mr. Harthad been requested by Dr. Alderson to see this child with theview of adopting any possible means of remedying the totalblindness under which she labours; but he pronounced thecase as wholly and lamentably irremediable. The corneas wereconverted into hard, dense, fleshy masses, through which capil-lary vessels plentifully meandered; and not a shadow of hoperemained of restoring any degree of vision, either by slicing offthese opaque masses (a measure which will in milder casessometimes avail) or by other means.On returning from the wards, and referring to some cases of

purulent conjunctivitis of children in process of cure in theout-patient department, Mr. Hart made some clinical remarks,of which we transcribe the substance.He said that the greater number of these cases were due to

inoculation by blenorrhagic matter from the mother; but. neither on the one hand did every blenorrhagic mother infecther child, nor on the other did the disease arise in childrensolely from that cause. He funy confirmed the opinion whichDr. Thomas Ballard had lately strongly expressed, that the..undue exposure of newly-born infants to strong light was aplentiful cause of the disease. Want of cleanliness was another.,lvloreover the aitection appeared, like other forms ot conjunc-tivitis, to be occasionally almost epidemic. The early symptoms,of the disease were well known to all practitioners. A littleswelling and redness of the lids externally, and of the conjunc-tiva internally, with a gumming of their edges, and an escapeof a lemon-coloured fluid from between them, consisting ofblood-pigment, serosity, and fibrin, diluted with the tears.The swelling and redness increase, and an abundant purulentsecretion soon occurs. Sometimes ectropion ensues from theexcessive swelling of the palpebral conjunctiva. If the diseasebe not successfully combated, corneal complications follow :infiltration at the edge of the cornea, and multiple ulcers; thendeath of the cornea, sloughing and escape of the lens, andstaphyloma. This was the history, Mr. Hart observed, whichmight be deciphered in the blinded and staphylomatous eyes ofthe child in the Victoria ward. But happily these results mightbe considered as very rare and unlikely to accrue, if proper treat-ment were adopted in due time. The disorder usually appearedon the third or fourth day. It was often sufficient at this time,when the lids were just become stiff and congested, to apply acold lotion, which is very well borne ; to see that the eyeswere sponged with tepid water (so that a stream ran under thelids) every hour; and to apply to the edge of the lids with alittle brush the following ointment, the object of which is to

prevent them from sticking together: citrine ointment, onedrachm; olive oil, four drachms; lard to one ounce and a half.At the same time a laxative may be administered. When the

symptoms are more strongly marked, and the purulent secretionestablished, more energetic means must be resorted to. The- use of an alum lotion (four grains to the ounce) every hour,applied beneath the lids by a small sponge or syringe, is a veryuseful measure; and Mr. Hart said that in hospital practice,where he could not count upon seeing his little patient broughtregularly and sufficiently often, and other attentions were com-monly wanting, he had found this treatment by frequent irri-gations with alum-water yield better results and more rapidlyarrest the disorder than any other. Where, however, themother will give proper attention, and in all private cases. he

employed and strongly advised the application of dilute causticpoints to the palpebral conjunctiva, followed by refrigerantsexternally. The dilute camtic points were prepared by melt-ing nitrate of silver into stick with one or two parts of nitrateof potash. He had been furnished with points of differentstrength by Messrs. Savory and Moore. Thus the degree ofcauterization could be graduated at will. It was only necessaryto pass the stick over the palpebral conjunctiva. The lidshould be everted for the purpose, and a little brush impreg-nated with a solution of common salt passed over the surfaceimmediately afterwards, so as to neutralize any excess ofcaustic; and then, as M. Wecker judiciously advised, the sur.face should be cleansed completely by the brush dipped in coldwater. The effect of these cauterizations is startling in thesuccess which attends them, if conducted with care and tho.roughly performed. They need in most cases to be repeatedseveral times, and in severe cases once or twice a day for atime. The inflammation soon assumes a healthy character. Itis very rare to see any corneal complications, and the mostformidable consequences of the disease are avoided. Mr. Hartreferred to other modes of treatment which have been recom-mended and employed: as, for instance, the instillation ofstrong nitrate of silver drops, &c., which he condemned;radiating incision of the conjunctiva, which he thought rarelynecessary and sometimes mischievous; and excision of a portion of the mucous membrane, to which he was much opposed.The application of a strong solution of nitrate of silver to the

lids by a camel’shair brush, as recommended by Dr. Mackenzie,he thought was a useful resource where the solid dilute causticpoints were not at hand, but when they were it was decidedlyinferior.

