October 1,
LECTURES ON DISEASES OE CONJUNCTIVA?BY C. MA CN AMABA.
1867.]
The child's head
ORIGINAL COMMUNICATIONS. DISEASES OF THE TIVA.?No. III.
ON
LECTURES
CONJUNC-
By C.
Surgeon
to
Macnamaka, Calcutta Ophthalmic Hospital.
the
Treatment.?In purulent conjunctivitis our main efforts must be directed towards the preservation of the cornea. If the conjunctivitis were not the primary cause of the ulceration of the cornea, we might very well leave it to itself, but as it is, unless we can reduce the inflammation going on in the mucous mem-
brane, no amount of care and skill on our part can insure the safety of the cornea. In considering the treatment, therefore, of purulent conjunctivitis, I would divide the disease into two classes
: the first to include the milder cases, in which the is unaffected ; the second, the more severe cases, in which ulceration of the cornea has already begun. I must again
cornea
impress on 3-011 the absolute necessity of ascertaining, the exact state of the cornea among children, and in fact among all patients suffering from purulent conjunctivitis ; and to do this, in many instances, it is necessary order that
to
administer chloroform, in
thoroughly examine the part; for the fold of swollen conjunctiva, covering the margin of the cornea, must often be pressed back with the point of the finger, before we we
may
ascertain the condition of the structures beneath it. In the first class of cases, discarding all consideration as to the cause of the disease, (unless in instances arising from the presence of a foreign body in the eye), or whether the patient be an infant or an aged person, but distinctly bearing in can
mind the fact that we are now discussing those cas?s which are complicated with ulceration of the cornea, we should at once order a solution of nitrate of silver (argt. nitrat. 5?, aqua
not
5iii) to be painted over the skin of the eyelids of the affected organ, and a solution of nitrate of silver (three grains to the ounce) may be dropped into the eye every second hour. These twenty-four hours consecutively, repaint the eyelids with the strong solution of nitrate of silver, and to continue the lotion until the congestion of the conjunctiva has subsided, and In the purulent discharge become thinner, and less profuse the majority of cases, it will probably be unnecessary to apply drops
should be continued for
and it will then
probably
be advisable to
the solution of nitrate of silver to the lids more than twice, but the instillation of the drops should be continued for a week or ten days, when the active symptoms of the disease will almost invariably have disappeared, and a solution of two grains of of zinc to an ounce of water may be substituted for the
sulphate
nitrate of silver lotion. It is seldom necessary, however, to use the nitrate of silver drops every second hour, as above directed, for more than two or three days ; after that we may generally order it to be dropped into the patient's eve every six hours, and In cases of this kind the patient docs afterwards twice a
day.
pain in the eye?and the poppy head fomentation will probably relieve any that does exist. The state of the bowels should be attended to, and, as a general rule, a generous dietary enforced. Quinine, and a moderate not suffer from
amount of
much
stimulants,
are more
tics j but the state of the in this matter.
pulse
often called for than can
alone be
antiphlogistrusted as our guide
difficulty with which we have to contend in treating the purulent conjunctivitis of infants and young children, arises from the fact that it is almost impossible to prevent their resisting our attempts to drop the solution of nitrate of The
silver into their eyes. I strongly deprecate the use of a syringe under these circumstances ;?the instrument not only frightens the child, but, if its point is inserted beneath the lids, it is likely to irritate the
part,
and do an incalculable amount of mischief.
drawn
apart,
237
must bo
firmly sccured, and the lids gently having been dropped into the eye, allowed to close. This proceeding should be four times, and the eyelids then bathed with
and the lotion
the lid may be
repeated three or tepid water, and
the child alloAved
to
rest for two
or
three
hours, when the lotion will have to be used again, in precisely the same way ; the
application being
continued
night
and
day,
until the purulent discharge almost ceases. In by far the majority of cases, if this plan be strictly followed out, a very considerable improvement will be noticcd in the state of the eyes. Within forty-eight hours the little patient will begin to open them, and can bear exposure to the light; the swelling of the lids and congestion of the conjunctiva begin to diminish, and we may then substitute a two-grain solution of sulphate of zinc for the nitrate of silver, the lotion being used three times a day. Bear in mind the fact, that a relapse is just as likely to occur in this as in any other form of the disease, and do not entirely discontinue the use of the sulphate of zinc lotion until the child has perfectly recovered ; and should a relapse occur, resume at once the nitrate of silver solution, which is almost a specific in cases of the kind. child's
I now proceed to consider the treatment of the second class of cases,?that is, those in which the cornea has become implicated, either during, or prior to, the commencement of our attendance on the patient. This subject is discussed at considerable length by M. Weckcr, who to confine the treatment which I
