principle of reaction having withdrawn from the vessels, the physical distention may be completely established, and the tonic powers of the artery permanently withdrawn: that portion of the tube primarily affected, as well as the capillary apertion which terminates its ramification, will become paralytic.

The fibrine will now be urged slowly through the barriers of coagulating lymph into the reticulated texture of the cellular tissue; whilst nature, opposed in her first endeavours to impede the destructive progress of the disease, fortifies, with fibrinous laminæ, the walls of the artery above, and blockades the capillary termination of the tube with a cone of coagulated lymph. Thus terminates the active stage of the inflammation.

The fibrine effused into the cellular tissue, and between the lamina of the cornea, retains its primary aspect until condensed and consolidated into complete opacity, by the absorption of its fluid parts. If no proximate exciting cause have arisen, the action of the organic trains subsides into quiescent tranquillity. The only traces of the acute inflammation are opacities and ulcerations of the cornea. The former may, by the judicious administration of scientific remedies, be ultimately removed; and the latter, by appropriate applications, be in a great measure restored to their primary convexity.

It frequently happens that the phenomena of inflammation, especially in the severely acute species from local injury, subside very tardily, or not at all: we may then suspect that some local and exciting cause has supervened on the original injury. I believe it will be found that, the more intense the degree of the superficial irritation, the more likely the chronic stage will be to follow in succession.

The conjunctiva is the external covering of the eye; the same tunic covers the ball and the interior of the palpebræ. These, therefore, will frequently be found to react upon each other, and to sympathise in their respective inflammations. There are three states in which the palpebræ are frequently found: the first that of simple arterial vascularity. In this stage of inflammation the pain is trifling, and the symptoms are comparatively mild. The appearance of the disease may be compared to a patchwork of scarlet velvet on a strawcoloured ground of a smoother quality. It is seldom that a solitary insulated portion is perceptible; for several of these distinct figures of vascularity may be seen on the first inversion of the lids, immediately before the stimulus of the mechanical displacement

causes the blood to fill the minute vessels of the membrane, producing, as a necessary consequence, the temporary congestion of the tunic of the ciliary cartilage.

These insulated portions of arterial vascularity are then the first stage of that peculiar series of phenomena which introduces the proximate and exciting causes of chronic ophthalmia. The activity of the inflammation in these insulated portions will be observed to be accompanied with deposits of fibrine; detached fragments of which frequently float towards the internal canthus. These foreign agents increase the inflammatory action, and portions of this coagulating lymph attached to the inflamed patches become successively organized. The organization of these fibrinous bodies has something peculiar in its arrangement. False membranes are not detected, as in the inflammations of the peritoneum, &c.; but the newly-formed vessels, instead of ramifying over the extended surface of the fibrine, instinctively tend towards each other, and, by their own elective affinities, condense the inflammatory process within a circumscribed capacity. The lymph having now become vascular, assumes an organic appearance: the organization of this substance exhibits an uneven aspect, with alternate elevations and depressions. The depressions, in the progress of the disease, are rapidly excavated, and the original elevations being increased by the intense vascularity of the accuminated processes of these newly-formed tubercles, the whole of the conjunctiva originally affected is transformed into a series of granulating patches. These detached portions subsequently coalesce, the circumferences of their basements uniting in every direction, and forming new centres of preternatural actions, accelerating the progress of this destructive disease. During this stage, ulcerations of the cornea proceed with rapidity, from the acuminated papillæ of the granulating surfaces stimulating the cornea to destructive inflammation.

In the third and last stage, the granulations assume a fungoid appearance; they are no longer granulated tubercles, but appear like vast carneous masses interspersed with deep and penetrating clefts. The fungoid tumors are not rounded off, but form angular projections. Frequently we perceive a number of these masses crowded together; they appear, indeed, as one solid mass, on a superficial inspection, but upon minutely examining them, especially by separating them with a probe, we detect the real nature of their constitution. They may be compared to lobes, with flat surfaces opposed to each other; processes of a delicate

membrane, apparently of a serous nature, covering their opposing surfaces, and secreting a fine transparent fluid, avert that friction of their several aspects which might lead to an adhesive and consolidating inflammation between their surfaces.

