Fungus from the iris, 5. Vacillation of the iris, 5. Cataract, 17. (d) Dislocation of the lens, 15. Choroiditis, 7. Retinitis, 2. Glaucoma, 4. (e) Hydrophthalmia, 2. Suppuration of the eye-ball, 7. Atrophy of the eyeball, 3. Fungoid, and various anomalous tumors of eye ball, 4. Neuralgia of the eye-ball, 7. Oscillation of the eyeball, 5. Amaurosis of various kinds and degrees, 100. Diseases of the lachrymal passages, 19. Epiphora, 14. Strabismus, 8. Tinea, 105. Lippitudo, 12. Hordeolum, 5. Ectropium, Entropium, 6. Inflammation of the eye-lids, 16. Edema of the eyelids, 9. Ulceration of the eye-lids, 6. Ptosis, 4. Adhesion of the eye-lid of the globe, 3. (f) Tumours in the eyelids, 27. Wound of the eye-ball and its appendages, 42."

3.

CHANGES IN THE TARSAL

CARTILAGES.

Mr. Middlemore alludes to a fact which he has observed-that obstinate chronic inflammation of the conjunctiva occasionally depends on a morbid state of the tarsal cartilages. Surgeons should be familiar with the fact, in order to avoid the liability to error in forming their prognosis.

." Several obstinate cases of chronic inflammation of the conjunctiva, depended on a shrivelled, uneven, and irregularly ossified state of the tarsal cartilage, and, although not absolutely curable, were yet capable of considerable alleviation by appropriate treatment. In very old persons, changes in the figure, the size, the consistence, and other characters of the tarsal cartilage, frequently take place, and, among these alterations, the undue incurvation of its extremities, or a shrivelling of its texture, with the deposition of specks of ossific matter, are the most common; and, of course, any material irregularity of surface or change of figure it may undergo, will influence the surface and condition of the palpebral conjunctiva which covers it, and produce certain effects upon the eye, correspondent, in their extent, to the changes the conjunctiva may have sustained.

Case. Sarah Mace, æt. 20, has a large spherical staphyloma of the left cornea, consequent on an attack of gonorrhoeal ophthalmia. The diseased eye-ball is somewhat inflamed, and the opposite eye is in a very irritable state.

Having placed her upon a table as for the operation of extraction, I introduced Beer's knife, at about an equal distance from the summit and base of the staphyloma, and brought out its point at a corresponding situation on the opposite side, and by gently urging the knife forward, a small semicircular flap was formed, which was immediately removed by the convex-bladed scissors, by an incision which constituted, as respects its outline, a portion of morbid cornea, of an equal size, and of the same form. The lids were then carefully closed, and a roller so applied as to keep them in apposition with the globe.

The operation occasioned very little pain; no bad symptom followed its performance, and in the course of a few days the opening in the cornea had closed, chiefly by the adhesion of its edges to a small portion of lymph in the centre. As this lymph became absorbed, the part diminished in magnitude, and, at the present time, the previously staphylomatous eye is smaller

the eye, are excited by the same cause, the violence of the injury inflicted.

"There is one other variety of dislocation of the lens, to which I shall, for a short time, direct attention; and it will afford me great pleasure if my brief allusion to it, should induce surgeons of greater experience, to favour the profession with their opinion, of a condition of disease which is sometimes adequate, to render the subject of it a burdensome and comparatively useless member of society.

A blow upon the eye may displace the lens and its capsule, and, at the same time, rupture the hyaloid membrane; or it may inflict such injury upon these parts, that the septa of the hyaloid membrane may become absorbed, and the vitreous humour acquire a morbid fluidity, so that the lens will sink backwards and rest upon the retina, and, by its compressive effect, cause total amaurosis. Now, in such instances, an examination of the eye, with the head inclined backwards, will detect a vacillating iris, and a slightly green-coloured body (which is the most common change of colour that the lens undergoes under such circumstances), at the lower and posterior part of the globe; and, whilst in this position, the vision of such an eye will be entirely destroyed. If the patient move the eye-ball freely and rapidly, the lens, or a greenish or amber-coloured body, will be seen to roll about in the eye. If the patient lean the head forward, the lens will rise into its proper place, or, perhaps its upper margin may be seen, if the pupil is somewhat large, and he will be able to see in this position, not perfectly, but sufficiently well to find his way about, even in walking in a strange road, or in a place to which he has not been accustomed. Now it may happen that, in some of these cases, the lens may not be wholly detached, a slight connexion still existing at its lower margin, and then, of course, it will not float about so freely in the vitreous humour, and will more readily come forwards if the head be inclined in such a direction; in other instances, the lens and its capsule appear to be wholly detached from the hyaloid