would, however, appear about to describe, to cases in which the cornca has been implicated, but employ it, as a general rule, in all severe instances of purulent conjunctivitis. It consists in applying caustic to the surface of the palpebral conjunctiva aud semilunar folds : there is no necessity for touching the orbital mucous membrane with the nitrate of silver. With regard to the caustic to be used in cases of this kind, solid nitrate of silver should never be employed, but a pencil, composed of equal parts of nitrate of silver and nitrate of potash, or of one of nitrate of silver and two of nitrate of potash. Should you not happen to Lave a pencil of this kind at hand, it is easy enough to prepare one by fusing the proper proportions of the salts together, aud allowing the fluid mixture to run into a fine glass tube. It solidifies immediately, and is then fit for use. The reason why we employ a dilute caustic pencil in these cases is, that our object is simply to destroy the epithelial layers of the conjunctiva, and not to cause sloughing of its connective tissue, which pure nitrate of silver necessarily would do, and thus lead to the formation of a conjunctival cicatrix, and very probably contraction of the mucous membrane. The rough surface thus formed would be likely to keep up irritation in the part, and by constantly rubbing against the cornea, might ultimately induce opacity in that membrane, which is hardly likely, hownot
ain
ever, to escape immediate destruction if solid nitrate of silver is applied to its surface. The patient must be placed under the influence of chloroform, and laid on his back before a window, so that the eye may be fully illuminated ; the lower lid of the inflamed eye is then to be carefully and fully everted, the conjunctiva being wiped dry with a bit of linen rag ; and the caustic pencil is to be
applied over the entire surface of its palpebral mucous membrane, particularly over its tarso-orbital fold. The instant the caustic has been applied, a white film forms over the part, and as soon as this appears an assistant should drop a little cold water over the everted lid, so as to decompose and wash away lid any excess of nitrate of silver that may be present. The may then be returned to its normal position, and the upper eye treated in precisely the same way ; but when the latter is much swollen we shall experience considerable difficulty in smearing It is over the upper tarso-orbital fold of the conjunctiva. that the whole of this portion
absolutely necessary, however, mucous membrane, as well
of the
as
the
semilunar
folds,
THE INDIAN MEDICAL GAZETTE.
238
should be smeared over with the caustic pencil, and it is for this reason that I strongly advocate the employment of chloroform in cases of this kind. We have not only time thus afforda vast amount of ed us to work but we save the
in,
patient
pain ; a matter of the greatest importance in cases of the kind, because, in the majority of instances of severe purulent conjunctivitis, the patient is already in an anxious, nervous state, and the torture to which we expose him by dragging open his eyelids, and applying caustic to them, is so great that the ner-
exhaustion thus induced is in itself almost sufficient to counterbalance the beneficial effects of the cauterization. A pencil of nitrate of silver, applied in the way above described to the surface of the conjunctiva, at once destroys its epithelial matter of which the purulent disfrom the vous
layers, charge
is
germinal produced, so that,
until the
epithelium
has reformed,
the discharge from the inflamed eye will diminish very per-
ceptibly. The length
of time necessary for
completing these changes circumstances, but, as a general rule, new layers of cells will have replaced those we have destroyed in about twenty-four hours, and with their growth the purulent discharge from the eye will re-commence. This will be the sign for the necessity of a re-application of the caustic; in fact, as soon as the pus re-appears after our first application, be in twelve, twenty-four, or thirty-six hours,so soon whothomust we re-apply the caustic, in precisely the same way as I have just described : but a pencil composed of one part of nitrate of silver, and three of nitrate of potash, will, as a general rule, be sufficiently strong after the first application. It may be necessary to continue this treatment for five or six days before the excessive action going on in the inflamed conjunctiva will have been overcome, and the purulent discharge cease; but, as the pus a general rule, after each application of the caustic, will take a longer time to reform, and will ultimately disappear altogether. M. Wecker's explanation of the action of the caustic is, that the hyper-action going on in the part is caused by the sluggish circulation of the blood through the congested varies under
different
vessels, and the caustic causes their dilated walls to contract, and necessarily accelerates the circulation of the blood through them. To keep up this action of the- caustic, he advises the application of cold compresses to the eyelids immediately after the cauterization. The compresses should, if retained without intermission, for they not only
possible,
be
prevent the
vessels from again dilating, but they wash away the abnormal secretion, and thus keep the eye perfectly clean,?a most important point to attend to in cases of the kind. The congestion being thus temporarily overcome, a more rapid circulation of blood takes place through the vessels, the nutrition of the parts is re-established, and the vessels are then more likely to remain of their normal calibres, the healthy blood acting as a direct stimulant on their contractile tissue. There is no necessity for syringing out the eye in order that we may keep it clean : it is quite sufficient, every time the cold compress is changed, to evert the lids slightly, and allow a little cold water to trickle into the eye. M. TVecker insists upon the importance of attending to the rules above laid down with
regard to the use of nitrate of silver. It should never be employed until suppuration has commenced, otherwise it may do positive harm. Having applied it, wait before using it again, till the whole of the deposit which it has formed on the surface of the conjunctiva has disappeared, and suppuration has been re-established ; otherwise we shall apply the caustic to the denuded basement membrane, and are likely to damage this delicate structure and the connective tissue beneath it, which will assuredly lead to the formation of cicatrices, and a permanently rough state of the conjunctiva. As I before observed, our only guide as to the frequency with which the cauterization should be employed must be on the condition of
the
mucous
membrane j as
soon
as
pus
reforms
we
may
be sure
[October 1,
epithelium has been reproduced, and safety use the diluted pencil of nitrate of
that tlie
therefore with
1867.
