First middlemore lecture by Bala Chander

"U,&.Y<Vo

.SURGEON GENERAL'S OFFICE 8

UBR&Blf.

THE ELEMENTS OF

OPHTHALMIC THERAPEUTICS, BEING

%ht pixhatb

«#ttbSlem0« fost-ftmtmaic JLtdam* DELIVERED AT THE

BIRMINGHAM AND MIDLAND EYE HOSPITAL,

1889.

D. C.

LLOYD-OWEN,

F.R.C.S.I.,

Senior Surgeon to the Hospital, and CoNsy^^rcjTnCpTm^LMic

Surgeon to the Children's Hosr^^^BiRMLNGJiAMr^^\y

BIRMINGHAM CORNISH BROTHERS, 37, NEW STREET. 1890.

''§

JUN &

19° 3

CONTENTS. PAGE

INTRODUCTION

Chapter SECTION I.— Mydriatics and

Myotics.

SECTION

II.— Astringents, Stimulants, and Irritants

SECTION

III.— Caustics

SECTION IV.— Antiseptics

--------

-:/-.--,-

Chapter 11;

------

SECTION I.— Heat and Cold SECTION

II.— Bloodletting

SECTION

III.— Counter-irritation

Chapter

------

48 52

lit

— Aconite — ChloralBromides— Gelseminum— Croton Chloral Hydrate — Quinine — Mercury — Iodide of Potassium— Salicylate of Sodium— Iron — Arsenic — Strychnia

INTERNAL REMEDIES.— Opium

...

INTRODUCTION.

T N delivering the * established by

first

of the annual series of lectures

Mr.

Richard MiDDLEMORE,

privileged in being able to act as the mouthpiece of the

medical profession

in this district, in

expressing their cordial

appreciation of his generosity, and of the service done to his professional brethren in

founding and endowing these

lectures.

Although Mr. MiDDLEMORE has reached a very advanced age, he

well

known

to take a

warm

interest

still in

the

progress and advancement of medical science, and especially

of ophthalmology, to which his

From icine,

life

has been devoted.

his earliest connection with this

branch of med-

which now dates back some sixty-odd years, Mr.

MiDDLEMORE

has always laboured, by his lectures and

his writings, to place the results of special research before his brethren

in general

practice,

â&#x20AC;&#x201D;a

conduct which has now culminated

and endowment of the

high-minded in

line

the establishment

RICHARD MiDDLEMORE B

Post-

INTRODUCTION.

Graduate Lectureship," of his labours, the

connection with the early scene

Birmingham and Midland Eye

Hospital.

This unity of method and purpose manifest throughout a long

life, is

a worthy

and complete

"Une

And

a fitting illustration of the poet's description of

pensee de

life

la jeunesse,

congratulate Mr.

executee dans l'age m'ur."

MlDDLEMORE,

in the

name

of our

profession, on witnessing the completion of his work.

Mr.

MlDDLEMORE is a lineal descendant of the Hawkesley

branch of the ancient and distinguished family of MlDDLE-

MORE, formerly

lords of the

manor

of Edgbaston, and

possessed of other manors and great estates in the counties of

Warwick and Worcester

from the time of

Henry

a family of great importance

down

to the time of the early

Georges. Mr.

MlDDLEMORE was

a student of St. Bartholomew's

Hospital, where his chief friend and fessor,

now

Sir

Richard Owen,

companion was Pro-

K.C.B., a friendship which

has continued warmly cemented to the present day. leaving St. Bartholomew's, Mr.

MlDDLEMORE came

to Bir-

mingham the bearer of a highly commendatory letter from Mr.

Abernethy to

Mr.

Hodgson, then Surgeon

to the

General

Hospital here, and by far the most distinguished surgeon

INTRODUCTION.

ill

throughout the midlands. For three years Mr.

MlDDLEMORE

HODGSON, and

as his friendly

acted as dressing pupil to Mr. assistant for

more than ten years afterwards.

probably by Mr. HODGSON'S example, Mr.

Instigated

MlDDLEMORE

early evinced a leaning towards the study of ophthalmology,

and

the year 1828 he was appointed assistant surgeon

to the

Birmingham and Midland Eye Hospital

he was

made

consulting

In 1831

staff.

;

Mr.

MlDDLEMORE

1834 he delivered his

on diseases of the eye; and

well-known work,

start

gained the

first

course of

1835 published his

MlDDLEMORE

en-

a journal of ophthalmology, but

the

enthusiasm necessary was lacking practitioners.

1835

Treatise on Diseases of the Eye.

In addition to this great work Mr.

deavoured to

surgeon, and in 1849 he retired to the

full

Jacksonian prize lectures

;

among

the ophthalmic

also the author of innumerable papers

published in the various English, and quoted by the various foreign medical journals.

that Mr.

MlDDLEMORE

By means

of which

it is

known

contributed greatly to the founda-

tion of the English school of ophthalmology.

Mr.

MlDDLEMORE was one

the Royal College of Surgeons fellows,

and

now

of the

first

who were

four

members

created honorary

the only survivor of the four

others being well-known and honoured

;

the

Birmingham men

INTRODUCTION.

Joseph Hodgson,W. Sands Cox, and Langston Parker. Besides the establishment of the lectures which bring us

here to-day, Mr.

MlDDLEMORE

has endowed a triennial

prize in connection with the British Medical Association,

and has given largely with the Blind

Asylum

having been educated in

to establish a fund

beginning a useful

city,

to help those who,

the institution,

life

this

may

of his

good works. Conscientious

his professional brethren

be hindered

by want of pecuniary means.

Long may Mr. MlDDLEMORE be spared fruit

connection

to enjoy the

in his relations

with

modest, never seeking notoriety,

simple, kind, generous, always maintaining a high standard

of professional

life,

Mr.

MlDDLEMORE

example which we may well said, in the

words of ClCERO Memoria bene

follow.

has furnished us an

Of him

redditae vitae sempiterna."

may

(Ehapter I.

In taking as the subject of these post-graduate lectures

some of the I

essential points of ophthalmic therapeutics,

endeavouring to follow, to the best of

intention of the benevolent

course those

ability, the

and enlightened founder of

this

namely, to digest and arrange for the service of

members of our

profession

who

are engaged in the

absorbing duties of general practice, the results of the searches and experience of those

re-

who devote themselves

particularly to ophthalmology.

