August 1,
1SG7.]
LECTURES ON DISEASES OF CONJUNCTIVA.?BY DR. MACNAMARA.
l$9
endemic, and propagated from one individual to another, generation to generation. It is commonly asserted that the glare of the sun, and the presence of numerous particles of sand in the atmosphere, are concomitant, if not positive causes of the disease among the lower classes in Egypt ; but this theory can hardly hold good, for in parts of India the people are subject to the same influences, and yet they do not suffer like the Egyptians from purulent conjunctivitis. With regard to the diphtheritic form of the disease, it is rare to meet with a there
ORIGINAL COMMUNICATIONS. LECTURES ON DISEASES OF THE
CONJUNC-
TIVA.?No. I. Br C.
Surgeon We may
Macnamara, Ophthalmic Hospital.
to the Calcutta now
proceed
to
the diseases of the
conjuncfar the larger proportion of tiva, and as they will the " eye cases you will meet with in practice, they demand a careful consideration. In many instances the conjunctivitis is of so trivial a nature, that we may safely leave it to run its own course, the hyperemia and congestion of the membrane speedily disappearing upon the removal of the cause of the disease. Unfortunately, in this country, the poorer classes are constantly exposed to influences which directly produce hyperemia of the conjunctiva ; the glare of a tropical sun, an atmosphere impregnated with dust out-of-doors, and with smoke within, combined with malarious influences, and the ammoniacal fumes given off from open sewers and cesspools, are so many direct causes of conjunctivitis, to which many people are perpetually exposed. I propose describing the various forms of conjunctivitis under the following heads :?Hypertemia, Muco-purulent, Purulent, Diphtheritic, Granular, and Pustular Conjunctivitis. It is difficult, in the first three of the above-mentioned affections, to "
study constitute by
and from
case among the natives ; it is nevertheless necessary to be prepared for its advent, as, in all human probability, instances of the kind will occur more frequently in the course of time, for
doubtless exists here, although not to the same Europe. Diphtheritic conjunctivitis is, at present, endemic only amongst the inhabitants of Belgium, in which country it is described as being of a most destructive nature, the conjunctiva undergoing the same train of pathological changes as those which characterise the disease in other parts of the body ; there is precisely the same tendency to the formation of fibrinous exudations, not only on the surface, but in the connective tissue of the mucous membrane, which, pressing on the vessels of the part, and impeding the circulation, causes a swollen and brawny condition of the lids, and the drabcoloured appearance of the mucous membrane, peculiar to this
diphtheria
extent
as
in
disease. As to the much
disputed question of the pathology of graconjunctivitis, I may here remark that the disease consists essentially of a neo-plastic growth springing from the germinal matter of the connective tissue of the conjunctiva, and that state of the villi of the mucous draw a line of demarcation between the commencement of one the swollen and hypertrophied met with, but by no means characteristic form of disease and the termination of that preceding it ; thus membrane generally of disease, is a secondary and very unimportant muco-purulent conjunctivitis is always preceded by liyper- of this form The enlarged papilla? are to be carefully distin?emia, and purulent conjunctivitis by both hyperemia and muco- symptom. which induce the phenopurulent conjunctivitis. The symptoms of diphtheritic, granu- guished from the neo-plastic growths, No doubt the word granular of mena marked well to are conjunctivitis. granular sufficiently lar, and pustular conjunctivitis rise to a confusion of ideas, being somehow condistinguish them from one another, and also from the first has given named affections of the conjunctiva. The discharge from the founded with granulations, but, as I shall subsequently explain, of granular conjunctivitis are more eye of a patient suffering from purulent conjunctivitis will, in the neo-plastic growths by far the majority of cases, if inoculated into the healthy nearly allied to tubercle than to granulations. I shall give no special description of the purulent conjuncconjunctiva, induce a like form of disease ; still this sequence, as is generally supposed, does not invariably follow ; for instance, tivitis of infants, or of gonorrhoeal conjunctivitis ; these may well be classed under the head of purulent conjunctivitis, and it the pus from the eye of a patient affected with purulent conjunctivitis may excite the diphtheritic form of disease, if introduced seems to me simply complicating a rather difficult subject to into the eye of a person previously susceptible to diphtheria. It split it up into unnecessary sub-divisions. And, again, with the exentliemateous forms of the disease, they are to be treated is consequently impossible to prognosticate, with absolute certhe form of exactly the same principles as ordinary hyperemia, or a from which upon conjunctivitis tainty, patient may suffer, although exposed to contagion ; and it behoves us, there- muco-purulent conjunctivitis. Hyperam ia of the conjunctiva, or simple conjunctivitis, as it is fore, to watch the invasion of the disease in each instance ; for frequently called, may be easily recognised by the following apupon an accurate diagnosis, and a well selected plan of treatment at this stage, the issue of the case often depends, and the remedies pearances of the conjunctiva, and by the symptoms to which to be employed in one set of cases are often absolutely injuthey give rise. rious in another, as, for example, in purulent and in diphtheritic You will remember that I told you that the healthy conjuncconjunctivitis. I need hardly remark that healthy pus as it is tiva was a transparent tissue, through which the white and called, that, for instance, from a wound of the scalp, or a thecal glistening sclerotic might be