may silver fear of our
again. If these rules are attended to, there is no cauterizing an eye affected with diphtheritic conjunctivitis in its early stages, or of any other of those mishaps taking place, a combination of which has thrown even this sovereign remedy into disrepute with some surgeons. With regard to the management of the orbital conjunctiva, which has been left untouched by the nitrate of silver, but which is swollen and probably overlapping the cornea, it is advisable, while the patient is still under the influence of chloroform, to cut four or five incisions through the mucous membrane, radiating from its chemosed portion, which overlaps the cornea, outwards I would make at least four such deep as far as the eyelids. incisions down to the sclerotic : they should be made with a cataract knife, or some such sharp-edged instrument, so as to prevent the tissues from being lacerated. There can, I think, be no doubt that by cutting through the swollen conjunctiva in this way, we relieve the pressure which the chemosis exerts upon the sclerotic layer of vessels, and thus give the cornea a chance of receiving sufficient nourishment to keep it alive ; and the
only thing advanced against these deep incisions is, that in healing four cicatrices must be left in the conjunctiva. I do not, however, conceive this to be a valid objection against this treatment, when placed in opposition to the fact that we may, by this means, do much towards preserving the integrity of the cornea, which is probably threatened with immediate destruction. I am no advocate, however, for repeated and numerous incisions through the chemosed conjunctiva; the operation should be performed as I have described, and as it is our objcct to relieve the congested vessels, we must encourage the bleeding from the wounds which we have made by keeping the lids open, and bathing the parts with warm water for ten minutes or so. If we allow the lids to close immediately after the conjunctiva has been incised, clots of blood form beneath them, and the pressure which these exert on the vessels stops the hemordefeats the principal object which we had in view
rhage, and in making
the incisions. These clots must therefore be prevented from forming for the space of about ten minutes ; the lids may then be closed, and the cold water compress applied. It will seldom be advisable to repeat these deep incisions into the mucous membrane, but each time the patient is put under the influence of chloroform, and after the palpebral conjunctiva
has been smeared
over with the caustic pencil, we may perhaps scarify the chemosed orbital mucous membrane, making superficial incisions in all directions, and then endeavour to excite haemorrhage from the divided vessels by the applica-
tion of warm fomentations.
With regard
to
the state of the cornea, our chloroform, we can make a
under the influence of
patient being thorough extoo carefully
amination of the part, and its condition cannot be considered ; for upon this inspection, and upon the treatment we pursue, our patient's sight, in a great many cases, depends. I am led to make this remark because it is possible that some of you might think it a needless trouble to administer chloroform every day to a patient under these circumstances ; but I am convinced that you cannot do all that is necessary, in any urgent case of this kind, unless the patient is under the influence of chloroform.
danger which we have to fear, if perforation of the cornea place, is that opacity will ensue, or a staphyloma of the iris occur, the elastic structures behind the iris pushing it through the opening in the cornea, (and, when in this position, pressing it through the corneal wound, so that it cannot possibly return to its normal position in the anterior chamber. In cases where a portion of the cornea is so far destroyed by ulceration that its posterior elastic lamina alone remains intact, it may happen at any moment that this delicate structure will be burst open by the distending force behind it, unless we relieve the intra-ocular pressure by puncturing the cornea with a broad needle, and The
takes
October 1,
NOTES ON ABYSSINIA.
1867.]
BY F. T.
