A uk( September 2,
1867.]
LECTURES ON DISEASES OF CONJUNCTIVA.?BY C. MACNAMAEA. 213 fed, and those M'hose constitutions have been impaired by disease but under any circumstances it too frequently ends in sloughing of the cornea, and partial, if not total, destruction of
ORIGINAL COMMUNICATIONS.
sight. remarked, to draw a line of demarcation between the termination of muco-purulent and the commencement of suppurative conjunctivitis, the latter being simply a more intense form of disease than the former. In all cases of purulent conjunctivitis, in its early stages, hyperoemia of the mucous membrane exists, which rapidly passes on into the muco-purulent form of the disease, but in its first stage it would be impossible, in any given case, to say positively if the conjunctivitis would advance on to suppurative inflammation or not, although, in by far the majority of instances, all doubts on the subject will be cleared away in the course of a few hours. In all cases, in fact, arising from the inoculation of gonorrhceal or other contagious matter into the eye, symptoms of intense inflammation declare themselves very rapidly, and leave us no It is
LECTURES ON DISEASES OF TIIE CONJUNCTIVA?Xo. II. 33y C.
Surgeon
Macxamara, Ophthalmic Hospital.
to the Calcutta
The causes which induce
impossible,
as
I have before
mucopurulent conjunctivitis are majority of cases it may be traced to zymotic influences, or else to contagion, (often spreading in this way through a school, a regiment, or a community); miasmatic influences and irritating gases from drains are a fruitful source of this form of conjunctivitis. Foreign bodies lodged on the conjunctiva may likewise give rise to muco-purulent conjunctivitis ; for instance, it is not a very uncommon circumstance for an insect to find its way into the eye, and becoming impacted room for doubt as to the formidable nature of the disease Avith in the folds of the conjunctiva, to induce muco-purulent conjunctivitis. Lastly, in the various exanthemata, this form of which we have to cope. In consequence of the stagnation of blood in the congested vessels of an eye affected with purulent conconjunctivitis is very apt to occur. Treatment.?The object to be kept in view in the treatment junctivitis, active changes are set up in the germinal matter of the part, and increased cell formations occur; as a result also of of muco-purulent conjunctivitis is, if possible, to remove the cause of the disease. As a general rule, there can be no difficulty this congestion, a considerable amount of serous effusion takes in accomplishing this, should the inflammatory action depend on place into the loose connective tissue of the mucous membrane of the eyelids,, and hence the oedema and swelling of the parts. the pressure of a foreign body; but if it be induced, as it too frequently is, from dust, over-exposure to the sun, or other The extent to which the eyelids are swollen in cases of this irritating causes, it may be difficult, especially among the kind is not a safe criterion of the intensity of the disease. I have lower classes, to protect them from these deleterious influences. frequently met with instances in which the eyelids were only In treating these cases, we should never overlook the fact that slightly swollen, and yet sloughing of the cornea has supervened the affection is a contagious one, and therefore it is our duty to very rapidly; but whether the patient's eyelids be greatly swollen or not, they feel soft and doughy to the touch, and isolate patients suffering from it, as far as possible. The state of the patient's general health must be taken into consideration; not, as in diphtheritic conjunctivitis, of brawny hardIt is a mistake, however, to suppose that we caa ness. the secreting organs will frequently be found at fault, and a evert the lids, especially the upper one, in cases of purulent little judicious starving in some cases, together with a blue pin black draught, and colchicum, will do wonders, particularly if the conjunctivitis, without giving the patient pain; for in many instances the eyelids are much swollen, and it always causes the individual is affected with a rheumatic or gouty diathesis. We have, however, a valuable remedy at hand in cases of mucopatient very considerable pain, under these circumstances, to evert his eyelids. I mention this fact because many authors purulent conjunctivitis, consisting of a lotion composed of two grains of nitrate of silver to an ounce of water, to be dropped speak of everting the lids and smearing caustic over the palinto the eyes twice or thrice a day ; the first few applications may pebral conjunctiva in cases of the kind, as though it were cause a little pain, but after this the patient ceases to feel the almost a matter of indifference to the patient. My experience slightest inconvenience from the lotion. Should the nitrate of leads me to a very adverse conclusion. I find that few adults can