made, and the bleeding checked by the pressure of the pince anneau, instead of making the tumour start from its place, by the application of the thumb-nails on each side of the incision, Dr. Desmarres directs his reader to seize the chalazion with a hook, or a pair of mouse-teethed forceps, (pinces à dents de souris), and dissect it out; a thing totally impracticable, on account of the softness of the tumour, and very likely to end, in the hands of an operator determined not to be beat, in the formation of a button-hole through the lid. The pith of Mr. Pott's adage, that fingers were made before forceps, is very well illustrated by Dr. Desmarres' superfluous machinery for the extirpation of a chalazion.

After some description of scirrhus and caries of the eyelids, the second part of the work of Dr. Desmarres is commenced by some remarks on the ophthalmiæ, and an arrangement of the different forms of conjunctivitis, which is by no means perfect. The following remarks on the opthalmia neonatorum are worthy of notice.

"The most efficacious treatment, especially at the commencement of this disease, and while there is yet no trace of ramollissement of the cornea, consists in suddenly arresting the inflammation by means of the nitrate of silver. If the disease is just beginning, a collyrium of this salt, of the strength of a grain and a half to two drachms and a half (un décigramme pour dix grammes) of water, dropped from hour ⚫to hour, between the eyelids, will suffice; but if it has already reached the second or third period, it will be necessary to have immediate recourse to cauterization with the same salt, in solution or solid. If we choose the former, about three parts of nitrate of silver are dissolved in one part of water,* and we touch with a pencil charged with this fluid all the surface of the conjunctiva, from the free edge of the eyelids to the cornea exclusively; this cauterization is to be repeated at the end of seven or eight hours during the first two days. After the first, sometimes only after the fourth cauterization, the swelling begins to abate: it is no longer necessary then to repeat it but at intervals of twenty-four hours during some days, till the secretion and swelling have almost disappeared. In the interval of the first cauterizations, we apply over the eyes compresses wet with cold water; at the same time we wash the surface of the conjunctiva frequently with a slightly astringent collyrium.

"If we prefer cauterization with the pencil, as the application of it is more easy, and the effect more active, we begin by separating the eyelids with two elevators, then touch the ocular conjunctiva round the cornea, taking the greatest care not to cauterize this last part; that being done, and the elevators being removed, we pass the pencil rapidly over the whole conjunctiva of the upper and lower eyelids.

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To prevent the caustic, which always remains in excess on the cauterized parts, from extending to the cornea, and from becoming a secondary cause of ramollissement of this part, each time that the pencil touches the conjunctiva, I cause to be injected upon it a considerable quantity of water, acidulated with hydrochloric acid (deur cuillerées à café d'acide pour deux verres d'eau), and instantaneously transform all the excess of nitrate of silver into an insoluble chloride, which separates from the conjunctiva in small whitish flocks; this plan, tried a considerable number of times, has always been followed by the best results.

"I have found great advantage from numerous scarifications of the palpebral conjunctiva, half an hour after each cauterization; it is an excellent means for preventing temporary swelling which commonly follows the use of the caustic.

"It is useful, at the same time, especially when the inflammation seems very acute, to apply near the eye, a leech, to be followed, if need be, by another next

Nitrate of silver being soluble in 1 part of cold or part of hot water, it is impossible to dissolve 3 parts of the salt in one part of water. If the salt be powdered and mixed with water in this proportion, a kind of paste is formed.-REV.

day; in the mean time some slight purgatives should be given to the little pa

tient.

"I have no sort of confidence in the treatment of this opthalmia with antiphlogistics, emollient lotions, and the mercurial preparations vaunted by many practitioners, in the first period of the disease. Revulsives seem to me to have no sort of efficacy. Mild collyria, praised by the greater number of authors, succeed only in those cases where a simple catarrhal ophthalmy has been mistaken for purulent conjunctivitis.

"If the cornea begins to ulcerate, or undergo ramollissement to a large extent, cauterization with nitrate of silver is far from being always efficacious; it always causes the swelling and the secretion to subside, but it by no means arrests the progress of the ulceration, at least, in many cases. It is then that we must distrust the concentrated collyrium of nitrate of silver, because it hastens still more the progress of the evil, and we must have recourse to purgatives, frictions on the brow with belladonna, mixed with an equal portion of blue ointment, and weak astringent collyria. Still, it must not be concealed, that these means, like all others, often fail." (p. 208.)