239
by all means apply eight or ten leeches to either temple; allowing the aqueous humour to escape. This little operation of the depletion may do him good, and can do him no harm. paracentesis of the cornea, under the circumstances, is often But, on the other hand, no more dangerous rule can be laid attended with the happiest results : it not only prevents the formdown than that, because a person is suffering from purulent ation of a staphyloma, but, by diminishing the intra-ocular presto be applied in an indisleeches are conjunctivitis, sure, it relieves the tension of the eyeball, and hence also relieves criminate manner. My own experience, especially among an from to neurosis which suffers the ciliary the patient often me lead would almost the natives of this country, intense degree. The puncture through the cornea should be made to reverse this rule, but in practice it will be found near its junction with the sclerotic, and the point of the needle impossible to lay down regulations on the subject. It would must only just be allowed to enter the anterior chamber, otherbe as absurd to deplete a weak, anxious, and anaemic patient wise the lens is almost sure to be injured ; but beyond this caution, labouring under purulent conjunctivitis, as it would be to which is not peculiar to these cases, no particular rules are necesabstain from the practice in a full-blooded and plethoric inthe method of of sary as to the puncturing the cornea in cases dividual : your own common sense must guide you in the kind. I believe I am tolerably safe, however, in saying that you matter. So far, therefore, from leeches being generally useful are far less likely to err on the side of non-interference than you in purulent conjunctivitis, I am inclined to think that stimuIt are to open the cornea too often under these circumstances. lants are mostly required; rum mixture with quinine and is by no means always sufficient to perform paracentesis once morphia being frequently called for, together with a generous in the treatment of a case of this kind; the puncture made dietary. The state of the patient's pulso will guide us as to in the cornea heals within twenty-four hours, and the aqueous the extent to which this practice should be carried : in many humour rapidly reforms, so that it will very probably be necescases the infusion of bark and ammonia will prove of the
sary to open the cornea each time that chloroform is administered to the patient. In the majority of the class of cases we are now considering, you will, therefore, during the time that your patient is under the influence of
chloroform, have, ls?,
to
make a
tho-
examination of the eye, and should you find the cornea ulcerated you must, 2nd, apply a pencil of dilute caustic to the palpebral mucous membrane and semilunar folds ; 3rd, incise or
rough
the orbital conjunctiva ; and 4th, puncture the cornea, if you find that one or more deep ulcers exist, but have not yet eaten through the cornea. If the eyelids are much swollen, it is of the greatest importance to paint the skin over them with a
scarify
saturated solution of nitrate of silver.
Cold compresses may
applied to the eye. We have still, however, one important adjunct to our treatment, and that is the instillation of an eight-grain solution of atropine (to an ounce of water) into the eye ; these drops may be applied every six hours. The object of this treatment is to paralyze the intra-ocular nerves, together with those supplying the cornea, and by relieving the tension of the ciliary muscle and cornea, to lessen the chances of the latter giving way, if partially destroyed by ulceration; the iris also being curled up when under the influence of atropine, its vessels are partially empty, and less aqueous humour will then be
therefore be secreted, so that the intra-ocular pressure will be reduced ; moreover, if the cornea gives way, the iris is less likely to be forced through the opening, than if it be allowed to remain in its normal position in the anterior chamber. The above may be considered as the special and necessary cases of purulent treatment for conjunctivitis, complicated with lesion of the cornea. We may now consider one or two bearing on the general treatment of cases of the kind,
points
complicated with ulceration or not; and probably one of the most important circumstances to attend to is the protection of the sound eye, if only one is affected; as the purulent whether
secretion from the diseased eye is very apt to get into the If therefore we can sound one, and induce a similar disease. protect the sound eye by a pad of cotton wool and a bandage, The we shall be doing the patient most valuable service.
patient himself will readily understand the advantage of this proceeding, and submit to the apparent discomfort of having his sound eye closed, so as to protect it from purulent infection. The pain from which many patients suffer in this disease may be relieved by the application of the extract of belladonna over the forehead, and the administration of morphia. We shall often have to use the latter drug in full doses at bed-time for it is then that the pain generally increases and prevents the patient from sleeping. With regard to the application of leeches, I would simply say that if you meet with a case of purulent conjunctivitis in a full-blooded plethoric individual,
greatest benefit : should it seem to increase the pain in the eye, it may be discontinued, but if it has no such effect, it is more than probable that the patient will improve greatly under its use. I have before remarked that, as a general rule, purulent conjunctivitis is not accompanied by any marked constitutional symptoms. Should the patient be feverish, diaphoretics will be useful, and, under any circumstance, we must be careful to
regulate But
the action of the bowels with mild laxatives if necessary.
purulent conjunctivitis has nothing to do with a faulty state of the liver or stomach, do not launch out at random with purgatives or drugs of this description in the hope of improving the state of the secretions. These drugs are useful enough when called for, but certainly, as a general rule, are actually harmful in the class of cases now under our consideration. With regard to the use cf morcury in purulent conjunctivitis, my experience does nut coincide with that of M. Wecker as to the advantage to be derived from calomel in the treatment of this disease ; and without entering upon a discussion as to the influence which mercury may possess in cutting short the process of inflammation, I am bound to observe that in the numerous cases of suppurative conjunctivitis which I have treated, I have never found any advantage whatever from the administration of as
calomel. On the other hand, in very many instances I have had occasion to repent having given it. Nevertheless it is my duty to inform 3'ou that so high an authority as M. Wecker strongly advocates the rapid salivation of patients suffering from this disease. He administers two grains of calomel every two hours, and in addition orders mercurial ointinont to be rubbed in over the
patient's forehead, for fifteen or twenty minutes, twice a day ; in fact, his object is to bring the patient as rapidly as possible under the influence of mercury.
With all due respect for the
opinion of this able Surgeon, I think you will find that his practice in this respect will not succeed, either among Europeans or Natives, in this country. Pure air, the best of all tonics, must, if possible, be obtained ; and all unnecessary confinement to bed, or to one room, be avoided.
