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STRATFORD, M.R.C.8., Surgeon and Oculist. ^TORONTO: fHINTKD BY A F. PLEES, 7. KIKO STREET WEST. 1851. I I REPORT OF THE 'i.,«.- TORONTO DISPENSARY, FOR JDiscasts of tl)c vgnc. CHURCH STREET, TORONTO, CANADA WEST. A.D. 1851. BY J. S. STRATFORD, M.R.C.S. Surgeon and Oculist. TORONTO: PRINTED BV A. F. PLEES. 7. KING STHEET WEST. 1851. , ' i oo^%^% or ( I aol mas 1955 T Si th ha it ar aF of 1 I REPORT or THB TORONTO DISPENSARY TOR DISEASES OE THE EYE. 1851. The within Report is respectfully submitted to the Governors arid Subscribers of the Toronto Dispensary for Diseases of the t.ye m this city. It is due to them, as an evidence that the confidence they have so generously reposed has not been totally misapplied, while it offers a satisfactory proof of the necessity and usefulness of such an institution. The language and detail may not be completely applicable to the taste of the general reader, but for this, the nature of the subject must, I think, plead a sufficient excuse. Number of Patients under treatment, during the year ending the 1st June, 1851 Cured 149 ■'..I 108 reatly relieved *" Discharged incurable ^^ Ceased to attend from some unknown cause o Remain under treatment •• The various diseases treated, bore the following proportion to total number of cases presented at the Dispensary : Simple inflammation of the conjunctiva Purulent opthalmia Gonorrhoeal opthalmia Purulent opthalmia of infants Pustular opthalmia Scrofulous opthalmia Tumours of the lids Granulated conjunctiva Hordeolum Foreign body in cornea Acute corneitis Partial dilitation of the pupil • Carried forvr-ard s s ft ssessf 149 the n 6 16 3 10 12 3 27 3 1 9 1 Toi 1 •' f? 4 h %'. ! Brought forward « » 101 Acute iritis • ^ Amaurosis ^ Muscse volitantes 3 Cataract • ^ Inversion of the eyelids 3 Eversion of the eyelids 2 Fungus hoematodes of the eye 1 Ephiphora 4 Stillicidium lachrymarum 2 Acute inflammation of the lachrymal duct] 2 Chronic do. do 3 Obstruction of the nasal ducts 2 T49 Simj)le Conjunctival Inflammation. Of the eleven cases of catarrhal opthalmia, three occurred during the month of November, and eight in February, March, and April, — during which months the east wind prevailed in a remarkable degree, being generally north-easterly, while it was also for the most part dry and dusty' The influence of cold upon the conjptitution appeared generally as the exciting cause; but that the simple influence of cold upon the body is likely to produce the disease, without a necessary condition of the system, is contrary to medical observation. The nature of this condition is at present hid in much obscurity ; but I believe it will hereafter be found to be firreatly dependent upon the positive state of the blood, at the period^ the body is submitted to the influence of cold. When the blood is loaded with the eff'ete, and useless material of the constitution, that should be removed by the excretions, then is the individual more susceptible to the influence ; and it is a curious fact, that the speedy solution of the catarrhal disease, goes hand in hand with the liberation of the excrementitious matter by the proper emunctories of the body. For example : the urine is always found loaded, and the stools dark coloured and biliary before the inflammatory action subsides, while the check upon the excrenentiiious operations of the skin, has been a subject of popular observation in all ages. During the early part of the year, the influenza also occurred pretty gene- rally in Toronto, and no doubt, had some influence in the produc- tion of the opthalmic disease. The immediate cause of the complaint appeared to be dependent upon intemperance in four individuals, who had been exposed for a considerable time to the night air. Two were washer-women, who had been working hard in rooms heated by a stove ; while one had walked a considerable distance in the rain, 'and got completely wet. T'lio oirmnt-nmc nrpfipptorl hv t1i*» inflivirlll.'lla lahourin.or Undf»r the complaint, were more or less redness of the conjunctival mem- \ 101 9 9 3 7 3 2 1 4 2 3 2 T49 occurred y, March, ^iled in a ile it was cold upon ; but that oduce the ontrary to resent liid und to be the period^ le blood is ition, that dual more , that the d with the tiunctories aded, and ory action ions of the s. During etty gene- le produc- complaint idividuals, tt air. Two ms heated ice in the in.or under ival mem- brane, where it covers the lids or is reflected over the sclerotic coat, while the corneal portion did not appear perceptibly to parti- cipate in that condition. This redness evidently depended upon the entrance and circulation of the red corpuscles of the blood in the minute vessels of the membrane, in which previously only a transparent or colourless globule had circulated. This change is so obvious to the senses, that it constitutes one of the most favourable positions in which the various results of inflammatory action may fie presented to the observation of the student. This redness was of a bright scarlet colour 'he vessels large and evidently superficial with regard to the sclerotic coat, moveable upon it, and when not very intense and that coat was implicated in the complaint, its minute pink vessels might be seen shining through the conjunctiva, presenting a very marked contrast. This redness of the conjunc- tival membrane was, in the first commencement of the complaint, irregular in intensity, shewing that some faciculi of its vessels were more filled or conjested than others; but as the disease proceeded, the redness became general throughout the membrane, but this was always more marked at the circumference, and diminished as the vessels proceeded toward the cornea. In one case, small spots of extravasated blood were observed eff'used into the areolar tissue, in others more or less eff"usion of a thin serous fluid was seen distend- ing the structure of the membrane, and giving it a thickened appearance. The pain for the most part was of a smarting character, not very severe, and generally confined to the inflamed structure. In two cases however, which seemed to be connected with influenza, the pain was more extended, implicating the head and throat, shewing a participation of the complaint in the mucous membrane of the frontal sinus, the fauces, and trachea. There was not much intolerance of light, save in the two cases above mentioned. A sensation of dryness, stiftness, and as it were the presence of a foreign body between the lids, was always complained of, especially at the onset of the disease; but after a time the lachry- mal secretion became more profuse, when some of these symptoms ceased. The secretion of mucus was at first thin, but afterwards became more thick and glutinous, and in the most severe cases