No. 2039.

SEPTEMBER 27, 1862.

A MirrorOF THE PRACTICE OF

MEDICINE AND SUEGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historias, tarn aliorum proprias, collectas habere et inter se com-parare.—MORAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium.

MIDDLESEX HOSPITAL.

CLINICAL REMARKS ON TWO CASES OF PHLYCTENULAR

CONJUNCTIVITIS, ILLUSTRATING THE BENEFICIAL

EFFECTS OF THE INSUFFLATION OF CALOMEL.

(Under the care of Mr. SOELBERG WELLS. )CASE I.-Camilla P-, aged twenty-three, was admitted

as an out-patient on July 23rd, 1862. She has been sufferingfor some years from frequent attacks of phlyctenular conjune-tivitis, and was under the care of Mr. Wells some months agowith this affection, which yielded very rapidly to the insuffla-tion of calomel. For the last four months her eyes have been

perfectly well; but within the last fortnight she -has noticedthat her left eye was getting a little red and irritable, and sheis now again suffering from phlyctenular conjunctivitis in thiseye. It is irritable and somewhat injected; a few dusky con-junctival vessels run towards the cornea, and on the scleroticthere are two phlyctenulse (one quite close to the lower edge ofthe cornea, the other a little distance from its outer margin),like small, white, opaque vesicles, elevated on and surroundedby a few scattered dusky-red conjunctival vessels. There isno photophobia, and but slight lachrymation. The eye is, how-ever, impatient of the slightest touch. It being a model casefor the insufflation of calomel, a little of this was at once dustedon both phlyctenulse, and with the best result ; for on the 25thof July (two days after the application) the phlyctenula on thesclerotic had completely disappeared, leaving no trace of itsexistence (no redness even) behind; that at the edge of thecornea was also almost well. The calomel was repeated.July 28th.-The lower phlyctenula has also entirely disap-

peared, and the eye looks perfectly well. Calomel was againapplied, in order to prevent a relapse, being continued at inter-vals of two days until August 8th, when it was left off, the eyecontinuing perfectly well.

Sept. lst.-No recurrence has taken place. She took nomedicine until August 20th, when, being in rather delicatehealth, she was ordered the compound iron mixture.CASE 2. -Susan A-, aged eight, was admitted as an out-

patient on August 2nd. Her eyes have until t.he last few daysbeen always well. There is now in the right eye a smallphlyctenula at the lower edge of the cornea, accompanied byconsiderable vascularity and some lachrymation, but no photo-phobia. Calomel was applied at once.Aug. 5th.-Much better; phlyctenula nearly gone, hardly

any vascularity remaining. Calomel repeated.13th.-No trace of the phlyetenula, no redness ; the eye per-

fectly well.Sept. lst.-There has been no recurrence.Mr. Wells made the following clinical remarks:—The insuf-

flation of calomel often acts as a charm in phlyctenular oph-thalmia-an affection which generally proves so obstinate inthe treatment, and so apt to recur. In order that there mightbe no doubt as to what was the agent in the cure, Mr. Wellsabstained from all other external or internal treatment in theabove and other cases of the affection. When the latter iscured the general health should of course be attended to; in-deed it will be well to do so from the commencement, if it is

urgently indicated. Calomel must not, however, be indiscri-minately applied in all cases of phlyctenular conjunctivitis orcorneitis; for if there is much lachrymation, vascularity, or

photophobia, or if there are ulcers of the cornea, it proves tooirritant, and often greatly intensifies these symptoms, whichshould therefore be first combated and subdued by atropine,counter-irritants, &c., and then recourse may be had to calomel

with striking advantage. It should be applied every day orevery other day. belI1!{ continued for a short time after thedisease is cured, in order to prevent any recurrence ; and thepatient should be warned to apply it again as soon as the eyegets at all irritable or red, for by the immediate re-applicationof the remedy we may almost always prevent any fresh out-break of the affection. We should carefully watch the effectof the first application, for should the calomel prove too irri-tating, it must be abstained from until the irritability of theeye has yielded to atropine, &c. The calomel should be verydry, so that it forms a fine impalpable powder; for if it is atall damp it is apt to form clots on the conjunctiva and cornea,which may act as irritants. It is to be applied with a finecamel’s-hair brush, held between the thumb and forefinger; aslight fillip with the middle finger against the handle of thebrush will jerk a little of the powder into the eye. Its actionappears to be specific and chemical, and not mechanically irri-tant, for the insufflation of other finely-powdered substances(magnesia, &c.) affords no analogous results. It is at presentuncertain whether it acts on the Meibomian glands, or, assome think, on the epithelial cells of the conjunctiva. It isalso a valuable remedy in the phlyctenular corneitis whichoccurs so frequently after scarlatina, measles, &c.; in variousforms of opacity of the cornea, particularly if they are not ofvery long standing, nor too dense; and in the retrogressivestage of so called scrofulous corneitis-that form in which anelevated infiltration is pushed forward towards the centre ofthe cornea, at the apex of a bundle or leash of vessels.

ROYAL LONDON OPHTHALMIC HOSPITAL.

CHANCRE IN THE THUMB OF A MIDWIFE; SECONDARY

RASH, SORE-THROAT, AND IRITIS.

(Under the care of Mr. HUTCHINSON.)I MRS. I aged thirty-eight, applied on June 26th. -Shehad acute iritis of the left eye of one week’s duration. Herarms were found to be covered with coppery stains, left by afading rash. In both tonsils were kidney-shaped ulcers, nowhealing. She said that she was a midwife, and that she hadpoisoned her right thumb. A troublesome sore formed, andabout a month afterwards the rash and sore-throat appeared.She had had hard glands above the elbow and in one armpit,but these had now subsided. The sore on the right thumb wasstill open, and the nail somewhat loose. The latter had beencut away at the lower part. The end of the thumb was muchswollen, and a large granulating surface was exposed. Therewas no specific hardness of the edges, and indeed the conditioncould not have been distinguished fiom that seen in some formsof onychia maligna.

Inquiries were made as to any sores on the genitals, but theexistence of suh was denied ; and as the date of the sore on thethumb and those of the rash and iritis exactly fitted with whatis usual in the sequence of primary and secondary symptoms,no doubt was entertained that the denial was truthful. Thepatient expressed the utmost willingness to submit to an ex-amination. She subsequently brought the prescriptions whichhad previously been given. They did not include any specificremedy, and the sore on the thumb had evidently been regardedas an ordinary whitlow.Under mercurial treatment the iritis rapidly subsided, the

thumb healed, and what remained of the rash disappeared.The case is not without its interest, as an instance of true

syphilis treated in its early stages without mercnry. In spiteof the omission of this remedy, the disease of the throat, theiritis, and the rash were all of them mild, and both the formerwere subsiding steadily before the mercurial was given. The

specific effect of the latter, in procuring the disappearance ofthe iritis and the healing of the ulcer on the thumb, was, how-ever, most marked.

WEST LONDON HOSPITAL.

TWO CASES OF CATARACT ; EXTRACTION BY LOWER

SECTION OF CORNEA ; RECOVERY OF SIGHT.

(Under the care of Mr. ERNEST HART.)Two cases of cataract were admitted in September into the

same ward of this hospital, and submitted to operation bycorneal extraction with the inferior flap. Both patients werefemales, and of the middle age. In the one, the right eye