ounces; dose for a child two or three years old, four drops thrice daily, to be increased one drop daily. Whilst Dr. Spengler advocates the coneine, or active principle of conium, one sixteenth part of a grain in six ounces of water: dose, one drachm thrice daily.

I have never employed this preparation; but I prefer henbane either to belladonna or conium, as being more certain in its effects, and I usually prescribe the extract in doses of from one to five grains thrice daily, according to the age of the patient. At the same time it must be admitted that henbane merely acts as a palliative, soothing excitability and irritation when set up; it does not strike at the root of the mischief in the same way as the hydriodate of potass, and consequently we cannot be surprised at the frequency with which relapse attends its exhibition. Like quinine, it requires watching, and we should carefully provide against torpor of the bowels, which will sometimes ensue.

Other cases occur in which the presence of worms in the alimentary canal keeps up the symptoms, which will not yield to the usual treatment. A dose of turpentine and castor oil answers extremely well under such circumstances, and this may be repeated if necessary.

Again, attention should be paid to the state of a child's mouth and teeth. Intractable cases will frequently improve after the abstraction of a decayed tooth, or the lancing the tense inflamed gum over a tooth pushing its way through. In many instances the overcrowding of the teeth is the cause of much suffering, the jaw being too contracted to admit of their due and regular development. This is often very prejudicial to the ophthalmic symptoms, and is only overcome by the abstraction of one or more of the teeth, which, affording sufficient space to the remainder, removes the cause of irritation.

[Mr. Hancock has no faith whatever in any form of counter-irritation, but strenuously urges the regulation of the diet, which should be of the plainest character. He states that severe relapses have returned after a hearty solid meal.]-Lancet, July 30, 1853, p. 91.

123.-ON PURULENT OPHTHALMIA IN THE INFANT.

By JOHN F. FRANCE, Esq.

[In the infant this disease is easily diagnosed. When it appears within a week after birth, when the lids are of a vivid red colour and so swollen that they are separated with difficulty, a purulent fluid escaping, and the conjunctiva inflamed and chemosed, there can be no doubt of the nature of the complaint. In catarrhal ophthalmia there is not so great inflammation, the secretion is not purulent, and there is no tendency to oedema of the lids or chemosis of the conjunctiva.]

The treatment of infantile purulent ophthalmia consists in the following measures: -Should inflammation be very severe, the tumidity of the palpebræ and conjunctiva excessive, and every indication of intense vascular excitement be present, it is right to deplete to a small extent by scarifying the conjunctiva with a lancet. From two or three superficial strokes a sufficient flow of blood will be readily obtained by fomentation. But cases demanding direct depletion are exceptional; the immense majority, formidable as they are in appearance, are perfectly controllable by other means. The bowels must be freed by a purgative combined with some preparation of mercury. I generally prescribe for this purpose the grey powder with rhubarb, which usually effects all that is wished in the first instance-viz., to procure free secretion along the intestinal canal and from the glands associated with it; a slight laxative action should be maintained subsequently by castor-oil. The whole constitutional treatment is comprised in these simple measures; and the local is scarcely more complex.

We must first enjoin thorough cleansing of the eyes from all purulent secretion by tepid ablution. The sponge, I will here remark, should on no account be used for any other purpose, as the disease is highly contagious. Ablution should be repeated at least every hour, the upper lid being gently detached from the lower; the warm water suffered to flow between them, and wash away all accumulated discharge. You can hardly be too precise and earnest in enjoining the observance of these points, for their neglect diminishes in a serious ratio the chances of perfect

recovery. The use of a syringe is advantageous for the purpose of effectually cleansing the surface of the conjunctiva, and may be recommended accordingly when there is reason to think it will be intelligently and carefully handled. In the larger number of cases, however, among the poor, it is safer to direct simply thorough sluicing between the lids, as just described. This plan is quite adequate to accomplish the object in view, and is free from the chance of splashing morbid secretion into the eyes of the attendant—an accident which an ill-managed jet of fluid from a syringe might cause.

Subservient to the prime object of removing all discharge is the use of some unirritating ointment to obviate agglutination of, the palpebræ, and prevent accumulation of the purulent matter during sleep. Spermaceti or zinc ointment may with this view be smeared along the edges of both palpebræ and upon the surface of the lower one, which is often overlapped by the tumefied upper lid. Having thus secured a free outlet for discharge, and relieved the conjunctival surfaces from the purulent and lachrymal secretion, the next point is to employ a collyrium. That which I have found of the greatest service, and habitually use, is a solution of nitrate of silver, a grain or a grain and a half being dissolved in the ounce of rosewater. Two or three drops of this should be instilled upon the conjunctiva three times daily, the part having been first cleansed from all matter which may have gathered since the last ablution. Continuing this application for four or five days, you will find the eyes so lately streaming with pus and intensely inflamed, gradually assuming a less angry aspect, the swelling diminishing, the discharge rapidly lessening, and the affected organ returning progressively to the state of health.