assumed the character of pus. In the two cases mentioned above, as being connected with influenza, there was catarrhal fever, frequent chills, heat of skin, disordered stomach, and foul tongue ; but these symptoms I appre- hend were more dependent upon the influence of the epidemic than upon the opthalm.c complaints. The treatment consisted, in the first place, in the employment of general and topical blood-letting, according to the intensity of the inflammatory' action and tone of the constitution ; active pursra- tives, such as calomel and jalap, followed by salts and tarlarized ■:'{ :i! antimony. The use of warm fomentations to the eyes, and blisters ?o the nape of the neek or behind the ears. These were continued until t" e^ acute inflammatory action had subsided, after wh ch Sullting and astringent applications -^^/PP^-jtrL" io"- vinum opii or the solution of the nitrate of silver. I have occasion a Iv employed the powerful astringents in the very commencement Sf {hL7o7plaint, a's recommended by Mr Me en and Mr^Guthne but think that their use is to be deprecated until the acute stage has subsided, when they are remarkably benehcial. Purulent Ophthalmia. Of the six cases of purulent ophthalmia, "'l """"'^ du",^» wereToal appearance i.lenticul with the corapluiut ab"- j^^?" '' ^^' W a, it nro -ressed (which it often did with great rajpid.tv) t e Kn^rn\rrn^:h':tiin^^^^^^^^^^ in the commencement was seen bright and ^/^^^ ' ,^^^^'^^^^^^^^^^ above examples, the inflammatory disease impit^ its extent, of the eye/besides the conjunct.va and «« f "f,^ "^^'^^.^f ,„i produced more or less derangement of "'« ='^'1'^' .j-,,^ ;„ f^^ Fn two cases P™re», translucence to ing -a density of structure, and g"""f * 1, eharacteristic. , Z part, which constitutes '''»«', f'^f.r^^'evidei.tly nourish- Vhese different structures of "'« cornea a j^ ^^^^_._^, ea by two sets of vessels a superfie.aj ^»>^-';Jj „„„;,,; these trunks of the first se 9y''>'^»''>„°'„ the margin of the cornea, and are prolonged a short distance ^P"" ' '.^ "" ,° ;„„ but a transparent ?rosLlate with each other, ^"""g ''^tanT 'o tue epithelium •.- fluid, to supply tiie t-.s^'":"\S,„CrsU the proper substance while the deeper set «f ^''^,''^>'; " f j "„„ arteries, and terminate of tiio cornea, are derived fic n "le en a y ^_^^^^ ^^ cartilage. ;„ loops of veins in the ^f/ "' = ;°?4tv"sels that proceed to the From these radiate minute ''a'^'';''^;,;,,,, » fluid of such little tubular structure of '''« '°™^"' ,f ""^''t ^perfectly pr eserved. density, that the transpai-oncy of he pa't 's P ^^J^l ^^.^ When under disease, these tacts o a- te,„led, carry the Great """^ers of these mine «sels, tie ^^^^ red globules of the blood, a»d as "ay „;„ ,eeu traversms; two distinct r,ct8 of vessels. Ked ves.eu, a ^.^^j^_ he conjunctival layer, "Pl'-^ "g„ t^, f:,Tle the pink tint of the ■"V"t-eCtu;: T^t^elnfllimmS of the cornea, gives an im- PtTdV^i^ratio^of the deeper se^^^^^^ ^„_.„^„ „,y , ' The vessels of the conjunc iva f ^«""°. permanently long d-.tcnded with red. ^lood -J^» , P o^^Ti^flelli^y of disten- bad^ffects, dependent, '" a" F»bab''i ^^ . .^^^ ^^^^ „f tionin theparf sothut adep«s.' o' '! g ,„„„ected with the r the cornea, would seem » f'^ "l sV *« "'"'™ P'"''" ' disease. Not so the ,7'"»'« ™ffected withou. the cor"ea ap- seUlom happens that they ^f °"° T^,^ ,„,„!, being earned into pearing more or less ^^qne; eoa|ulabL^ tL tubular spac^^.. In its structure, and perViaps ''f,?"^''/" ,' i,;^ „„pears to be quickly many eases, as I have ^e °re Vem^ked, tb . p,^__^^ transparent removed by the abwrbent f"n<="°"' ° that the lymph ha. r-''-' "Sil:."«"'''oth:'rT:xC:l'ofXbody, ontmaybave shown to conjunc- next, the the mem- im. The ayers fol- s of more the most ulting in- which are hlch tends aole afford- lucence to Stic. iy nourish- he arterial iva; these ;ornea5 and transparent thelium ; — r substance I terminate jf cartilage, ceed to the such little reserved, itly evident, id. carry the iy mark the n traversinfif rcle, extend" L tint of the gives an im- inea may be permanently ity of disten- 1 structure of ed with their roper; for it be cornea ap- r «2arried into ppacr. In to be quickly } transparent ihe lymph has )r it may bave 9 become hardened and sacculated in the tubular spaces; and although a foreign body, is permitted to remain uninfluenced by the circu- latory apparatus, would seem to have assumed a tolerance similar to that which obtains in the case of shot and grains of powder, or other foreign bodies, which often remain quiescent in the animal economy for some time. Many cases of permanent opacity of the cornea must, I think, be thus accounted for, as we often see an opaque spot completely surrounded by transparent cornea. Here we should be able to see vessels carrying a fluid of sufficient density to preserve the character of the opaque spot; for, was this deposit under the influence of the circulation, coagulable lymph must still be con- veyed to tue diseased structure; or was it but the transparent fluid of health, it must be obvious that the dense matter once removed, and not renewed, the part would eventually become transparent : showing that, in some cases at least, this opaque matter is beyond the action of the absorbent vessels, and must remain an inorganic deposit,— explaining the reason why it is perfectly uninfluenced by any remedial means. ... . , . , , i • c .i. The case of purulent ophthalmia, m which sloughing of the cornea occurred, was an inhabitant of this city, of a leueophlegmatic debilitated constitution (not long out from Ireland), evidently sut- ferinff from the effects of poor, unhealthy diet, and vitiated atmos- pheric influence. Here, a free administration of bark, and a gener- ous diet, combined with the local employment of astringents, soon arrested the sloughing, and encouraged the rapid cicatrization of the wound. Gonorrhoeal Ophthalmia. 'n appearance and character the Gonorrhceal Opthalmia bears a strict analogy with the preceding complaint. In some cases th^ rapid intensity of the symptoms, as compared with the former variety, would seem to offer some slight diagnostic peculiarity ; but everi in these, I fancied thcit the positive state and condition of the constitution was sufficient to account for the difference. Certain it was, that intense redness of the conjunctiva, great ^ tumefaction of the lids, and profuse yellow discharge, shewed a condition of tue highest inflammatory action, which m many cases rapidly spread to the cornea, and deeper tissues ot t..e -rlobe, often causing blindness or derangement ot vision. ^ In all the cases, the application of infectious matter to the eve, was clearly traced. In one instance, a stage-driver in the western country, having gonorrhoea upon him, ^^^"[^Pl^^^^^f °*^.