silver excite any increased irritation, it must be at once disconundergo this treatment, on account of the intense suffering it heroic to allow tinued ; barring complications of the kind, this lotion will cure causes, and I have never seen a child sufficiently almost every case of muco-purulent conj unctivitis within a few the application to be repeated. The congestion of the conjunctival vessels is great, and comes days, provided the affection arises from contagion or zymotic on so rapidly in this form of disease that the situation of the influences, the latter cause undoubtedly inducing by far the we meet with in practice. If the nitrate of j meibomean glands are speedily covered in by the swollen velvety majority of instances silver appear3 to cause irritation or pain, cold water, or a weak | looking mucous membrane, both the palpebral and orbital solution of acetate of lead, may be kept constantly applied over J conjunctiva being of a uniformly deep scarlet colour ; the former is thickly covered with engorged villi, which produce the velvet the eyelids, and in these cases a saline purgative will generally be like appearance above noticed; in other case3 the enlarged villi serviceable. It is advisable, under any circumstances, to order the or a little are flattened and rounded from pressure against the eyeball, the patient to smear the glycerine and starch ointment, cold cream, along the margin of the lids at bedtime, so as to palpebral conjunctiva presenting somewhat the appearance of or an ounce a granulating sore. prevent them from sticking together during sleep ; of simple ointment containing twenty grains of the yellow oxide In cases where the serous effusion into the connective tissue of mcrcury may be employed in the same way. As the acute of the conjunctiva is excessive, this membrane becomes so symptoms pass off, a lotion composed of acetate of alum, two much swollen that the lids are thrust away from the eyeball; grains to an ounce of water, with about ten grains of extract of but the fibres of the orbicularis contracting firmly prevent the oellndona, may be substituted for the nitrate of silver. I need lids from being everted for some time. The distending force from within may, however, ultimately gain the ascendancy, and the lid hardly add that, if practicable, the patient should abstain from work, and keep out of the glare of the sun ; neutral tint glasses, will then be turned backwards on itself, in exactly the same or a manner as it is when we evert it in making an examination of the gauze shade, should be worn when he is exposed to glare or is more dust, and he shoud be cautioned against working by lamp or candleparts, acute ectropium in fact resulting. This accident light. If the eyes are over-strained, it is almost impossible to liable to occur in young children than in adults; officious cure the swollen conjunctivitis: they must have rest as well as medicine. or ignorant attendants are apt at night to evert the Purulent conjunctivitis.?The symptoms of this formidable to the eye. The lotions or in the to lids, attempts apply drops disease'vary much in intensity in different individuals and in accident may not be noticed till some hours afterwards, and in different placc.3; it is most destructive among the poor and ill numerous
; but in the
,
"M*
.
THE INDIAN MEDICAL GAZETTE.
214
the meantime the fibres of the orbicularis at the line of eversion form a constricting hand, which presses firmly on the part the vessels of the th& circulation of blood and
through impedes portion of the lid, and unless the ectropium is speedily the reduced, and the parts returned to their normal position, is irrecoverable and to injury is slough, conjunctiva very likely done to the eye. Another symptom consequent on the congested of state of the conjunctiva is that the puncta, at an early stage the disease, are closed, and thrust away from the eyeball, so that with the the tears cannot pass through them ; this, combined causes a stieam hypersecretion of fluid from the lachrymal gland, of tears to be constantly overflowing from the inner corner of the eve, and running down over the cheek, causing the patient everted
considerable inconvenience. But the chemosis of the orbital midable complication of purulent
conjunctiva
is most
for-
conjunctivitis, leading
to
alterations in the nutrition, and too often to destructive ulceration of the cornea ; the pressure of the effused serum interfering with the circulation of blood through the deeper layer of the conjunctival vessels, and hence the disastrous effects so often met with in cases of the kind. During the active stages of purulent conjunctivitis we will always find the swollen conjunctiva overlapinping the margin of the cornea to some extent, and in many stances the chemosis is so great that, as Dalrymple remarks, the
conjunctiva
becomes elevated into crimson folds which surround
the cornea and appear to
bury
it beneath them.