It is

most probable that

at least for

the cultivation and mastery of the

some time

more abstruse

come

details

must be the pursuit and remain the possession of a com-

number of

paratively small

these

special

number of the ordinarily

less

aspects serious

come under

practitioners. aside, there

diseases

But,

leaving

remains a large

of the eye which

the care of the

family medical

attendant.

The treatment studied

them

of these diseases has been very carefully

by ophthalmologists, and the

are

among

rules

which guide

the rudiments of their knowledge.

But

these rules are not yet as they should be the

possession of the whole profession. a

This

moment wishing such shortcoming

to causes other than the

which leave him but

My lectures will of disease

;

but as

say without for

to be considered

demands on the

little for

common due

student's time,

the study of ophthalmology.

be directed particularly to the treatment is

little

value to discuss remedies

make plain the try, when crucial

without at the same time endeavouring to indications for their exhibition,

points

between

diseases

shall

be mistaken for one

liable

another demand, to add to the directions for treatment

some I

hints for guidance in diagnosis.

would say

further, that

quote authorities

not

these lectures

and

;

to accept the suggestions laid before

the general concensus of opinion held

For convenience of reference

my it

lectures

into chapters

you

my I

intention to

would ask you

as expressions of

by ophthalmologists.

have broken the text of

and sections when producing

book form.

SECTION

MYDRIATICS AND MYOTICS. Mydriatics. the

eye,

â&#x20AC;&#x201D; In

the

mydriatics and

very prominent place.

and contracting the

modern treatmeat of

diseases of

myotics have come to hold a

For besides pupil,

their action in dilating

and so affecting the merely

mechanical adaptation of

its

changes to the requirements

of treatment, they have an important influence in modi-

the conditions of the nerves and

fying

blood-vessels of

the eye, and so are eminently serviceable in the general

treatment of

its

ment of eye

This latter feature

diseases.

diseases

of distinctly recent development

some of the drugs employed cocaine

its

;

operation — notably

— being of very late adoption. take

will

in the treat-

the pupil

first

— seriatim,

all

the mydriatics

and then compare

— the

dilators of

their action

and

their therapeutic value.

The

mydriatics generally employed are the vegetable

alkaloids derived from plants of the natural family Solanaceae;

and they are

all

very similar, almost identical,

chemical composition, and their therapeutic action.

Atropa belladonna

are atropine, derived from

;

their

They

duboisine,

from Duboisia myoporoides hyoscyamine, from Hyoscyamus ;

niger

;

and daturine, from Datura stramonium.

These

mydriatics from the solanaceae, consist of only three pure alkaloids is

— atropine, hyoscyamine, and hyoscine.

Daturine

nearly pure atropine, and duboisine nearly pure hyoscy-

amine, and

all

three alkaloids are isomeric.

Besides these

four derivatives from the solanaceae, there are two other alkaloids, virens, last, is

gelsemine, derived

from

Gelseminum semper

and cocaine, derived from Erythroxylon coca.

though more generally used

also a valuable mydriatic,

The

for its anaesthetic effect,

though the dilation produced

Besides their action in dilating the

of brief duration.

pupil, these

eye.

That

of the

iris

drugs also affect the accommodation of the to say, the intra-ocular muscles, the sphincter

and the

ciliary muscle, are

both influenced by

the action of mydriatics, the effect of the drugs being pro-

duced on the intra-ocular ganglionic system which governs them.

It is

a question not yet finally decided whether,

besides paralysing the sphincter of the pupil, mydriatics irritate

the oculo-pupillary branches of

the sympathetic,

and by so doing, add to the paralysis of the sphincter an irritation of the radiating fibres of the

And

this

need not occupy us further now, than to notice

that dilatation of the pupil produced carried to a

iris.

by mydriatics can be

more complete degree than

possible

interruption of the nerve supply from the third pair alone,

without the addition of irritation of the cervical sympathetic.

To produce moderate

dilatation of the pupil, an exceed-

ingly feeble solution of atropine suffices

thousand traces of

will at the

which

one part

in eighty

end of an hour produce a dilatation

remain

will

;

for twenty-four hours.

But

order to affect the power of accommodation a solution of at least

one part

twelve hundred

tions apply only to eyes in a

affect eyes the seat of disease,

persons in iris in

whom 'it

normal

needed. state,

These

solu-

they would not

nor the eyes of some old

difficult to

produce dilatation.

a state of inflammation will not dilate in answer to

weak

solution,

nor

will

a ciliary muscle in a state of

spasm yield

readily.

days of persistent use are necessary, before, ditions, the desired effect

The in

such con-

produced.

sulphate of atropine

employed, and

many

Strong solutions, and often

the

salt

most generally

has the advantage of being readily soluble

water without the aid of

The

of wine or acid.

spirit

pure alkaloid, on the other hand, needs a small quantity of spirit of

tity to

wine or acid to render

be of use, and

soluble in sufficient quan-

should not therefore be used as a

local application to the eye,

and

on account of the smarting

produced by these agents, when brought

irritation

contact with the cornea and conjunctiva.

A solution or olive

oil,

of the pure alkaloid, however, in castor

to the value of

which

was,

oil

believe, the first

to call general attention, forms a very valuable local appli-

cation in abrasions and ulcerations of the corneal surface,

and

in the irritation

ating effects

of the

due to granular oil

are

gained, in

The

sedative effects of the drug.

lids.

solution of sulphate of atropine

Here the addition

lubric-

the

strength of the aqueous

most generally

useful

that in the proportion of one in two hundred of water, but

where the

full

effect is

dilatation, in the

needed, as in producing extreme

attempt to separate adhesions of the

iris

to the anterior capsule of the lens, or to cause complete

paralysis of the muscle of accommodation, a solution of

one

in a

hundred, or even one in sixty,

required.

In certain persons, atropine acts as an irritant to the

IO conjunctiva, and in some,

even cause redness and

will

and more or

puffiness of the eyelids,

use to continue

little

may

atropine

its

eczema of the

When

this occurs,

application.

