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ST. THOMAS’S HOSPITAL.

CLINICAL LECTURE,

BY MR. GREEN.

TnE subject of Mr. Green’s Lecture thisday, was on wounds of the cornea, and hecommenced by making some general remarkson inflammation of the cornea. He observed,that the effect produced by injury was notalways proportionate to the cause in thesecases, for when the cornea is wounded in theoperation for cataract with the knife or

needle, in either of which cases there is aclean cut, and the least possible mischief done to the part ; yet a destructive inflam-mation is often set up, which terminates inloss of vision. Whilst, on the other hand,many lacerated wounds of the cornea, occa-sioned by a blunt body with considerable ’,force, were seen to terminate with but

slight inflammation. These varied effectswere attributable, Mr. Green observed, todifferent states of constitution ; but in allcases it was incumbent to adopt early aprompt and decisive treatment. First, to

remove the cause was a clear indication inthose cases where the cornea had been punc-tured by an extraneous bodv, part of whichwas left behind. This should be removed,as it keeps up excitement; but, continuedMr. Green, I will not say that in every in-stance it is possible, or even proper ; andthis observation leads me to mention a caseof Mr. Cline’s, which you will perceive isone in point. In performing the operationfor the extraction of a cataract, and when inthe act of making an incision through thecornea, the patient’s eye became suddenlyaffected with spasm, and in consequence ofthis, the point of the knife was brokenoff. Under these circumstances, Mr. Clinedeemed it proper to withdraw the knife ;the point being of course left in the eye.In the course of a day or two, it was found,on examining the eye, that the aqueous hu-mour had become turbid, and was of abrownish colour ; soon afterwards it becameclear, and then was again thickened. Itcontinued thus alternately to be clear andclouded until, at the end of a week, the eyewas left in the same state as when the ope-ration was commenced. The point of the.knife was, in this case, so far acted upon bythe aqueous humour, as to become oxydised,.and then mixing with the fluid, it became atlength absorbed. Under these circum-

stances, therefore, in which the point of aninstrument has penetrated deeply into thecornea, it will not be necessary to makefurther incisions with a view of extracting

it. But this is an exception to a generalrule : the remainder of the treatment inwounds of the cornea, consists in a vigorousadoption, modified of course by circum-stances, of the antiphlogistic plan of treat-ment. Having made these few general ob-servations, I shall proceed to relate to youa case which is now in the Hospital.

(Mr. Green proceeded to read from hisbook the particulars of the case alluded to ;but as we prefer our own report to anywhich Mr. Green or his dressers can make,we will insert the notes as taken daily byourselves, observing, by the way, that therewere various inaccuracies in the report readby Mr. Green. This was accounted for tous afterwards by the dresser who wrote thecase remarking, that he did not see the pa-tient for the first three days ! Such is themanner in which " authenticated cases"are got up.)

. CASE.—John White, mtat. 32, a robust

Irish labourer, was admitted into Edward’sWard on the 7th of November, on accountof injury to the right eye.

He stated, that six days previous to ad-mission, he was employed in holding a lightfor a person who was employed at some

smith’swork, and was chisellin iron. Whilstthus engaged, a small piece of the iron flewoff and struck his right eye ; it occasionedvery severe pain, and was soon followed byinflammation. The only means he had re-course to was, the application of two

leeches.On proceeding to examine the state of

the eye, it betrayed great intolerance oflight, and there was considerable externalredness of the lids, with some swelling.There was excessive vascularity, with che-mosis of the conjunctiva, but more espe-cially of the palpebral portion ; the corneawas generally opaque, or rather it was

hazy; and immediately opposite to the innermargin of the pupil, was a light coloured oryellowish spot, of about the size of a grainof wheat. It appeared to be a small inter-

stitial abscess of the cornea ; Mr. Green,however, considered it to be a slougli of thecornea, and subsequently wrote down in thebook, " Inflammation nf the conjunctiva, withslough of the cornea, from mechanical injury."The patient complained of excessive pain

in the eye, extending’ to the brow and tem-ple ; he had a frequent flow of scaldingtears, and laboured under much febrile (,x-citement, his pulse being quick and hard,the tongue furred, and the skin hot; thebowels were moderately lax.Mr. Green directed 16 ounces of blood to

be taken from the arm, eight leeches to beapplied " in the neighbourhood of the eye,"and the decoction of poppies to be appliedtepid. A purging powder, composed of

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scammony and calomel, to be given imme- (diately.3. The appearance of the eye much the

same ; there is, however, less sharpnessabout the pulse. Ordered to be bled to theamount of twelve ounces, and the purgingpowder to be repeated.