seen, and that on everting either abscess, although carefully inoculated into the conjunctiva, the upper or lower lid, a number of small reddish bands or cannot excite inflammation ; the nature of the properties of streaks could be traced beneath the conjunctiva, extending healthy pus, as contra-distinguished from that which is capable backwards from the margin of the lids; they mark the of propagating disease by contagion, is one of the many pathoposition of the meibomian glands, and as the latter are situated logical problems yet to be solved : but the spread of the various beneath the mucous membrane, it follows that if the conjuncforms of conjunctivitis by this means, is an established fact, tiva is congested, these glands will be more or less occluded. although, as I have before remarked, we cannot be always sure As we advance in life, the conjunctiva naturally becomes somethat the pus will, in every instance, propagate a disease similar what liypercemic, nor is this condition, under the circumstanccs, to that from which it to be considered in itself as an indication of disease. originated. The contagious nature, however, of all forms of conjunctivitis attended with a purulent In hyperemia we shall notice, on everting the lids, that the discharge, should lead us to separate the affected from the palpebral conjunctiva is not only injccted, but that its surface healthy portion of the community. A remarkable instance of is uneven ; this arises from two causes,?first, that its villi bethe melancholy results which follow a neglect of this rule, is to come prominent from the turgid state of the vessels which he foundin the case of the purulent form of the disease as seen they contain; and, secondly, its glands are thrown into in Egypt at the present day ; this affection of the eye being nular
"
"
THE INDIAN MEDICAL GAZETTE.
190 increased
activity, and becoming enlarged, these, together with villi, give the mucous membrane a rough appearancc, particularly on the tarso-orbital fold, which is also somewhat swollen, from the serous effusion poured out into its loose the swollen
cellular tissue. and chemosed.
The caruncle and
similar folds are
also red
conjunctiva is usually only slightly affected in simple hyperemia; it may be that its superficial vessels are somewhat congested, in which case they are seen coursing over the sclerotic in a reticulate manner towards the cornea Congestion of the orbital conjunctiva can hardly be mistaken for that of the sclerotic, for in the former the enlarged vessels may be readily made to glide over the surface of the sclerotic by gently pressing upon, and moving the mucous membrane under the point of the finger ; the vessels of the congested conjunctiva again are most marked towards its palpebral fold, and generally decrease in number and size as they approach the cornea ; the larger vessels, moreover, are separate and distant from one another, and are of a bright scarlet or vermilion colour; whereas hyperemia of the sclerotic is always most marked immediately round the margin of the cornea, the vessels being of so minute a size, that they cannot be distinguished from one another ; the part appearing as though it had been stained of a delicate violet or pink, the intensity of the pigmentation decreasing about two lines from the margin of the cornea, and being gradually lost in the normal whiteness of the sclerotic. We do not often meet with cases of hyperemia of the sclerotic without the conjunctiva being also somewhat congested, so that in the majority of instances the contrast between the two is sufficiently marked to attract the attention The orbital
of the most casual observer.
The amount of uneasiness,
or even pain, to which hypenemia conjunctiva may give rise, depends very much upon the idiosyncrasy of the patient. Some people feel pain so much more acutely than others, but the most sensitive individual suffering from simple hypersemia seldom complains of anything beyond a sensation $s if sand or grit had fallen into the eye, which is caused by the constant rubbing of the congested vessels of the mucous membrane against the surface of the cornea. This symptom is apt to vary with the age of the patient, being less marked in
of the
old persons than in the young, not because the sensations of the former class arc always blunted, but on account of the muscular fibres of the orbicularis losing their contractile
power, and pressing the lids less firmly against the eyeball than in the case of adults ; the adipose tissue also contained in the cavity of the orbit, is often gradually absorbed as we advance
socket, and thus recedes lids, which then hang loosely over the eyeball. Under these circumstances, considerable hyperacmia of the conjunctiva may exist, without the patient feeling any inconvenience whatever from it, simply because the congested vessels of the palpebral conjunctiva hardly touch the cornea. These circumstances must be taken into consideration, when judging of the sensations experienced by those suffering from the milder forms of conjunctivitis. In cases of hypenemia, if the patient is exposed to the glare of the sun or lamplight, it causes a sensation of weariness and irritation in the eye, and this symptom is augmented if the eyes are used for any length of time, so that the patient is often prevented from pursuing his usual avocation for more than a few hours together. The secretions from the lachrymal and conjunctival glands are increased iu quantity, but are not altered iu character ; the disease is consequently nou-contagiof his eyes ous, but the patient complains watering a good deal. This symptom, like the last mentioned, is increased by overwork, or exposure to a bright light ; it is due to irritation of the conjunctival and lachrymal glands; added to this, the slightly swollen and congested state of the mucous membrane of the lids extends to the lining membrane of the puncta and canaliculus, and the natural passage of the tears into the in
life,
and the
eyeball
sinks into its
to some extent from the
[August 1,
1867.