As soon as all chemosis has disappeared, tumefaction of the integuments has abated, and the quantity of purulent secretion declined, it is advisable to diminish the frequency with which the nitrate of silver collyrium is used. At a still later stage of convalescence it may be changed for a solution of sulphate of zinc. The compound zine collyrium of our 'Guy's Pharmacopoeia' is eligible at this period of the disease. Its composition I have previously mentioned-viz., sulphate of zinc, two grains; opium wine, two drachms; and rose water, six drachms. The reason for substituting this, as early as the circumstances of the case will permit, for the nitrate of silver drops, is to avoid the chance of discolouring the conjunctiva. The possibility of such discolourization is not for a moment to be weighed in the scale against the striking utility of this collyrium, yet it does constitute a sufficient ground for discontinuing it when the complaint is unquestionably subdued. A solution of alum (three grains to the ounce) may be employed in the same way as the compound zinc collyrium, to conclude the cure which the nitrate of silver has brought about. Other astringent solutions as well are, I believe, sometimes used instead of the nitrate of silver collyrium from the beginning, but I would emphatically dissuade you from trusting to them. This is not a disease with which it is justifiable to experiment or temporize. With the fullest confidence I can recommend the plan of treatment above described, because I have always found it successful; and I deprecate resort to other means, because the uncertainty of them is evident from the unsuccessful cases every now and then applying too late at our Eye Infirmary.

When the cornea is found to be hazy or opaque the treatment does not essentially differ from that already described. If it be ulcerated the only addition indicated is greater care to avoid the slightest pressure on the globe in examination, or in the processes of ablution, and injecting collyria; but, if the ulceration has extended through the laminæ of the cornea, and opened the anterior chamber, a point of nitrate of silver may be sometimes advantageously applied, to excite healing action at the bottom of the ulcer and procure quicker closure of the opening.

If the iris has prolapsed, or there is reason to expect that it will do so, owing to the depth to which an ulcer of the cornea has advanced, it is proper to apply belladonna around the orbit, with the view of obtaining dilatation of the pupil and consequent retraction and disentanglement of the iris. The application of belladonna would supersede that of caustic, if the prolapse were quite recent, until the iris should have withdrawn from the corneal aperture. The nurse, however, must be directed to prevent any belladonna reaching the mouth of the little patient, either by means of the discharge, or its own fingers, or the mother's breast. The best mode of guarding against so serious an accident is to apply the extract by simply smearing it over the inner portion of two rings of soap or resin plaster, which may then be

placed so as to surround the patient's orbits. These must be renewed or moistened twice a day.

After all morbid discharge has ceased, the case has become chronic, and any ulcer which may have existed has closed or shows a disposition to do so, the black wash, composed of seven grains of calomel to an ounce of lime water, is extremely useful, promoting cicatrization, and tending to disperse the hazy opacity which always surrounds a cicatrix. Some degree of opacity may result from the inflammation to which the cornea has been subjected, independently of ulceration; and in such cases likewise, in their chronic stage, the black wash is beneficial.

If destruction of the entire cornea has taken place, it can be of no avail in restoring vision to apply nitrate of silver to the part, or belladonna to the brow; the treatment then becomes merely palliative, and the only remaining object is to relieve the conjunctival inflammation and control the deformity which ensues.-Lancet, April 30, 1853, p. 401.

124. THE CURE OF SQUINTING BY THE USE OF PRISMATIC

SPECTACLES.

By T. SPENCER WELLS, ESQ.

[This method of treating squinting was first recommended by Dr. Kurke, a Dutch physician. The following remarks are a summary of the experience of Dr. Von Grafe, of Berlin, who has tried the plan very extensively :]

The glasses are fitted in ordinary spectacle frames. They are simple prisms of various degrees, from 1 to 20. It would be possible to make them achromatic; but I have only seen the ordinary ones in use.

The operation upon the sound eye, as explained by Dr. Von Grafe, is as follows: When a prismatic glass is held before one eye on any point of sight in the converging direction of the optic axis, the light falling upon this eye is diverted from its former course, and no longer arrives upon the macula lutea, but forms a more or less excentric picture, according to the refracting power of the prism. From its position, this is no longer combined with the central picture on the other retina into one perception, but is perceived separately. Thus the object upon which the optic axes converge is seen double.