Sometimes

skin in the neighbourhood of the eye. it

less

be tolerated by substituting an ointment for

a watery solution, or by adding to the watery solution a small proportion of carbolic or boric acid, or by using

But

gelatine discs charged with the alkaloid. to say, such a result

The

am bound

the rare exception.

susceptibility to this

be an idiosyncrasy, and

it is

form of

irritation, I believe to

better not to lose time in trying

these variations of vehicle, but to at once change the drug

some other

for

similar in action.

The

sulphate of duboisine

or hyoscyamine are the best substitutes.

much more powerful

Duboisine possesses a action than atropine will

a solution of one part in a million

produce marked dilatation of the pupil

one part

mydriatic

two hundred

ophthalmic purposes.

is is

as strong as especially

;

a solution of

needed

worthy of

for

notice,

however, that whilst duboisine does not often act as a local irritant,

possesses

marked toxic

properties,

and

its

use should be carefully watched.

Hyoscyamine has great value as a mydriatic, a solution of one in three hundred will fully dilate the pupil, and

completely paralyse the accommodation, and the effect will

not pass off for some days. riot

keep

well,

and

in special cases,

The

solution, however, does

therefore less fitted for use, except

than the other mydriatics.

Daturine, which

almost identical with atropine, has

special value.

Within the a synthetic tice.

few years, a drug called homatropine,

last

salt,

has been introduced into ophthalmic prac-

from the amygdalate of

a product obtained

from atropine by splitting

tropine, a salt derived

into

tropine and tropic acid, and substituting amygdalic acid for the

tropic acid.

oleaginous liquid

and

;

a soluble crystalline

obtained

this,

the form

result, the

hydro-bromate

ophthalmic therapeutics, and

of homatropine,

produces

similar to those of atropine, but

more is,

effects

quickly,

and

its

of an

with hydrobromic acid, forms

This

salt.

used

acts

are of shorter duration.

effects

therefore, very useful for diagnostic purposes, because

whilst

produces

of the pupil, and complete

full dilatation

paralysis of the ciliary muscle,

from

effects pass off in

its

twenty-four to thirty-six hours.

drug has attracted more attention during the

three or four years than cocaine. the medical world

last

was only brought before

by Kohler, of Vienna,

and before the end of the same

in October,

year,

1884

;

have counted

between eighty and ninety communications to British and foreign journals, concerning

Whatever may be practice,

useful because

effect

fact,

that

and as a mydriatic. it

on the eye alone.

ultimate position in other divisions of

a settled

local anaesthetic is

its

most valuable

as a

In the latter role

produces a brief but extremely wide

dilatation of the pupil, sufficient to allow of the freest oph-

thalmoscopic examination, without more than the briefest disturbance of the accommodation, and with probably less

danger to eyes threatened with glaucoma than

by other mydriatics whose

effects are

which

will

—To

dilate the pupil, either to

—To —To

sedative nerves, 4.

thirty-six hours.

iris

free

improve the

relieve

when

in ulcers or

iris,

and also

wounds.

spasm of the accommodation.

relieve pain

action on

— In

vision, or

from adhesions to the capsule of the

during attacks of inflammation of the

from adhesions to the cornea, 2.

more than

directly therapeutic effects of mydriatics are

to keep the lens,

useful combi-

thoroughly paralyse the accommodation,

whilst the effect does not last

The

offered

lasting.

With homatropine cocaine forms a most nation,

and

reflex

the terminal

spasm by

their directly

branches of the ocular

these are implicated in disease.

addition

these actions,

common

to all

the

mydriatics in greater or less degree, must be added the special local anaesthetic effects of cocaine.

take the uses more in detail,

sider the simple

dilating

effect

employed when central vision in the

will first of all con-

mydriatics.

This

obstructed by some opacity

media, such for example as a central, senile cataract,

or a lamellar cataract of moderate extent.

It is useful

permitting the patient to take the benefit of vision through a portion of the transparent media, outside the area of

For

obstruction.

that

and even

required,

purpose a very weak solution

this

necessary only at long-

and should be used with caution.

intervals,

Mydriatics are also used to draw the

towards

its

iris

and prevent

ciliary attachments,

wounds near the

tion in ulcers or

its

post-iritic

incarcera-

centre of the cornea.

atics in acute

are necessary.

must be

in the

the ounce of water.

inflammation of the It

may

iris,

proportion of

In using mydri-

frequent instillations

readily be understood that in the

treatment of inflammation of a structure like the constantly and rapidly varying the position of

parts, in response to the stimuli of light it

secured.

before

capsule,

Dilatation of the pupil to

iris

iris,

its

which

relative

and accommoda-

things necessary that rest should be

all

ually insures the repose needed,

withdrawing the

iritis,

adhesions exist, strong solutions are

five to eight grains to

tion,

backwards

obtain and maintain dilatation of the pupil in

when

necessary. If atropine be used,

is all

from

its

its fullest

and

at the

extent effect-

same

time,

normal contact with the lens

removes the serious danger of adhesions between

the two structures.

A very good way of insuring absorption, and of obtaining somewhat of a cumulative

effect of atropine, is to instil the

solution every five minutes for a quarter of an hour,

and

to repeat this proceeding every two, three, or four hours,

according to the acuteness of the attack.

two great advantages

first, it

This plan has

likely to insure ab-

H sorption, because an eye in an inflamed condition, with vessels

gorged and

absorb a

fluid

tension

somewhat

from without so readily as

normal conditions there

its

and,,

;

second

even

its

increased, will not it

would do under

ordinary cases

excessive lachrymation, which will wash out the

solution instilled, before time for absorption has been al-

lowed.

The

repetition of the instillations every five minutes

for a quarter of

intervals

â&#x20AC;&#x201D;these quickly repeated

â&#x20AC;&#x201D; they are

irritating to

hour, as

They have another

any other method.

better than

vantage, too

an hour, meets these adverse conditions

instillations

recommended by some

In attempting to break

less

iris

authorities.

down

and the

iritic

and

post-iritic

lens capsule,

it is

to obtain full paralysis of the sphincter of the

existence of a distinct dilator muscle

conclusively that paralysis of the sphincter

be reasonably hoped for

adhe-

necessary

iris.

is still

but some facts have been observed which,

may

and

less disturbing to the patient,

the eye, than instillations every hour or half-

sions between the

The

ad-

with good

disputed,

think,

not

all

show that

attempting to break down

synechias.