LECTURES ON DISEASES OE CONJUNCTIVA?BY C. MA CN AMABA.
1867.]
The child's head
ORIGINAL COMMUNICATIONS. DISEASES OF THE TIVA.?No. III.
ON
LECTURES
CONJUNC-
By C.
Surgeon
to
Macnamaka, Calcutta Ophthalmic Hospital.
the
Treatment.?In purulent conjunctivitis our main efforts must be directed towards the preservation of the cornea. If the conjunctivitis were not the primary cause of the ulceration of the cornea, we might very well leave it to itself, but as it is, unless we can reduce the inflammation going on in the mucous mem-
brane, no amount of care and skill on our part can insure the safety of the cornea. In considering the treatment, therefore, of purulent conjunctivitis, I would divide the disease into two classes
: the first to include the milder cases, in which the is unaffected ; the second, the more severe cases, in which ulceration of the cornea has already begun. I must again
cornea
impress on 3-011 the absolute necessity of ascertaining, the exact state of the cornea among children, and in fact among all patients suffering from purulent conjunctivitis ; and to do this, in many instances, it is necessary order that
to
administer chloroform, in
thoroughly examine the part; for the fold of swollen conjunctiva, covering the margin of the cornea, must often be pressed back with the point of the finger, before we we
may
ascertain the condition of the structures beneath it. In the first class of cases, discarding all consideration as to the cause of the disease, (unless in instances arising from the presence of a foreign body in the eye), or whether the patient be an infant or an aged person, but distinctly bearing in can
mind the fact that we are now discussing those cas?s which are complicated with ulceration of the cornea, we should at once order a solution of nitrate of silver (argt. nitrat. 5?, aqua
not
5iii) to be painted over the skin of the eyelids of the affected organ, and a solution of nitrate of silver (three grains to the ounce) may be dropped into the eye every second hour. These twenty-four hours consecutively, repaint the eyelids with the strong solution of nitrate of silver, and to continue the lotion until the congestion of the conjunctiva has subsided, and In the purulent discharge become thinner, and less profuse the majority of cases, it will probably be unnecessary to apply drops
should be continued for
and it will then
probably
be advisable to
the solution of nitrate of silver to the lids more than twice, but the instillation of the drops should be continued for a week or ten days, when the active symptoms of the disease will almost invariably have disappeared, and a solution of two grains of of zinc to an ounce of water may be substituted for the
sulphate
nitrate of silver lotion. It is seldom necessary, however, to use the nitrate of silver drops every second hour, as above directed, for more than two or three days ; after that we may generally order it to be dropped into the patient's eve every six hours, and In cases of this kind the patient docs afterwards twice a
day.
pain in the eye?and the poppy head fomentation will probably relieve any that does exist. The state of the bowels should be attended to, and, as a general rule, a generous dietary enforced. Quinine, and a moderate not suffer from
amount of
much
stimulants,
are more
tics j but the state of the in this matter.
pulse
often called for than can
alone be
antiphlogistrusted as our guide
difficulty with which we have to contend in treating the purulent conjunctivitis of infants and young children, arises from the fact that it is almost impossible to prevent their resisting our attempts to drop the solution of nitrate of The
silver into their eyes. I strongly deprecate the use of a syringe under these circumstances ;?the instrument not only frightens the child, but, if its point is inserted beneath the lids, it is likely to irritate the
part,
and do an incalculable amount of mischief.
drawn
apart,
237
must bo
firmly sccured, and the lids gently having been dropped into the eye, allowed to close. This proceeding should be four times, and the eyelids then bathed with
and the lotion
the lid may be
repeated three or tepid water, and
the child alloAved
to
rest for two
or
three
hours, when the lotion will have to be used again, in precisely the same way ; the
application being
continued
night
and
day,
until the purulent discharge almost ceases. In by far the majority of cases, if this plan be strictly followed out, a very considerable improvement will be noticcd in the state of the eyes. Within forty-eight hours the little patient will begin to open them, and can bear exposure to the light; the swelling of the lids and congestion of the conjunctiva begin to diminish, and we may then substitute a two-grain solution of sulphate of zinc for the nitrate of silver, the lotion being used three times a day. Bear in mind the fact, that a relapse is just as likely to occur in this as in any other form of the disease, and do not entirely discontinue the use of the sulphate of zinc lotion until the child has perfectly recovered ; and should a relapse occur, resume at once the nitrate of silver solution, which is almost a specific in cases of the kind. child's
I now proceed to consider the treatment of the second class of cases,?that is, those in which the cornea has become implicated, either during, or prior to, the commencement of our attendance on the patient. This subject is discussed at considerable length by M. Weckcr, who to confine the treatment which I
