November 1,

18G7.]

LECTURES ON DISEASES OE CONJUNCTIVA.? C. MACNAMAEA

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in the mucous membrane

ORIGINAL COMMUNICATIONS. LECTURES ON DISEASES OF THE CONJUNCTIVA.?No. IV. By C.

Surgeon

to

Macnamaka, Ophthalmic Hospital.

the Calcutta

Biphtlicritic Conjunctivitis, is at present a comparatively rare form of disease in India, and I must, therefore, depend very much upon the description and experience of others for an account of its symptoms and treatment. The subject demands special consideration, because, although fortunately uncomamongst us at present, it is impossible to predict when it may appear in an endemic form, and, under any circumstances, it is necessary to at we should he acquainted with all that is known on the subject. In some parts of Germany, or rather of Belgium, the havoc -which diphtheritic conjunctivitis commits among the lower classes is truly fearful, for when once a patient has been attacked, with it, his chances of recovery are even less promising than in cases of purulent conjunctivitis; the truth being that the affection of the conjunctiva is simply a local manifestation of a more general form of disease. Unless diphtheria be endemic, "we are hardly likely to meet with instances of this kind of conjunctivitis, but, on the other hand, if a person be susceptible to the influences which engender diphtheria, any cause inducing local irritation in the conjunctiva may give rise to the disease; in this way the discharge from the eye of a patient suffering from purulent conjunctivitis may he said to produce the diphtheritic form of the disease. our

mon

If we tear in mind the characteristic features of diphthcria> shall readily comprehend the nature of the train of sympThe toms likely to to induced when it attacks the conjunctiva. we

tendency manifests itself here, as in the mucous membrane of the fauces and other parts of the body, for a fibrinous exudation to occur, not only on the surface, but into the connective same

tissue of the mucous membrane; the eyelids become swollen, hard, and brawny, so that it is with difficulty that they can he everted, or, in many cases, even separated from one another, and in attempting to drag them apart we often put the patient to considerable pain. On examining the conjunctiva, Ave shall find

it of a buff color, streaked here and there with a reddish coloration, the inner surface of the lids presenting a mottled appearance; this arises from the butT-coloured fibrinous exudations having infiltrated the part, and in doing so, exerting pressure on the vessels and

branches; others

give

exudations

stopping the larger

circulation through their smaller vessels remaining patent, while way, and their altered contents stain the fibrinous around them, and thus give rise to the mottled

some

of the

The contrast therefore between the appearance above noticed. appearance of the mucous membrane of the lids, in this the first stage of diphtheria, and that of purulent conjunctivitis, is very marked; in the latter the mucous membrane is swollen, and of a uniformly deep scarlet colour, with spots of eccliyiuosis scattered over its surface, the enlarged and prominent villi giving it almost the appearance of a granulating sore; whereas in diphtheritic conjunctivitis the mucous membrane is of a drab colour, mottled over with patches of extravasated blood, and a few large and contorted vessels

tempt to heres

are usually seen on its surface. If we atthis fibrinous exudation we shall find that it adto the conjunctiva; we inay detach it, hut it breaks

remove

firmly

away in shreds, and from the jagged surface of the wcund which is left a bloody serous fluid oozes away; the exudation in fact is by no means limited to the surface of the conjunctiva, hut exists in the sub-mucous connective tissue. The changes and appearance of the conjunctiva above described are by no means confined to the eyelids; exactly the same condition exists

principally

covering the sclerotic, the fibrinous conjunctiva throughout the -whole of its extent, and too often extending to the cornea. The period during which the exudation is being formed in tho connective tissue may be considered as the first stage of diphtheritic conjunctivitis; it usually lasts about six days, and is accompanied with fever and considerable pain in the eyes, extending to the temples and head. As a general rule, both eyes are affected, the disease being, as I before remarked, a local manifestation of a general disease. The second stage is one of reaction, degenerative changes taking place in the fibrinous exudations, which, together with the disintegrated blood corpuscles, arc thrown off from tho surface of the conjunctiva as an irritating bloody fluid, containing exudation

infiltrating

the

shreds of fibrinous substance. The appearance of the everted lids now becomes completely altered; the vessels are dilated and

turgid

described

with

as

blood;

in fact it assumes all tho characters

indicative of the second stage of purulent conjunc-

tivitis. In the third

stage

of the disease the

inflammatory

action sub-

sides, and the effects of the previous changes which have taken place in the conjunctiva become apparent; of these the destruction of the sub-conjunctival tissues, consequent on the deleterious influences exercised by the fibrinous exudation^n the part, is most obvious, and in the reparation of tho damage thus done cicatrices are