Theoretically this phenomenon should be observed when a prism of very moderate power is used; but observation teaches us, on the contrary, that no diplopia follows when weak prisms are employed, especially if the base be directed outwards. This might be explained in two ways. Either the picture on one retina is suppressed, or the eye which sees through the prism takes a new position, which is not perceived by the observer, so that the picture is not formed excentrically, but falls, like that of the other eye, upon the macula lutea. The improbability of the first supposition at once appears from the fact that no diplopia is produced by weak prisms, while more powerful ones produce it at once, and the greater the excentric position of the picture the more easily it would be suppressed. The truth of the second explanation is established by a more exact observation of the position of the eyes. On applying the prism we see the optic axes deviate from their former position and return to it as the prism is removed. At the moment of removal the object is seen double, because both axes are not directed upon it. Thus, in order to prevent diplopia, an involuntary strabismus occurs, and we can produce this in any direction by corresponding positions of the prism, but most decidedly so inwards, less so outwards, much less so downwards, and least of all upwards. We can also produce strabismus in this manner in diagonal directions.

It follows that by the use of prismatic glasses we have the power of altering the tension of any given muscle of one eye without producing any alteration in the other. This is the peculiar advantage which none of the ordinary orthopædic means formerly employed possessed. On the contrary, the result hoped for from their employment was not only frequently frustrated by the movements of associa tion of the two eyes, but sometimes, as in cases of recent muscular paralysis, an effect directly the reverse of that desired was brought about.

The increased contraction called for from the relaxed muscle by the use of pris matic glasses is the source of their curative power. For example, in a case of con

vergent strabismus with diplopia, a prism with its base directed outwards, alters the position of the excentric picture on the retina of the squinting eye so greatly, and brings it so near the macula lutea, that single vision follows any voluntary power conveyed to the abductor muscle. Consequently, the angle of the squint is somewhat diminished. As it becomes less, and the power of the abductor increases, prisms must be used gradually diminishing in power, until at last a perfectly accurate corresponding position of the eyes is attained at all distances,-in other words, the squint is perfectly cured. I have seen patients of Dr. Von Grafe's who were thus completely cured in about six weeks, commencing with strong glasses of the numbers from 15 to 20, and gradually wearing them less and less powerful. They are principally applicable in young persons, who squint but slightly; and in cases of diplopia biocularis, where the abnormal position of one eye is only observed when an object some feet distant is regarded, they are the only certain means of cure.

In more marked degrees of strabismus the muscle must be divided, because the use of strong prisms, and the efforts of the patient to avoid diplopia, become very troublesome; and if the union of the two images causes too great an effort, an effect is produced exactly the opposite of that desired; for if the diplopia cannot be removed, the double images separate still further from each other, because, when distant, they are not so intolerable as when near.

In many cases after operations for the cure of strabismus by division of the muscle in one or both eyes, although great improvement follows, the cure is not perfect. Some degree of squint still persists in one eye, and probably some diplopia when objects at certain distances from the eye are attentively regarded. In such cases, the prismatic glasses suffice to complete the cure commenced by the operation. I saw several instances in which this proved to be the case in the practice of Dr. Von Grafe.

I have patients under my care at present who are wearing these spectacles, and I shall take a future opportunity of making the results known. Messrs. Watkins and Hill, opticians, of Charing-cross, have had the glasses ground and fitted for me, and make them at any angle which may be required. Messrs. Bland and Long, of Fleet-street, also make them.-Med. Times and Gazette, August 27, 1853, p. 216.

125.-ON THE USE OF TWO NEEDLES AT ONCE IN CERTAIN OPERATIONS ON THE EYE, ESPECIALLY THOSE FOR CAPSULAR CATARACT AND ARTIFICIAL PUPIL.

By WILLIAM Bowman, Esq., F.R.S.