^ slight affection of the eyes, was advised to wash them with his urine. Thirty-six hours alter, he got a most severe attack ot inflammation of the conjunctiva: this, however at first he neg- lected, merely washing his eyes with cold water, and wiping ^em on the towel in the bar-room. In a few days, no less than \\ * ;! 10 t.„ individ-als Wers -^^^^^^ «. -- ^^^ ^a'cut^ w^ proved had »f ° Jf„Xl I" aL individuals, it was inflammation of the co^janc^^^^^^ .^^^^^. ^^^ ^^ j; . tu«:ncV::nnZZ;.ion lasted even fo^a •o"^e, t.™e In these instances, however, fl*™f ^e^^^ '™?S„t"y ariesteS intense i^f,^^i:^Z::^ll^::ZfZ:lZ of a p^rouacted lt"nonetort?"hadtf deplore the loas of vision, or ,ny r"more acSve antiphlogest^c treetmen .^^B^^^^^^^^^ r;t4^t^dp^grer;trs.:«^^«^^^ I incised th^ co„j«.,cava a ^^^^^'^^^tXiXoi ^^ these, the «n«'»°!^i'''?;Xved ; but tlmt this operation upon tension was considerably reiievea , ""I; , secondary influ- the conjunctival «'«'"''7;' '|f„^fy "^t":' beifg a"^^^^^^^ that under present circumslances. Purulent Ophthalmia of Infants. The svn.ntoms which the cases of this disease presented, .howTd a marked affinity with the preceding variety ; m fact, hey were c^ses of acute i^nflammation of the conjunctiva occur- ring fTom a similar cause, in the eyes of a new-born infant The dislase commenced in each case on abouUhe third o^fourtb day^ i!^'.^.^?ll^tll^^^^^^^ afTeM,^ as'soo, a. the Sr^'LeTJg'a^fw^ie ke'p^^^^^^^^^ closed ; the lids sweiied ana ise, who it L of acute lis, it was e disease ; few days, in others, lated with thstanding mger time, this diffar- ■ applied to >nstitution ? city, at a inoculated •wards, the n the towel duals were ionjunctiva. )n was very itly arrested a protracted ision, or any lalmia, was the head of landed even ing was re- larked with n two cases, Tyrrell In eling of disH jralion upon andary in flu- assured that tic portion of of the knife, se presented, iety ; in fact, [ictiva, occur- infant. The or fourth day, which were IS soon as the B swelled and 11 looked ted, and there Was a gteat discharge of yellow purulent fluid If an attempt was made to examine the eye-ball, the Sulars muscle closed spasmodically, and ^omeUmes censed a cor^Dlete "version of the lids; then too we might see the con- juncUva highly vascular and inflamed, and perchance the cornea ^^Tn^Vu Stsre^Viry was made, if the mother had, at the t me of her confineme^it, a vaginal discharge, and after a utl^^ ^ hesitation all confessed that they had. Two stated that their u'Ss W given them gonorrhea during Fegnancy but th third stoutly declared that we meant to insult her. The husbana, howeverrsubsequently acknowledged that he had been infected, and feared that he might have inoculated his wite The treatment consisted in the '•^PP/^^^^^^" ^^.Vj",^"^^ '°a^n, «*nnerior evelid, and the injection of a solution of alum (two grains to?he ounce of water) frequently introduced between the lids by itsT: syr^rge. ^The\tren|th of ^\^^^'l\Z^^f^^t increased, and after a time was changed ^^^^^^^^^^/.^^^^^^^^^^^^ nitrate of silver, while the bowels were Kept X" wi ' and rhubarb powder, and an occasional <^ZJ^iltTe\ore mU>h Two of the cases were seen early in the disease, be ore mu^a misch'f had resulted to the cornea, -^ seemed speed dyt^^^^^ Sr disease had been mistaken by ^he medic.l gent^^^^^^ that attended the mother, he delaring that the ^^ f ^^/^^^^ taken cold, and advised the eyes to be washed with warm water. The consequence of this neglect was total blindness ot both eyes, from destruction of the cornea. Pustular Ophthalmia. The subjects of this disease were all ehildren, aPP^e-'lyf^ a strumous habit, with light hair, ""''.^^^^'^"tiX^the mneT, Udot looking into the eye, a small elevation, situated on ttie C""""' or'^^WeSoat, migh^ ie seen, having a more « e- ^-e ^ - villus of coniunotival vessels. In the first place, the little eievavion tnpea^d lE spot of effused lymph, and as it progr««sed seerned Kkfon a pustular character? Sometimes even -Icemtio,, took Xce, and when situated upon the surface of the ™'"|»by degrees Lnet'rated its differe.. layers, then the ™f."'''^"f J^X^^'l^d Lmour might be seen pro ecting like a little s>"""'f.°J''^//i"^ when this lave way, the anterior chamber was emptied, the ms was again secretec^ and the diseas^^^ but in mosi casus Willi » ^vweiviCi «*».'*- ui-ii.— „ ft m i^'. M 13 which not unfrequently destroyed the use of the organ. It Is 5 eldom, however, that the disease proceeded to this extent, being generally arrested by very simple treatment— such as the use ot free purgative and alterative medicines, and the application of the wine of opium to the eye. In one instance, however, the child had been neglected, and it was necessary to touch the ulcerated surface of the cornea, with a point of nitrate of silver. This stimulated the ulcer to a healthy action, and healing, saved the prolapsus of the iris and other evil consequences. ' In many of these cases an herpetic eruption might be seen on the face and head, coexistent with the disease of the eye, indicating the identity of its constitutional origin. Scrofulous Ophthalmia. The nature of the diseases classed under this head were intimately allied to the preceding variety : the same cast of countenance, the same character of constitution predommated ; indeed, when we take the constitutional characteristic as a type of the disease, an infinite variety of ophthalmic complaints must be included under this head, a circumstance that is apt to lead to great confusion, making it difficult to define our ideas as to the nature of the local complaint, as it influences a vast variety of them. The generality of patients with this complaint were young children, ranging from two to twelve years of age. The most marked symptom of their disease was a great intolerance of light ; so great, indeed, was the pain and inconvenience produced by the slightest application of the influence of light to the eye, that the child instinctively covered them, and often buried its head under its clothes : here you might see the brows knit and the eyelids spas- modically closed, by the violent contraction of the orbicular muscle. Was an attempt made to separate the lids, it was most strenuously resisted ; and even when that was accomplished, the eyeball was seen involuntarily turned upwards, while the child screamed from pain and fear, and hot acid tears streamed down the cheeks. Often after the most patient trials to see the condition ot the cornea, we had to give up the investigation without complete success. In many cases in which v/c succeeded in our explorations, great was our surprise to find that the eye had scarcely any other visible symptom of disease,— perhaps a slight redness of the conjunctiva covering the lids or reflected over the globe might be seen. This redness was