nose being plugged up, they collect in the inner corner of the eye, and overflowing, induce the lachrymation complained of. On the other hand, in many cases of hyperaemia of the conjunctiva the diseased action extends in the opposite direction, irritation of the mucous membrane of the naris spreading
the lachrymal passage to the eyelids, as frequently, noticed in a common cold. Causes of hyperemia of the conjunctiva.?These are numerous
through
especially in the tropics. are constantly exposed
The glare of the sua to which we for nine months out of the twelve,
combined with the state of the atmosphere, which is often loaded with dust out-of-doors, and within, among the lower orders of natives, with the smoke from the wood-fires over which cook their food, together with the fumes of ammoniacal gases, miasmatic influences, and exhalations from open cesspools, and all manner of putrescent filth, are constant sources
they
of irritation and hypersemia of the conjunctiva. The presence of a foreign body on the conjunctiva may also give rise to congestion of the mucous membrane. Under this head we should
place those cases in which an inverted cilium, by brushing against the eye, keeps up persistent irritation and hypercemia of the conjunctiva. Disease of the retina may by reflex action cause congestion of the conjunctiva, and among hypermetropics, the accommodating power of the eye is overstrained in order that the necessary convexity of the anterior -surface of the lens may be maintained, and hypersemia of the conjunctiva is the result. Lastly, congestion of this membrane may arise from a faulty state of the secreting organs; for instance, the functions of the stomach or liver become deranged, too often from over-eating or drinking, and hyperaemia of the conjunctiva is induced. The treatment of this affection should, as far as practicable, be directed towards the removal of the cause of the disease ; for instance, the eye may be protected from the glare of the
dust, by neutral tint, or blue glasses. This is a of relieving hypersemia arising from over-exposure, but it is unfortunately beyond the reach of the poorer classes, being quite incompatible with their occupation. Astringent lotions, composed of from three to four grains of sulphate of zinc, to an ounce of water, are very beneficial in hypersemia. Acetate of lead (four grains to the ounce) is probably preferable to the sulphate of zinc ,? but in either case do not prescribe the vinum opii or tincture of opium, of the kind, as the so often added to lotions quantity of opium administered cannot possibly do any good, and the spirit contained in the tincture will, if in any quantity, assuredly do Order your patient, therefore, to evert the lower lid, harm. and allow a few drops of the above-mentioned lotion to run into the affected eye twice a day ; it tends to constringe the dilated vessels of the conjunctiva, and thus accelerates the blood passing through them, inducing a more stream of healthy action in the part. The abnormal changes being apparently confined, in simple hypersemia, to dilatation of the vessels, either through defective nervous influences, or a faulty interchange between the blood and the tissues, we may rely upon the simple treatment above indicated; and, as a further means to the same end, we may order the patient to use the coldwater douche to the closed eyelids, for ten minutes, night and morning. Cold compresses are recommended upon the same principle ; they are most refreshing, and may be applied over the closed lids with great advantage for fifteen minutes at a time, specially after a day's work. The water employed should not be too cold, or excessive reaction may follow its use. the eyed "When the hyperemia depends on overstraining to protect the organ by rest, and our first care must be ordinarily fair treatment; our eyes cannot stand with impunity all the wear and tear that we (of this go-ahead age) are apt to force upon them. As I have before remarked, we may often have to attack the congested conjunctiva through a judicious use of from
sun,
or
very
simple
means
August
1,1867.]
LECTURES ON DISEASES OP THE CONJUNCTIVA.?BY DR. C.MACNAMARA. 191
alteratives, and such like remedies, rather than by local applications ; frequently abstinence, as regards tobacco and alcohol, must be enjoined, overloading the stomach with food must be prevented, and a dose of blue pill and black draught administered. These means are as frequently required in one class of cases, as tonics arc in another, consisting of growing youths (students for instance), who, in addition to more or less general debility, suffer from hypertemia of the conjunctiva ; although astringents, and restriction as to the amount of reading and writing they perform, are doubtless called for in these cases, still a genei'ous dietary, exercise, and iron must be employed, together with the cold-water douche, if we would effect a permanent cure. It is almost superfluous to remark that if hypera>mia depends on the presence of a foreign body in the eye, the offending substance must be removed ; if an inverted cilium, it must be carefully extracted ; and in examining an eye, never forget to glance at the cilia, particularly at those growing near the inner or outer angle of the eye. One single hair may be sufficient to keep up such an amount of hypersemia as to render a patient unfit for ordinary work, and unless the offending cilium is removed, the disease will certainly never be relieved. It is well, after extracting an eyelash under these circumstances, to run needle armed with nitrate of silver down to the bulb of the hair, and by exciting a slight amount of inflammation, to destroy a
the bulb and prevent the hair from growing again.