A person lately put himself under my care with fungoid excrescences of the conjunctiva: he is blind; the cornea of both eyes are opaque, in part from solid interstitial deposits, of a circumscribed nature, and partly from effused lymph of a more superficial character. The disease has existed twelve months. The apparently central deposits, I strongly suspect, are preceded by interstitial absorption, or inflammatory ulceration. It is somewhat difficult to conceive, considering the extreme density of the texture connecting and consolidating the lamina of the adult cornea, in which way these albuminous patches have primarily originated. If we consider them as simple fibrinous effusions, what a force must have projected the lymph so as to deposit it in the condensed connexions of the corneal laminæ! If, however, the interstitial absorption precedes the deposit, we can readily perceive how the effused lymph may occupy the space excavated by the hand of nature for its reception. In this light these opaque deposits may be esteemed the results of a salutary process of nature, to unload the adjacent vessels, and to relieve the patient from the intolerable pain produced by the congested vessels, tearing asunder the condensed laminæ of the transparent cornea. These opaque spots which occupy the central departments of the cornea are therefore the results of the inflammatory action of vessels pervading the interior tunics of the laminated transparency. In the natural state, these vessels are diaphanous, and carry a pellucid fluid, eliminated from the blood: they are principally prolongations of the superficial vessels, partaking of their peculiar character. If we review the progress of this disease in its different stages, we perceive the preternatural formations causing the greatest inconvenience. Towards the third stage, however, the cornea, in the majority of cases which have come under my observation, appears insensible to the stimulus of the fungoid excrescences, being itself completely opaque, and partially disorganized.

Having thus endeavoured to point out a fertile source of embarrassment to those practitioners who are not aware of the frequency of its occurrence, I must express my belief of the high improbability of the successful treatment of chronic ophthalmia, if these exciting causes are overlooked.

When the disease has not produced disorganization of the cornea, the interference of the art of surgery may suspend its progress, and avert that unhappy termination. The proximate exciting cause must be first removed, and the subsequent treatment directed to the effects which have already resulted from the specific irritant. By perseverance in the practice of these principles, we may frequently restore the despairing patient to the inestimable blessings of the light of heaven, to his own great comfort and satisfaction, to the public credit and benefit of the successful practitioner, and to the permanent honour of the art of surgery.

Liverpool; June 2d, 1850.

PUERPERAL FEVERS.

Observations on the Puerperal Fevers which occurred at the Maternité of Paris in 1829; on the various Modes of Treatment employed, and particularly on Mercurials, Emetics, and Bloodletting. By M. TONNELLÉ.

M. TONNELLE has had so much experience upon the very important subject of puerperal fevers, and he delivers his opinions with so entire a freedom from partiality to any preconceived opinion of the pathology of the disease, and of the treatment it requires, that we are sure we shall confer a benefit upon our readers by giving them an abstract from the Archives* of the excellent essays he has published. It will be seen that M. T. corroborates the opinions which have been lately published by Dr. LEE and other English practitioners, who have endeavoured to arrive at correct notions of the pathology of puerperal fever.

The points to which our attention is directed are, 1st, the organic alterations which are detected in puerperal fever; 2d, a history of the symptoms; 3d, a description of the treatment. Before these subjects are discussed, some general reflections are made upon the causes of the disease.

The puerperal fevers observed at the Maternité in 1829 were more frequent and severe than had ever been known since the foundation of the institution. The disease frequently occurred in an epidemic form, particularly in January, May, August, September, and October; and during these months it raged with great violence. It might, at first, be supposed that the developement of the disease depended upon the cold and moist weather which reigned

*Mars 1830.

throughout the year; but, as a proof that the disease did not entirely depend upon these causes, it is stated that, during the keen dry coldness of January, puerperal fevers were very frequent; but, on the other hand, in December, when the weather appeared to be precisely the same, but very few cases occurred. The influence of moist weather is equally doubtful: for, although these fevers happened frequently during the summer, which was cold and rainy, they were very rare at certain intervals, during which the conditions of the atmosphere remained the same, and very common during the long and remarkable dryness of the spring. The vitiated state of the air in hospitals, and those moral affections which are usually considered to play so important a part in the production of puerperal fevers, cannot fairly be admitted as causes: they act in a uniform and constant manner. The disease, on the contrary, usually occurred very irregularly, raging during a week or a month, then suddenly disappearing, and again becoming frequent. Much has been said by authors of the influence of peculiarity of constitution, previous diseases, and the duration and difficulties of labour; but it must be evident that either of these causes can only refer to individual cases of the disease, and that they cannot in any manner explain the simultaneous occurrence of a great number of cases. There was no reason whatever to believe that the disease spread by contagion. It often happened that patients were attacked with puerperal fever directly after delivery, although they were in insulated wards, and had no communication with the other women. M. Tonnellé would, therefore, refer the origin of the disease to some more general and moveable cause, to some secret influence of the atmosphere, which, although impenetrable to our senses, is no less certain.

Of the morbid appearances. Inflammation of the peritoneum was the most frequent alteration that was observed after puerperal fevers; but it is erroneous to suppose that it always exists. Sometimes this membrane was of a perfectly natural appearance, and the most minute investigation failed to detect any appreciable marks of disease; and it was particularly in the most severe and rapidly fatal cases that this integrity of the peritoneum was remarked. In these instances there mostly existed some alteration of the womb, or of its vessels, or the parts connected with it.

*It was not uncommon to see ten or twelve women attacked during a day or night with puerperal fever.