formed, which, in contracting, press upon and occlude tho vessels of the

conjunctiva, so that the mucous ultimately be entirely destroyed and replaced by white, glistening, cicatricial tissue. The dangers, therefore, to which the eye of a patient suffering from diphtheritic conjunctivitis are exposed, arc twofold: first, the fibrinous exudations may infiltrate the cornea, and in degenerating destroy its laminated structure; and, secondly, if the patient escapes this evil, the rough cicatrices which replace the palpebral conjunctiva, by constantly rubbing against the surface of tho cornea, induce opacity of this structure, and ultimately loss of sight; the cicatrices are not only thus harmful, but in contracting they shorten and contract tho palpebral margin of the li;l, inducing a most obstinate form of entropion. M. Wecker states that the severity of the three stages of diphtheritic conjunctivitis varies in different individuals, and that if the first stage runs a rapid course, the case may be mistaken for one of purulent conjunctivitis ; with regard to treatment, however, no danger would arise even if a mistake of this kind were to occur, for should the cornea be involved, the dilute caustic pencil would bo the agency upon which we should rely, under any circumstances. It is hardly necessary to warn you against mistaking cases of conjunctivitis occurring among people in a very low state of health, on whose conjunctiva false membranes are apt to form, with those affected with diphtheria, for beyond a somewhat similar appearance of the parts at first sight, there is 110 analogy whatever between the two forms of disease; these false membranes may be readily detached from the surface of the conjunctiva, the mucous membrane appearing of a florid red color beneath them, whereas in diphtheritic conjunctivitis we can only detach broken shreds of the fibrinous exudation, the surface of the wound presenting a yellow granular appearance from which a yellowish-red serous fluid exudes. As in suppurative, so in diphtheritic conjunctivitis, it is tho complications to which the cornea is subjected which render the disease so dangerous to the integrity of the patient's sight, and unfortunately the virulent character of the affection renders We someour best efforts often unavailing in saving the eye. times find, 011 opening the lids of a person suffering from this affection, that the cornea is of a yellowish-grey color, owing to the infiltration of its structure with the diphtheritic exudafew

remaining

membrane may

tion, and when the second stage of the disease is established tho the exudative appears to break down en niass? with material; a large staphylo.na resulting. In other eases a deep cornea

TIIE ITsDIAI^ MEDICAL GAZETTE.

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circumferential ulcer may be seen surrounding the cornea,?a most dangerous symptom in this disease, for in spite of all our care the ulcer generally spreads rapidly, a few hours often to

complete the mischief, and, the cornea giving -way, destroyed. These ulcers are sometimes peculiarly treacherous, the cornea appearing almost to dissolve away ; at first it looks hazy, as if affected with keratitis; this condition having lasted for a few days, the anterior and middle layers become disintegrated and destined, and on examining the eye at a first glance the cornea may appear bright and clear, the posterior elastic lamina alone remaining intact; a moment's observation, however, will conviuce us of the fact that tlie elastic lamina is bulged forward from the pressure of the aqueous fluid behind it, nor can it stand this tension long ; it is almost certain to burst open, and then the lens, the aqueous humour, and a portion of the iris escape through the wound. Treatment.?Diphtheritic conjunctivitis being a local manifestation of a very intractable form of disease, it is almost impossible effectually to ward off the injurious consequences which too often follow its invasion. German practitioners advocate the plan of administering mercury in large and repeated doses, so aa to bring the patient under the influence of this drug as speedily as possible. Calomel and mercurial inunction are recommended ad libitum, and appear to be the means upon which they rely to stay the progress of the disease ; and certainly, as our German brethren have had the most experience in diphtheritic consufficing

the eye is

junctivitis, sideration.

these methods of treatment demand

My

own

experience

would

dispose

our

careful con-

me

to

rely

more

upon large doses of the tincture of ferri muriatis combined with chlorate of potash, than on any other drugs in the first stage of the disease; thirty drops of the tincture, together with twenty grains of the chlorate of potash, may be administered every three hours, and this in spite of the fever which generally attends the outset of the affcction; the state of the bowels must be attended to ; hot baths at bed-time often induce perspiration and quiet the patient. As a general rule, a lowering plan of treatment is to be avoided ; on the other hand, soup and a

