Leading articles.

Therapeutic Indications for the General Practitioner in Ophthalmic Practice.

CHARLES H. FRANCIS, M. D., CHICAGO, ILL.

In no other branch of medicine is a knowledge of specific medication of more value than in the treatment of diseases of the eye. A remedy prescribed without regard to its most direct indication, is here as elsewhere, destined to meet with failure.

"EYE WATERS."—Under this heading will be considered boracic acid, sodium biborate, sterile water and normal salt solution, all of which are commonly used at different times in the preparation of so-called colyrii.

Briefly, the indications for these remedies, regardless of what the disease may be, are: redness or swelling of the conjunctiva of the globe or lids; or of the lids themselves, enlarged blood vessels, enlarged follicles in the conjunctivae, ulcer or injury of the cornea or conjunctivas; mucus; mucopurulent or purulent discharge; itching, smarting or burning of the "eyes," and increased or decreased lachrymation. One of these remedies should always be used freely after the removal of a foreign body, which has been imbedded in the cornea.

Boracic acid is more especially indicated in the acute cases, with a discharge from the conjunctival sac, and in ulceration or injury of the cornea or conjunctivae: It possesses more antiseptic power than the other remedies mentioned.

Borax solution is directly indicated in the chronic cases, with little or no discharge, with itching or burning, and increased or decreased lachrymation. Boracic acid and sodium biborate should always be used in the strength of a saturated solution, and slightly warm. Normal salt solution and sterile water should only be used in the absence of the above remedies. The physician should always dispense these remedies himself. It is legitimate to color the solution with a few drops of a 1 to 2000 potassium permanganate solution, or with the same quantity of a 5 per cent argyrol solution.

The normal conjunctival sac, including the cornea, is constantly invaded by a variety of micro-organisms. These bacteria seem to do little or no harm, except when owing to "exposure to cold," certain forms of disease or traumatism, foreign bodies, etc., the conjunctivas is so changed that they find a point of entrance and soon produce some variety of inflammation or ulceration of, the conjunctivae or cornea.

Antiseptics and germicides of sufficient strength to destroy bacteria, cannot be used in the eye without injury to that organ. We must therefore use our solutions in such quantities, and often enough to wash away the germs, and to keep them washed away until such time as the tissues have sufficiently recovered to resist further invasion.

The use of large quantities of mild antiseptic solutions in the conjunctival sac at frequent intervals, is the key to successful treatment of many of the inflammatory diseases of the conjunctivae and cornea; and is a method almost entirely neglected by a large majority of the physicians in general practice. It does not matter materially, whether we use boric acid, borax, normal salt solution or sterile water, provided the solution be sterile, and used in sufficient quantity, and used often.

We should get into the habit of irrigating the eye, instead of dropping in a few drops of "eye water." In acute catarrhal conjunctivitis of mild severity, I would say that the ordinary medicine dropper should be filled at least five or six times and poured "into the eye" every hour or two. In chronic cases this quantity used three times a day is sufficient. In purulent or gonorrheal ophthalmia, it often becomes necessary to direct that the eye be irrigated almost constantly with an irrigator or fountain syringe containing one of the above solutions. Too much force of the stream should be avoided by placing the irrigator not more than one or two feet above the patient's head.

MORPHINE.—This remedy is mentioned here simply to be condemned. I believe it should never be placed in any solution to be used in the eye.

COCAIN.—Cocain should never be used in the eye except when some operative procedure is to be undertaken, or for the purpose of examination. A four per cent solution is the proper strength to use. A few drops of this is sufficient for the removal of foreign bodies, etc., while for operations on the eye it is necessary to use six to eight drops each time and to repeat at intervals of from three to five minutes until it has been used three or four times. The anesthetic effect is greatest at the end of about ten minutes.

Cocain causes the patient to wink less frequently, thereby exposing the cornea to the air for longer periods of time with a tendency to dryness. The infrequent winking also permits bacteria to collect on the cornea which otherwise would be brushed away by the normal motion of the lids. The tendency to ulceration of the cornea is decidedly increased by the prolonged use of this remedy.

ATROPIN.—The indication above all others which calls for the use of atropin in the eye is the so-called "circumcorneal zone of redness." This may be described as a pinkish- or purplish-red flush, immediately surrounding the cornea and extending away from it but a short distance. It seems to be made up of very small, hair-like blood vessels which radiate in all directions from the margin of the cornea. They are more or less straight, deep seated, and do not move when the conjunctiva is moved.