examining the eye of a patient suffering from purulent conjunctivitis, we cannot be too careful to ascertain the condition of the cornea beneath these fold3 of conjunctiva, for it is In
here that ulceration frequently commences, and extends round the circumference of the cornea ; the access of nutritive material is thus cut off from the centre of the latter, and in consequence it
sloughs and the eye is destroyed. I cannot insist too strongly on this point. The central part of the cornea may look bright and clear in the morning; on examining it in the evening it is hazy; and next day a slough has formed, the cornea gives way, and the eye is lost. Instances of this kind are by no means unfrequent. Disorganization does not, however, always occur in this way in cases of purulent conjunctivitis. We may find, on examining the eyes, that the cornea is covered with hazy flocculent looking patches, which gradually extend themselves until its surface becomes wholly involved; the ulcerative process advances rapidly at one and the integrity of the corneal tissue or more of these spots, is destroyed, and gives way, and prolapse of the iris occurs. The moment this happens, the intra-ocular pressure being relieved, the remainder of the cornea flattens, and the vitreous humour at the same time forces the lens forward, so that the iris is jammed between the two, and its protruded portion prevented from regaining its position in the anterior chamber. In some cases of suppurative conjunctivitis we find, on examining the eye, the whole of the cornea looking like a piece of moist wash leather,?a most hopeless
condition, indicating
that sloughing of the part has probably progressed
so far as all chance of recovery. Lastly, in a few instances the cornea appears as though it had been stained with a solution of carbonate of lead, being of a pinkish white colour and semi-transparent; these changes seem to on
to
preclude
depend
fatty degenera-
tion of the fibrous elements of the cornea, which lose their tenacity and become unable to resist the intra-ocular pressure; the cornea then giadually gives away and bulges forwards, particularly towards its centre, which may ultimately burst just like au over-distended bladder, and through the rent thus made a large hernia of the iris occurs. These particular classes of cases are seldom marked by any very acute symptoms, the patient suffering little pain in the eye ; the chemosis is seldom a
comparatively
prominent feature of the disease, nor is there much purulent discharge from the eye ; but these gradually advancing, degenerative changes iu the fibrous structure of the cornea indicate
[September 2, 1867:
dangerous state of tilings occurring, as a complicasuppurative conjunctivitis. "When speaking of muco-purulent conjunctivitis, I mentioned that small spots of eccliymosis are generally to be seen in the conjunctiva in the purulent form of the disease ; these hemorrhagic effusions are not only numerous, hut often of considerable size, as -we might expect from the more intense congestion of the vessels which exist in the suppurative form of the disease; but this ecchymosis is a matter of very small importance, as the effused blood becomes rapidly absorbed as soon as the inflammaa
most
tion of
tory action subsides. The nature of the secretion from the
conjunctiva varies 'with
the progress and character of the disease ; at first it is watery, then it contains muco-purulent matter, and lastly it will be found to consist of pus, which is often tinged with blood. In many cases the quantity of pus formed is by no means great, and one must not always expect a stream of purulent fluid to
gush
out from between the
patient's eyelids
the moment we
separate them, although in many instances this is the case. The purulent matter is generated from hyperaction of the matter of the connective tissue and
epithelial cells, activity, owing to the stagnation of blood in the part; rapid but imperfect cell growth occurs, and these cells degenerating before they have had time to be converted into formed material, produce pus, which oozes away from the surface of the congested conjunctiva as above
germinal which
are
thrown into
a
state of intense
described. A tolerably accurate index of the intensity of the changes going on in the conjunctiva is afforded us by the increased temperature of the eyelids, which may be readily measured with the thermometer, and which will bo found to range several degrees above the normal temperature of the skin; in the
muco-purulent and milder forms of conjunctivitis, there is no perceptible increase in the temperature of the lids. In purulent conjunctivitis, as I have before mentioned, suppuration generally commences within forty-eight hours from the beginning of the attack, so that the first stage of the disease is of remarkably short duration, and this is one of the diagnostic symptoms between it and diphtheritic conjunctivitis. In the latter suppuration does not come on until the fibrinous exudation has begun to degenerate and become disintegrated, a period usually exceeding five days, and until this time is accomplished, there is no purulent discharge from the surface of the mucous membrane. There can be 110 doubt as to the contagious nature of the pus in purulent conjunctivitis ; this is the reason why both eyes are usually affected, the matter finding its way from the diseased into the sound eye, unless the are taken to prevent this accident. But it
strictest appears inoculated
precautions
that this pus may, under certain circumstances, if into the eye of a person predisposed to diphtheria, induce the diphtheritic form of conjunctivitis; and M. Wecker states that in other instances it may cause an attack of acute granular conjunctivitis: but these are very exceptional cases, and, as a general rule, pus from the eye of a person suffering from purulent will a like form of disease, if in"
conjunctivitis
propagate
oculated into the eye of another individual. At the commencement of the attack, the
patient will
com-
of the affected eye itching a good deal, as if sand or dust had got into it; but this symptom is of a nature, very transient corresponding to the first stage of the affection, which, as I have before remarked, seldom lasts more than hours. In the
plain
thirty-six stage the chemosis and swelling of the lids are often considerable, and the pain is frequently very acute, but by no it means constantly in proportion to the swelling of the parts; depends to a great extent upon the degree to which the deeper second
structures of the eye are involved, and upon the to of the patient; but in all instances pain in the eye, extending the temple, is a constant symptom of severe purulent conjunctivitis, and one which the is sure to
temperament
patient
bring
prominently
September 2,
AlSTiESTHETIC LEPEOSY.?BY J. N.
