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to deep venous embarrassment; and which I propose, on that fully destructive agent. The strong solution of the pernitrate
account, to call the " venous ulcer." of mercury twice or thrice applied, at intervals of two or three
There is yet another species of ulcer to which I must allude, days, to certain sores that are thus found to be peculiarly
also at times associated with varicosity, but which has, in its obstinate, will seldom fail to induce cicatrisation. And here 1
worst forms, escaped the designation "varicose." It is the may remark, as to the value of this remedy when applied to
ulcer that I have found connected with arterial incompetency, certain specific sores, as sypbilitic lupus, and especially secon-
and which I therefore propose to designate the arterial ulcer. dary syphilitic ulcers about the throat and _palate, that it seldom
It is a very characteristic ulcer. It is surrounded by dense fails at once to change their character. To these parts, how-
skin, of a pink or pale hue. Its size varies from that of a ever, it must be carefully applied.
small and somewhat superficial ulcer, with a welted edge-as it ! With respect to the venous ulcer, I know but of one mode
is often seen, creeping along the ulcer behind the inner malleo- of inducing permanent cicatrisation-namely, by those inci-
lus and tibia,-to an ulcer pervading the whole leg, leaving a sions at the edges to which I first drew the attention of the
few islands of dense, thickened integument, and making its profession some years since; by which the veins are freely
way gradually through the aponeurosis into the deeper struc- divided, as well as any dense tissues which, by maintaining a
tures. Such an ulcer results from impairment of nutrition, state of morbid tension, counteract the healing tendency. I
through defective supply of arterial blood; and the welt, as have now practised these incisions on a large number of cases,
well as the indurated integument, show various degrees of and so have many other surgeons-amongst whom I may men-
such impairment short of vital extinction. The welt, as com- tion Mr. Henry Smith,-and with a constancy of success that
monly seen in the least severe of this class of cases, is, in all encourages me again to recommend them. But in all these
probability, due to nutritive efforts almost at the confines of cases the varicose veins above the ulcer should be obliterated
arterial circulation. It is the ulcer with "defect of action" of by the ligature, for their own sakes; for they are functionally
Syme. I need not say that this is a still more formidable form ruined, and worse than useless.
of ulcer; and is, as far as any remedies that have hitherto The arterial ulcer is incurable by any known means; and
been devised, incurable. amputation is a resort full of risk, as the ulcer is so commonly
To recapitulate. I have attempted to show, in the course of associated with renal disease. If a fitting case offered itself,
the foregoing remarks and observations :- instead of amputation, I should propose tying the popliteal
1st. That there are no substantial grounds for accrediting artery, with the object of closing up the diseased arterial
ulcers, on legs with varicose veins, to the diseased veins, in the trunks, and of obtaining a new arterial system by means of
relation of effect ; that, in fact, the varicose ulcer, in the sense those abundant new branches, and their ample anastomosis,
in which it is usually understood, is a fiction. which in the injected case of which I have spoken appeared to
2nd. That when ulcer and varicosity co-exist the veins are be quite equal to, and even prepared for, such an emergency.
much more likely to suffer injury from the ulcer, than the
ulcer from the veins. In fact, the veins cannot be brought for[The foregoing paper-a portion of the Lettsomian Lectures
1867, which, for want of time, Mr. Gay omitted in that
within the confines of the ulcerative process without suffeiing course-was read
in common with the other ulcer tissues. recently at a meeting of the Medical Society
of London.]
3rd. That ulcers of the leg are, in relation to their patholo- Finsbm-y-Dlacp. April. 1868.
gical genesis, divisible into three species :-
1. The simple ulcer; that in which the morbid processes
are limited to the confines of the tissues directly engaged CASE OF HÆMORRHAGE ON THE
therein.
2. The venous ulcer; most frequently with "bronzing" of FORAMEN CENTRALE.
the skin ; dependent upon obstructive disease of the trunk BY HENRY M.B.
veins, superficial or deep. And POWER, F.R.C.S., LOND.,
OPHTHALMIC SURGEON TO ST. GEORGE’S HOSPITAL.
3. The arterial ulcer, generally without discoloration, which
is due to incompetency of the arteries, from disease of their
coats.
THE following case, which has lately been under my care, is
In some cases, however, the two morbid changes which
long to the second and third classes are conjoined. Allof beiIfl one of considerable interest, and presents a remarkable general
these ulcers are capable of being more or less varied by secondary similarity to that of Dr. Harley, lately recorded in the columns
agencies, by which subordinate varieties are determined. of THE LANCET.