frequently but a few fasciculi of vessels, tending to form a minute pustule. Often even had this greatly subsided, leaving but a slight mark to indicate its presence, «A^- *u^r.Ui\A l.r.ri mn^tirnrl frnm tlio intolerance of licht for six or eight months. In other cases again, the organic disease ot the la •gan. It Is tent, being i the use of ation of the e child had ited surface stimulated ! prolapsus ht be seen of the eye, head were me cast of dominated ; c as a type )laints must at to lead to LS as to the t variety of jvere young The most ice ©flight; iroduced by eye, that the ;ad under its syelids spas- ular muscle, strenuously eyeball was d screamed I the cheeks, iilion of the ut complete jxplorations, jly any other Iness of the 3be might be ji of vessels, this greatly ts presence, light for six isease of the eye "was more grave, the cornea, iris, and other structures of the eye, were evidently affected ; and did the disease of these parts progress, the complete destruction of the organ might be the ultimate result. From this contrariety of circumstances, the essential nature of the disease is evidently clothed in great obscurity, and offers a fit subject for our investigation. That the chief symptom, the great intolerance of light, is dependent upon disease of the retina, it is difficult to conceive. We have but to observe how very readily and powerfully the slightest causes act upon the retina, causing blindness : while the length of the continuance of this complaint, its speedy removal without any ill consequences to vision, must convince us that at least it is not dependent upon organic disease. I have seen this symptom exceedingly severe, w"»ile the admission of the rays of light into the eye were prevented to a very great extent by a thick capsular cataract. If it is dependent upon an affection of the retina, it must be a species of sympathetic neuralgia, in which the sen- sibility only of the expanded nerve is greatly exalted; but I confess I am inclined to look upon the disease more as a neural- gic affection of the iris, ciliary nerves, and sometimes all the branches of the fifth pair supplying the eye. The observations ot Mr. Lawrence, regarding injuries of the fifth pair of nerves, go to bear out this suggestion, and shew a vast sympathy between the retina and the ophthalmic branches of this nerve, winch has not yet been explained. The treatment of this disease for the most part was by purgative and alterative medicines, often repeated for a consider- able period, and these were combined or followed with bark or steel, when there was any marked debility in the patient. A point of the utmost importance was a necessary attention to the diet, which should be light, nutritious, and not easily running into the acetous fermentation. I may mention a marked case ol the influence of diet upon this disease. A little boy, about ten years of age, had had this complaint for eight or ten months, had been shut up in a dark room, his eyes covered w^ith bandages, and the most feeble rays J light prevented from reaching the eye. He had been leeche«., purged, and blistered, but to no effect ; for still the intolerance of light continued as severe as ever. On inspection of the eyeball but the slightest traces ot disease were visible. A few purgations of ihubarb, calomel, and jalap were exhibited, followed by grey and ihubarb powder ; the eyes directed to be freely exposed to the airand light, having a green shade to intercept the more direct rays ; a diet consisting of coffee and crackers for breakfast and supper, a little under- done fresh beef, with rice or custard pudding for dinner, was recommended. The symptoms rapidly subsided under this treat- ment, and in a few days 1 met him out walking before ine nousc, 14 .1 J 1- 1 i^A tli«. he could go to play. After a few days I greatly ^^^/g^'^^Vw^s concerned to find that the intolerance of called again, and was ^^^"^^'"^'' '^gti^nina him, I found that he L'dVefn &iTZt^^^^ ^-^} had been inauioUio " nonvinced, was the cause of unknown to ''-/''^>;;''yp,,]^t^^„'^fThe remedies' above specified, the relapse ior, on repeiiuou ui ^,, ., ^ ^„_„r»toTn^of the com- vasculai disease in the several issue, of the eye. * ^^^'"^^;^^^^^ one such case where I used quinine m two-giain do.^es WUD marked advantage. Granulated Conjunctiva. This condition of the eyelids represents ^y ^ 'h« J^'J at. nded whhinflammatiL which fas extended to the «rsd ^«w;i«m.« 1 have observed the complaint to ioliow as a conse *^ncTa i theSies of ophthalmif which have b-npre™^^^^ """^Tconjunctival membrane consists of three parts :epitt^- Stsn:s»«S^.:^v, ^^t z^^, t'ttai ?:^1etth^: is the P«-"- ^uSSg^^^ ■ S«mrk;^"amp«lTie'orvaricose-Iikediktations«n.hesj^^^^ fom Tse the cartilage derives its nourishment; after whtch th« 16 few days I olerance of and that he table food, he cause of ; specified, of the corn- such a diet, x-sanguine, whiteness of completely vas present, ation of the itment, was this disease, lating symp- [ to use the ny apparent 1 remember doses with :ar the most t themselves would, from , In all cases conjunctiva, to the tarsal r as a conse- en previously hthalmia. If aratus of the e will show f a scrofulous larts : epithe- nembrane on irteries, veins, lent and sen- reflected over ory apparatus traversing the the cartilage, on the surface, fter which the blood is returned by the veins into the general circulation. During health the amount of blood sent to these parts is not great, but no sooner does acute inflammation arise, than this circu- latory apparatus is taxed to the utmost : first, that of the con- iunctival membrane, then the peculiar circulation of the cartilage shares in the excitement, all the vessels are greatly distended with blood, and the ampullro of the cartilage participates in the congestion, and may ultimately become thickened and diseased to a great extent, forming the appearance called granulations ; these enlarged ampull© are also covered with a thickened and hvpertrophied mucous membrane, and are the cause which pro- duces the irritation of the globe, so constantly evinced in the disease. A similar condition of disease has been observed in some varieties of laryngitis, where the cartilaginous structure is covered with mucous membrane, and takes on a very similar eranalated appearance. . .u tj When examining these patients, if we evert the lids, we observe a morbid structure bearing the external appearance of a granulating ulcer, but these elevations are infinitely more firm ; luffice it tS show that the smooth, delicate, lining membrane of the lids, is thus morbidly changed in character, to enable us to comprehend the effect which such a state of things must produce, uDonthe globe. The constant friction and irritation ot these elevations cause the vessels of the