In the first stage of the disease, we consider the application of the solution of nitrate of silver every hour, unnecessarily frequent. Thrice in twenty-four hours would be sufficiently often; while, every two or three hours the puriform secretion should be carefully removed by means of a slightly astringent collyrium, such as a solution of one grain of bichloride, of mercury, and six grains of chloride of ammonium in eight ounces of water, employed warm, with a small bit of sponge. We also regard scarification of the conjunctiva, after each cauterization, as excessive; much greater benefit is derived, indeed, from applying a leech to the external surface of each upper eyelid, than from scarification of the conjunctiva. Notwithstanding Dr. Desmarres' protest, our experience leads us to recommend one grain of chloride of mercury, to be given every twenty-four hours, and blisters to be applied behind the ears. Should onyx or abscess of the cornea occur, or the cornea appear softened or ulcerated, extract of belladonna should be added to the above-mentioned collyrium, and the same substance should be carefully painted on the lids and brow at least thrice a day. The chloride of mercury should now be omitted, and from half a grain to a grain of sulphate of quinine should be given every eight hours. This last remedy, though of the highest importance, is altogether overlooked by our author. Neither does he refer to the propriety of regula ting the diet of the nurse, who is often found to be counteracting the antiphlogistic treatment applied to her child, by the use of alcoholic stimulants. Gonorrheal ophthalmia. Dr. Desmarres' treatment for this very dangerous disease consists, in the first place, in phlebotomy, which, he thinks, should be repeated morning and evening, as long as the state of the pulse permits it. Leeches are to be liberally applied near the eye. Every three hours, from a grain and a half to three grains of chloride of mercury are to be given internally, with the addition of a small dose (quelques centigrammes) of extract of belladonna. The patient is to keep his bed, and be put on spare diet. Cauterization is to be employed, as in the ophthal mia neonatorum.

Granular conjunctiva. This being a very troublesome and obstinate complaint, our readers may wish to know Dr. Desmarres' method of

treatment.

When the so-called granulations are small, few in number, and pretty red, he recommends solvent salves, such as those of red or white pre

cipitate; the bulk of a barleycorn being introduced under the eyelids morning and evening. After employing one of these salves for some time, it is well to stop and watch the effects. Calomel applied locally is sometimes very advantageous.

When the granulations are very numerous, large, disposed to bleed, and form a thick layer on the surface of the conjunctiva, Dr. Desmarres, despairing of their solution, excises them with a pair of scissors bent on the flat, taking care to leave the conjunctiva as entire as the removal of the diseased product will permit. To facilitate the operatio inverts the upper eyelid, and introduces under it the index-finger of his left hand, with the nail turned forward. This puts the eyelid on the stretch. Ile employs no forceps.

Scarifying the granulations from time to time, he finds useful. If made too deep, however, scarifications, as well as excision maladroitly performed, produce cicatrices on the inner surface of the eyelids, equally injurious to the cornea with the granulations themselves.

Cauterization with nitrate of silver and sulphate of copper is of great use. The sulphate of copper is of service chiefly when the granulations are pretty vascular; when they are pale and almost cartilaginous it is worthless. Pure nitrate of silver, on the other hand, is in general teo powerful. Dr. Desmarres recommends the oculist to provide himself with a series of pencils, formed of nitrate of potass and nitrate of silver, in the proportions of one half, one fourth, and one eighth of caustic, the remainder being nitrate of potass. These pencils are hard, and not easily affected by the atmosphere. He applies the pure nitrate of silver pencil when the granulations are pale, cf old standing, and of great thickness. This application recalls a sort of life into them. Next day, or two days after, if they have not become sufficiently red, he touches them again. When the superficial eschar falls off, they are found to be vascular, disposed to bleed, and less in size. Then it is that cauterization every second day, with sulphate of copper, should be commenced. By and by the redness of the granulations disappears, and they tend to reassume the pale yellowish hue that they had at first. Now is the time for the double nitrate of potass and silver. Dr. Desmarres considers it of the greatest importance to keep up in the granulations a vascular activity, suflicient to make them disappear. (p. 223).

Vasculo-nebulous cornea. The next section is headed Pannus, and confirms our opinion of the faults of Dr. Desmarres' arrangement. He is now entering on one of the sequelæ of different ophthalmia, and actually calls his readers to the consideration of vasculo-nebulous cornea or pannus, which is the result, not of granular conjunctiva alone, but of corneitis also, before he has treated of the latter disease.

eve.

Pannus literally signifies cloth, and appears to have been used originally as synonymous with pterygium crassum, a disease in which there is an appearance as if a bit of red cloth were stuck upon the surface of the After a time, pterygium and pannus were employed distinctively; the former being applied to the well-known triangular hypertrophy of part of the conjunctiva bulbi, while the latter was used to signify a thickening, with vascularity, of the covering of the cornea. A thic' ened, opaque, and vascular state of the cornea may result from three different ophthalmia. It may be the consequence either of scrofulous conjunc

tivitis, of corneitis, or of chronic puro-mucous ophthalmia. This last ending in granular conjunctiva, a vasculo-nebulous state of the cornea, especially of its upper half, is apt to follow. In scrofulous corneitis, the whole cornea having become nebulous and rough, red vessels are seen to 'shoot over its surface, till the whole is as red as if covered with a bit of red cloth. This is the condition to which the term pannus has most frequently been applied; while vascular cornea has commonly been employed as a distinctive appellation for the more scattered redness sometimes seen on the cornea in scrofulous ophthalmia, and vasculo-nebulous cornea for the condition resulting from granular lids.