There can be no doubt that atropine, besides paralysing the branches of the third nerve, stimulates the branches of

the sympathetic and

its

associate the

over dilatation of the pupil dilating nerves

some

may

;

fairly

fifth,

which preside

and so excitement of these reckoned upon as a factor of

value, in detaching the adhesions.

would now draw attention to a most important caution

the use of mydriatics, and that

account be used

glaucoma normal.

;

that

is,

is ;

that they

must on no

cases of glaucoma, or of threatened

eyes the tension of which

lay particular stress upon this, because

now and then

that

been mistaken for

see cases of

iritis,

used with disastrous

and

which atropine has been

In order to explain this

effect.

what way mydriatics are

Glaucoma

briefly,

is,

far the

just as

;

the expression of a fairly strict equili-

fluid into the eye,

equally constant and proportionate withdrawal.

most important route taken by the escaping

that through the anterior filtration area, as

that

is,

fluid is

called

;

through the ring of tissues immediately posterior

to the corneal margin,

and anterior

to the ciliary

margin of

marked by the ligamentum pectinatum.

the

iris,

ring

marks the

site

of Schlemm's canal, with

its

in order that the

means of escape may be

easy,

This

contained

plexus of veins, which constitute the principal outlet.

all

of the fluids secreted, through

brium between the constant secretion of its

will

injurious.

interference with the normal channel of outflow

and

I will

an increased tension of the eyeball,

due to the retention within

normal tension

happens

glaucoma which have

glance briefly at the pathology of glaucoma, and seen in

above

Now above

things necessary, that the stream of fluid through the

angle of the anterior chamber should be unimpeded. But this route

can be

free,

only when the angle

widely open.

be closed, by the anterior surface of the

iris

being

pressed against the posterior surface of the cornea, the outflow becomes, in great measure, perhaps entirely, arrested. It

may now

be readily seen

from whatever cause,

may

how

act

dilatation of the pupil,

the production of an

attack of glaucoma, in an eye predisposed to

it,

intensely aggravate an attack already begun.

The

of gathering the

iris

sufficient oftentimes to

the angle, and so to stop the

occurrence of

the

precipitate

attend

its

vanced

life,

retention.

when

fully

complete the blocking of

means of all

the

always

exit of fluid,

and

symptoms which

well, therefore, in

all

ad-

things, not to mistake an

attack of glaucoma for an attack of

not be

the pupil

examine the tension of the eyeball before

using atropine, and above

will

effect

into folds, towards the angle of the

anterior chamber, which takes place dilated,

may

made

diagnostic points,

This mistake

iritis.

attention be paid to the following

which refer

the

acute forms.

The

chronic forms of glaucoma are not likely to be mistaken for

iritis

pain.

;

there iritis,

no congestion of

and

veins,

no redness nor

acute glaucoma, there

always

considerable vascular congestion of the anterior tissues of the eyeball, but in glaucoma the tension

always more

markedly increased, the eyeball having a peculiar hard, unyielding feeling, and the pupil being more or less dilated, the dilatation being usually, not evenly circular, but oval,

with the long axis vertical.

Whilst

iritis,

the tension

normal, or at most only a hardness, and the pupil too,

somewhat

iritis

little

full,

never approaching

markedly contracted.

The

pain,

different in character.

generally a burning, throbbing pain in

when

the eyeball, and

extends to surrounding parts,

generally most marked on the temple and on the inner side

down by

of the orbit, extending

though

it is

The

often severe,

rarely of

it is

pain of acute glaucoma

The

terribly severe.

the side of the nose

is,

eyeball feels as

pain radiates through

all

extreme

;

severity.

on the other hand, if

bursting,

and the

the branches of the ophthalmic

division of the fifth nerve.

Severe headaches, and nausea,

and vomiting, and even delirium sometimes accompany

it.

In inflammation, therefore, with contracted pupil and

normal or only safe

;

tension,

slightly increased tension, mydriatics are

cases in it is

which there

doubt as to increase of

better to run the chances of the possible risks

attending their non-employment for a short time, rather

than to bring about the positive disaster which their use

glaucoma inevitably

entails.

In spasm of the accommodation, the use of mydriatics is

distinctly indicated.

this

term

meant a

tonic

spasm, or cramp of the ciliary muscle, such as

found as the result of injury or

most usually

irritation, or

sometimes

as the result of excessive, or too prolonged exercise of this

muscle

in eyes the seat of faults of refraction.

know

that patients suffering from hypermetropia, for example,

cannot see objects clearly at any distance, either near to or far away, without exercising their is,

accommodation

;

that

without accommodating the curvature of their crystalline

lenses to the degree required to focus clear images on their retinae,

The

calling into action their ciliary muscles.

constant strain thus kept on the muscles produces a state of permanent tension, which frequently passes into tonic

spasm, and at overstrained, only.

The

last,

the accommodation becomes permanently

and kept adjusted

optical complications thus induced are

selves a source of serious trouble, but, as

and

in the parts

symptoms, as well is

about the eyes.

them-

usual in spasm,

symptoms of discomfort

there are also considerable eyeballs,

near objects

for vision of

in the

relieve these

as to relieve the optical complications,

necessary to cause relaxation of the spasm, by paralyzing

the ciliary muscle. fully afforded.

When

this relief

prescribe a

needed

weak dose of

must be

a mydriatic

an expedient simply weakens

to aggravate the evil, such

the power of the ciliary muscle, and

does not render

makes

stimulus.

Full paralysis of the muscle relieves

less able to

incapable of responding to

act, whilst

by rendering

response to stimulus impossible.

Mydriatics

are

phlyctenular and are

great

use

the

treatment

other ulcers of the cornea

when they

accompanied by increased vascularity and congestion.

They fifth

anaesthetize the extremities of the branches of the

pair

of nerves,

and

marked manner

control

the superficial vascular supply by their constringent action

the

blood-vessels.