1867.]
215
In forming our prognosis, also, we must constantly bear in mind pain usually increases towards bed-time>the fact that purulent conjunctivitis is very apt to relapse. and by no means disappears, as some authors state. When the A patient may apparently be on the high road to recovery, when in comes some on, suppurative stage instances, there is a sudden a return of all the worst symptoms takes place, and his cessation of pain about the tenth day of the disease, but thissuddenly of ultimate improvement become very much impaired. prospects frequently depends upon perforation of the cornea and the eva-Even in apparently trivial cases I have seen constant relapses cuation of the contents of the eyeball; the moment the intraof this kind occurring, which, in spite of my best efforts, have ocular pressure is removed, the patient experiences relief. The terminated in serious damage to the eye. pain of purulent conjunctivitis, however, varies according to the to our
notice.
intensity
of the disease.
The
In cases where the affection is compara-
tively mild, it may be absent to a great extent, the patient simply complaining of a pricking, aching sensation in the eyelids, especially the upper one. In instances of this kind the external inflammatory action has not been sufficiently severe to effect the circulation in the choroid, and consequently there is none of that intense pain in the eye which is a marked feature of the form of the disease.
more severe
general rule, the constitutional disturbances which occur in cases of suppurative conj unctivitis are of a very trivial characAs
a
ter ; there may be some amount of fever present, but it is not a noticeable feature of the disease, as it is in diphtheritic conjunctivitis. The patient complains of restlessness and want of
sleep,
but this is often occasioned
the pain from which he suffers. In severe and
cases
there is
always
by the anxiety
of mind and
marked intolerance of
light;
the lids may be so much swollen that the patient cannot open them, he still prefers being in a dark room, and the moment he is brought towards the light there is a gush of tears from between the lids, and an instantaneous increase of pain in the eye. In less severe cases the patient does not experi-
although
ence any great uneasiness from a short exposure to the light, but always prefers a dark room and the exclusion of as much
possible from his eyes. physiognomy of a person suffering from purulent conjunctivitis, in its second stage, is characteristic of the disease ; the patient's face is usually pale, and his countenance indicates pain and distress; lie is led into your presence by a companion, being unable to see; the eyelids are more or less red and swollen, their palpebral margin being usually of a scarlet colour, and pus is seen oozing from between them; the patient holds a' light
as
In fact the
handkerchief or his hands before his eyes, so as to screen them from the light as much as possible. It does not follow that both affected ; the sound one, however, is usually kept at once induces pain in the diseased organ. Considerable difficulty is often experienced in opening the lids in cases of this kind, for not only are they frequently very much swollen, particularly the upper one, but the individual involuntarily resists our attempts to admit light into eyes are
always
closed: exposure to light
.the eye. Under these circumstances we should not hesitate for a moment to administer cbloi'oform. The patient's sight may depend we make our first examination ; and any upon the care with which on the lids is to be avoided, as deep ulceration or pressure pulling of the cornea may exist, and if it does, the surgeon may unawares put a finishing stroke to the matter by exerting pressure on the the force thus applied causing the ulcer to give
eyeball, irreparable damage is done, which might well be only five minutes were employed in administering chloroform before examining the eyes. On opening the lids, the conjunctiva will be found in the state I have already described?of a uniformly deep crimson colour, the villi much enlarged, and the chemosed mucous membrane overlapping the margin of the cornea; spots of ecehymosis will be noticed, way, and avoided if
and the
mucous
membrane will be covered with a film of pus.
But the condition of the cornea should be our chief care; if it is bright and clear, and ho ulceration going on at its circumference, our prognosis may safely be a favourable one; if, on the other hand, ulcerationhas commenced, our opinion must be very guarded;
begun, we can give the patient reasonable hope of recovery : he may regain some amount of sight in the diseased eye, but at best it will be very imperfect. and if sloughing of the cornea has
no
1867.]
