not at once form our prognosis, as when we can get a fair inspection of the cornea. So long as the eyelids are swollen and tense, and present a shining and florid surface, the cornea is generally safe, although it may be upon the verge of destruction; for no sooner is its vitality lost, in part, or in toto, than the tension of the palpebræ diminishes, the color becomes purplish, and the surfaces lose the shining or erysipelatous appearance; the discharge also becomes thinner and whiter; whilst under the circumstances first described, the secretion is thick and yellow. If the cornea can be exposed at the time that the palpebræ are swollen, and of brilliant color, it will rarely be found to be in any great danger, as the chemosis is very rarely then complete; on the other hand, when the cornea cannot be seen, in consequence of the swollen state of the eyelids, it is probable that the chemosis is great, perhaps complete, but it is not necessarily so.

As the surgeon cannot expose the cornea, or ocular conjunctiva, he cannot, of course, divide the chemosis. "He may, however," says Mr. T. "soon reduce the palpebræ, so as to obtain a view of the cornea; and, if necessary, he might make the division of the chemosed conjunctiva: this can be accomplished, by applying a leech or two to the surface of the eyelid, according to the age and strength of the little patient; after the leech has filled itself, and fallen off, bleeding from the bite should be encouraged, by the application of warmth and moisture, until the surface becomes nearly colourless, and somewhat flaccid : in children of two or three days old, a single leech will sometimes suck as much blood as will produce this effect, and in most cases it is necessary to arrest the bleeding after a short time, for the infant will not bear the loss of much red blood: by this means, the tension of the part being reduced, the cornea may be exposed with much less force, and, unless a great state of prostration should forbid it, the chemosis might be then divided, as in the adult."

Mr. Tyrrell has not yet tried the operation in the infant. If the disease proves destructive to vision, it generally is so from neglect. Out of a large number of cases in which the tumefaction of the eyelids has been excessive, (appearing almost bursting,) but in which the color has been florid and the surface shining, he hardly recollects a single instance of even partial slough of the cornea ensuing under the influence of local bleeding, to such an extent as to nearly destroy the color of the palpebræ; which usually also produces some general prostration.

After the abstraction of blood, the weak solution of alum should be used frequently tepid, and increased in strength, if necessary. The cilia and canthi should be lightly touched with a camel's hair brush dipped in some simple ointment-and, if the case proves obstinate, a weak solution of the nitrate of silver may be resorted to.

Should the cornea, on inspection, be found more or less hazy, and threatened with mortification, Mr. T. would advise division of the chemosis, four incisions being probably enough.

CHRONIC INFLAMMATION OF THE CONJUNCTIVA FOLLOWING PURULENT AND CATARRHAL OPHTHALMIA.

Mr. Tyrrell describes, under this head, the complaint commonly known as "granular lid." He looks on that complaint as the result of the ophthalmiæ mentioned, and believes that he has shewn that these diseases commence in the palpebral division of the conjunctiva, and from thence extend to the ocular portion. They disappear in the contrary order; leaving, first, the occular part of the membrane, or that in which they appear last, and linger in the palpebral portion of the tunic, or that in which they first appeared; and, in this division of the membrane, the morbid action may remain in so trifling a degree as to es

cape the observation of the careless practitioner, who may be satisfied with the perfect restoration of vision, independently of slight occasional interruption from a collection of superabundant secretion. In order to prevent the occurrence of the chronic affection, the palpebral conjunctiva should be carefully examined, when the acute disease appears to have been completely subdued; and if the membrane of the eyelid has not perfectly recovered its natural aspect, the remedies should be continued until all morbid appearance be subdued. The examination should extend to the conjunctiva of both eyelids.

He has, he assures us, repeatedly observed, that according to the severity of the acute stage, and in proportion to the extent of exhaustion created by the treatment employed, has been the risk and rapidity in the development of the chronic form.

We see nothing particular in Mr. Tyrrell's observations on this complaint. But his treatment of it when the stage of "granulated lid" has set in, that is, when the villi of the palpebral conjunctiva have decidedly enlarged, should be quoted. He first sets forth Mr. Saunders' plan of removing the villi with the knife, and comments on its inefficiency. He then relates a case illustrative of his method." I made frequent examinations of the diseased membrane; and, whenever I found it to be of a deep red colour and turgid, I directed a leech to be applied to the outer surface; but when it presented a lighter colour and was softer to the touch, I had applied immediately to it a more powerful astringent than I had previously used. That which I applied most frequently, and from which the most good resulted, was the solution of the diacetate of lead undiluted. It was smeared upon the diseased membrane by means of a camel's hair brush, the part being exposed by eversion of the eyelid, and cleansed from secretion by a piece of dry lint. Thus the astringent came in immediate contact with the morbid projections. I also occasionally applied the sulphate of copper, in substance, to the granular surface under similar circumstances; but it was used lightly, and not allowed to rest long enough in contact with the surface to produce an escharotic effect."