10. The speck in the cornea has in-creased in size, and the abscess has evi-

dently burst through the internal lamellae ofthe cornea, for there is now a collection ofmatter in the bottom of the anterior cham-ber of the eye, of a crescentic shape. Thefebrile irritation continues great, and thevascularity of the eye is not diminished.

Repeat the venesection and the purgingpowder.

11. The quantity of matter in the ante-,rior chamber has increased; the externallamellse of the cornea, situated over the

speck, have now given way, and a portion ofthe viscid matter is seen filling up the open-ing. The patient complains of much painin the eye ; the chemosis and vascularitycontinue unrelieved.

Twelve leeches were applied to the eyelast night ; and Mr. Green, to-day, directeda similar number to be used, and the purgingpowder to be repeated.

13. It is now apparent, on examiningthe eye, that the aqueous humour has es-

caped through the ulcerated aperture of thecornea, giving to the eye a collapsed appear-ance ; the iris has fallen forwards, and thematter in the anterior chamber is almost

entirely gone. The aperture in the corneais covered by a gelatinous looking substance,much resembling part of the eye of a fishwhen boiled.

15. There is less inflammation in the

eye ; the cornea has a peculiar striated

appearance, which is, probably, owing tothe proximity of the iris. The gelatinousbody, covering the opening of the cornea,has increased in size. Upon looking directlydown on the eye, as the patient lies in bed,the pupil does not appear to be irregular ; -,but, on viewing the eye from the outer side,a little bag or sac of the iris may be ob-served protruding towards the breach in thecornea.

Mr. Travers, at the request of Mr. Green,saw the patient to-day ; he recommended,in this stage of the disease, that a weaksolution of nitrate of silver (one grain to anounce) should be instilled into the eyetwo or three times a-day, and the decoctionof bark, with tell grains of the extract, to begiven three times a-day.At the same time that Mr. Travers sug-

gested a trial of this plan of treatment, heremarlced, that circumstances might pro-bably arise, which would forbid a perse-verance therein.

IS. The vascularity of the eye has much

increased since the last report, and there isI great pain experienced. The febrile excite-ment, also is considerable; the pulse is

quick, tongue furred, and the skin dry.Mr. Green directed the bark draughts to

be discontinued, and twelve leeches to beapplied to the eye. The fomentations to becontinued.

20. Both the local and constitutionalsymptoms are less severe. The appearanceof the cornea, at the aperture, is much thesame ; the gelatinous looking body con-tinues unchanged.

24. There is but little variation sincethe last report. Mr. Green ordered the

projection on the cornea to be touched withthe lunar caustic, and afterwards twelveleeches to be applied to the eye.

2I. The prolapsus of the iris has not in-creased ; it would seem that the healingprocess has commenced in the cornea, forthere is a halo or dusky white hue to beseen at the verge of the external opening inthe cornea. Mr. Green remarked, that heconsidered the gelatinous-looking body whichhad for some time covered the opening inthe cornea, and was, indeed, considerablyabove its level, to be a portion of the la-mella of the cornea that had sloughed, buthad not separated, and which was pushedforwards by the prolapsed iris. The entire

perforation of the cornea, he considered,

was confined to a small point.30. Appearance of the eye much thesame. Repeat the application of the caustic.

December 2. A sensible improvementhas taken place within the last few days.There is now no projection beyond the’levelof the cornea ; the part at which the .ib-scess was situated, is opaque, and there isa nebulous appearance some way around it.The disfiguration of the pupil is trifling;the patient has some vision, but, at present,imperfect; the vascularity is inconsiderable.

Mr. Green’s report of the case was onlycontinued up to the 28th, the day on whichhe lectured, but we have thought it right togive a subsequent report. Mr. Green, in thecourse of reading the case, and also subse-

quently, made some general observations,principally in reference to the treatment.He said that the indications were very clear;in the first instance there was great inflam-mation of the conjunctiva, and also of thedeeper seated tunics, which required activetreatment. But, subsequently, when theinflammation had s-ubsided, and a slough hadformed in the cornea, which slough wasseparating, then a gentle tonic constitutionalplan, combined with a mild local stimulant,were obvious modes of relief. And, lastly.,when the iris fell forwards to the opening,the small projecting portion was destroyedwith caustic, so that the edges of the aper-ture in the cornea were not kept asunder,

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but the process of cicatrization was allowedto go on.