LECTURES ON DISEASES OF CONJUNCTIVA.?BY C. MACNAMAEA. 213 fed, and those M'hose constitutions have been impaired by disease but under any circumstances it too frequently ends in sloughing of the cornea, and partial, if not total, destruction of
ORIGINAL COMMUNICATIONS.
sight. remarked, to draw a line of demarcation between the termination of muco-purulent and the commencement of suppurative conjunctivitis, the latter being simply a more intense form of disease than the former. In all cases of purulent conjunctivitis, in its early stages, hyperoemia of the mucous membrane exists, which rapidly passes on into the muco-purulent form of the disease, but in its first stage it would be impossible, in any given case, to say positively if the conjunctivitis would advance on to suppurative inflammation or not, although, in by far the majority of instances, all doubts on the subject will be cleared away in the course of a few hours. In all cases, in fact, arising from the inoculation of gonorrhceal or other contagious matter into the eye, symptoms of intense inflammation declare themselves very rapidly, and leave us no It is
LECTURES ON DISEASES OF TIIE CONJUNCTIVA?Xo. II. 33y C.
Surgeon
Macxamara, Ophthalmic Hospital.
to the Calcutta
The causes which induce
impossible,
as
I have before
mucopurulent conjunctivitis are majority of cases it may be traced to zymotic influences, or else to contagion, (often spreading in this way through a school, a regiment, or a community); miasmatic influences and irritating gases from drains are a fruitful source of this form of conjunctivitis. Foreign bodies lodged on the conjunctiva may likewise give rise to muco-purulent conjunctivitis ; for instance, it is not a very uncommon circumstance for an insect to find its way into the eye, and becoming impacted room for doubt as to the formidable nature of the disease Avith in the folds of the conjunctiva, to induce muco-purulent conjunctivitis. Lastly, in the various exanthemata, this form of which we have to cope. In consequence of the stagnation of blood in the congested vessels of an eye affected with purulent conconjunctivitis is very apt to occur. Treatment.?The object to be kept in view in the treatment junctivitis, active changes are set up in the germinal matter of the part, and increased cell formations occur; as a result also of of muco-purulent conjunctivitis is, if possible, to remove the cause of the disease. As a general rule, there can be no difficulty this congestion, a considerable amount of serous effusion takes in accomplishing this, should the inflammatory action depend on place into the loose connective tissue of the mucous membrane of the eyelids,, and hence the oedema and swelling of the parts. the pressure of a foreign body; but if it be induced, as it too frequently is, from dust, over-exposure to the sun, or other The extent to which the eyelids are swollen in cases of this irritating causes, it may be difficult, especially among the kind is not a safe criterion of the intensity of the disease. I have lower classes, to protect them from these deleterious influences. frequently met with instances in which the eyelids were only In treating these cases, we should never overlook the fact that slightly swollen, and yet sloughing of the cornea has supervened the affection is a contagious one, and therefore it is our duty to very rapidly; but whether the patient's eyelids be greatly swollen or not, they feel soft and doughy to the touch, and isolate patients suffering from it, as far as possible. The state of the patient's general health must be taken into consideration; not, as in diphtheritic conjunctivitis, of brawny hardIt is a mistake, however, to suppose that we caa ness. the secreting organs will frequently be found at fault, and a evert the lids, especially the upper one, in cases of purulent little judicious starving in some cases, together with a blue pin black draught, and colchicum, will do wonders, particularly if the conjunctivitis, without giving the patient pain; for in many instances the eyelids are much swollen, and it always causes the individual is affected with a rheumatic or gouty diathesis. We have, however, a valuable remedy at hand in cases of mucopatient very considerable pain, under these circumstances, to evert his eyelids. I mention this fact because many authors purulent conjunctivitis, consisting of a lotion composed of two grains of nitrate of silver to an ounce of water, to be dropped speak of everting the lids and smearing caustic over the palinto the eyes twice or thrice a day ; the first few applications may pebral conjunctiva in cases of the kind, as though it were cause a little pain, but after this the patient ceases to feel the almost a matter of indifference to the patient. My experience slightest inconvenience from the lotion. Should the nitrate of leads me to a very adverse conclusion. I find that few adults can silver excite