membrane, and, of course, when this takes place, the crystalline body will, in the erect position of the body, sink downwards, as an effect of its weight, and, by resting upon the retina, induce complete amaurosis.

I have seen many of these cases recently, and shall briefly refer to one or two of them, but, I must confess, I had never noticed this form of injury, until my worthy and enlightened friend, Mr. Smith, of Southam, obligingly sent to me a man, in whom the lens passed freely into either chamber of the eye, in accordance with the posi tion of the head, sometimes coming in front of the iris and pressing that membrane (which was in a state of vacillation), towards the retina, and on leaning the head backwards, it would pass the pupil and resume its proper position, so that, I apprehend, in this instance, the hyaloid membrane was entire. It may be desirable to state that the lens preserved its transparency."

Mr. Middlemore mentions two other cases, which, however, we need not introduce. He observes, with respect to the treatment, that the lens cannot be broken up or destroyed by any means short of extraction. This he thinks it only desirable to perform where the sight of the other eye is seriously impaired, or the affected one is suffering a great degree of irritation from the agitation of the lens, or much interruption to vision from its movements.

"In the instances to which I have referred, I have operated in the following manner. The patient being seated in a chair, with the head a little inclined forward, I make a free incision at the lower part of the cornea, with the triangular extraction knife, and having introduced a small hook beneath the flap, I succeeded in drawing the lens through the opening; in one case, after considerable delay, in the other, without the slightest difficulty, The difficulty in removing the lens, arose from its great mobility, and the impossibility of fixing the hook in the central and more solid part of its substance."

ON THE OCCASIONAL EFFECTS OF TuMORS IN THE EYELIDS.

Tumors in the eye-lids, and especially when near the tarsal margin, or situated between the tarsal cartilage and the palpebral conjunctiva, or when arising from the latter part, or growing from the precise edge of the eye-lid, will sometimes give rise to acute or chronic ophthalmia, and also excite amaurotic symptoms. Mr. Middlemore frequently removes tumors from the eye-lids, for the cure of acute or chronic ophthalmia, which had resisted every variety of previous treatment, but which yields with amazing rapidity to this. He relates three cases of this kind, which deserve attention.

"A child was sent to me, a few days ago, with acute ophthalmia, which, to copy the words of its medical attendant, had refused to yield to every method of treatment he could suggest; it was also mentioned, that a little tumour existed in the eye-lid; but as it was very small, at some distance from the tarsal margin, and inadequate, as was presumed, both from its size and situation, to give rise to any irregularity of the mucous surface, it was considered to have no influence in maintaining the inflamed state of the eye. On carefully examining this child's eye, I found it to be acutely inflamed; and I discovered, also, a minute tumour situate between the tarsal cartilage and the conjunctiva lining the eye-lid; and although I perceived the propriety of removing this tumour, yet, as the eye was a good deal inflamed, I certainly did not consider this to be a favourable time for its extirpation; I therefore recommended various measures which usually relieve conjunctivitis, but without any beneficial result; and I then removed the tumour, at the child's second visit, and with the effect of curing the ophthalmia in a few days, without the use of any lotions or medicines of any kind.

A gentleman had a small granular excrescence at the margin of the upper tarsus, with great dimness of vision of the eye of the same side. I removed this warty growth with a fine liga

ture; and which eventually removed the amaurosis also, an effect by no means expected or contemplated by the patient.

Miss A. of Birmingham Heath, had a small fungoid growth at the edge of the left inferior tarsus, with various impairment of vision of the left eye. This growth was almost entirely removed by the application of the sulphate of copper and her sight was completely restored. However, I ought to mention, that she took, at my recommendation, the carbonate of iron during the time she was in attendance at my house, for the purpose of having the sulphate of copper applied to the tumour."