Ulcers,

however, situated

the

margin of the cornea, should be treated cautiously by mydriatics, because iris,

perforation should take place, the

being drawn towards the margin,

placed in the most

favourable position for prolapse and subsequent incarceration in the cicatrix.

the

found

asthenic

in patients

forms of corneal

whose

such as are

ulcer,

nutrition has suffered as the result

of exhausting diseases, in badly nourished children, and also in

women

reduced by excessive lactation, together

with other weakening causes, mydriatics are not of fore-

most

value, because they tend to produce, at least in the

early stages of their application, an anaemia of the structures

involved rather than a hyperemia, and to lessen secretory

power, which

same reason

obviously not what

For the

needed.

those forms of abscess, which occur in

course of severe conjunctivitis, or purulent and gonorrhceal

ophthalmia, or as the result of direct breaking ulceration

centres

infiltration,

down and

mydriatics

are

not

indicated.

The

therapeutical uses of cocaine call for a

tended notice. the is

more ex-

This remedy has passed so speedily into

hands of the general body of practitioners that

now used almost

disease which fore, to

know

indiscriminately in

come under

their notice.

all

cases of eye is

well, there-

the limits, as at present ascertained, within

which

may be

used wisely and beneficially.

means

of producing anaesthesia of the ocular surface, cocaine If a four per cent, solution

invaluable.

be dropped four or

times in course of ten minutes, on to the corneal or

five

conjunctival surface, such a degree of insensibility of those structures will be produced as will permit of

any operation,

not only cutting operations, but the application of caustics,

and of the actual cautery, being performed without

pain.

In facilitating the extraction of foreign bodies impacted in the corneal surface, cocaine

most

in conditions of corneal disease

useful.

It is useful, too,

where spasmodic closure of

the lids with corneal irritation, the so-called photophobia,'

renders inspection of the eye

Cocaine in

some

is,

the corneal epithelium. cent, has

and even injurious

After a solution of even

if it

become thinned and

This

five

its

cells

are cast

due to diminution of the lymph supply, a

which

characteristic of certain forms of keratitis,

dread of light but to local

presence

among them

of the eyelids

per

* I use the term so-called photophobia, beeause the inability to eyelids,

upon

flattened, then the deeper layers

begin to shrink, and ultimately the external off.

has

be exposed, shows marked changes.

epithelium becomes dried and damaged,

layers

effect

been employed, frequently for some time the

cornea, especially

The

difficult.

however, not an unmixed blessing, for

cases a very peculiar

irritation of the

of invading leucocytes.

â&#x20AC;&#x201D;blepharospasm â&#x20AC;&#x201D; due

nerve

fibrils

It is really a

to the irritation.

the result of increased sensitiveness of the retina.

open the

not really due

of the cornea by

spasmodic closure

True photophobia

21 result of the anaesthesia, aided

cornea

produced,

may

And

may

cause troublesome

in diseased conditions of cornea, in

entrance of micro-organisms into the tissues complication,

this

layers of the

be easily conceived that solu-

tions of otherwise harmless agents

changes.

When

by evaporation.

condition of disturbance of the superficial

which the

a probable

most necessary to avoid lowering the

vitality,

and so weakening the

by the

persistent maintenance of the anaesthetic effect of

resisting

power of the cornea,

strong solutions of cocaine. In the use of mydriatics there are two or three conditions in

which the utmost caution must be observed.

should be carefully watched

in the case of old

children on account of their toxic effects.

They

persons and

These are pro-

duced by some considerable quantity of the solution finding its

way down

the tear passages into the throat.

dry throat with some headache and giddiness condition

or the

may go

on to actual delirium.

who

within the experience of those of us

tions of these drugs, to see old people

called "

These if

restless, feverish,

effects

not to stop

The

Merely follow, It

use strong solu-

become what

moithering," and even get up and wander about in

mild delirium under their influence

become

may

warn us it

;

and

to see children

and the subjects of

hallucinations.

to lessen the frequency of application,

altogether.

disturbing effect of mydriatics upon vision must

also not be forgotten.

Many

a patient has passed hours

22 of misery in fear of blindness through the instillation of

atropine into the conjunctival sac, for want of a few words of timely explanation of the effect upon vision. I

the

inclined to lay stress

upon the cautions

necessary in the use of mydriatics because

it is

a matter of

observation that in the treatment of diseases of the eye atropine

becoming adopted

unguarded use seems

as a routine expedient.

Its

prompted by some such

to be

sage aphorism as that which old players at whist have

formulated for the guidance of vacillating neophytes mysteries —

When

doubt lead trumps."

in its

Now some

such loose rule seems to be becoming imported into the general, as distinguished from the special, treatment of eye diseases.

When

guiding maxim. I

doubt use atropine," seems to be the

Against

this

happy-go-lucky method,

would, for the reasons above given, utter an earnest

MYOTICS.

—

shall

now

turn to the consideration of the

actions and uses of myotics, the contractors of the pupil.

Those ordinarily employed

in practice are

derived from

calabar bean and jaborandi, though other drugs, such as

opium, morphine, coniine, and digitaline contract the pupil

when

applied locally.

In practice the most active and powerful myotics are

those derived

from calabar bean

alkaloid eserine.

— the

extract,

and the

Formerly the extract was greatly used,

but

pose

so uncertain in strength, and so liable to

in solution, that

The

eserine.

salts

decom-

has been superseded by the alkaloid

of this

most used are the

alkaloid

sulphate and the salicylate.

Many

experiments have been performed

ascertain the exact action of myotics on the

case of eserine

highly probable that

peripheral sympathetic nerve fibres, and

probable that

order to

In the

iris.

paralyses the is

also highly

stimulates the terminations of the branches

of the third pair to the

iris,

so that whilst there

a passive

myosis due to paralysis of the sympathetic supply to the iris,

there

due to direct stimulation

also an active myosis,

of the sphincter.

The

effect is

not limited to the

Full

iris.

doses stimulate the ciliary muscle, and so increase- the

power of the

refractive

examining eyes

eye.

which the

may

This iris

be proved by

wanting, which have

been subjected to the influence of strong solutions of In

eserine.

of the

iris

all cases,

however, the effect upon the sphincter

greater and

lasting than that

upon the

ciliary muscle.