Hypertemia of the conjunctiva, depending on liypermetropia, maybe cured by a judicious selection of convex glasses to relieve the overstrained muscular apparatus of the eye; but as this subject, as well as that of congestion depending on retinitis, will be more fully treated of in a subsequent lecture, I shall leave it for the present. Muco-purulent, or catarrhal conjunctivitis, may be considered as an aggravated form of hypertemia, with this difference, however, that the discharge from the conjunctiva, though still consisting chiefly of a watery fluid, contains albumen and shreds of muco-purulent matter* and further, that this mucopurulent matter possesses contagious pi-operties ; in this respect, therefore, the disease we are considering differs essentially from simple hyperajmia. In the early stages of muco-purulent conjunctivitis, we shall find that the vessels of the palpebral conjunctiva arc principally affected, so that the position of the meibomian glands is speedily occluded by the congested mucous membrane covering them ; the palpebral surface of the lids appears of a uniformly red colour, the conjunctiva being slightly swollen, especially at the tarso-orbital fold ; the semi-lunar fold and caruncle are also in a similar condition, and, as a general rule, both eyes are equally affected. In consequence of this turgid state of the vessels of the conjunctiva, the villi are more prominent than in health ; the loop of vessels contained in the papilla not only being congested, but serous effusion taking place into their connective tissue ; the basement membrane covering the villi is distended, in the same way that a glove might be by the fingers of the wearer. The vessels of the orbital conjunctiva ai-e affected, occasionally, to such an extent that the sclerotic is entirely hid by the uniformly red and congested mucous membrane covering it, and under these circumstances there is generally a good deal of chcmosis, or serous effusion beneath the conjunctiva In the majority of instances, however, the vessels of the orbital conjunctiva are not so deeply injected as above described, but many large and separate vessels may be seen coursing over the sclerotic, in a reticulate manner, from the palpebral conjunctiva towards the cornea. The
amount of chemosis present varies cases ; very much in different it is always most marked in the tarso-orbital and semi-lunar folds ; in some cases the chemosis the conjunctiva for-
bulges
wards, and causes it slightly to overlap the margin of the cornea. To the same cause, viz., over-distension of the vessels, we must attribute the spots of ecchvniosis seen on both the palpebral and
orbital conjunctiva, in
cases of muco-purulent conjunctivitis; lisemorrhagic spots are usually small but numerous, and doubtless depend upon rupture and extravasation of blood from
the
some
of the minute vessels of tho mucous membraue.
The secretion from
the lachrymal and conjunctival glands during the different stages of the disease ; at the commencement it is augmented in quantity, but is normal in quality",; as the congestion increases, the circulation through the vessels is impeded, and the first effect of this noticed in the secretion is that albumen is to be found in it, and ultimately from liyperaction of the epithelial cells of the conjunctiva ancl conglomerate glands, increased cell formation occurs, and we find a vast number of epithelial, together with mucous and varies in character
pus cells mixed up with the serous fluid which escapes from the eye. This muco-purulent matter usually collects in whitish which may generally be seen floating about in the tears, when the lower lid is everted, they escape over the corner of tho eye, the flakes of mucus being deposited on the
flakes,
and
surface of the
conjunctiva, especially
on
the tarso-orbital fold.
The diseased action is not confined to the conjunctiva and lachrymal apparatus ; after a time the lining membrane of tho meibomian glands also participates in the irritation going on in its immediate vicinity, and the consequence is that the nature of their secretion becomes altered in character, as well as increased in quantity, and accumulating on the margin of the lids during sleep, it dries and gums them together, so that on waking the patient has often considerable difficulty in opening his eyes until
they
have been washed, and the concretions removed.
in mind the fact that muco-purulent conjunctivitis advanced stage of hyperemia, we should naturally expect
Bearing is
an
patient
to
of
augmentation of the symptoms The conjunctival vessels being more iutensely congested than in hyperemia, the patient coir. plains more urgently of a sensation as if grit or sand had fallen into his eye, and it is often difficult to persuade him that this symptom docs not depend upon a foreign body lodged beneath the lids ; he also complains of the affected eye itching a good deal, and of the upper lid feeling stiff and heavy, especially after work or exposure to the glare of the sun or candlelight ; the lachrymal secretion being increased, the eye waters much, and a tear is apt to collect between the lids, and hanging in front of the cornea to cause some impairment of vision, until the patient wipes it away. These symptoms increase towards evening, and in the morning the patient awakes and finds his eyelids stuck together, by the dried secretion from the A person suffering from muco-purulent meibomian glands. conjunctivitis does not experience any actual pain in the eye or super-orbital region, nor is there any marked intolerance of light, so that ho usually comes to consult you with his eyes wide open, and complaining of the above-mentioned sympOn examining the eyes, as already described, you will toms. find the vessels of the palpebral and orbital conjunctiva more or less deeply congested, the villi in the palpebral mucous membrane prominent, and small spots of ecchymosis scattered over the mucous membrane, which is generally somewhat swollen, especially at the tarso-orbital and semi-lunar folds ; in consequence of the chemosis, the puncta become more or less displaced and occluded, the tears therefore accumulate at the the
complain
an
characteristic of that affection.
inner cornea of the eye, overflow and run down over the cheek ; floating in this aqueous fluid, flakes of ropy muco-purulent matter may be seen, which are apt to be deposited on the surthe face of the cornea or as the tears escape from
conjunctiva,
An attack of conjunctivitis of this kind usually disappears in the course of ten or twelve days, unless its exciting circumstances cause should continue in operation, under which it may pass on into the purulent, or other forms of inflammation, or it may degenerate into a state of chronic eye.
hyperoemia.