would, however, appear about to describe, to cases in which the cornca has been implicated, but employ it, as a general rule, in all severe instances of purulent conjunctivitis. It consists in applying caustic to the surface of the palpebral conjunctiva aud semilunar folds : there is no necessity for touching the orbital mucous membrane with the nitrate of silver. With regard to the caustic to be used in cases of this kind, solid nitrate of silver should never be employed, but a pencil, composed of equal parts of nitrate of silver and nitrate of potash, or of one of nitrate of silver and two of nitrate of potash. Should you not happen to Lave a pencil of this kind at hand, it is easy enough to prepare one by fusing the proper proportions of the salts together, aud allowing the fluid mixture to run into a fine glass tube. It solidifies immediately, and is then fit for use. The reason why we employ a dilute caustic pencil in these cases is, that our object is simply to destroy the epithelial layers of the conjunctiva, and not to cause sloughing of its connective tissue, which pure nitrate of silver necessarily would do, and thus lead to the formation of a conjunctival cicatrix, and very probably contraction of the mucous membrane. The rough surface thus formed would be likely to keep up irritation in the part, and by constantly rubbing against the cornea, might ultimately induce opacity in that membrane, which is hardly likely, hownot
ain
ever, to escape immediate destruction if solid nitrate of silver is applied to its surface. The patient must be placed under the influence of chloroform, and laid on his back before a window, so that the eye may be fully illuminated ; the lower lid of the inflamed eye is then to be carefully and fully everted, the conjunctiva being wiped dry with a bit of linen rag ; and the caustic pencil is to be
applied over the entire surface of its palpebral mucous membrane, particularly over its tarso-orbital fold. The instant the caustic has been applied, a white film forms over the part, and as soon as this appears an assistant should drop a little cold water over the everted lid, so as to decompose and wash away lid any excess of nitrate of silver that may be present. The may then be returned to its normal position, and the upper eye treated in precisely the same way ; but when the latter is much swollen we shall experience considerable difficulty in smearing It is over the upper tarso-orbital fold of the conjunctiva. that the whole of this portion
absolutely necessary, however, mucous membrane, as well
of the
as
the
semilunar
folds,
THE INDIAN MEDICAL GAZETTE.
238
should be smeared over with the caustic pencil, and it is for this reason that I strongly advocate the employment of chloroform in cases of this kind. We have not only time thus afforda vast amount of ed us to work but we save the
in,
patient
pain ; a matter of the greatest importance in cases of the kind, because, in the majority of instances of severe purulent conjunctivitis, the patient is already in an anxious, nervous state, and the torture to which we expose him by dragging open his eyelids, and applying caustic to them, is so great that the ner-
exhaustion thus induced is in itself almost sufficient to counterbalance the beneficial effects of the cauterization. A pencil of nitrate of silver, applied in the way above described to the surface of the conjunctiva, at once destroys its epithelial matter of which the purulent disfrom the vous
layers, charge
is
germinal produced, so that,
until the
epithelium
has reformed,
the discharge from the inflamed eye will diminish very per-
ceptibly. The length
of time necessary for
completing these changes circumstances, but, as a general rule, new layers of cells will have replaced those we have destroyed in about twenty-four hours, and with their growth the purulent discharge from the eye will re-commence. This will be the sign for the necessity of a re-application of the caustic; in fact, as soon as the pus re-appears after our first application, be in twelve, twenty-four, or thirty-six hours,so soon whothomust we re-apply the caustic, in precisely the same way as I have just described : but a pencil composed of one part of nitrate of silver, and three of nitrate of potash, will, as a general rule, be sufficiently strong after the first application. It may be necessary to continue this treatment for five or six days before the excessive action going on in the inflamed conjunctiva will have been overcome, and the purulent discharge cease; but, as the pus a general rule, after each application of the caustic, will take a longer time to reform, and will ultimately disappear altogether. M. Wecker's explanation of the action of the caustic is, that the hyper-action going on in the part is caused by the sluggish circulation of the blood through the congested varies under
different
vessels, and the caustic causes their dilated walls to contract, and necessarily accelerates the circulation of the blood through them. To keep up this action of the- caustic, he advises the application of cold compresses to the eyelids immediately after the cauterization. The compresses should, if retained without intermission, for they not only
possible,
be
prevent the
vessels from again dilating, but they wash away the abnormal secretion, and thus keep the eye perfectly clean,?a most important point to attend to in cases of the kind. The congestion being thus temporarily overcome, a more rapid circulation of blood takes place through the vessels, the nutrition of the parts is re-established, and the vessels are then more likely to remain of their normal calibres, the healthy blood acting as a direct stimulant on their contractile tissue. There is no necessity for syringing out the eye in order that we may keep it clean : it is quite sufficient, every time the cold compress is changed, to evert the lids slightly, and allow a little cold water to trickle into the eye. M. TVecker insists upon the importance of attending to the rules above laid down with
regard to the use of nitrate of silver. It should never be employed until suppuration has commenced, otherwise it may do positive harm. Having applied it, wait before using it again, till the whole of the deposit which it has formed on the surface of the conjunctiva has disappeared, and suppuration has been re-established ; otherwise we shall apply the caustic to the denuded basement membrane, and are likely to damage this delicate structure and the connective tissue beneath it, which will assuredly lead to the formation of cicatrices, and a permanently rough state of the conjunctiva. As I before observed, our only guide as to the frequency with which the cauterization should be employed must be on the condition of
the
mucous
membrane j as
soon
as
pus
reforms
we
may
be sure
[October 1,
epithelium has been reproduced, and safety use the diluted pencil of nitrate of
that tlie
therefore with
1867.