Reviews and Notices of Books.The Encyclopædia Britannica. Eighth Edition. Edinburgh

Adam and Charles Black. 1860.

[THIRD -NOTICE.]IN our previous notices of this most valuable publication, we

traced the progress of kindred works, and pointed out theextraordinary advance which this, the eight edition of theI I Encylopoedia Britannica," has made when contrasted withthose preceding it. At present the whole circle of humanknowledge may be said to be included within its ample limits.Its list of contributors embraces names known throughout theworld as the highest authorities on the subjects of which they

treat. Their articles are essays many of which have been re-

published at high prices, and have commanded an enormous sale.A work which in its scientific elucidations is supported by thelabours of men whose names represent all that modern philo-sophy has accomplished, and everything that ancient learningcould suggest, and in its literary department numbers thosewhose erudition and research have constituted their writingsthe standard of comparison as well as of reference on the re-spective subjects of which they treat, cannot fail to possess extra-ordinary excellence. Its value is materially enhanced by theaccompanying General Index, itself no inconsiderable volume,which without difficulty enables the reader at once to refer toany one of the different subjects, or the matters incidental tothem, discussed in the twenty-one volumes constituting theseries. Without such a gnide it would have been almost,

impossible rightly to appreciate the scope and magnitude-of the several volumes, as the plan of the Encyclopeadia in-cludes many general treatises and systems, embracing animmense number of subordinate and collateral topics to’

which the general title affords no doe. The compilation isthereby rendered convenient to all’ readers, especially to thosewho require quick reference to such important sources of

knowledge. A large class exists to whom the want of-a fixedresidence renders the possession of many books inconvenient.We may observe that the possession of the present work in-sures a well-ordered and accessible repository of knowledge, thevalue of which to the colonist or traveller cannot be exagge-rated. The farmer edition met with deserved success, upwards.

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of thirty thousand copies having been sold from its commence-ment. This induced the publishers, in the year 1852, again toenter on the costly enterprise of a new edition. The responsi-bility of such a proceeding cannot be too highly estimated,when it is remembered that every branch of science and litera-ture had, since the completion of the previous issue in 1842,made rapid progress, and in many instances undergone analmost complete revolution, while popular education had pro-portionately advanced, and a far higher standard of publictaste become established. A double difficulty was thus to beencountered: the deserved reputation of the publication hadto be worthily sustained, and the existing condition of scienceto be adequately represented. Both have been achieved most

completely. A distinguished member of the medical profes-sion was selected for the grave responsibility of editing thesevolumes, whose claims to public patronage the publishers deter-mined should rest, not on the foregone conclusion of an accom-plished fame, but on the distinct and independent ground ofduty ably and honourably discharged. Dr. Thomas Stewart

Trail], professor of Medical Jurisprudence in the University ofEdinburgh, was entrusted with the editorial charge. Unfor-

tunately he did not live to see the work completed. With thevaluable assistance of his son, it had, however, previous to hisdemise, made such progress as to place its editorial uniformitybeyond question. The publishers do but justice to Dr. Traillwhen they declare that "his acknowledged taste and eminencein most departments of learning and science, which the cultureof a long life had greatly improved, pointed him out as beingwell qualified for the task."In bringing out the present edition, it was a matter of serious

inquiry and reflection on the part of the publishers whetherthey should depart from that systematic arrangement whichhad hitherto eventuated in success. Works based on a some-what similar plan had issued from the press-imitations ratherthan rivals of their original. Their reputation proved ephe-meral because their authors forgot that an Encyclopaadia, tobe good required to be great. This is obvious when it is

remembered that experimental philosophy had reduced to

the rank of exact science many subjects previously envelopedin doubt and uncertainty. Natural philosophy had grownfamiliar with the researches of Herschel, the labours of