1SG7.]
LECTURES ON DISEASES OF CONJUNCTIVA.?BY DR. MACNAMARA.
l$9
endemic, and propagated from one individual to another, generation to generation. It is commonly asserted that the glare of the sun, and the presence of numerous particles of sand in the atmosphere, are concomitant, if not positive causes of the disease among the lower classes in Egypt ; but this theory can hardly hold good, for in parts of India the people are subject to the same influences, and yet they do not suffer like the Egyptians from purulent conjunctivitis. With regard to the diphtheritic form of the disease, it is rare to meet with a there
ORIGINAL COMMUNICATIONS. LECTURES ON DISEASES OF THE
CONJUNC-
TIVA.?No. I. Br C.
Surgeon We may
Macnamara, Ophthalmic Hospital.
to the Calcutta now
proceed
to
the diseases of the
conjuncfar the larger proportion of tiva, and as they will the " eye cases you will meet with in practice, they demand a careful consideration. In many instances the conjunctivitis is of so trivial a nature, that we may safely leave it to run its own course, the hyperemia and congestion of the membrane speedily disappearing upon the removal of the cause of the disease. Unfortunately, in this country, the poorer classes are constantly exposed to influences which directly produce hyperemia of the conjunctiva ; the glare of a tropical sun, an atmosphere impregnated with dust out-of-doors, and with smoke within, combined with malarious influences, and the ammoniacal fumes given off from open sewers and cesspools, are so many direct causes of conjunctivitis, to which many people are perpetually exposed. I propose describing the various forms of conjunctivitis under the following heads :?Hypertemia, Muco-purulent, Purulent, Diphtheritic, Granular, and Pustular Conjunctivitis. It is difficult, in the first three of the above-mentioned affections, to "
study constitute by
and from
case among the natives ; it is nevertheless necessary to be prepared for its advent, as, in all human probability, instances of the kind will occur more frequently in the course of time, for
doubtless exists here, although not to the same Europe. Diphtheritic conjunctivitis is, at present, endemic only amongst the inhabitants of Belgium, in which country it is described as being of a most destructive nature, the conjunctiva undergoing the same train of pathological changes as those which characterise the disease in other parts of the body ; there is precisely the same tendency to the formation of fibrinous exudations, not only on the surface, but in the connective tissue of the mucous membrane, which, pressing on the vessels of the part, and impeding the circulation, causes a swollen and brawny condition of the lids, and the drabcoloured appearance of the mucous membrane, peculiar to this
diphtheria
extent
as
in
disease. As to the much
disputed question of the pathology of graconjunctivitis, I may here remark that the disease consists essentially of a neo-plastic growth springing from the germinal matter of the connective tissue of the conjunctiva, and that state of the villi of the mucous draw a line of demarcation between the commencement of one the swollen and hypertrophied met with, but by no means characteristic form of disease and the termination of that preceding it ; thus membrane generally of disease, is a secondary and very unimportant muco-purulent conjunctivitis is always preceded by liyper- of this form The enlarged papilla? are to be carefully distin?emia, and purulent conjunctivitis by both hyperemia and muco- symptom. which induce the phenopurulent conjunctivitis. The symptoms of diphtheritic, granu- guished from the neo-plastic growths, No doubt the word granular of mena marked well to are conjunctivitis. granular sufficiently lar, and pustular conjunctivitis rise to a confusion of ideas, being somehow condistinguish them from one another, and also from the first has given named affections of the conjunctiva. The discharge from the founded with granulations, but, as I shall subsequently explain, of granular conjunctivitis are more eye of a patient suffering from purulent conjunctivitis will, in the neo-plastic growths by far the majority of cases, if inoculated into the healthy nearly allied to tubercle than to granulations. I shall give no special description of the purulent conjuncconjunctiva, induce a like form of disease ; still this sequence, as is generally supposed, does not invariably follow ; for instance, tivitis of infants, or of gonorrhoeal conjunctivitis ; these may well be classed under the head of purulent conjunctivitis, and it the pus from the eye of a patient affected with purulent conjunctivitis may excite the diphtheritic form of disease, if introduced seems to me simply complicating a rather difficult subject to into the eye of a person previously susceptible to diphtheria. It split it up into unnecessary sub-divisions. And, again, with the exentliemateous forms of the disease, they are to be treated is consequently impossible to prognosticate, with absolute certhe form of exactly the same principles as ordinary hyperemia, or a from which upon conjunctivitis tainty, patient may suffer, although exposed to contagion ; and it behoves us, there- muco-purulent conjunctivitis. Hyperam ia of the conjunctiva, or simple conjunctivitis, as it is fore, to watch the invasion of the disease in each instance ; for frequently called, may be easily recognised by the following apupon an accurate diagnosis, and a well selected plan of treatment at this stage, the issue of the case often depends, and the remedies pearances of the conjunctiva, and by the symptoms to which to be employed in one set of cases are often absolutely injuthey give rise. rious in another, as, for example, in purulent and in diphtheritic You will remember that I told you that the healthy conjuncconjunctivitis. I need hardly remark that healthy pus as it is tiva was a transparent tissue, through which the white and called, that, for instance, from a wound of the scalp, or a thecal glistening sclerotic might be seen, and