may silver fear of our
again. If these rules are attended to, there is no cauterizing an eye affected with diphtheritic conjunctivitis in its early stages, or of any other of those mishaps taking place, a combination of which has thrown even this sovereign remedy into disrepute with some surgeons. With regard to the management of the orbital conjunctiva, which has been left untouched by the nitrate of silver, but which is swollen and probably overlapping the cornea, it is advisable, while the patient is still under the influence of chloroform, to cut four or five incisions through the mucous membrane, radiating from its chemosed portion, which overlaps the cornea, outwards I would make at least four such deep as far as the eyelids. incisions down to the sclerotic : they should be made with a cataract knife, or some such sharp-edged instrument, so as to prevent the tissues from being lacerated. There can, I think, be no doubt that by cutting through the swollen conjunctiva in this way, we relieve the pressure which the chemosis exerts upon the sclerotic layer of vessels, and thus give the cornea a chance of receiving sufficient nourishment to keep it alive ; and the
only thing advanced against these deep incisions is, that in healing four cicatrices must be left in the conjunctiva. I do not, however, conceive this to be a valid objection against this treatment, when placed in opposition to the fact that we may, by this means, do much towards preserving the integrity of the cornea, which is probably threatened with immediate destruction. I am no advocate, however, for repeated and numerous incisions through the chemosed conjunctiva; the operation should be performed as I have described, and as it is our objcct to relieve the congested vessels, we must encourage the bleeding from the wounds which we have made by keeping the lids open, and bathing the parts with warm water for ten minutes or so. If we allow the lids to close immediately after the conjunctiva has been incised, clots of blood form beneath them, and the pressure which these exert on the vessels stops the hemordefeats the principal object which we had in view
rhage, and in making
the incisions. These clots must therefore be prevented from forming for the space of about ten minutes ; the lids may then be closed, and the cold water compress applied. It will seldom be advisable to repeat these deep incisions into the mucous membrane, but each time the patient is put under the influence of chloroform, and after the palpebral conjunctiva
has been smeared
over with the caustic pencil, we may perhaps scarify the chemosed orbital mucous membrane, making superficial incisions in all directions, and then endeavour to excite haemorrhage from the divided vessels by the applica-
tion of warm fomentations.
With regard
to
the state of the cornea, our chloroform, we can make a
under the influence of
patient being thorough extoo carefully
amination of the part, and its condition cannot be considered ; for upon this inspection, and upon the treatment we pursue, our patient's sight, in a great many cases, depends. I am led to make this remark because it is possible that some of you might think it a needless trouble to administer chloroform every day to a patient under these circumstances ; but I am convinced that you cannot do all that is necessary, in any urgent case of this kind, unless the patient is under the influence of chloroform.
danger which we have to fear, if perforation of the cornea place, is that opacity will ensue, or a staphyloma of the iris occur, the elastic structures behind the iris pushing it through the opening in the cornea, (and, when in this position, pressing it through the corneal wound, so that it cannot possibly return to its normal position in the anterior chamber. In cases where a portion of the cornea is so far destroyed by ulceration that its posterior elastic lamina alone remains intact, it may happen at any moment that this delicate structure will be burst open by the distending force behind it, unless we relieve the intra-ocular pressure by puncturing the cornea with a broad needle, and The
takes
October 1,
NOTES ON ABYSSINIA.
1867.]
BY F. T.