The operation consists in the simultaneous employment of two needles introduced at different points through the outer coat, and made to act in concert upon false membranes, opaque capsule, or iris, or even on the lens itself under certain circumstances. Several advantages attend this mode of operating. Opaque portions of capsule are often very tough, and, being attached to the suspensory ligament of the lens, or to the pupillary borders of the iris, these extensile structures readily allow the opaque membrane to recede before the needle, rather than be torn or cut through, and the surgeon vainly sweeps the membrane before the instrument from side to side, at the risk of serious injury, and consecutive inflammation of the ciliary processes or iris. Two needles, brought to bear upon the opaque capsule from different sides of the cornea or sclerotica, furnish each other with a point of resistance, and the capsule may be torn open or cut at pleasure. If it be reticulated, it is possible to twist one of the needles round and round the band so as to get a hold upon it in case it should prove very tough. The needles usually act perfectly if passed through any convenient opposite points of the margin of the cornea, the pupil being always, where possible, dilated by atropine. It is but seldom desirable that one of the needles should be passed through the sclerotica. Both the hands of the operator being engaged, it is necessary that the lids should be held open, either by an assistant or by the wire speculum. The second needle may be used in cases where the first, or single needle, has failed to cut through the capsule. The instruments are the ordinary cataract needle, the stem cylindrical and of a size to easily occupy the corneal puncture, the point either straight and cutting, or slightly curved, accord

ing to circumstances. In no case is it necessary to enter the instrument beyond half an inch in depth; the stem may therefore be made thicker from this distance. This plan of operating enables the surgeon to cut through softened and rotten iris, without dragging it from its attachment, and otherwise injuring the interior of the globe. Mr. Bowman has used it successfully in the formation of artificial pupil.-Lancel, June 11, 1853, p. 545.

126. ON THE USE OF AN ARTIFICIAL MEMBRANA TYMPANI, IN CASES OF DEAFNESS, DEPENDENT UPON PERFORATION OR DESTRUCTION OF THE NATURAL ORGAN.

By JOSEPH TOYNBEE, Esq., F.R.S.

[As a test of the merit of Mr. Toynbee's ingenious invention, we need only observe, that it has obtained the medal of the Society of Arts. He thus describes it:]

The artificial membrana tympani made by Messrs. Weiss, from these directions, has hitherto been perfectly successful. As supplied by them, the portion of vulcanized India rubber or gutta percha is about three-quarters of an inch in diameter, which leaves sufficient margin for the surgeon to cut out a membrane of any shape that may seem to him desirable, and to leave the silver plate either in the centre or towards the circumference, at his discretion. The silver wire is of sufficient length to admit of the membrane being introduced or withdrawn by the patient, but is not perceived externally, except upon especial observation. A second kind of artificial membrane is made, by fixing the layer of gutta percha or vulcanized India rubber between two very delicate silver rings, from the eighth to the sixth of an inch in diameter; these rings are riveted together, leaving a portion of the membrane drawn moderately tense in their centre; a margin of the membrane is also left beyond the circumference of the rings, so as to prevent the latter being in contact with and irritating the tube of the ear. To the surface of one of these rings the silver wire is fixed by two branches, and they should be joined, so that the outer surface of the rings should look obliquely outwards and forwards, instead of directly outwards, thus imitating the direction of the natural membrana tympani. This kind of membrane is often preferable to that previously described, if the meatus is sufficiently large to admit of its passage. A pair of forceps is made, whereby the artificial membrane can be more easily introduced and withdrawn.

[The following remarks are very interesting:]

The cases in which the artificial membrana tympani is of the greatest benefit are those where there is a well-defined aperture in the natural membrane; or, if it be entirely absent, where there is simple hypertrophy of the mucous membrane of the tympanum, with or without discharge from its surface. In these cases, it will be found that the organ has by no means entirely lost its power of discerning sounds; as a general rule, the human voice is heard when the mouth of the speaker is situated within about a foot of the patient's ear, and when the sounds are spoken slowly and distinctly. The diminished power of hearing just noticed, while it entirely excludes the sufferer from the advantages of general conversation, is, however, greatly aggravated when, to the affection of the membrana tympani and mucous mem brane of the tympanum, the stapes has become anchylosed to the fenestra ovalis, or the nervous expansions have been injured. In such cases where the patients require to be shouted to close to the ear, the artificial membrane will not prove of any

service.

The Mode of Applying the Artificial Membrana Tympuni.-As in cases of perforation or destruction of the membrana tympani there is so frequently catarrhal inflammation of the mucous membrane of the tympanum, it is obviously important that no foreign substance should be placed in contact with that membrane; and, as. there is always a margin of the membrana tympani remaining, the object of the surgeon should be to keep the artificial membrane external to the latter. After carefully noting the size of the inner extremity of the meatus to which the natural membrana tympani was attached, the operator should then cut the artificial membrane as nearly of the size and shape of the natural one as possible, taking care at the same time to keep the margin quite smooth and regular. The patient must then XXVIII.-17.