Brewster, and the experiments of Thompson. Politics and socialphilosophy had undergone revolutions, shaking to their centreprevious systems, and developing from their overthrow new

experiences. Biographical literature had assumed an import-ance far in advance of previous years. Mechanics and manu-factures had called steam to the indefinite multiplication ofdisciplined powers. Arts had found new stimuli in the active

sympathies of a prospering people. Great and material changeshad everywhere taken place. Much of the knowledge of thepast had become matter of history, while much of the expe-rience of the present was but progressive experiment. Torender essays which treated of such matters reliable, the pro-gress of science invited to details which precluded that brevityhitherto considered essential for encyclopaedic dissertations.

Recognising these changes, the publishers from the beginningresolved that the revision and extension of the articles shouldbe more thorough than had ever been attempted in any pre-vious edition-a determination rendered necessary by the ad-vancement of knowledge, as well as by the increased demandfor works of the same class resulting from the diffusion ofeducation throughout the country.The doubts which existed in the minds of the publishers as

to what was the best course to be pursued in reference to thepresent edition, eventuated in their adherence to their previousplan. The order and arrangement which had hitherto beenadopted seemed most conducive to a satisfactory delineation ofthe higher subjects of inquiry, and best calculated to effectuallycommunicate a knowledge of them, and so most likely to beproductive of beneficial effects. While recognising the im.

portant changes which the lapse of time had accomplished inthe nature and number of matters to be discussed, the pub-lishers state that, on taking a review of the entire field of know-ledge to be gone over by the encyclopaedist, and on carefullystudying afresh all the methods both of system and detail thathave hitherto been proposed for such a work, it appeared thatthe arrangement previously followed in this Encyclopaedia, was,all things considered, decidedly the best. This method con-sisted of that judicious combination of the systematic and theparticular found to characterize the several articles throughoutthe work. The publishers observe, in commenting on its

adoption," It has in few instances been attempted to exhibit any

science or department of knowledge according to the ana-

lytical or merely technical headings occurring in the order ofthe alphabet ; but it has, on the contrary, so far as was judgedadvisable, been attempted to treat each science completely andat once in a systematic form and under its own proper designa.tion, referring for particulars to its subordinate heads."The advantage of this method rests in its suitability to all,

whether it be desired to acquire a systematic or scientific viewof any subject, or to obtain that precise information on specialpoints that may satisfy the exigencies of the moment.

This edition of the " Encyolopsedia Britannioa" may be justlyregarded as a mirror of the present condition of human know-ledge, as reflecting the experience, opinions, and conclusionsof men of science, with the practical wisdom as well as theoryof our time. It supplies that which Lord Bacon desired whenhe observed :-

" A just story of learning, containing the antiquities andoriginals of knowledges, and their sects, their inventions, theirtraditions, their divers admiristrations and managings, theiroppositions, decays, depressions, oblivions, removes, with thecauses and occasions of them, and all other events concerninglearning throughout the ages of the world, I may truly affirm tobe wanting. The use and end of which work I do not so muchdesign for curiosity or satisfaction of those who are lovers oflearning, but chiefly for a more serious and grave purpose,which is this, in a few words, ’that it will make learned menwise in the use and administration of learning. "’-(Advance-ment of Learning, Book II.)A work, to assume the form of an Encyclopaedia, adequate

for so great a purpose, could only do so through the con-

joined labours of authors animated by a desire to conscientiouslydischarge their responsible duties. Such a work is the present.Its publishers truly observe that " its list of contributors em-braces the names of the greater number of individuals mostcelebrated in scientific literary and political history, who haveadorned the annals of this country for a long series of years," and proceed to state-" They were all aware when they con-tributed articles to the work that their names would be givenalong with them, and the fair presumption is that they didtheir best to make them worthy of their celebrity." We cer-tainly agree in the following conclusions of the publishers inreference to these contributions :-"We are pretty confidentthat those who look into the articles referred to will find thatthis presumption has been fully realized, and, speaking gene-rally, they are worthy alike of the authors and the subjects."The propriety and advantage of periodical exhibitions, in