conjunctiva to become enlarged and to carry red blood. The portion of the mernbrane thus acted upon, covering the globe, becomes evidently thickened, ihe coniunctrval vessels first carry a more dense fluid th.anusual, when the cornea takes on a hazy look, not unlike ground glass. Should the irritation continue, red blood may be seen traversing these delicate vessels, which for the most part take their course in straight lines, like rays from the circumference a most to tne centre of the cornea, occasionally the proper substance of the cornea participates in the disease, and we observe coagulable Ivmph deposited in its structure— then we see also the deep pink vessels, and hear the individuals complain of pam m the brow, That opacity may sometimes result from congestion of the con- junctival circulation is certain ; but it is not very frequent or enduring in this disease, and always appears as a thin superticial scum on the surface of the cornea. As the complaint progresses, we may have superficial ulceration of the conjunctiva as is known by its thin transparent character, appearing as though a piece had been cut out of its surface. This, when confined to the mucous membrane, often heals without leaving any opacity behind it. If the ulceration continues, it penetrates the layers ot the cornea, opens up the anterior chamber, and permits th^ escape ' x\. i... ^t «u« «^To /^aiisina deransemeiit or oi more or less iiuiuuuia vn lu^ -^j- 5 o ■ , ^ destruction of the organ. Fortunately these extreme revolts o\ •i 16 this disease are not very frequent ; for I have seen persons who have iSured under tlis CO Va^^^ o^ eight years, in whom the corneal opacity was by no means extreme. Another of the most marked characteristic symptoms of this complaint is its liability to exacerbations. After you have Xyed the acute inHammatory action by proper antiphlogistic means and the eye appears to be progressing favourably, all at ^nce a relapse of conjunctival irritation is observed, attended w"thrncreaTedrednesiand lachrymation and g^eat mtolerance Tf li-ht. The patient declares that he has taken iresh cold ; but the ifc;ease ofL disease may often be tra-d to so^e m^^^^^^ tion of diet, with more or less derangement of the chylopoietic viscera. So marked in many cases is this into erance of light Sat on; is led to believe that it must bear a strict analogy wi h he scrofulous ophthalmia before adverted to ; and one is greatly inclined to believe that the same constitutional influence exer- Ssesatreat weight in the persistence of this con^plamt Every sureeonTnows how liable the cartilaginous structures of the body rjrSise":.e in this state of the -"f l^lieVthTt^le^Inula^^^^ a powerful argument to strengthen the belief that the ^anuiated state of the lids is dependent upon a disease of the tarsal partilaees, occurinff in a scrofulous constitution. ..... The iiew which I here present of the character of this disease will in some degree explain the reason why it has so long been an rDDrobrhmi medicinse ; for, if we treat it only as a local disease, ThTconsdrutronal influence continually operating, is acted upon by a ereat variety of causes, producing frequent aggravation of the tocal complaint. I have known persons in whom this disease had prTc^rered with continual exacerbations for ejght or ten years : aid curLs to say, that in many these were marked by a periodi- cal advent? In the treatment oi the cases that have presented themsdves to my notice, I have been guided by the above convic- S I have, no doubt, employed local means ; but as I have looked upon the constitutional influence as the cause of the continuance of the complaint. I have not failed to address myself ^^nSl"a^t^X:;;y degree of a<.te inflammator,^^ w„ nresent as known by the redness of the conjunctiva, mtoler- rnoeTStandafeelins «f I''" '» "^ """' \ '«-<>. '"™"t'y Zd antWoK-"<= •««'>•«" '" "«<=»''*''"" "'"'"' '"f ,r"^'/hv d?^ capping, leechinK, and blisters ; active purgatives, followed by he 3nu^d use of alterative medicines, a strict >»«en"on to the character of the ingesta, using only gruel, sago, or » f"'^-""';;;*' soon as there was a marked change in the above m.-«'»-f^>;<'jJ»^ tions, and the f silver, varying m crength ttccordinc to the circumstances of the cas«. -v.r holdmar -n v,ew I rsons who it years, in ams of this you have liphlogistic ibly, all at I, attended intolerance li cold ; but le indiscre- ihylopoietic ce of light, lalogy with le is greatly uence exer- lint. Every of the body is will form granulated the tarsal ' this disease jng been an ocal disease, jted upon by ation of the i disease had ir ten years : )y a periodi- re presented ibove convic- ut as I have lause of the idress myself rv natory action ctiva, intoler- ,ve invariably nsity, such as llowed by the ention to the rrow-root. As tioned indica- I to the eye* r in c'rength ^ir^op 5" view I n the object intended to be produced, viz., the causing of a con-, tracted state of the conjunctival vessels, which, from the continual irritation, had become enlarged and varicose; at the same time also hoping to exercise a similar salutary influence upon the diseased condition of the cartilages. I have seldom ventured to employ the heroic remedies of late so strenuously advocated by authors,— who appear to me in many instances to have let their zeal get the better of their judgment,-by using violent escharotics, such as pure nitrate of silver, bichloride of mercury, and even the mineral acids. These, in many cases that have come under my observation, have tended to bring on the more grave symptoms that shew themselves in this complaint, such as opacity and ulceration of the cornea. With the local stimulants a more nutricious diet was recommended, precisely similar in character to that advocated in scrofulous ophthalmia ; this shou d be persisted in for years, especially avoiding all crude indigestible matter, and particularly the employment of all salted provisions. At this stage, also, the continued employment of gentle alterative medicines, such as the carbonate of soda and powdered rhubarb, will be fonnd beneficial, and in obstinate cases the employment ot a seton.