We should not have thought it necessary to say so much on a question of nomenclature, had it not been that a peculiar method of curing vasculonebolous cornea having been introduced by Jaeger and Piringer, these oculists, or others who took upon themselves to explain their peculiar method of cure, announced it as a plan for curing pannus; whereas it was never meant, as far as we understand, to be applied to any other state than the vasculo-nebulous cornea resulting from granular lids. The plan in question, which is pretty fully noticed by Dr. Desmarres (p. 231), is nothing else than the reinoculation of the conjunctiva of the diseased eye with puriform fluid taken from the eye of another person-of a child especially, affected with mild ophthalmia neonatorum-so that the eye may again undergo the process of an acute purulent ophthalmia; and being treated energetically, and systematically, may have the chance of being cured, both of the acute disease and of the chronic affection under which it had previously laboured. This proposal, we need scarcely say, must be attended with considerable danger-the danger of the new ophthalmia proving uncontrollable, and the cornea being thereby destroyed even in the best constitutions; and is, therefore, one not to be tried rashly in any case, and ought never to be ventured on in cases of pannus or vascular cornea resulting from scrofulous conjunctivitis or corneitis.

If Dr. Desmarres' account of the treatment of vasculo-nebulous cornea by inoculation is correct (for it is to be observed that he does not derive it from Jaeger or Piringer, but from other authorities at second-hand), there are several particulars about it worthy of note. 1. The conjunctiva corneæ should be, not merely red and opaque, but actually fleshy or sarcomatous; and the whole cornea should be in this state. 2. Though both eyes be diseased, one only needs to be inoculated, as the inoculation infallibly propagates itself from the one eye to the other; but this does not happen if the other eye is sound. 3. The ophthalmia produced in diseased eyes by inoculation, is always much less acute than it would be in a healthy eye; and, what is very fortunate, it seems to exhaust itself on the abnormal tissue, which becomes softened, swells, and then undergoes absorption. 4. It is only when the inflammation passes beyond these, its proper limits, that it requires to be repressed by antiphlogistics, such as cold water externally, and Seidlitz water as an internal remedy. If the pain is very acute and fever high, venesection, leeches, cupping on the temples, scarification of the conjunctiva, and more active purging, are to be employed. 5. Inoculation does not cure leucoma; it only removes the film which conceals it, and thus displays it to view. This should form partly, then, the basis of the inoculator's prognosis 6. On

the other hand, if by mischance he should inoculate an eye, in which the cornea is partly sound, and not entirely vasculo-nebulous, the sound part will become opaque from the inoculation. Some of these particulars smack a little of the incredible, so that it would require a stout stomach to swallow them. An American gentleman has, on this occasion, assumed the part of Palæphatus, but even his de de de is scarcely sufficient to make them go down.

Dieffenbach devotes a chapter to the operation for the removal of pterygium, and another to pannus and leucoma. He regards pterygium not as an inflammation or degeneration of the conjunctiva, but as a particular organic formation upon it, and from which it may be separated. He raises it with a hook, and separates by scissors. We may compare his views with what Desmarres says of

Opacities of the cornea. After describing the various sorts of specks or opacities of the cornea, he enumerates a great many remedies which have been proposed for their cure. He regards the whole of them as acting only by increasing the action of the absorbents, and thinks that daily excitation of the eye, by touching it with a feather, may produce as good an effect as any of the vaunted specifics. He tried a salve, composed of axunge and porphyrized pumice-stone, and found the results equivalent to those of all other topical applications. He omits to mention the form in which he used iodide of patassium, as well as several other substances, so that we are at a loss to know whether they were employed in salve or in solution. Hydrocyanic acid, we presume, he used in the form of vapour, but even this important particular he does not state. He merely mentions that this powerful narcotic seemed to possess no advantage over other remedies for the cure of opacities of the cornea, and that he did not succeed with it in cases of photophobia. Against opacities resulting from corneitis, we know of no remedy so useful as the vapour of hydrocyanic acid. The extravagant falsehoods, published some time ago, regarding its effects in other diseases of the eye, such as cataract and amaurosis, over which it has no power, have thrown it too much into the shade. We have seen great benefit result from the use of a solution of caustic potass, two grains to the ounce, applied daily to the opacity with a camel-hair pencil.

Dieffenbach advises removal of the opacity by the knife. He says that the objection, that the subsequent cicatrix will be as opaque as the layer removed, is contradicted by experience. The operation consists in total or partial excision. Partial or superficial excision is very simple. The eyelids are kept open by the speculum, the edge of the opacity fixed by a small hook, and with a small thin knife the most superficial layer of the central portion of the opacity is carefully dissected off. This completes the operation. Cold water is applied; and after a few weeks, a further portion of the opacity is removed, and so on until the whole is taken away. The general result is, that the leucoma loses its cartilaginous whiteness, is smoother, smaller, and clearer, partly from contraction of the new cicatrix, and partly from clearing of the deeper layers of the cornea. Complete excision is performed when a leucoma is thick and prominent, about the size of a pea, and lies directly before the pupil, o that the patient cannot see. It is fixed by the hook, and removed as before, without opening the anterior chamber. The edges are brought 8-IV.

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