that on everting either abscess, although carefully inoculated into the conjunctiva, the upper or lower lid, a number of small reddish bands or cannot excite inflammation ; the nature of the properties of streaks could be traced beneath the conjunctiva, extending healthy pus, as contra-distinguished from that which is capable backwards from the margin of the lids; they mark the of propagating disease by contagion, is one of the many pathoposition of the meibomian glands, and as the latter are situated logical problems yet to be solved : but the spread of the various beneath the mucous membrane, it follows that if the conjuncforms of conjunctivitis by this means, is an established fact, tiva is congested, these glands will be more or less occluded. although, as I have before remarked, we cannot be always sure As we advance in life, the conjunctiva naturally becomes somethat the pus will, in every instance, propagate a disease similar what liypercemic, nor is this condition, under the circumstanccs, to that from which it to be considered in itself as an indication of disease. originated. The contagious nature, however, of all forms of conjunctivitis attended with a purulent In hyperemia we shall notice, on everting the lids, that the discharge, should lead us to separate the affected from the palpebral conjunctiva is not only injccted, but that its surface healthy portion of the community. A remarkable instance of is uneven ; this arises from two causes,?first, that its villi bethe melancholy results which follow a neglect of this rule, is to come prominent from the turgid state of the vessels which he foundin the case of the purulent form of the disease as seen they contain; and, secondly, its glands are thrown into in Egypt at the present day ; this affection of the eye being nular
"
"
THE INDIAN MEDICAL GAZETTE.
190 increased
activity, and becoming enlarged, these, together with villi, give the mucous membrane a rough appearancc, particularly on the tarso-orbital fold, which is also somewhat swollen, from the serous effusion poured out into its loose the swollen
cellular tissue. and chemosed.
The caruncle and
similar folds are
also red
conjunctiva is usually only slightly affected in simple hyperemia; it may be that its superficial vessels are somewhat congested, in which case they are seen coursing over the sclerotic in a reticulate manner towards the cornea Congestion of the orbital conjunctiva can hardly be mistaken for that of the sclerotic, for in the former the enlarged vessels may be readily made to glide over the surface of the sclerotic by gently pressing upon, and moving the mucous membrane under the point of the finger ; the vessels of the congested conjunctiva again are most marked towards its palpebral fold, and generally decrease in number and size as they approach the cornea ; the larger vessels, moreover, are separate and distant from one another, and are of a bright scarlet or vermilion colour; whereas hyperemia of the sclerotic is always most marked immediately round the margin of the cornea, the vessels being of so minute a size, that they cannot be distinguished from one another ; the part appearing as though it had been stained of a delicate violet or pink, the intensity of the pigmentation decreasing about two lines from the margin of the cornea, and being gradually lost in the normal whiteness of the sclerotic. We do not often meet with cases of hyperemia of the sclerotic without the conjunctiva being also somewhat congested, so that in the majority of instances the contrast between the two is sufficiently marked to attract the attention The orbital
of the most casual observer.
The amount of uneasiness,
or even pain, to which hypenemia conjunctiva may give rise, depends very much upon the idiosyncrasy of the patient. Some people feel pain so much more acutely than others, but the most sensitive individual suffering from simple hypersemia seldom complains of anything beyond a sensation $s if sand or grit had fallen into the eye, which is caused by the constant rubbing of the congested vessels of the mucous membrane against the surface of the cornea. This symptom is apt to vary with the age of the patient, being less marked in
of the
old persons than in the young, not because the sensations of the former class arc always blunted, but on account of the muscular fibres of the orbicularis losing their contractile
power, and pressing the lids less firmly against the eyeball than in the case of adults ; the adipose tissue also contained in the cavity of the orbit, is often gradually absorbed as we advance
socket, and thus recedes lids, which then hang loosely over the eyeball. Under these circumstances, considerable hyperacmia of the conjunctiva may exist, without the patient feeling any inconvenience whatever from it, simply because the congested vessels of the palpebral conjunctiva hardly touch the cornea. These circumstances must be taken into consideration, when judging of the sensations experienced by those suffering from the milder forms of conjunctivitis. In cases of hypenemia, if the patient is exposed to the glare of the sun or lamplight, it causes a sensation of weariness and irritation in the eye, and this symptom is augmented if the eyes are used for any length of time, so that the patient is often prevented from pursuing his usual avocation for more than a few hours together. The secretions from the lachrymal and conjunctival glands are increased iu quantity, but are not altered iu character ; the disease is consequently nou-contagiof his eyes ous, but the patient complains watering a good deal. This symptom, like the last mentioned, is increased by overwork, or exposure to a bright light ; it is due to irritation of the conjunctival and lachrymal glands; added to this, the slightly swollen and congested state of the mucous membrane of the lids extends to the lining membrane of the puncta and canaliculus, and the natural passage of the tears into the in
life,
and the
eyeball
sinks into its
to some extent from the
[August 1,
1867.