In testing the comparative duration of the effects of eserine

upon the sphincter of the

muscle

in a

iris,

and upon the

ciliary

healthy eye, a recent author found that whilst

the effect of a solution of a certain strength upon the ciliary

muscle lasted slightly over an hour and a

upon the sphincter of the

The

iris

half,

the effect

lasted seventy-two hours.

pupillary contraction produced

by myotics

much

more considerable than that produced by the strongest It is rarely

light.

the

pupillary

The

much

iris,

consequently

look somewhat irregular in

some

sulphate of eserine

solution of as

may

opening

more contracted

shape,

equal in each part of the

parts than in others.

the salt most generally used.

as four grains to the

be occasionally employed, but, as a

ounce of water

rule, solutions

from one quarter of a grain to two grains to the ounce answer every useful purpose. Pilocarpine,

the

active

carpus pinnatus), has

same purposes

principle

come considerably

as eserine.

It is best

intents

and purposes the same

therapeutically they ever, a

may

w eaker drug than r

and

form of

in the its

action

as that of eserine,

be grouped together. eserine,

(pilo-

into use for the

used

nitrate or hydrochlorate of pilocarpine, all

jaborandi

is,

and

how-

and needs to be used

solution at least four times the strength of eserine.

in a

has

the advantage of being less irritating locally than eserine,

and of remaining longer undecomposed

Now all,

First of

as to the therapeutical uses of myotics.

they are of signal value

eye.

in solution.

For

glaucomatous states of the

just as mydriatics are capable of inducing a con-

dition of increased tension of the eyeball,

up and retracting the

folds of the

iris

by puckering

into the angle of

the anterior chamber, and so obstructing the outflow of the intra-ocular fluid

by blocking the

filtration

area

;

so on

the other hand, myotics relieve the condition of impeded

25 outflow,

by contracting the pupil and stretching the

iris

out of the angle of the anterior chamber, and so widening of the

the interspaces

which the retained

ligamentum pectinatum, through

fluid finds escape.

a forerunner of

means

operative treatment, and as affording an immediate

of at least temporary relief in cases of glaucoma, before

operation can be resorted

to,

myotics are of undoubted

value.

In the treatment of mydriasis, the result of interference

with the action of the branches of the oculo-motor nerve,

whether from the result of syphilis or rheumatism, the local stimulant effect of myotics

valuable as an aid to the

general and special constitutional treatment. In corneal ulcers of asthenic type, such as are found in infants

and adults suffering from mal-nutrition, and

cases of corneal abscess and ulcer where necrosis

and perforation threatened, myotics are very valuable

They produce

remedies.

and augment

secretion,

in all

rapid local

rapid increase of vascular supply

and

at the

same time reduce the

tension of the eyeball, thus increasing chances of repair

and reducing

risks of perforation.

easily estimated,

nutrient stream its

centre

;

and

when we remember is

that the course of the

from the margin of the cornea towards

also that the nutrient supply comes, for the

superficial corneal

layers,

from the conjunctiva, and for

the deeper layer from the sclerotic. of a

Their direct value

remedy which

The

beneficial action

lessens tension of the eyeball,

and so

removes interference by pressure, with the currents of the vascular supply and

And

its

products,

thus very apparent.

an ulcer be threatening perforation,

may

easily understood that the intra-ocular pressure, even

be not

abnormally increased, acts with relatively greater force

upon the thinned and ulcerated part of the cornea, which offers less resistance,

than upon the firmer healthy portion.

Diminution of the internal tension by the use of myotics here becomes of primary importance, and should be at

once secured. I

will

now

interesting

call

your attention

physiological

myotic, equal

strength,

together, the myotic acts

mydriatic. it

that

fact,

moment

for a if

to the

a mydriatic and a

be introduced into the eye

first,

but

soon overcome by the

This points to the practical deduction, that

be necessary to counteract the

of a mydriatic,

effect

atropine, for example, as in the case of the precipitation of

an attack of glaucoma by sufficient to rest

incautious

its

use,

so that the atropine to

sum up

may

not re-assert

its

not

First, the indications for the

instillations,

influence.

briefly the indications

cations for the use of mydriatics

(a)

contented with one or two applications of

a myotic, but to keep up the effect by repeated

Now

and contraindi-

and myotics

in treatment.

use of mydriatics.

Their sedative use, to

relieve

pain

and

spasm where the terminations of branches of the

reflex

fifth

pair

of nerves are irritated, either by injury, or by the presence

27 of invading leucocytes, as infiltration, especially in

The

(b)

dilating

certain

forms

of corneal

phlyctenular keratitis.

power

a most valuable aid to other

treatment in inflammation of the

therapeutical

drawing

outwards and preventing

its

iris,

adhesion to the

capsule of the lens, and also in wounds and in perforating ulcers near the centre of the cornea,

away and preventing

its

incarceration.

by drawing the

iris

It is also useful in

permitting an extended examination of diseased and ab-

normal conditions of the deeper structures of the globe, through the widely opened pupil. Their paralysing power

(c)

of use in overcoming

spasm of the accommodation, and by suspending the action of the ciliary muscle, to permit an accurate estimate to be

gained of the nature and exact amount of refractive

The

be noted (a)

errors.

contra-indications in the case of mydriatics are to :

In cases of increased intra-ocular tension except

where there

increase

of tension with absolutely entire

posterior synechia, here the well-known action of atropine in

limiting secretion

may be

of use,

operative measures be

not warranted. In diseases of the ciliary body,

(b)

becoming

when the

indications for the use of myotics are

(a)

In natural and

it is

soft.

The when

eyeball

artificial

necessary to overcome

it.

dilatation of the

pupil

28 (b)

In wounds and perforating ulcers at the corneal

margin, in order to draw the

inwards, and prevent

iris

its

prolapse and subsequent incarceration in the cicatrix. (c)

a stimulant locally in cases of impaired function

of the accommodation, such as the paralysis of the ciliary

muscle following diphtheria. (d) iris,

diminish intra-ocular pressure by stretching the

and so restoring the routes

for

passage of fluids through

the openings in the ligamentum pectinatum. (e)

influence nutritive supply

by lessening the

ten-

sion in corneal ulcers with suppurative tendencies.

The

contra-indications in the case of myotics are

(a)

Their prolonged use

liable,

through the great

vascularity they encourage, to bring on a low form of

and so give

rise to

adhesions between the

iris

iritis,

and the

lens

capsule. (J?)

They should not be used

secondary glaucoma

with complete posterior synechia, because of their power of increasing the intra-ocular secretion. (c)

Toxic

effects

should be watched

for,

and when

present should cause the administration of the drug to be

immediately suspended.