The plan, he informs us, answers, but he has occasionally modified it a little, having now and then incised the tumid membrane very lightly, by transverse incisions, extending the whole length of the tarsus; not so deep however as to injure the tarsus, but only to open the vessels of the diseased conjunctiva of the eyelid. He has usually made three or four parallel incisions in each superior eyelid; and afterwards has encouraged bleeding from the part, by the application of a sponge moistened with hot water; and then as soon as the vessels have been pretty well emptied, he has applied a powerful astringent.

In some few cases change of air has been requisite. When the granulations are large and flabby, the cure is generally slow. General treatment calculated to invigorate-the use of the undiluted solution of the diacetate of lead—and when the granulations are small, hard, and pale, the light employment of the sulphate of copper, are the measures that he recommends, and he adds repeated blisters behind the ears.

SCROFULOUS OPHTHALMIA.

Mr. Tyrrell thinks, and most practical surgeons will agree with him, that there is no particular form of ophthalmia which, par excellence, can be called the scrofulous. The strumous constitution can modify them all, though the simple and pustular or phlyctenular forms are the most affected by it. The prominent feature is extreme intolerance of light.

General means

On the subject of treatment Mr. Tyrrell has not much to say. and remedies are indispensable, of course. As local means, Mr. T. rarely employs any others than counter-irritation, by means of small blisters placed be

hind the ears, or above the eyebrows; never, however, continuing the irritation, by promoting discharge from the blistered surfaces by stimulating applications, but preferring the repetition of the blister. He generally uses simple warm water, or a decoction of poppy-heads or chamomile flowers, with, now and then, a few leeches to the palpebræ, when the conjunctival vessels are numerously and very fully distended with red blood.

"Many surgeons employ more powerful local agents in the treatment of this disease than those I have recommended; but, a very extended and impartial trial of such means, has induced me, by degrees, more and more to lay them aside, and adopt the simple plan which I have detailed. I have seen obstinate cases much benefitted, for a time, by the use of some severe counterirritant, as the tartar-emetic ointment, issues, setons, &c. ; but I have seen much more evil than good result from these means; and most sincerely believe that the disease is to be more effectually and permanently removed by the plan I have proposed. To astringent and stimulating applications to the organs themselves, I have very strong objections; arising from the observance of the frequent and serious mischief they produce.-I mean the common astringent and stimulating lotions, ointments, or drops. If they are employed at all, it should be when any general error of system, or important functional derangement has been removed; and I believe, that the advantage frequently obtained by their casual use at such a period, has led to a very exaggerated idea of their efficacy." 162.

We must say that, so far as we have seen, we are quite disposed to agree with Mr. Tyrrell.

CHRONIC SCROFULOUS OPHTHALMIA.

The characteristics of this form of ophthalmia are the following:

"In the most simple cases of chronic disease, the only differences which can be observed, exist in the number and colour of the vessels carrying red blood, which become less numerous, more tortuous, and of a darker or purplish hue, as the chronic form is assumed; and if there be discoloration of the palpebræ, such discoloration is also of a dark character. Otherwise, whatever may be the nature of the affection in its origin, whether simple, pustular, or catarrhal, as it affects the scrofulous person,-under continuance, it usually implicates nearly the whole of the ocular portion of the conjunctiva, as well as the palpebral. In the former, the vessels become large and tortuous, and of a dark red or purplish hue; and many pass from the sclerotic portion of the membrane to its corneal division: and whenever this occurs, the latter becomes thickened and loses its transparency, especially in those parts in which the vessels are rendered apparent, from being distended by red blood. In some cases, but few of these vessels are to be perceived, whilst, in others, they are exceedingly numerous; but the nebulous condition of the membrane is usually greater in proportion to the number of these vessels. This state of cornea is denominated vascular and nebulous, similar to that which results from the irritation of the granular eyelid as a consequence of chronic purulent or catarrhal inflammation; but there is a very marked difference in the mode of distribution of the vessels carrying red blood to the cornea. In the case of granular eyelid, they are rarely found encroaching upon the cornea in any direction, except from the upper part, as I have previously described; but in the scrofulous disease, they will be generally perceived passing over the sclerotic to the surface of the cornea, at nearly all points of the circumference of the latter, though the larger vessels usually take their courses from the directions of the recti muscles. Now and then also, we have a granular state of the eyelids. This, however, but rarely happens, unless the disease in its origin has been of a catarrhal or purulent kind." 165.

Indolent ulceration of the corneal part of the conjunctiva is common.

The subjects of this disorder are generally pallid, with a feeble circulation. The treatment must, naturally, be directed towards the improvement of the general health. When the functions are improved, slight local stimulants, such as the vinum opii, or a weak solution of the bichloride of mercury, may be dropped into the eye once in twenty-four, or forty-eight hours. If the application creates a severe and continued pain, it rarely effects good, and should be laid aside; but if the smarting it produces does not exceed a few minutes in duration, leaving the eye tranquil, it may be continued usually with the best effect. Counter-irritation, in a very moderate degree, by small blisters applied behind the ears, may be resorted to when there is much intolerance of light, excepting when the powers of the patient are exceedingly depressed.