— Under strict attention to the foregoing plan, the disease will gene- rally subside, the enlargement of the vessels diminish, and the cornea become clear. But, as during the continuance of the constitutional influence, a relapse is very hable to occur; the indications of activity in this state of the disease should be invariably attended to ; often shall we have to begin de novo the active treatmtnt of this complaint ; but our patience must not be wearied, and while we combat the active symptoms, we must apply ourselves more strictly to remedying the constitutional influence. Here many of the remedies which have been so greatly lauded in strumous disease may exercise a beneficial influence, such as change of air, sea-bathing, &c. ^ .i . j j In cares in which inflammatory action has recently extended to the cornea, and lymph has been deposited in its structure, alterative doses of calomel and opium were used to encourage its absorption ; and when ulceration had occurred, bark sometimes was found useful. . Acuie Corneitis. This disease generally happened to young persons, from five to fifteen years of age. In all, there was more or less opacity of the cornea, according with *' intensity of the inflammatory action. In some cases a thin ciwud-like appearance was visible ; in others the white tint was much more dense, completely obscuring any internal view of the organ. There was always a pink zone of vessels around the margin of the cornea,evidently the deep schlerotic vessels appertaining to the circulation of the proper substance of the cornea, these could be traced to its very margin, forming a iii 18 marked contrast with the clouded appearance of that tunic. Tn one case the conjunctival circulation appeared to Participate u the complaint when the stri« of enlarged vessels could be distinctly noticeTas a complication of the disease. There was always some pain t the brow, of a dull aching character, but no fever or ^"'^^Tre'trSni consisted in the employment of pur.ative^ followed by alterative doses of mercury, so as slightly to affect the mouUi! Counter irritation, by means of blisters, was repeatedly Tpl ed to the neighbouring parts, and in some cases the abstraction ot- h lood by cupping was employed. These means, if persevered m L a consi'deraWe time, generally removed the disease ; b u in one case of a very obstinate character, it seemed to have little effect, until the repeated application of leeches to the neighbouring par every second day, fov upwards of a month, as advised by Doctor Beaumont, eventually relieved the complaint. Partial Dilatation of the Pupil. A child was presented that had a partial dilatation of the pupil. Upon looking into the eye, the Iris on the right side was observed to be irregular, towards its outer and inferior surface, a portion appeared removed, or as it were cut out of its tissue of about one eF|hth of an inch in diameter. The pupil was a circle until it approached the vacant spot, when it suddenly extended to the greater circumference of the Iris, leaving a space in which this membrane was totally deficient. It happened in a child "P^J^rds ^f a year old, and was said to have been caused by a sudden explosion of a gun, close to the infant a few days previous to my seeing it. Therlwas noappearanceofinflammation, and the effectwasinall pro- bability produced by some paralytic influence upon the c^l'^ry nerve which was deficient going to that portion of the Iris In the lett eye the pupil was perfectly normal, and both the Irides were fully acted on by the natural stimulus of light. Acute Iritis. Of the cases of Acute Iritis that were under treatment, two were decidedly of a venereal character, while the others appeared io be irrespective of any observable constitutional influence. In each eye affected with Iritis, the first symptoni which indi- cated the attack, was a zone of pink vessels around the margin of the cornea, dependent upon the increased amount of red blood carried by the vessels of the sclerotic cont, connected with he drculatory apparatus of the Iris. Due reflection as to the distri- bution of these vessels serves to guide our diagnosis to the structure primarily affected. In inflammation of the cornea proper we always piuimi y^ _ .„_i- o- the ipfl^'^'^d part : here the vessels nnd a pinit zone encirciing use a r — • » -i • t '*.'„ evidently pass onwards to the diseased structure, while in Intis, that tunic, rticipate in le distinctly Iways some o fever or purgatives, affect the repeatedly abstraction srsevered in but in one little effect, lourinsr part 1 by Doctor of the pupil, i^as observed e, a portion f about one rcle until it nded to the 1 which this d upwards of en explosion ny seeing it. was in all pro- ciliary nerve In the left es were fully eatment, two s appeared to action, the supera-^ bundant liquor Morgagni is at first removed ; after which the lens !3 icUiced into ;ransparent variety of 1 which the ;his variety iegree en- Limour, the [lark rim of )il. Again, supplied to in incipient e a material ctiire of the Tiilar views British As- tern to have lar cataract omical cha- sufficiently ?xture, may iiversity in ts presented iflammatory ippearance ; oon partici- tory action, eased struc- ould convey its transpa- lar cataract, ataract, evi- part bears a I apprehend : cataract, or occasionally the lens, the n the lens,or 1 conclusions jrogress and 3t as above- ns, produces he lens evi- ate of things tory action is )mes opaque, , the sup e ra- nch the lens Itself is submitted to their influence, and in process of time, (some- times a considerable period) we find only a fragment of the lens remaining — and eventually nothing but the thickened and opaque capsule is left behind, constituting the hard coriaceous cataract. That such is the progress of traumatic cataract, is confirmed by observation on those cases when the capsule is but slightly wounded; and even when complete dislocation of the lens from its capsule occurs, sufficient testimony or confirmation of these facts may be learned. Any person who has closely watched the progress of congenital cataract, must be convinced of its great analogy, and strict accordance in all its changes with the foregoing events. — The history of the one is the description of the other, differing only as to the period of its occurrence ; indeed it is no more or less than traumatic cataract, caused by some pressure or injury to which these delicate parts are submitted during birth. These facts I fully pointed out in my manual of the Anatomy and Diseases of the eye, published in 1828. There is a variety of congenital cataract that appears to depend upon the partial deposition of lymph upon the capsule previous to birth ; this may be centrical or otherwise diversified, remaining stationary through life, and often causing but trifling inconvenience or deformity. One case of this description presented itself in a woman 25 years of age. In the treatment of cataract the operation of reclination was performed in three cases ; in two the success of the operation was complete without any subsequent inflammation, but in one a con- siderable amount of opacity of the capsule supervened, and required subsequent removal. The two cases that succeeded were _ soft lenticular cataracts, apparently uninfluenced by any constitutional peculiarity ; but in the third case the patient had previously lost one eye from rheumutic inflammation ; and although there did not appear