This concludes the report of Mr. Middlemore. He appears to be zealous, industrious, and intelligent; qualities calculated to ensure his success. We trust he will continue to detail the results of his private and public experience.

MIDDLESEX HOSPITAL.

I. WOUNDS Of the Knee-JOINT.* Sir Charles Bell, in a clinical lecture on Injuries of the Knee-joint, published in the Medical Gazette, refers to some cases which have lately occurred in the institution to which he is attached.

Case 1. A boy, 14 years of age, was admitted under the care of Mr. Arnott, with a penetrating wound of the joint. He was a shoemaker; and while he was at work, a sharp knife which he was using slipped, and ran into the knee, about an inch deep; it entered at the inner part of the kneejoint, just above the patella. On admission, a small wound only was observed; but the knee was inflamed, and attended with considerable effusion; there was also pain upon the slightest motion. Leeches and ice were applied, and the wound was covered with plaister and a solution of sealing

Med. Gazette, May 17th, 1834.

wax. After this, no bad symptom was observed; at least such was the case seven days after the injury, the period when Sir Charles Bell's lecture was delivered.

The able lecturer observes, that this is "a pleasant case to set out with," adhesion of the outward wound removing apprehension. The next case displays the series of evil consequences which is apt to succeed a wound of the articulation. It may be told in the language of the lecturer.

"There is another case, that of Cooper in Clayton's ward. He is 18 years of age, and has had a severe wound of the left knee-joint; it was occasioned by his falling upon his scythe. He is a strong lad. The point entered the kneejoint, penetrated the capsule, and, it is supposed, cut the cartilage. The inflammation is already considerable. Leeches have been applied, and cold lotions; but notwithstanding all the means employed, the inflammation continues unabated.' The next report says, that the inflammation involves the whole leg and thigh.' Another report is dated some weeks afterwards; it states that abscesses form in succession in various parts of the thigh and leg, as well as in the joint, and that he is now reduced extremely low, being very faint, so that poor hopes are entertained of his recovery.' It appears, that after remaining in this state, in danger of dying from hectic, with night sweats and diarrhoea alternating, the constitution of a fine healthy country lad struggling with the disease, he seemed to rally a little with the assistance of generous diet, wine, porter, and all that could be given him to support his strength. At length slowly and progressively he shewed improvement; the great swelling of the limb subsided, the abscesses closed, and there was a hope of his being dismissed with an anchylosed joint. But then came another mischief, which all are subject to in large hospitals, a relapse, attended with erysipelas involving the leg and thigh, and having a most prejudicial effect on his constitution, and carrying him back we may say three months in the cure. He again recovered; and

after being a patient seven months, he was discharged with a stiff-joint."

This case affords occasion to Sir Charles to point out the effects to be dreaded when the wound does not unite. Suppuration in the joint—extension of infiammation and suppuration to the veins of intermuscular cellular tissue external to it. On these mischievous results the lecturer makes some eloquent remarks. From wounds of the articulation he slides by an easy process to the subject of loose cartilages. He appears to dread the operation, and deprecates it strongly unless the disease is productive of most serious inconvenience. He mentions the case of a young surgeon who was absolutely precluded from successfully pursuing his profession. When he was called to a patient, and at the moment when he was about to cross the saddle, the loose cartilage would frequently get between the heads of the femur and the tibia, when he required to be lifted from his horse, to be placed in bed, and to remain there for some days.

Under ordinary circumstances the best plan is to apply an elastic bandage and compress, which will cause the absorption of the effused synovia which occupies the joint. The bandage confines the loose cartilage in its recess, and prevents its getting between the ends of the bones, which it is most apt to do when the capsule is distended with fluid.

Sir C. Bell relates an interesting case which occurred in the hospital.

"A woman was admitted with a loose cartilage in the joint. She stated. that, she began to feel her knee painful, and something move in it, about three years ago.' She said, 'she obtained no rest day or night, and there was no cessation of the pain; she could walk, but she was subject to occasional extraordinary lameness;' and, in short, that her suffering was so great that she was willing to undergo any hazard through an operation, with the hopes of relief.' The operation was performed; an incision was made on the inside of the patella; two loose cartilages were withdrawn; severe inflammation very soon followed, with frequent rigors