The more severe cases, in which the corneal conjunctiva is affected are exceedingly difficult to manage. The tendency to relapse is most troublesome. Every possible general precaution should be taken, and the general treatment should be such as to sustain without stimulating. Mr. Tyrrell speaks highly of Battley's solution of the yellow bark.

Mr. T. believes that warm water is the best local application, though stimulants are sometimes advantageous. Mr. T. speaks favourably of counterirritation, but slightingly of setons and issues. He is confident that these are often prejudicial in children and in weakly persons. He relates two cases in support of this opinion.

EXANTHEMATOUS OPHTHALMIA.

This is-inflammation of the conjunctiva, with erysipelatous affection of the palpebræ. A rare disease, allied to the catarrhal.

The disease presents the following characters :-The eyelids are somewhat swollen, red, and shining, particularly at the margins; but the color is much lighter and the tension less, than is common in erysipelas; the cilia are partly loaded by a light yellow viscid matter, and some similar morbid secretion may also be usually found at the inner canthus : the palpebral conjunctiva is red, tumid, and villous; and the ocular part of the membrane is of a dirty yellowish red color, and elevated around the cornea by a deposit of serum into the subjacent cellular membrane, (serous chemosis ;) this deposit is greatest at the lower part of the circumference of the cornea, and least at the upper part, from the gravitation of the fluid in the cells; it is also often irregular, causing protrusion of the membrane, at several points, giving the appearance of vesicles.

The patients who present this form of ophthalmia are generally weak, with disturbance of the digestive organs. They are generally, too, advanced in life and of irregular habits.

A few smart purges, strict diet, and the local use of a slightly astringent lotion and ointment will usually soon effect a cure. If there is much gastric uneasiness, an emetic proves of service.

The forms of ophthalmia, most common in the fevers which are attended by cutaneous eruption, are, the pustular and catarrhal, or muco-purulent: the latter commences with symptoms, so similar to those which usher in the purulent disease, that the medical man should be on his guard. If then, the conjunctival affection begin with much pain and heat, and there be a rapid change in the palpebral part of the membrane, so that it become thickened, villous, and of a deep carmine color, and at the same time the secretion present a yellow tinge, there is every reason to dread the development of the acute purulent inflammation; and it will most probably take place, unless means be pursued to check and subdue the first stage.

"Whilst in the first stage, the disease may usually be subdued by local bleeding, with leeches, and the subsequent use of warmth and moisture, with some

slight astringent, as alum; the means appropriate to the cure of the febrile disease otherwise, as purgatives, abstinence, &c. will aid in subduing the local complaint; but should the attack commence with severe pain, and rapid tumefaction of the conjunctiva, with other symptoms of acute kind, and the circulation be full and incompressible, and the patient possessing good constitutional power, I can discover no good reason why the force of the circulation should not be lessened, by abstraction of blood from the arm; it would probably lessen also the violence of the febrile disease, and expedite recovery: the surgeon should, of course, be extremely cautious not to remove more blood, than would be requisite to reduce the force of the circulation a little below the ordinary standard, and not so much as to produce prostration. I have seen this plan adopted in the first stage of purulent ophthalmia, occurring with small-pox, and with the best effect, generally, as well as locally. The remedy is, however, a hazardous one, and should not be adopted, without a perfect conviction of the power of the patient being good, and the action of the heart and arteries being above par, not in frequency, but in force." 181.

We would recommend surgeons to be very cautious in employing general bleeding in the exanthemata. We would undoubtedly pause ere we resorted to it.

The local disease comes on at various periods of the febrile attack; sometimes quite in the commencement: occasionally during its height; and, sometimes, as the severity of the general disease is passing off. Mr. T. prefers general bleeding when the ophthalmia is developed in the early stage of the fever. When chemosis, &c. have supervened, Mr. T. would adopt nearly the same plan as if the fever were not present, though he would be more cautious in lowering the patient.

During, says our author, the continuance of, or subsequent to some of the exanthematous diseases, when the febrile action has been unusually severe, and has occasioned great prostration of the general power, inflammation of the conjunctiva sometimes arises, attended with ulceration of the cornea, by which this transparent texture usually suffers extensively; the progress of the ulcerative process being rapid. Mr. Tyrrell has seen the same thing in cases of typhus fever.

"I would recommend," says Mr. T. " that the treatment should be such, as is best calculated to promote and maintain a good state of the general power; as, a nutritious diet, with the moderate use of an accustomed stimulus, tonic medicines, with proper regulation of the secretions, and the use of mild astringents, or stimulating lotions to the eyes. I should not advise the application of any powerful stimulus locally, until the general power is much improved for, during the state of great debility, a strong stimulus may excite a degree of action, which the part is not able to support; and more extensive sloughing may result. A solution of nitrate of silver, injected upon the surface of the ulcer or depression, may be of service, when the general power is considerably re-established, and no healthy local action appears to take place." 184.

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We have completed a notice of the ophthalmiæ, and have extracted such facts or opinions as we think are calculated to be useful. In our next number, we shall take up the remaining portions of the work, and complete our account of it. We need scarcely add, that we consider it a very valuable addition to the existing books upon diseases of the eye, and we believe that it will prove eminently useful.