SECTION

II.

ASTRINGENTS, STIMULANTS, AND IRRITANTS. Astringents, stimulants, and irritants are local remedies

which

may

be appropriately classed together, because the

differences in their actions are for the

of degree rather than of kind. effect rather

most part differences

They vary

than in diversity of method.

in intensity of

Thus, the same

substance used in solutions of varying strengths

may

either astringent, stimulant, or irritant.

When it

the slightest, or purely astringent effect

tissues,

and so to

restore a relaxed tissue to

This

gree of firmness.

inflammation, and

more or

less definite

desired,

about a simple contraction of the

in order to bring

its

normal de-

necessary in certain stages of

probably limited to producing a

degree of contraction and condensation

of the relaxed tissues, with which the reagents employed are

brought directly If the

in contact.

same reagents be used

in stronger solutions

are needed to produce the astringent effect, they stimulants,

than

become

and by restoring the tone of the blood-vessels

and rousing the natural action, either

forces,

by hurrying

they

stir

up flagging curative

on. repair of lost tissues, or

promoting the regression and absorption of inflammatory products, and so restore the to their

normal conditions.

weakened and

altered tissues

3Q Still

stronger applications of the

and give

irritant effects,

may

This dilatation

may

of the vessels.

be only of sufficient extent to produce

intense redness and congestion it

same substances produce

rise to dilatation

or, if

;

pushed

further,

still

produce an actually disorganising inflammation.

The

slighter effects of these remedies are useful in the

simpler forms of conjunctival inflammation, and in the earliest

and

latest stages of the

more severe forms

;

and

the relaxation which follows the over-excitement of inflam-

mation generally. Their more profound for the

active

effects are reserved

and severe stages of inflammation of

the conjunctiva,

when speedy changes

alterative action

nutrition,

diseased tissues and their secretions,

are needed. I

will

take

first

special indications for

all

its

the astringent action, and the

employment.

In the conjunctiva, as in

all

tissues, there is a

normal

degree of compactness, which, during the progress of an inflammation, becomes loosened the vessels and

by the engorgement of

by consequent exudation of plasma and

invasion of leucocytes.

And,

like inflamed

mucous mem-

branes generally, the conjunctiva undergoes great relaxation,

owing

its

lax structure and yielding attachment to

the firmer tissues beneath

inflammation

surface.

When

the acuteness of the

past, the condition of relaxation remains,

accompanied by more or its

it.

The

less

muco-purulent secretion from

restoration of tone

and the consequent

checking of secretion, are the objects sought by the use of pure astringents, or of more powerful re-agents, in the limited astringent degree of their action.

After care has been taken to distinguish and remove as far as possible the exciting cause, this astringent action

appropriate in the relaxed conditions of the conjunctiva

which follow the excessive hypersemia induced by cold and the irritation of foreign bodies, affections of the lachrymal passages, exposure to irritating vapours, and the effect of over-strain of the eyes.

equally appropriate in the

It is

chronic stages of follicular conjunctivitis, and in the

initial

and terminal stages of the more severe forms of conjunctivitis

â&#x20AC;&#x201D; catarrhal, blenorrhceal, and The

purulent.

astringents in general use are the pure vegetable

astringent tannin, which in the form of the glycerine of better, of

tannin, or

still

vaseline,

very useful

tiva,

and

an ointment compounded with

simple relaxations of the conjunc-

the later lingering stages of follicular and

granular conjunctivitis.

The mineral

astringents in general

use are the nitrate of silver in the proportion of half a grain, to a grain, to

an ounce of water

mercury

sulphate

and chloride of

;

perchloride of

the proportion of one-eighth of a grain

half a grain to

two grains

the

zinc,

alum, and the acetate of lead

â&#x20AC;&#x201D;

to the

;

the

sulphate of copper,

the proportion of from

ounce of water.

Closely allied to the astringent action of these remedies,

apparently only an extension of

it, is

their stimulant action.

using them in increased quantities, that

to say, in the

proportion of four or five grains of the sulphate of zinc, or

alum

;

copper

two grains of the chloride of ;

two to four grains of the

sulphate of

zinc, or

nitrate of silver

to the

ounce of water,

or a

;

quarter to half a grain of the perchloride of mercury

â&#x20AC;&#x201D;

all

stimulant effects are produced.

full

In this category should be included one of the favourite

eye applications of the general profession, the vinum

local opii,

which owes

more than

its

value to the alcohol in

to the opium.

It is little

used

its

â&#x20AC;&#x201D;

composition

at all

â&#x20AC;&#x201D; by

ophthalmic surgeons.

These stimulant of conjunctivitis,

effects are useful in the various

forms

when the acuteness of the inflammation

has in a measure subsided, and the bright red colour has

given place to a more livid hue.

when

in the later stages, repair is at

matory products are slow

;

as before mentioned,

a standstill, or inflam-

being absorbed.

Besides the stimulants just mentioned, which are used in solution, there are others

made up into ointments. The stimulant powders

boric acid.

form of dry powder,

and

into the conjunctival sac,

in the later stages of interstitial keratitis,

infiltration is

tenular keratitis,

in the

in general use are calomel,

These are dusted

and are employed

when the

used

when

slow to clear away irritation

;

and

in phlyc-

and the so-called photo-

phobia have subsided. They are also useful in phlyctenular conjunctivitis,

cornea.

and

in indolent

and vascular

ulcers of the

Boric acid effects

If a considerable quantity of

mischief.

dusted into the conjunctiva, some lower palpebral

Whether

this

acting upon

fold,

due

and

to the chloride of

an irritating mass.

sodium it

mentioned

not prepared to say.

calomel be

apt to remain in the

collect into

and converting some of

perchloride of mercury, as or not,

ill

may produce

but calomel, unless carefully watched,

;

much

a harmless substance, and produces no

the tears

into an irritating

in the text-books,

But

have more than

once seen a large superficial slough of the lower palpebral conjunctiva follow such a careless application.

Stimulating ointments act very powerfully, and are

most

useful.

The

salts of

mercury, especially the yellow

oxide, the red oxide, and the nitrate,

all

in free dilution,

act very beneficially in chronic conjunctival diseases, in

the various forms of keratitis,

past,

and the

infiltrations

when

and

the acute stage

remain unabsorbed.