any affection of the capsule previous to the operation, this was felt evidently more firm than in the preceding cases ; and a subsequent attack of inflammation which produced the capsular opacity was evidently of a rheumatic character. Proper precautions had been taken to treat the constitutional peculiarity prior to any attempt at operation, or undoubtedly the inflammation would have been sufficiently intense to have destroyed the eye. In the cases of congenital cataract, the opaque capsule was freely divided by the needle, and the soft lens cut up j in one case it was necessary to separate the adhering portions of the capsule a second time ; the separated parts were however absorbed by degrees, and left the pupil perfectly clear. In one case of incipient lenticular cataract, which could clearly be perceived as a slight cloud before the eye, not unlike very diluted milk, and was especially proved to be seated in the lens by a catoptric examination. In this instance the patient complained of ti; 24 fulness about the head and eyes, had a quick full pulse, and was evidently of a plethoric habit. Bleeding and active purgatives followed by alteratives were eniployed, the patient put upon low diet, and forbid the use of the organ for a considerable period.-- The cloud before the eye very greatly diminished, and the v.sible opacity became much less, so that I flattered myself that I had by these means lowered the tone of the system, and diminished the quantity of albumen in the blood, and thereby had succeeded in removing the superabundant production of the liquor Morgagni that miffht have ended in the absorption of albuminous deposit m the texture of the lens, and have eventually caused confirmed cataract. At all events I think this is a subject well worthy the attentive consideration of the surgeon, and certainly deserves to be tried m cases of incipient lenticular cataract, for we might possibly super- sede by timely means the necessity of an operation. Amaurosis. The cases of Amaurosis that presented themselves at the Dispensary were for the most part of long standing, in which vision was more or less totally destroyed. A remarkable example of congenital predisposition to this disease happened in the cases ot three brothers ; which hereditary tendency they seemed to have derived from their mother. . The elder brother first presented himself complaining of loss of vision ; he stated that about a year ago, a little saw dust got into his eye which caused slight irritation ; this lasted for several days, during which time he frequently observed flashes of light m the eye, and that even in a dark place, which surprised him much ; he also experienced a dazzling kind of pain in the eyeballs ; a few days after he was at work— hewing some timber, and suddenly observed a mist come before his eyes— felt giddy, and became sick at stomach, so that he was obliged to leave his work; by degrees vision became more indistinct, not in consequence of a haze or cloud before his eyes, but in consequence of the darkness and indis- tinctness of the objects around him. At the time he asked for assis- tance, the darkness or deficiency of vision was very great, so that although he managed to go about the streets of Toronto, it was more by his previous knowledge of the localities, than an ability of distinguishing the places by means oi vision. He indistinctly saw the windows of the room, but could not see the frames ; in a prin- ted book, he could see the lines of words, but could not distinguish, the largest letters. He complained that the darkness had a net- like character that seemed to prevent his seeing ; the pupil was moderately dilated, and the eye had all the appearance of health. — The colour of the ivis was light blue, and did not appear to have any remarkable deficiency in the black pigment, so as to lead to a g.jppQgJtJonj tlmt the confusion of vision was in any way caused by cll e, and was purgatives it upon low e period. — I the visible at I had by iinished the ucceeded in orgagni that jposit in the led cataract. lie attentive ) be tried in isibly super- ;lves at the g, in which ible example 1 the cases of raed to have lining of loss dust got into several days, light in the m much ; he [balls ; a few ind suddenly became sick i by degrees of a haze or 3SS and indis- ked for assis- rreat, so that ronto, it was an ability of distinctly saw s ; in a prin- ot distinguish. ss had a net- lie pupil was e of health. — )pear to have IS to lead to a ay caused by 25 the reflection of the rays of light at the bottom of the eye. Con- stitutionally he seemed weak and debilitated, and at the present time presented no symptoms of cerebral or constitutional irritation. A seaton to the nape of the neck was employed, and the protio- dide of mercury was gradually exhibited until the system was completely under its influence ; this was continued for some time, and many of the symptoms gradually diminished, so that he could again distinguish persons when he met them in the street, was enabled to go about his duties with much greater facility, and appeared very thankful for the advantages derived from his improved state of vision. Two of the brothers presented themselves afterwards with precisely similar symptoms ; in one case the complaint immedi- ately followed a severe blow upon the head, but in the other it appeared to happen without any obvious cause. In one there was more pain and other constitutional symptoms, so that bleeding from the arm was practised, and in each of these cases the protio- dide of mercury seemed greatly to mitigate the disease, and in the more recent case to restore almost perfect vision. The positive seat of the disease in these cases, appeared to me to depend upon an aff'ection of the retina, in the commencement evidently compli- cated with cerebral irritation, which however I conceive was but of temporary duration. The net-like deficiency of vision, the flashes of light in the eye, and the dazzling kind of pain com- plained of, distinctly point to the retina as the part atfected, and was particularly contrasted with a case which I suspected to depend upon compression or disease of the optic nerves. Here the individual complained of pain in the forehead from the first ; had complete loss of vision, which was perfect darkness without any of the occular spectra complained of in the preceding cases; the pupil was largely dilated, while the eyes had every appearance of perfect health. Another variety of amaurosis sometimes presents itself, dependent upon disease influencing the origin of the optic nerves, this of course is accompanied with the symptoms of cerebral iritation from the first, and is particularly marked by pain in the head and double vision, at the very onset of the complaint. Fungus Ilcematodcs of the