though non-stimulating dietary arc demanded. Morother preparation of opium should be given in sufficient doses at bed-time to procure the patient sleep during the night. With regard to the local treatment, do not use oaustic in the first stage of the disease, for the circulation in the conjunctival vessels is already impeded by the fibrinous formation surrounding them, and caustic would simply intensify this condition ; in fact we shall in these cases, as in all other forms of conjunctivitis, do well to remember the rules already laid down on this subject. Caustic is not to be employed unless a purulent discharge exists. In the first stage of diphtheritic conjunctivitis, M. Wecker employs cold water compresses to the eyelids, but above all things enforces the administration of calomel every two hours ; he also recommends the application of leeches to the temple; he speaks favourably of the effects of tartar emetic in relieving the feverish symptoms. As soon a3 the patient is salivated, he affirms that the conjunctiva loses its buff-grey appearance, the second stage of the disease being speedily established. "When once the purulent discharge has commenced, the conjunctiva becoming red and vascular, the local treatment must be altered and conducted upon precisely the same principles as I have already laid down for the treatment of purulent conjunctivitis. A solution of five grains of nitrate of silver to an ounce of water should be dropped into the eye frequently in cases where generous,

phia

or

some

there is no ulceration of the cornea, but when ulceration has commenced the dilute caustic pencil must be applied carefully to the

conjunctiva, together with the eye being kept scrupulously

tarsal

discharge is possess irritating properties, diseased action, if allowed

always

that *he

not

and

cold compresses over the lids, clean. We should remember

only contagious, but appeal's to consequently to keep iip the

to remain in contact with the eye.

[^oyember 1,

1867.

general treatment will still consist of the tincture of iron and chlorate of potash, morphia, and hot baths. In the third stage of diphtheritic conjunctivitis very little can be done, a mild astringent lotion beyond ordering the

The

patient

to be used twice a day, and bathing the eyes frequently in tepid water. We cannot prevent the formation and contraction of the cicatrices which are the natural consequence of the

loss of tissue, of the disease.

unfortunately following the previous destructive action

Granular Conjunctivitis, often Ophthalmia.

called

Military

a common form of disease, particularly among the classes, if exposed to malarious or ctlier debilitating influences. It depends upon the presence of numerous small granular bodies scattered in the connective tissue of the conjunctiva, and often in the cornea; these neo-plastic growths spring from the germinal matter of the part; they contain no blood-vessels or nerves, and are, therefore, utterly unlike the

This is

lower

villi in every respect. On everting the lid of a person suffering from granular conjunctivitis, it is true that we shall, in the majority of instances, find the papillae of the conjunctiva more or less congested, their hue

varying according to the stage of the disease; in chronic cases the epithelium covering the villi becomes thickened, and they are prominent and of a dusky-brownish red hue, and of course confined to the tarsal conjunctiva. On the other hand, the neo-plastio growths of granular conjunctivitis may often be best seen beneath the orbital conjunctiva, on account of the transparency of this structure ; they are frequently, however, so small that we must employ a lens in order that we may clearly detect them; but, whether situated in the tarsal or orbital mucous membrane, these neo-plastic growths lock like small granular masses, aptly compared to a millet seed, situated immediately beneath the conjunctiva. As the disease advances these granular bodies may increase in size till they become as large as a tapioca seed ; they may then be distinctly noticed scattered among the enlarged villi of the palpebral and orbital conjunctiva, and

sometimes on the cornea. If we examine them in their early stages, having previously submitted them to the action of an ammoniacal solution of carmine, we find that they consist of little beyond lowly developed germinal matter, which subsequently undergoes fatty

degeneration, and is then no longer colored by carmine. The granular bodies are indirectly an offspring from the germinal matter of the connective tissue, which is much augmented in quantity in these cases, and it is often difficult to draw a line of demarcation between the health}' germinal matter and the neo-plastic growths of granular conjunctivitis ; but however similar to healthy germinal matter in appearance, their functions are perfectly dissimilar, for in place of the granular bodies becoming developed into formed material, they degenerate into a fatty substance which is gradually absorbed, and the space which it has occupied contracting, small cicatrices are left to mark the former position of neo-plastic growths. It is to the fact of a conglomeration of these cicatrices, and the consequent contraction of the conjunctival issue thus induced, that the unfavourable results of this mainly due, the cicatrices presenting

form of disease

are

rough and uneven surface, which, by constantly rubbing against the cornea, induce irritation, and subsequently vascular opacity, of that important a

structure.

It is quite possible to mistake the enlarged glands of the conjunctiva for the neo-plastic growths'of granular conjuncti-

vitis.

In all cases of irritation

of the

mucous

membrane, the

glands become swollen, and may frequently be seen beneath the conjunctiva, looking very much like the neo-plastic growths cf granular conjunctivitis; nor can I lay down any special rules to enable you to distinguish between the neo-plasms and the enlarged glands of the conjunctiva, which are still held by many

November 1, pathologists

to

1S67.]

ANAESTHETIC LEPEOSY.?BY J.

constitute the essential elements of the granular conjunctiva in this form of disease. (To be continued.)

bodies noticed in the

j

I

I

N., M.A.,

M. D.

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