nose being plugged up, they collect in the inner corner of the eye, and overflowing, induce the lachrymation complained of. On the other hand, in many cases of hyperaemia of the conjunctiva the diseased action extends in the opposite direction, irritation of the mucous membrane of the naris spreading
the lachrymal passage to the eyelids, as frequently, noticed in a common cold. Causes of hyperemia of the conjunctiva.?These are numerous
through
especially in the tropics. are constantly exposed
The glare of the sua to which we for nine months out of the twelve,
combined with the state of the atmosphere, which is often loaded with dust out-of-doors, and within, among the lower orders of natives, with the smoke from the wood-fires over which cook their food, together with the fumes of ammoniacal gases, miasmatic influences, and exhalations from open cesspools, and all manner of putrescent filth, are constant sources
they
of irritation and hypersemia of the conjunctiva. The presence of a foreign body on the conjunctiva may also give rise to congestion of the mucous membrane. Under this head we should
place those cases in which an inverted cilium, by brushing against the eye, keeps up persistent irritation and hypercemia of the conjunctiva. Disease of the retina may by reflex action cause congestion of the conjunctiva, and among hypermetropics, the accommodating power of the eye is overstrained in order that the necessary convexity of the anterior -surface of the lens may be maintained, and hypersemia of the conjunctiva is the result. Lastly, congestion of this membrane may arise from a faulty state of the secreting organs; for instance, the functions of the stomach or liver become deranged, too often from over-eating or drinking, and hyperaemia of the conjunctiva is induced. The treatment of this affection should, as far as practicable, be directed towards the removal of the cause of the disease ; for instance, the eye may be protected from the glare of the
dust, by neutral tint, or blue glasses. This is a of relieving hypersemia arising from over-exposure, but it is unfortunately beyond the reach of the poorer classes, being quite incompatible with their occupation. Astringent lotions, composed of from three to four grains of sulphate of zinc, to an ounce of water, are very beneficial in hypersemia. Acetate of lead (four grains to the ounce) is probably preferable to the sulphate of zinc ,? but in either case do not prescribe the vinum opii or tincture of opium, of the kind, as the so often added to lotions quantity of opium administered cannot possibly do any good, and the spirit contained in the tincture will, if in any quantity, assuredly do Order your patient, therefore, to evert the lower lid, harm. and allow a few drops of the above-mentioned lotion to run into the affected eye twice a day ; it tends to constringe the dilated vessels of the conjunctiva, and thus accelerates the blood passing through them, inducing a more stream of healthy action in the part. The abnormal changes being apparently confined, in simple hypersemia, to dilatation of the vessels, either through defective nervous influences, or a faulty interchange between the blood and the tissues, we may rely upon the simple treatment above indicated; and, as a further means to the same end, we may order the patient to use the coldwater douche to the closed eyelids, for ten minutes, night and morning. Cold compresses are recommended upon the same principle ; they are most refreshing, and may be applied over the closed lids with great advantage for fifteen minutes at a time, specially after a day's work. The water employed should not be too cold, or excessive reaction may follow its use. the eyed "When the hyperemia depends on overstraining to protect the organ by rest, and our first care must be ordinarily fair treatment; our eyes cannot stand with impunity all the wear and tear that we (of this go-ahead age) are apt to force upon them. As I have before remarked, we may often have to attack the congested conjunctiva through a judicious use of from
sun,
or
very
simple
means
August
1,1867.]
LECTURES ON DISEASES OP THE CONJUNCTIVA.?BY DR. C.MACNAMARA. 191
alteratives, and such like remedies, rather than by local applications ; frequently abstinence, as regards tobacco and alcohol, must be enjoined, overloading the stomach with food must be prevented, and a dose of blue pill and black draught administered. These means are as frequently required in one class of cases, as tonics arc in another, consisting of growing youths (students for instance), who, in addition to more or less general debility, suffer from hypertemia of the conjunctiva ; although astringents, and restriction as to the amount of reading and writing they perform, are doubtless called for in these cases, still a genei'ous dietary, exercise, and iron must be employed, together with the cold-water douche, if we would effect a permanent cure. It is almost superfluous to remark that if hypera>mia depends on the presence of a foreign body in the eye, the offending substance must be removed ; if an inverted cilium, it must be carefully extracted ; and in examining an eye, never forget to glance at the cilia, particularly at those growing near the inner or outer angle of the eye. One single hair may be sufficient to keep up such an amount of hypersemia as to render a patient unfit for ordinary work, and unless the offending cilium is removed, the disease will certainly never be relieved. It is well, after extracting an eyelash under these circumstances, to run needle armed with nitrate of silver down to the bulb of the hair, and by exciting a slight amount of inflammation, to destroy a
the bulb and prevent the hair from growing again.