Mr. Green further observed, that as theiris had become adherent to the inner mar-gin of the aperture in the cornea, the pupilwould be somewhat altered in shape ; butthe opacity of the cornea, he remarked,being out of the centre of vision, would in-terfere but slightly with the function.With respect to the effusion of matter

into the anterior chamber of the eye, calledhypopioa, Mr. Green said, that although itis generally called matter, it is in fact

lymph; and that in regard to the treatmentof this symptom, it was the concurrent opi..nion of the best writers and practitioners,that an opening should not be made in thecornea for the purpose of evacuating thematter, except in those cases where it wasso abundant that great pressure was in con-sequence made on the cornea ; and here, asthe excessive distention might lead to

sloughing, it would be proper to make anopening in the cornea, in the most depend-ing part, and not in the centre, as recom-mended by Scarpa.

On Fungous Exostosis.

Dec. 13. Gentlemen, said Mr. Green, 1mentioned to you, at the conclusion of mypreceding lecture, some particulars respect-ing a case of tumour at the hip. The’patientwas then in King’s ward, but the case hassince terminated fatally, as indeed might heexpected. We have had an opportunity ofexamining the parts, which I have broughtdown for your inspection, and I purposemaking this case, with some observationsthereon, the subject of my lecture to-day.The patient’s name was George Webb ;

he was 24 years of age, and was admittedunder the care of Dr. Scott, on the secondof November, but was subsequently trans-ferred to me. I found, on examination,that there was a very extensive swelling atthe left hip ; it extended up towards theloins, down the thigh, and inwards to thegroin ; the joint formed the centre of theswelling. The tumour was very hard andfirm, but at the same time slightly elastic ;its surface was irregular, and there was anindistict feeling of fluctuation, as thoughthere were matter deeply situated ; this lat-ter circumstance induced me to thrust in alancet, but only a few drops of blood fol-lowed. There was no preternatural heatiof the part, and not much pain evincedon pressure. The patient’s sufferings were ,,

very great; he could obtain no sleep, norease in any position of the body ; the painof which he principally complained was atthe knee.The history which he gave of his case I

was this :-He said, that five months ago I,

he was attacked with violent pain in th4knee, which was so severe as to prevent himfrom walking, or even from standing. The

only means of relief which he had recourseto, was applying some stimulating lini-ments, but at this time he was, it appears,sent about from place to place in quest ofhis parish, and therefore had no attentionpaid to him. About a month before his ad-mission into the hospital, a swelling appear-ed on the fore part of the thigh, which ra-pidly extended to the back part. A setonwas introduced at this time, but it occa-sioned much pain and irritation.Now, in the history of this case, there are

several circumstances well worthy of atten-tion :—the size of the tumour, its situation,with the joint forming the centre ; spread-ing as it did, the firmness of the swelling, its.inequality of surface, and the indistinctsense of fluctuation. The fact, that only afew drops of blood followed the puncture bya lancet. You will then observe the rapidprogress of the tumour-it being only fivemonths from its commencement, although-it had attained a great size ; the great con-stitutional irritation which prevailed, thequick pulse, hot skin, and want of rest.Now, it was apparent on nrat sight, that

this was a case in which little or nothingcould be done, and therefore I have little tosay on the treatment, worthy of attention,Narcotics were given, and poultices appliedto the part ; the narcotics were graduallyincreased until four grains of opium weregiven for a dose, and the local applieationswere changed from moist warmth to coldevaporating lotions. There was one thingclearly to be perceived, viz. that the com-plaint soon got much worse after the man’sadmission into the Hospital. And the re-port made on his state on the 30th, saysthat he had, then, cold sweats, with a weakfluttering pulse. He died early on the

morning of the following day. (December1.)On examination there was found to, be a

large tumour arising from the whole of theilium, (and not from the femur as I sup-posed during life,) it extended over thesacrum as far as the second lumbar verte-bra. It filled up the cavity of the ilium, andextended downward between the tuberosity of fthe ischium and the trochanter major. In thelumbar vertebra, and also on the sacrum,there is some appearance of a bony deposi-tion, and also of absorption. But the tumourwas firmly connected to the ilium, and fromthence appeared to arise. (The diseasedparts were handed round for the inspectionof the pupils.)You will see that the base of the tumour

is hard and firm-it is rarely so hard fromthis, there is radiating to the circumference.a whitish fibrous texture, and there is a

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softer, gelatinous mass, filling up the in-terstices. There are spiculae of bone hereand there deposited in the substance of the ! itumour, and at the outer part of the swelling’you find a soft substance, not unlike brokendown coagulable lymph, mixed with a fewred particles. There is a firm membrane

covering the exterior of the tumour, whichis, probably, the periosteum. Sir AstleyCooper would have termed this a case ofperiosteal fungous disease.