By way of conclusion, I must make a few remarks on the John B-, aged seventeen, a French polisher, came to the
treatment of these ulcers, which, however, becomes moderately
Westminster Ophthalmic Hospital on the 8th of February,
simple if based upon a recognition of their respective patho- 1868, complaining that all objects seen with the right eye
logical bases, and of the agencies by which they become
secondarily modified. appeared of a red colour. He had observed this symptom for
There is one rule which is universally applicable-namely, seven weeks. The patient was a small, thin lad, with ruddy
that rest is an essential part of their treatment, with the foot face, pinched expression, and stammered most painfully. On
elevated above the pelvis in the ulcers of the first and second examination the eye appeared perfectly healthy. Its
classes, and on a level with it in those of the third. external
tension was natural. The iris was dark-brown, and responded
First with respect to the simple ulcer. There are no marked
peculiarities in its condition that cannot be reconciled with actively, both directly and renectorially, to variations of light.
action its immediate confines, subordinated to constitutional
on He stated that he was reading by gaslight, when he observed
derangement. If it be acutely inflamed, bleeding is required a small red spot, the size of a split
pea, between the page and
by leeches or scarification (the latter across the edge of the his eyes. He soon found that the right eye only was affected.
ulcer is an excellent plan), hot applications, constitutional
He was in no way alarmed, but continued to read for an hour,
treatment, purgatives, calomel when the biliary system is de-
ranged, and opiates. If the inflammation be subacute, and during which time the spot gradually increased in size till it
especially. if the tissues be thickened and the edge welted, attained that of a sixpence. There was no pain at the moment
blisters should be applied over the surface and the affected of the appearance of the spot, but in the course of a few
border. It may safely be alleged that no one remedy is capable minutes he experienced some sharp shooting pain in the eye,
of so much general benefit as the blister, for which we are, I be- and in the course of the supra-orbital nerve. There appears
lieve, indebted to Mr. Syme. Iodine or iodide of potash is an also to have been a considerable degree of intolerance of light,
admirable remedy, especially if the ulcer has invaded the peri- accompanied by lachrymation ; but in the course of two or
osteum and occasions severe nocturnal pain. Irritability must three hours these symptoms gradually passed off, and there
be subdued by opium, with quinine or iron, and the use of a has been no recurrence of them. On presenting various small
strong solution of nitrate of silver to the surface. If neuralgia circles to him, at a distance of ten inches, he picked out one as
exist, the offending nerve-filament must be tracked out and being exactly covered by the spot, which was, as he had stated,
divided, as Mr. Hilton recommends, and appropriate consti- just equal to a sixpennypiece in diameter; its edges were’well
defined. On looking at a pale-green-coloured blank wall, at
tutional remedies administered. If it be combined with con-
stitutional weakness, tonics and change of air, with generous the distance of eighteen feet, he saw a dark brick-red spot,
diet, are required ; and if with struma or syphilis, the reme- about the size of a man’s head, and the rest of the field of
dies appropriate to these diseases. If the ulcer persist after vision was of a dull-grey colour. With the left eye he had a
the subjugation of secondary states or conditions and a certain myopia of one-fourth, but he could see to read the smallest of
period of rest, the surface should be destroyed by some power- Snellen’s test types with facility. The acuteness of vision of
 497
the right was so far lowered that he could only just see No. A FEW CASES ILLUSTRATIVE OF THE
18 of Jager’s test types. On ophthalmoscopic examination,
the pupil being dilated with atropine, the eye was noticed to
TEMPERATURE AND ITS RELATION TO
be perfectly tolerant of light. The media were very clear. THE RESPIRATIONS AND PULSE
The optic disc was cleanly defined, rather more pink than
natural, vertically elongated, with a beautifully marked IN TYPHOID FEVER.
small posterior staphyloma on its apparent inner side.
The external and larger choroidal vessels were very distinct. HALL BY T. REDWOOD, M.A., M.D. Durham.
The foramen centrale was nearly at the same level as the optic
disc, and rather nearer to it than usual. It presented a minute THE following cases are sent for publication in the hope that
clot of blood, the size of which is accurately given in the ac-
companying woodcut. The central retinal vessels were rather I
I they may help to demonstrate the value of the clinical ther-
mometer in disease, and stimulate practitioners to a constant
use of it in cases of fever, in which the, perhaps short, expe-
rience of upwards of two years has convinced me it is in-
valuable, both as an aid in diagnosis and prognosis, and as a
corroborant, if not actually a forewarner, of other symptoms.