The

ments of the yellow and red oxides are best used

oint-

in the

strength of half a grain, or a grain, to the drachm of ben-

zoated lard, or vaseline

;

and that of the

proportion of five to ten grains of to the

drachm of

corneal

most

lard or vaseline.

and conjunctival

Ung Hydrarg :

the

Nitrat

Besides being useful in

affections, these

beneficial in blepharitis,

nitrate in

by which

ointments are

meant the

in-

flamed condition of the muco-cutaneous margin of the eyelid, so

among

common

badly-nourished children, especially

the poor.

The

irritant effect of local applications is really

aggravation of the stimulant effect, and that

it is

stimulus

needed. is

only an

but rarely

only wanted when the response to

It is

very slow and imperfect, and care must always

be taken that the

be not carried too

effect

troublesome inflammation set up. in

far,

far

and actually as

and

their results are concerned,

your attention what

it is

sufficient to direct to

have said as to the use of stimulants.

There are two especial cautions to be observed

The

use of this class of remedies. of

use

their

the treatment of superficial inflammations of the eye

them

much

to the causation of

parable

damage

to sight.

be used when there

this

simple caution has led

needless suffering, and to irreIrritating remedies should never

any evidence of disease of the

deeper membranes of the eye. for

It is

by no means uncommon

ophthalmic surgeons to see cases of

and even

whole

strictly limited to superficial affections of the

Ignorance or neglect of

eye.

to the

and emphasizes the injunction, that

collectively,

their use

first refers

in the

choroiditis, greatly

sclerotitis,

and

iritis,

aggravated by the use of local

irritants -through

want of knowledge of the true character

of the disease.

less

all

these affections there

more or

redness and congestion of the superficial vessels

the eye, but

must not be supposed on that account

alone that astringents or stimulants are indicated. attempt, at least, at

made

more accurate

diagnosis, should

before deciding on local treatment.

An be

In order that a

mistake

may

attack, as to

not be

made

whether

it is

a conjunctivitis, or an

earlier stages, care should

judge by comparison of the

and

eyes,

whether the

its

iris

iritis in

the

be taken to notice the action of

the pupil in the rapidity and regularity of light,

inflammatory

at the outset of an

its

response to

two

irides of the

of the inflamed eye has lost any of

brilliancy of colour.

The

character and degree of the

pain attending the attack should also be noted, bearing in

mind

mem-

that the pain in inflammation of the deeper

branes

excess of the apparent inflammation, whilst in

superficial inflammation

and congestion are

the redness

And

altogether out of proportion to the pain experienced. in

distinguishing between

early

which

iritis,

there

sclerotitis,

with or without an

one simple means of

differentiation,

not generally taught, and which the most inexpert

may employ/

It consists in

taking the lower eyelid under

the point of the forefinger and using face of the eyeball from the cornea

the same time

sweep the

downwards, making

firm pressure on the globe.

The

vessels of the ocular conjunctiva will be for the

moment

emptied, and the white sclerotic will be seen clearly,

any congestion of the

sclerotitis,

and

iritis,

zone of straight vessels visible

and unaltered by

corneal pink zone

sclerotic,

exist, the

will

the

But

such as accompanies

well-known peri-corneal pink

be uncovered, and

the pressure.

present,

blood-

vascular engorgement be limited to the conjunctiva. if

sur-

will

Whenever

local irritant

remain

this peri-

must be used.

3ÂŤ

The second important astringent, lead,

and

one mineral

caution refers to

which

its salts,

have refrained from

noticing specially earlier in these remarks, in order that notice of

them may

receive greater emphasis

This

the acetate of lead in particular. stock, routine

remedy

salt

most dispensaries

â&#x20AC;&#x201D;

allude to

has become a

treatment

in the

of superficial inflammations of the eye, and lead lotion

seems to be prescribed almost as a matter of course by

many

an earnest protest. liarity,

Against

practitioners.

which should exclude

remedies

this

advantage, that

custom

would express

Acetate of lead has a dangerous pecu-

applications to the eye.

having

this

and

class,

if it

from the

list

brought

has the in contact

enormous

enters

into

forms

chemical union with the corneal

dense,

opaque,

permanent

film.

dis-

with a cornea

epithelium ever so slightly abraded,

its

of local

has no advantage over other

tissue,

Many

once

and eyes

have been irreparably damaged by the use of acetate of lead lotion, which, without

sound recovery.

it,

would probably have made a

SECTION

III.

CAUSTICS.

come now

on caustics and

their uses in the

distinctly purulent forms of conjunctivitis.

In these cases

to touch

the salts of silver and mercury are the most trustworthy,

and among them In

value.

all

the nitrate of silver stands foremost in

cases of catarrhal, blennorhceal, and purulent

all

ophthalmia, from whatever cause, the nitrate of silver

proportion commensurate with the stage of activity of the disease

the surest remedy.

In the earlier stages, whilst

the discharges are watery and mucous,

weak

solution,

the

present,

necessary to use

But

it is

above

all

;

where copious purulent discharge it

in in is

from four to thirty grains

must be borne

mind

applications of the nitrate of silver, or that

must be used

one or two grains to the ounce of water

active stages,

to the ounce.

using strong-

any other

caustics,

things necessary to limit their action to

the parts actually needing

it.

should be applied carefully, and

ensure this the caustic all

superfluous particles

should at once be neutralized and washed away by copious affusions of

warm

water.

the best neutralizing agent

with this converts

all

In the case of nitrate of silver is

chloride of sodium

;

contact

the superfluous nitrate of silver into

the chloride of silver, which

inert.

In very severe cases of purulent ophthalmia, especially

38 those owning a gonorrheal origin, the nitrate of silver may,

by those accustomed stick

;

that

in the

it,

be used

the form of mitigated

form of one part of nitrate of

silver,

melted with two or three of nitrate of potash, and moulded into shape.

When

form

this solid

used to touch the

conjunctiva great care must be taken to keep the cornea free,

and

to follow the application

immediately by

free

washing with a strong solution of chloride of sodium.

The

perchloride of mercury

of cases as the nitrate of its

silver,

use in strong solutions

greater and