any increased irritation, it must be at once disconundergo this treatment, on account of the intense suffering it heroic to allow tinued ; barring complications of the kind, this lotion will cure causes, and I have never seen a child sufficiently almost every case of muco-purulent conj unctivitis within a few the application to be repeated. The congestion of the conjunctival vessels is great, and comes days, provided the affection arises from contagion or zymotic on so rapidly in this form of disease that the situation of the influences, the latter cause undoubtedly inducing by far the we meet with in practice. If the nitrate of j meibomean glands are speedily covered in by the swollen velvety majority of instances silver appear3 to cause irritation or pain, cold water, or a weak | looking mucous membrane, both the palpebral and orbital solution of acetate of lead, may be kept constantly applied over J conjunctiva being of a uniformly deep scarlet colour ; the former is thickly covered with engorged villi, which produce the velvet the eyelids, and in these cases a saline purgative will generally be like appearance above noticed; in other case3 the enlarged villi serviceable. It is advisable, under any circumstances, to order the or a little are flattened and rounded from pressure against the eyeball, the patient to smear the glycerine and starch ointment, cold cream, along the margin of the lids at bedtime, so as to palpebral conjunctiva presenting somewhat the appearance of or an ounce a granulating sore. prevent them from sticking together during sleep ; of simple ointment containing twenty grains of the yellow oxide In cases where the serous effusion into the connective tissue of mcrcury may be employed in the same way. As the acute of the conjunctiva is excessive, this membrane becomes so symptoms pass off, a lotion composed of acetate of alum, two much swollen that the lids are thrust away from the eyeball; grains to an ounce of water, with about ten grains of extract of but the fibres of the orbicularis contracting firmly prevent the oellndona, may be substituted for the nitrate of silver. I need lids from being everted for some time. The distending force from within may, however, ultimately gain the ascendancy, and the lid hardly add that, if practicable, the patient should abstain from work, and keep out of the glare of the sun ; neutral tint glasses, will then be turned backwards on itself, in exactly the same or a manner as it is when we evert it in making an examination of the gauze shade, should be worn when he is exposed to glare or is more dust, and he shoud be cautioned against working by lamp or candleparts, acute ectropium in fact resulting. This accident light. If the eyes are over-strained, it is almost impossible to liable to occur in young children than in adults; officious cure the swollen conjunctivitis: they must have rest as well as medicine. or ignorant attendants are apt at night to evert the Purulent conjunctivitis.?The symptoms of this formidable to the eye. The lotions or in the to lids, attempts apply drops disease'vary much in intensity in different individuals and in accident may not be noticed till some hours afterwards, and in different placc.3; it is most destructive among the poor and ill numerous
; but in the
,
"M*
.
THE INDIAN MEDICAL GAZETTE.
214
the meantime the fibres of the orbicularis at the line of eversion form a constricting hand, which presses firmly on the part the vessels of the th& circulation of blood and
through impedes portion of the lid, and unless the ectropium is speedily the reduced, and the parts returned to their normal position, is irrecoverable and to injury is slough, conjunctiva very likely done to the eye. Another symptom consequent on the congested of state of the conjunctiva is that the puncta, at an early stage the disease, are closed, and thrust away from the eyeball, so that with the the tears cannot pass through them ; this, combined causes a stieam hypersecretion of fluid from the lachrymal gland, of tears to be constantly overflowing from the inner corner of the eve, and running down over the cheek, causing the patient everted
considerable inconvenience. But the chemosis of the orbital midable complication of purulent
conjunctiva
is most
for-
conjunctivitis, leading
to
alterations in the nutrition, and too often to destructive ulceration of the cornea ; the pressure of the effused serum interfering with the circulation of blood through the deeper layer of the conjunctival vessels, and hence the disastrous effects so often met with in cases of the kind. During the active stages of purulent conjunctivitis we will always find the swollen conjunctiva overlapinping the margin of the cornea to some extent, and in many stances the chemosis is so great that, as Dalrymple remarks, the
conjunctiva
becomes elevated into crimson folds which surround
the cornea and appear to
bury
it beneath them.