which by international communion the progress of the arts andsciences may be fully ascertained, is now admitted to be one ofthose great truths which enlarged practical minds impress ontheir generation. A new edition of an Encyclopaedia may notinaptly be regarded as an analogous collection of great dis-coveries, novel facts, advances in learning and science apper-taining to all countries, marking the mental as well as materialprogression of the age. Both are objects of national concern-both ought to be objects of international support. The geniusand energy of individuals have in England frequently laidthe foundation of works which the country regards with pride.Personal enterprise has in such instances been uniformlyaccompanied by public co-operation. We are satisfied that on

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the present occasion there will be no departure from that rule,especially when it is known that"The eighth edition of the ’Encyclopaedia, Britannica’ is

the largest literary enterprise ever undertaken by any singlehouse in Great Britain, involving an expense which, but forthe liberal patronage of the public, would have been almostappalling. The editor has to acknowledge that his efforts havebeen warmly seconded by the proprietors, who have grudgedno outlay in order to render this great work as perfect as pos-sible in every department."We affirm that their efforts have been attended with as com-

plete success as it was possible for a publication of the characterand extent to attain. Whether we consider the number andnature of the articles, the varied and valuable illustrations withwhich they abound, the ample and accurate information theysupply, we are alike led to the same conclusion, that this is awork whose importance cannot be too highly estimated, andwhose publishers are pre-eminently entitled to be considered

. as great literary benefactors of this empire.

General Report of the Royal Hospital of Bethlehem for the yearendang 31st December, 1862. Printed for the use of theGovernors.

So much attention has recently been directed to the often-raised question of moving this ancient charity into the coun-try, and then locating St. Thomas’s Hospital on its site, thatthe annual account of the proceedings at Bethlehem has almostbeen overlooked. Notwithstanding, a brief summary of thefacts contained in the last Report must prove interesting to theprofession.During the year embraced by the present Report, 163 curable

patients were admitted; 80 discharged cured; 48 left uncured;10 sent out for special reasons; and 16 died, of whom 6 sankthrough disease of the heart or lungs, while 4 cases ended

. fatally from paralysis. Regarding the aggregate recoveries,the Report, however, states their number was not less than thelast ten years’ average ; and as the ratio ranged actually underiifty per cent. on the admissions, that acknowledgment showsthe proportion of cures was less than that often recorded atother establishments for the insane, where a seiection of casesplaced under treatment does not prevail like that pursued atthe important metropolitan institution at Southwark.

In concluding this short notice of the Bethlehem HospitalAnnual Report, one remark cannot but suggest itself -

namely, that seeing this richly endowed charity, which, ac-cording to the official document now passed under review, pos-sesses a net annual income of £19,816 10s. 3d., only cured 80insane patients during the past year, such results seem rathersmall from so large an expenditure of cash, and, if cures alonebe held in view, would make the average cost of every cureeffected to reach nearly £250 for each patient so discharged.Of course this is not a fair mode of reasoning upon all thebenefits accruing to lunatic inmates treated at Bethlehem

Hospital. Nevertheless, impartial critics cannot help con-

sidering it highly desirable that the benefits of so opulent aninstitution were rendered more extensive, and more commen-surate with its many capabilities.

POOR LAW MEDICAL RELIEF.To the Editor of THE LANCET.

SIR,-It affords me satisfaction to inform you that thescheme I propounded, with the view of improving the systemof administering medical relief to the poor, and which, fromthe spirit of your comments, I was gratified to find had re-ceived your favourable consideration, has excited a largeramount of interest amongst the thoughtful portion of our com-munity than I could have anticipated ; but being fully awarethat innovators are generally considered troublesome, and thatinnovations, however good and just, are almost invariablystrenuously opposed for a time, I was prepared to have to con-tend with opposition. That members of the medical profession

should not at once adopt my views in their entirety I wasready to expect, though 1 am proud to assert, those with whomI have hitherto conversed, some of them thoroughly conversantwith Poor-law medical relief, have expressed their full assent.