239
by all means apply eight or ten leeches to either temple; allowing the aqueous humour to escape. This little operation of the depletion may do him good, and can do him no harm. paracentesis of the cornea, under the circumstances, is often But, on the other hand, no more dangerous rule can be laid attended with the happiest results : it not only prevents the formdown than that, because a person is suffering from purulent ation of a staphyloma, but, by diminishing the intra-ocular presto be applied in an indisleeches are conjunctivitis, sure, it relieves the tension of the eyeball, and hence also relieves criminate manner. My own experience, especially among an from to neurosis which suffers the ciliary the patient often me lead would almost the natives of this country, intense degree. The puncture through the cornea should be made to reverse this rule, but in practice it will be found near its junction with the sclerotic, and the point of the needle impossible to lay down regulations on the subject. It would must only just be allowed to enter the anterior chamber, otherbe as absurd to deplete a weak, anxious, and anaemic patient wise the lens is almost sure to be injured ; but beyond this caution, labouring under purulent conjunctivitis, as it would be to which is not peculiar to these cases, no particular rules are necesabstain from the practice in a full-blooded and plethoric inthe method of of sary as to the puncturing the cornea in cases dividual : your own common sense must guide you in the kind. I believe I am tolerably safe, however, in saying that you matter. So far, therefore, from leeches being generally useful are far less likely to err on the side of non-interference than you in purulent conjunctivitis, I am inclined to think that stimuIt are to open the cornea too often under these circumstances. lants are mostly required; rum mixture with quinine and is by no means always sufficient to perform paracentesis once morphia being frequently called for, together with a generous in the treatment of a case of this kind; the puncture made dietary. The state of the patient's pulso will guide us as to in the cornea heals within twenty-four hours, and the aqueous the extent to which this practice should be carried : in many humour rapidly reforms, so that it will very probably be necescases the infusion of bark and ammonia will prove of the
sary to open the cornea each time that chloroform is administered to the patient. In the majority of the class of cases we are now considering, you will, therefore, during the time that your patient is under the influence of
chloroform, have, ls?,
to
make a
tho-
examination of the eye, and should you find the cornea ulcerated you must, 2nd, apply a pencil of dilute caustic to the palpebral mucous membrane and semilunar folds ; 3rd, incise or
rough
the orbital conjunctiva ; and 4th, puncture the cornea, if you find that one or more deep ulcers exist, but have not yet eaten through the cornea. If the eyelids are much swollen, it is of the greatest importance to paint the skin over them with a
scarify
saturated solution of nitrate of silver.
Cold compresses may
applied to the eye. We have still, however, one important adjunct to our treatment, and that is the instillation of an eight-grain solution of atropine (to an ounce of water) into the eye ; these drops may be applied every six hours. The object of this treatment is to paralyze the intra-ocular nerves, together with those supplying the cornea, and by relieving the tension of the ciliary muscle and cornea, to lessen the chances of the latter giving way, if partially destroyed by ulceration; the iris also being curled up when under the influence of atropine, its vessels are partially empty, and less aqueous humour will then be
therefore be secreted, so that the intra-ocular pressure will be reduced ; moreover, if the cornea gives way, the iris is less likely to be forced through the opening, than if it be allowed to remain in its normal position in the anterior chamber. The above may be considered as the special and necessary cases of purulent treatment for conjunctivitis, complicated with lesion of the cornea. We may now consider one or two bearing on the general treatment of cases of the kind,
points
complicated with ulceration or not; and probably one of the most important circumstances to attend to is the protection of the sound eye, if only one is affected; as the purulent whether
secretion from the diseased eye is very apt to get into the If therefore we can sound one, and induce a similar disease. protect the sound eye by a pad of cotton wool and a bandage, The we shall be doing the patient most valuable service.
patient himself will readily understand the advantage of this proceeding, and submit to the apparent discomfort of having his sound eye closed, so as to protect it from purulent infection. The pain from which many patients suffer in this disease may be relieved by the application of the extract of belladonna over the forehead, and the administration of morphia. We shall often have to use the latter drug in full doses at bed-time for it is then that the pain generally increases and prevents the patient from sleeping. With regard to the application of leeches, I would simply say that if you meet with a case of purulent conjunctivitis in a full-blooded plethoric individual,
greatest benefit : should it seem to increase the pain in the eye, it may be discontinued, but if it has no such effect, it is more than probable that the patient will improve greatly under its use. I have before remarked that, as a general rule, purulent conjunctivitis is not accompanied by any marked constitutional symptoms. Should the patient be feverish, diaphoretics will be useful, and, under any circumstance, we must be careful to
regulate But
the action of the bowels with mild laxatives if necessary.
purulent conjunctivitis has nothing to do with a faulty state of the liver or stomach, do not launch out at random with purgatives or drugs of this description in the hope of improving the state of the secretions. These drugs are useful enough when called for, but certainly, as a general rule, are actually harmful in the class of cases now under our consideration. With regard to the use cf morcury in purulent conjunctivitis, my experience does nut coincide with that of M. Wecker as to the advantage to be derived from calomel in the treatment of this disease ; and without entering upon a discussion as to the influence which mercury may possess in cutting short the process of inflammation, I am bound to observe that in the numerous cases of suppurative conjunctivitis which I have treated, I have never found any advantage whatever from the administration of as
calomel. On the other hand, in very many instances I have had occasion to repent having given it. Nevertheless it is my duty to inform 3'ou that so high an authority as M. Wecker strongly advocates the rapid salivation of patients suffering from this disease. He administers two grains of calomel every two hours, and in addition orders mercurial ointinont to be rubbed in over the
patient's forehead, for fifteen or twenty minutes, twice a day ; in fact, his object is to bring the patient as rapidly as possible under the influence of mercury.
With all due respect for the
opinion of this able Surgeon, I think you will find that his practice in this respect will not succeed, either among Europeans or Natives, in this country. Pure air, the best of all tonics, must, if possible, be obtained ; and all unnecessary confinement to bed, or to one room, be avoided.