examining the eye of a patient suffering from purulent conjunctivitis, we cannot be too careful to ascertain the condition of the cornea beneath these fold3 of conjunctiva, for it is In
here that ulceration frequently commences, and extends round the circumference of the cornea ; the access of nutritive material is thus cut off from the centre of the latter, and in consequence it
sloughs and the eye is destroyed. I cannot insist too strongly on this point. The central part of the cornea may look bright and clear in the morning; on examining it in the evening it is hazy; and next day a slough has formed, the cornea gives way, and the eye is lost. Instances of this kind are by no means unfrequent. Disorganization does not, however, always occur in this way in cases of purulent conjunctivitis. We may find, on examining the eyes, that the cornea is covered with hazy flocculent looking patches, which gradually extend themselves until its surface becomes wholly involved; the ulcerative process advances rapidly at one and the integrity of the corneal tissue or more of these spots, is destroyed, and gives way, and prolapse of the iris occurs. The moment this happens, the intra-ocular pressure being relieved, the remainder of the cornea flattens, and the vitreous humour at the same time forces the lens forward, so that the iris is jammed between the two, and its protruded portion prevented from regaining its position in the anterior chamber. In some cases of suppurative conjunctivitis we find, on examining the eye, the whole of the cornea looking like a piece of moist wash leather,?a most hopeless
condition, indicating
that sloughing of the part has probably progressed
so far as all chance of recovery. Lastly, in a few instances the cornea appears as though it had been stained with a solution of carbonate of lead, being of a pinkish white colour and semi-transparent; these changes seem to on
to
preclude
depend
fatty degenera-
tion of the fibrous elements of the cornea, which lose their tenacity and become unable to resist the intra-ocular pressure; the cornea then giadually gives away and bulges forwards, particularly towards its centre, which may ultimately burst just like au over-distended bladder, and through the rent thus made a large hernia of the iris occurs. These particular classes of cases are seldom marked by any very acute symptoms, the patient suffering little pain in the eye ; the chemosis is seldom a
comparatively
prominent feature of the disease, nor is there much purulent discharge from the eye ; but these gradually advancing, degenerative changes iu the fibrous structure of the cornea indicate
[September 2, 1867:
dangerous state of tilings occurring, as a complicasuppurative conjunctivitis. "When speaking of muco-purulent conjunctivitis, I mentioned that small spots of eccliymosis are generally to be seen in the conjunctiva in the purulent form of the disease ; these hemorrhagic effusions are not only numerous, hut often of considerable size, as -we might expect from the more intense congestion of the vessels which exist in the suppurative form of the disease; but this ecchymosis is a matter of very small importance, as the effused blood becomes rapidly absorbed as soon as the inflammaa
most
tion of
tory action subsides. The nature of the secretion from the
conjunctiva varies 'with
the progress and character of the disease ; at first it is watery, then it contains muco-purulent matter, and lastly it will be found to consist of pus, which is often tinged with blood. In many cases the quantity of pus formed is by no means great, and one must not always expect a stream of purulent fluid to
gush
out from between the
patient's eyelids
the moment we
separate them, although in many instances this is the case. The purulent matter is generated from hyperaction of the matter of the connective tissue and
epithelial cells, activity, owing to the stagnation of blood in the part; rapid but imperfect cell growth occurs, and these cells degenerating before they have had time to be converted into formed material, produce pus, which oozes away from the surface of the congested conjunctiva as above
germinal which
are
thrown into
a
state of intense
described. A tolerably accurate index of the intensity of the changes going on in the conjunctiva is afforded us by the increased temperature of the eyelids, which may be readily measured with the thermometer, and which will bo found to range several degrees above the normal temperature of the skin; in the
muco-purulent and milder forms of conjunctivitis, there is no perceptible increase in the temperature of the lids. In purulent conjunctivitis, as I have before mentioned, suppuration generally commences within forty-eight hours from the beginning of the attack, so that the first stage of the disease is of remarkably short duration, and this is one of the diagnostic symptoms between it and diphtheritic conjunctivitis. In the latter suppuration does not come on until the fibrinous exudation has begun to degenerate and become disintegrated, a period usually exceeding five days, and until this time is accomplished, there is no purulent discharge from the surface of the mucous membrane. There can be 110 doubt as to the contagious nature of the pus in purulent conjunctivitis ; this is the reason why both eyes are usually affected, the matter finding its way from the diseased into the sound eye, unless the are taken to prevent this accident. But it
strictest appears inoculated
precautions
that this pus may, under certain circumstances, if into the eye of a person predisposed to diphtheria, induce the diphtheritic form of conjunctivitis; and M. Wecker states that in other instances it may cause an attack of acute granular conjunctivitis: but these are very exceptional cases, and, as a general rule, pus from the eye of a person suffering from purulent will a like form of disease, if in"
conjunctivitis
propagate
oculated into the eye of another individual. At the commencement of the attack, the
patient will
com-
of the affected eye itching a good deal, as if sand or dust had got into it; but this symptom is of a nature, very transient corresponding to the first stage of the affection, which, as I have before remarked, seldom lasts more than hours. In the
plain
thirty-six stage the chemosis and swelling of the lids are often considerable, and the pain is frequently very acute, but by no it means constantly in proportion to the swelling of the parts; depends to a great extent upon the degree to which the deeper second
structures of the eye are involved, and upon the to of the patient; but in all instances pain in the eye, extending the temple, is a constant symptom of severe purulent conjunctivitis, and one which the is sure to
temperament
patient
bring
prominently
September 2,
AlSTiESTHETIC LEPEOSY.?BY J. N.