I should not so soon have sought to trespass further on yourspace relative to this question, important as I consider it, hadit not been for some unhappy comments inserted in your lastweek’s impression, signed " Nemo Mortalium." The authorhas introduced his subject by complimenting me on the strengthof my arguments in favour of " Medical Reform," but at oncerushes away from the point, as if demented-" There is a blacksheep-and a very black one too-in the flock."

I hold, Sir, that black things should be rendered uncommonlyconspicuous, and that their black antecedents should be soinvestigated, and exposed, by the constituted authorities as toprevent the possibility of their doing more harm.

I hope " Nemo Mortalium" is not the black thing he refersto ; but, I think you will agree with me, it is really impossibleto scrutinize that which he has put forward as argument,coupled with the worst insinuations against his professionalbrethren, and all under an anonymous cloak, without arrivingat the conclusion that it is undesirable to discover anythingmorally darker. It would serve no good purpose to criticizeline by line his humiliating document, because each readercan do that for himself ; I will therefore only direct attentionto a few of his assertions.

In the second line he informs us " that my arguments aregood." In the eighth "the argument bad beyond measure."He then writes about " each surgeon feeling the weight on hisneighbour’s shoulder," and that that will be an excuse for theirdenying themselves to the poor patients at night !Would the patients thus treated at night, had they the

power to select, apply to iiieh surgeons by day?" All the doctors might be out !" " They cannot help being

out !" " Those who are struggling hard with life will, byclap-trap, endeavour to win the good-will of the poor," &c." Medical orders for wine and beef-tea will be strewed aboutby the dozen ! Gin will be administered in large doses to oldwomen, and a more deadly cordial to little children !"

After this general and unwarrantable attack, he assumes thecharacter of the maudlin philanthropist.

" Believe me" (who can ?) " the poor man wants a guide anda protector," &c. " And there can be no better guarantee ofa surgeon’s respectability than his election by a board ofguardians !"Was ever greater twaddle penned by a professional man ?

It is notorious that the guardians too frequently treat theirmedical officers in a manner which men of honour and spiritare compelled to resent.One of the greatest recommendations to the system I have

propounded is, that it would to some extent remove the pro-fessional man beyond the sphere of the guardian power-fromthe degrading influence of canvassing uneducated men for anappointment involving scientific knowledge, &c. &c. Com-plaints would necessarily become few, because the poor canappreciate kindness, attention, and skill, to the same extent asthose in a higher station ; a,nd the poor patient failing to obtainall he desired, would be at liberty, under certain conditions,equally with the rich patient, to seek other aid. The poorwould certainly be better satisfied, and probably generallybetter cared for. That caprice and other improper motiveswould sometimes influence them, there is not a question ; but,in my opinion, not to a greater extent than we find to be thecase, and have to tolerate, from other classes of so)iety.

In carrying out the system suggested one great point wouldbe gained-the striving medical men would be placed on anequality : rivalry and heartburnings, the inevitable consequenceof local connexions amongst those in authority, would thereby,in a great measure, be annihilated.The cudgels have been taken up by me in the interest of the

poor, as well as in that of those of my medical brethren whoare still struggling in the atmosphere of parish work; andthat the latter should have been so scandalously libelled by ananonymous writer, in your widely circulated columns, is amatter which you will probably deal with in your usual im.partial manner. In what I have written on this subject, I canhardly be suspected of having been actuated by selfish motives,because the question has long since ceased to be of any personalconcern to myself. The signature of "Nemo Mortalium,"under which he has shielded himself, will admit of peculiarinterpretations, and the extraordinary character of his epistleimpels me to suggest that he would have rightly appendedthereto, sed uizus asinorum.

I am, Sir, yours faithfully,Southampton, Sept, 1863. EDWIN HEARNE, M,D.EDWIN HEARNE, M.D.