Eye. This happened in a child about fouryears of age ; it was marked by the premonitory symptoms of the disease, especially the white shining appearance at the bottom of the eye, which by degrees became enlarged, and showed an evident bulging of the fungoid mass as the disease progressed. The eyeball was extirpated, and when examined, distinctly provetl the nature of the complaint, showin"-;! eonsolete disor'anization of the internal struv^ture ot the eye; this was transfornu'd into a dense brain like structure, affording scarcely any traces of the normal condition; no re-jippear- 26 ance of the disease occurred in the orbit, but the child died in about twelve months after the operation, apparently Irom the influence of a similar disease in the brain. Invertlon of the Eyelids. The invertion of the lids in two cases were very simple in their character, depending upon a slight thickening of the conjunc- tival lining the lower lid! These were easily cured by the exci- sion of a suitable piece of skin covering the diseased eyelid, the cut surface being brought together by sutures ; the disease disap- peared as the wound healed. The third was a very protracted and obstinate case ; the inversion of the lid had caused considerable irritation, and thickening of the corneal conjunctiva, and even the cornea itselt had begun to participate in the disease, and besides the intolerable misery in this case attendant upon the disease, would decidedly have caused blindness. The patient had been previously operated upon at the General Hospital, (and from the obstinate character of the complaint) with but temporary benefit. In this instance it was the upper eyelid that was inverted, and for its re- lief I performed the operation recommended by Mr. Guthrie, con- sisting of a complete division of the diseased eyelid at both its angles including the tarsal cartilage, ; this was perfectly everted up towards the brow, and confined by three sutures, supported by sticking plaster in that position, until by the gradual healing of the wound, the lid was brought by degrees to its normal position. To assist this operation, a piece of the lax skin of the eyelid was re- moved, and this greatly tended to preserve the proper direction of the tarsal margin. In many of these obstinate and protracted cases, a vitiated curvature of the tarsal cartilage dependent upon its long continuance in the abnormal state, is the true reason that the more simple and less complicated means are not available. Here how- ever, the disease was completely cured without any other deformity being observable, than the two little notches at the angles of eye- lids. In the worst of cases this operation far excells the barba- rous method of removing the whole tarsal margin which has been practised by some surgeons, in utter despair of remedying the complaint. Eversion of the Eyelids. In both instances of this complaint, it was the result of orbiial disease. In one case an abscess had occurred in the areolar tissue ^ of the orbit, api)arently from inflammation of the periosteum of the orbital plate of the temporal bone ; a sinus was remaining which led to a piece of dead bone, in the structure above-mentioned, appa- parently about the centre of the orbital plate. In consequence of the contraction of the areolar tissue, the upper lid was drawn up- wards, so that it would not descend sufficiently to cover the globe, which was consequently liable to continual irritation, while the lid 27 d in about ifluence of simple in J conjunc- tlie exci- tl, the cut ise disap- •acted and nsiderable I even the )esides the ise, would previously obstinate In this for its re- thrie, con- t both its y everted ported by liny- of the ition. To d was re- irection of cted cases, on its lonji^ t the more Here how- deformity es of eye- the barba- has been idying the t of orbiial eolar tissue eum of the r which led led, appa- iquence of drawn up- the globe, hile the lid was also partially everted which caused some disfigurement. In this case I advised to endeavour the separation of the piece of diseased bone, being careful to watch its progress, and particular to guard against the supervention of disease of the brain, for I considered this untoward result not unlikely to happen — after reflecting on the location and great tenuity of the orbital plate; and was fearful that inflammatory action here, might be attended with as fatal con- sequences, as often results from caries of the petrious portion of the temporal bone in diseases of the ear. After the disease of the bone had been cured, I suggested that by freely dividing the adhesions within the orbit, and keeping the upper lid forcibly depressed by means of sutures affixed to the cheek with sticking plaster, until the granulations had filled up the deficiency, which would effectually cure the eversion and contraction of the lids. The other case presented a far greater degree of deformity, a complete eversion of the upper lid, which had been produced by a timiour of the orbit. This tumour,from the womans description had been of an encysted character, in all probability an hydatid, as she described the discharge as fluid and like water; it had been inju- diciously opened by a medical man, and not completely removed as should have been the case. The cyst continued to discharge for some time, but gradually contracting produced great puckering and derangement of the neighbouring parts, that ended in complete eversion of the lid. I proposed to perform an operation for the re- moval of the deformity, but the old lady has not yet consented. Diseases of the Lachrymal Apparatus. I have thought it better to include all the varieties of the dis- eases that influence these organs under one head, especially as I had hoped ere this to have brought the report to a close. Through the whole I have endeavoured to be as concise as the subject mat- ter would permit, and I had thought that perspicuity was conso- nant with the comprehension of the subject; but from the una- voidable extent, I shall endeavour to conclude as hastily and as briefly as possible. The diseases of the lachrymal apparatus admitted for treat- ment, upon the whole were not very numerous, and although each case presented interesting matter for the consideration of the ophthal- mic surgeon, still there is nothing that demanded very special consideration. I might mention that one case of stricture of the lachrymal sac, appeared to be cured by the employment of anals probe, which was passed daily for a considerable time. In ano- ther instance I was obliged to employ the common style; a tube had been prcviou-dy nsvd, but was found to become obstructed, and consequently useless, while its presence seemed liable to excite considerable local irritation. Church Street, Toronto, C. W. June 5th, 1851.