It is not unworthy of notice, that the

growth has taken place from the externalas well as the internal surface of the bone-this is a result which I have before seen inflat bones, as for instance, in the cranium.And there is a good specimen of this, in theMuseum of the College of Surgeons. Nowas I have this case before me, I shall say a

few words on exostosis, but more especiallyon that which is of a malignant kind.

Fungous exostosis is of two kinds, tiieone issuing from between the periosteumand bone, or rather growing from the sur-face of the bone, and having its growth con-tributed to by the periosteum, and the otherissuing from the medullary part of the bone.When the disease originates from the exter-nal surface of the bone ; the symptoms are,a swelling of the part, which in general in-creases slowly, it then becomes tuberculatedon its surface, and there is at length a senseof fluctuation at different points of the tu-mour. Very commonly, openings are formed,by ulceration, giving exit to a thin discharge ;portions of the tumour also come away bysloughing, with the loss of much blood.With respect to the degree of pain expe-rienced, much depends on the situation ofthe tumour, and if it be placed so that itpresses upon a nerve, great pain is expe-rienced. In the case before us, the tumour

pressed on the sciatic nerve ; we could notdiscover that it was enlarged or inflamed;but this situation of the swelling accountsfor the violent pain in the knee, on the sameprinciple that we have pain in the kneefrom disease of the hip joint. Otherwisethan this, there is only a dull obtuse achingfelt occasionally, and I should certainly say,that pain is not an essential characteristic offungous disease.Now the medullary fungus is very much

of the same kind, and is distinguished bynearly the same symptoms as the periosteal.The difference is, that the swelling in themedullary disease occupies more of the cir-cumference of the limb ; it is a more diffusedswelling. In both cases the progress of thedisease is comparatively rapid, and they areboth uniformly marked by loss of health.There is great febrile irritation, the patientbecomes sallow, feeble, and emaciated, andin this way the powers of the constitutionare undermined, and the patient sinks.

Now these are the characters of the disease

during life, and on inspection after death! you find the same appearances as you haveseen to-day in the tumour. You find a tu-mour between the periosteum and bone, butmore adherent to the latter. It is more orless radiated, not always so distinct as inthe present case. You will find a whitishsubstance like coagulable lymph, which ispartly organized and partly not. This isI shown by throwing in an injection, when wefind that portions only of the tumour arereddened by it. In addition to these, youwill find a softer mass, resembling brokendown coagulable lymph, mixed with a littleblood. In some instances, we find cellsfilled with matter resembling half putridbrain-a something between pus and thatcurd-like matter contained in scrofulous ab-scesses. These circumstances, I think, in-dicate that the deposits are the products ofan inflammatory kind of disease, but of apeculiar nature.The medullary fungoid tumour, I should

observe to you, is more lobalated than theperiosteal ; the parts, when cut into, looklike fat or jelly. But you have the same

appearances of cells, the same appearanceof broken coagulable lymph, mixed withred particles of blood. And there is one

thing which I may mention, that is commonto both also, namely, an imperfect suppura-tion ; but this does not take place in gene-ral, until the latter stages of the disease,and in the present case was not found tohave occurred at all.

The remainder of the time usually appro-priated for the Lecture, was occupied inshowing different drawings illustrative of theappearances of fungoid disease. Some ofthese appeared to be remarkably well exe-cuted, and faithful delineations of the di,versified characters of the disease in itsdifferent stages. In the course of exhibit-

ing these specimens, lklr. Green remarked,that he thought there was some alliance be-tween fungoid disease and hydatid disease,." as we every now and then meet with themin conjunction."

Mr. Green, in conclusion, spoke of a caseof fungoid tumour of the upper eye-lid,growing from the orbit. The patient is alittle girl, and has been the subject of twooperations for the removal of the disease,.but without deriving any benefit therefrom,for she is now in the Hospital on account ofthe disease returning. The particulars ofher case, with an account of the operationsperformed, were fully reported in THE Lah-CET some time since.