1867.]
215
In forming our prognosis, also, we must constantly bear in mind pain usually increases towards bed-time>the fact that purulent conjunctivitis is very apt to relapse. and by no means disappears, as some authors state. When the A patient may apparently be on the high road to recovery, when in comes some on, suppurative stage instances, there is a sudden a return of all the worst symptoms takes place, and his cessation of pain about the tenth day of the disease, but thissuddenly of ultimate improvement become very much impaired. prospects frequently depends upon perforation of the cornea and the eva-Even in apparently trivial cases I have seen constant relapses cuation of the contents of the eyeball; the moment the intraof this kind occurring, which, in spite of my best efforts, have ocular pressure is removed, the patient experiences relief. The terminated in serious damage to the eye. pain of purulent conjunctivitis, however, varies according to the to our
notice.
intensity
of the disease.
The
In cases where the affection is compara-
tively mild, it may be absent to a great extent, the patient simply complaining of a pricking, aching sensation in the eyelids, especially the upper one. In instances of this kind the external inflammatory action has not been sufficiently severe to effect the circulation in the choroid, and consequently there is none of that intense pain in the eye which is a marked feature of the form of the disease.
more severe
general rule, the constitutional disturbances which occur in cases of suppurative conj unctivitis are of a very trivial characAs
a
ter ; there may be some amount of fever present, but it is not a noticeable feature of the disease, as it is in diphtheritic conjunctivitis. The patient complains of restlessness and want of
sleep,
but this is often occasioned
the pain from which he suffers. In severe and
cases
there is
always
by the anxiety
of mind and
marked intolerance of
light;
the lids may be so much swollen that the patient cannot open them, he still prefers being in a dark room, and the moment he is brought towards the light there is a gush of tears from between the lids, and an instantaneous increase of pain in the eye. In less severe cases the patient does not experi-
although
ence any great uneasiness from a short exposure to the light, but always prefers a dark room and the exclusion of as much
possible from his eyes. physiognomy of a person suffering from purulent conjunctivitis, in its second stage, is characteristic of the disease ; the patient's face is usually pale, and his countenance indicates pain and distress; lie is led into your presence by a companion, being unable to see; the eyelids are more or less red and swollen, their palpebral margin being usually of a scarlet colour, and pus is seen oozing from between them; the patient holds a' light
as
In fact the
handkerchief or his hands before his eyes, so as to screen them from the light as much as possible. It does not follow that both affected ; the sound one, however, is usually kept at once induces pain in the diseased organ. Considerable difficulty is often experienced in opening the lids in cases of this kind, for not only are they frequently very much swollen, particularly the upper one, but the individual involuntarily resists our attempts to admit light into eyes are
always
closed: exposure to light
.the eye. Under these circumstances we should not hesitate for a moment to administer cbloi'oform. The patient's sight may depend we make our first examination ; and any upon the care with which on the lids is to be avoided, as deep ulceration or pressure pulling of the cornea may exist, and if it does, the surgeon may unawares put a finishing stroke to the matter by exerting pressure on the the force thus applied causing the ulcer to give
eyeball, irreparable damage is done, which might well be only five minutes were employed in administering chloroform before examining the eyes. On opening the lids, the conjunctiva will be found in the state I have already described?of a uniformly deep crimson colour, the villi much enlarged, and the chemosed mucous membrane overlapping the margin of the cornea; spots of ecehymosis will be noticed, way, and avoided if
and the
mucous
membrane will be covered with a film of pus.
But the condition of the cornea should be our chief care; if it is bright and clear, and ho ulceration going on at its circumference, our prognosis may safely be a favourable one; if, on the other hand, ulcerationhas commenced, our opinion must be very guarded;
begun, we can give the patient reasonable hope of recovery : he may regain some amount of sight in the diseased eye, but at best it will be very imperfect. and if sloughing of the cornea has
no