I have found it especially useful in giving notice (often a couple
of days beforehand) of relapse and of any threatened complica-
tion, thereby putting us on our guard, and enabling us to ward
off or modify the one or the other without any loss of time.
In every case a self-registering thermometer (made by Mr.
Casella) was used, and retained in the axilla, with the arm
close to the side, for five minutes at least, and the respirations
were generally counted twice, in order to ensure accuracy. 1
should mention, too, that the temperature was taken as nearly
as possible at the same time (in the afternoon) each day. A
short account from notes taken at the bedside by myself is
appended to each case, and the cause, where satisfactorily
made out, mentioned.
larger and more numerous than usual, but not tortuous, and
one ran in close proximity to the spot, and could be followed
beyond it. I was unable to observe any indication of a rupture
in this vessel, showing that the haemorrhage had proceeded
from it. The fundus of the left eye presented the same cha-
racters as the right, with the exception of the blood spot; the
colour of the foramen was dark, but formed a marked contrast
to that of the right eye. He was ordered decoction of cinchona,
tincture of cinchona, and bichloride of mercury, and was
directed to give up his work, which involved much straining
and stooping.
On Feb. 24th the spot had slightly changed its appearance,
the central part being of a deep black-red colour, and the peri-
phery of a smoky hue, apparently from infiltration of the
colouring matter into the adjoining tissue. The subjective
symptoms were unaltered.
On March 3rd the dusky halo had become fainter. His
vision was much improved ; he could see No. 12 of Snellen’s
test types, and he stated that the red spot was smaller, and
that the excentric portions of the field of vision were much
clearer. In this state he remained without change to March
10th, when a relapse occurred, with some shooting pain and
lachrymation, in consequence, apparently, of his return to CASE 1 (the early notes of which are missing) was a girl
work, and the muscular exertion required. He was then ad- aged seven years, and was unmistakably caused by a tub, full
mitted into St. George’s Hospital, where he still remains. The of pig-wash, which was placed opposite the door (always open),
red spot resumed its original size, and its colour has become and had been left undisturbed for some months. Two other
darker, during the last month. The principal changes, objec- cases occurred in this house, one of which died of perforativee
tive or subjective, that have been noticed are that the colour peritonitis, the thermometer suddenly running up to 105° the
of the red spot seen by himself, though it is still quite opaque, day before (the fourteenth of illness). Two mild cases also
has become lighter red when he looks towards the light, and occurred in houses built on the top of the last. The imme-
assumes, for the space of a minute, the complementary colour diate removal of the tub stopped any further spread of the
of a bright green when he looks towards a shaded part of the disease in this particular spot; and there has been no typhoid
room, changing again to red after the lapse of that time. He fever there since. These cases occurred in August, 1865. In
can now see No. 5 of Snellen with the right eye at the distance the above case (Case 1), sulphate of copper was tried on the
of two inches. The small staphyloma has increased in size, eleventh day, with the effect of increasing the abdominal pain
and has become much more strongly shaded on its surface, in a most marked manner ; otherwise it was not remarkable
presenting a shrivelled appearance, which renders it probable beyond being complicated with some bronchitis, and showing
that its formation has been recent, perhaps only just antece- the good effects of the frequent exhibition of small doses of
dent to the occurrence of the ecchymosis. turpentine in tympanitis.
It is a matter of interest to determine the origin of the CASE 2.-A servant-girl, aged fifteen years, was brought
blood in these cases. Does it proceed from the choroidal home ill on the fourth day. Intense headache, pains in the limbs,
vessels, or from the branches of the arteria centralis retinse? I diarrhoea, and a general state of very high fever existed when
am inclined to think from the latter; first, because the subjec- seen that day; and, altogether, it promised to be a very severe
tive symptoms clearly indicate that the effusion is in front of case. Spots appeared on the breast on the fifth day, and on
the sentient surface ; and, secondly, on account of its very the legs on the eighth, the former being earlier than usual by
limited extent, which is in accordance with the extremely about three days. Very severe double bronchitis existed
small size of the retinal capillaries, which may with care be throughout, and no doubt helped to bring this case to a fatal
seen to traverse the immediate vicinity of this portion of the termination. The motions were dark-green or dark-lead in
retina, and from the rupture of one of which I presume it colour, and treacly in consistence, from the sixth to the eleventh
would proceed. day. She complained a good deal of her throat, which was
Upper Seymour-street, April, 1868. erysipelatous, and the larynx apparently (from sound of voice,