Hypertemia of the conjunctiva, depending on liypermetropia, maybe cured by a judicious selection of convex glasses to relieve the overstrained muscular apparatus of the eye; but as this subject, as well as that of congestion depending on retinitis, will be more fully treated of in a subsequent lecture, I shall leave it for the present. Muco-purulent, or catarrhal conjunctivitis, may be considered as an aggravated form of hypertemia, with this difference, however, that the discharge from the conjunctiva, though still consisting chiefly of a watery fluid, contains albumen and shreds of muco-purulent matter* and further, that this mucopurulent matter possesses contagious pi-operties ; in this respect, therefore, the disease we are considering differs essentially from simple hyperajmia. In the early stages of muco-purulent conjunctivitis, we shall find that the vessels of the palpebral conjunctiva arc principally affected, so that the position of the meibomian glands is speedily occluded by the congested mucous membrane covering them ; the palpebral surface of the lids appears of a uniformly red colour, the conjunctiva being slightly swollen, especially at the tarso-orbital fold ; the semi-lunar fold and caruncle are also in a similar condition, and, as a general rule, both eyes are equally affected. In consequence of this turgid state of the vessels of the conjunctiva, the villi are more prominent than in health ; the loop of vessels contained in the papilla not only being congested, but serous effusion taking place into their connective tissue ; the basement membrane covering the villi is distended, in the same way that a glove might be by the fingers of the wearer. The vessels of the orbital conjunctiva ai-e affected, occasionally, to such an extent that the sclerotic is entirely hid by the uniformly red and congested mucous membrane covering it, and under these circumstances there is generally a good deal of chcmosis, or serous effusion beneath the conjunctiva In the majority of instances, however, the vessels of the orbital conjunctiva are not so deeply injected as above described, but many large and separate vessels may be seen coursing over the sclerotic, in a reticulate manner, from the palpebral conjunctiva towards the cornea. The
amount of chemosis present varies cases ; very much in different it is always most marked in the tarso-orbital and semi-lunar folds ; in some cases the chemosis the conjunctiva for-
bulges
wards, and causes it slightly to overlap the margin of the cornea. To the same cause, viz., over-distension of the vessels, we must attribute the spots of ecchvniosis seen on both the palpebral and
orbital conjunctiva, in
cases of muco-purulent conjunctivitis; lisemorrhagic spots are usually small but numerous, and doubtless depend upon rupture and extravasation of blood from
the
some
of the minute vessels of tho mucous membraue.
The secretion from
the lachrymal and conjunctival glands during the different stages of the disease ; at the commencement it is augmented in quantity, but is normal in quality",; as the congestion increases, the circulation through the vessels is impeded, and the first effect of this noticed in the secretion is that albumen is to be found in it, and ultimately from liyperaction of the epithelial cells of the conjunctiva ancl conglomerate glands, increased cell formation occurs, and we find a vast number of epithelial, together with mucous and varies in character
pus cells mixed up with the serous fluid which escapes from the eye. This muco-purulent matter usually collects in whitish which may generally be seen floating about in the tears, when the lower lid is everted, they escape over the corner of tho eye, the flakes of mucus being deposited on the
flakes,
and
surface of the
conjunctiva, especially
on
the tarso-orbital fold.
The diseased action is not confined to the conjunctiva and lachrymal apparatus ; after a time the lining membrane of tho meibomian glands also participates in the irritation going on in its immediate vicinity, and the consequence is that the nature of their secretion becomes altered in character, as well as increased in quantity, and accumulating on the margin of the lids during sleep, it dries and gums them together, so that on waking the patient has often considerable difficulty in opening his eyes until
they
have been washed, and the concretions removed.
in mind the fact that muco-purulent conjunctivitis advanced stage of hyperemia, we should naturally expect
Bearing is
an
patient
to
of
augmentation of the symptoms The conjunctival vessels being more iutensely congested than in hyperemia, the patient coir. plains more urgently of a sensation as if grit or sand had fallen into his eye, and it is often difficult to persuade him that this symptom docs not depend upon a foreign body lodged beneath the lids ; he also complains of the affected eye itching a good deal, and of the upper lid feeling stiff and heavy, especially after work or exposure to the glare of the sun or candlelight ; the lachrymal secretion being increased, the eye waters much, and a tear is apt to collect between the lids, and hanging in front of the cornea to cause some impairment of vision, until the patient wipes it away. These symptoms increase towards evening, and in the morning the patient awakes and finds his eyelids stuck together, by the dried secretion from the A person suffering from muco-purulent meibomian glands. conjunctivitis does not experience any actual pain in the eye or super-orbital region, nor is there any marked intolerance of light, so that ho usually comes to consult you with his eyes wide open, and complaining of the above-mentioned sympOn examining the eyes, as already described, you will toms. find the vessels of the palpebral and orbital conjunctiva more or less deeply congested, the villi in the palpebral mucous membrane prominent, and small spots of ecchymosis scattered over the mucous membrane, which is generally somewhat swollen, especially at the tarso-orbital and semi-lunar folds ; in consequence of the chemosis, the puncta become more or less displaced and occluded, the tears therefore accumulate at the the
complain
an
characteristic of that affection.
inner cornea of the eye, overflow and run down over the cheek ; floating in this aqueous fluid, flakes of ropy muco-purulent matter may be seen, which are apt to be deposited on the surthe face of the cornea or as the tears escape from
conjunctiva,
An attack of conjunctivitis of this kind usually disappears in the course of ten or twelve days, unless its exciting circumstances cause should continue in operation, under which it may pass on into the purulent, or other forms of inflammation, or it may degenerate into a state of chronic eye.
hyperoemia.