This symptom does not occur in diseases of the conjunctiva alone, but is associated with disease of the cornea and sclera, and the deeper structures of the eye. The redness is not the brick-red color which is present in inflammation of the conjunctiva alone. In that condition the blood vessels are large and tortuous and the redness more pronounced away from the cornea, and toward the fornix; and the blood vessels move when the conjunctiva is moved.

Other indications for atropin are: a contracted pupil which responds sluggishly or not at all to light; severe pain in the brow or parietal region, which is worse at night, and manifestly due to the inflammation in the eye. Atropin should always be used in perforating injuries of the eye-ball to place the eye at rest, and minimize the tendency to inflammation. Ordinarily a one per cent solution should be directed, using two or three drops every three to six hours as required.

The use of this remedy in refraction work, and to facilitate the examination of the fundus, is too well-known to require mention here. Atropin is contraindicated whenever the tension of the eye-ball is above normal.

ARGYROL.—For the man in general practice, I believe this remedy should displace nitrate of silver entirely in his eye work. The remedy may be used in almost any strength without injury to the eye. Argyrosis seldom ever occurs. For painting the conjunctivae of the lids, or dropping into the eye, by the physician, a 20 per cent solution is the correct strength. After being allowed to remain on the conjunctiva for a few seconds or more, it should be freely washed away with boracic acid solution. When giving it to the patient to be used at home, which should seldom, if ever be done, not more than half this strength should be used.

It is astringent and germicidal, and indicated in any disease of the conjunctivae, where the papillae or follicles are enlarged or the conjunctiva roughened. It is one of our very best remedies in purulent or gonorrheal conjunctivitis. Use three or four drops in the eye three times a day. For painting the lids in trachoma, after the granules have been expressed, it should be used every second day.

POTASSIUM PERMANGANATE.—This remedy is indicated wherever the gonococcus is found. It should be used in a 1:3000 solution. In gonorrheal conjunctivitis, the eye should be irrigated with this solution about every six hours. It undoubtedly has a marked effect in this disease.

HOT WET DRESSINGS.—These dressings changed every two hours during the day, and every four hours at night, are of great service in certain diseases of the eye. They are indicated in all cases where infection is pronounced, and the nutrition of the cornea is impaired; as indicated by haziness, inflammation, or ulceration of this tissue. They stimulate absorption and nutrition, and subdue swelling and inflammation.

Quite a large quantity of cotton is wet in a hot saturated solution of boric acid, wrung partially dry, and placed over the eye; this is covered with six or eight thicknesses of gauze and the whole dressing quickly covered with oiled silk. When properly applied and used according to indications, it is a most reliable agent.

COLD COMPRESSES.—Cold is indicated in the early stage of eye disease. In acute inflammation of the conjunctiva and lids, with great swelling, heat and burning, it gives prompt relief. In penetrating wounds of the globe it should be applied early to lessen the liability to extension of inflammation. As a means to prevent "black eye" following a blow or other injury, it is excellent. In an effort to abort styes, it is sometimes of service. Since cold impairs the nutrition of the cornea, it should not be used too long at a time; particularly in those diseases where ulceration of the cornea is likely to occur.

The best method of applying cold is to use the so-called ice-compresses. These are made by shaping cotton into spheres about the size of a small orange and covering them with one thickness of gauze. Place a cake of ice in a bowl beside the patient's head, put about four of these compresses on the ice, first wetting them a little so they will not adhere to the ice, and, with the patient lying down, place one of these compresses over the closed lid for a minute or two, then place it back on the ice, putting another in its place, changing in this manner from one-half to an hour, then rest for two hours, when the process may be repeated.

HYDRARGYRUM OXIDUM FLAVUM.— The yellow oxide of mercury has acquired an enviable reputation in the treatment of blepharitis marginalis, and corneal scar. It is also used in follicular conjunctivitis and in thickening of the conjunctivae from any cause. Six grains of the powder should be placed in a glass mortar, and dissolved with half a dram of glycerin. To this, add one ounce of white vaselin and carefully work the mercury in, until the whole is a smooth yellow mass.

For corneal scar, place a quantity nearly the size of a lentil into the lower fomix, then, with the eye closed, massage the cornea gently through the upper lid. Use it once a day, at night. It should not be used in the eye until the acute stage of inflammation has subsided. In blepharitis marginalis the crusts should be carefully and thoroughly removed with warm water and warm borax solution, and the lids dried, after which a quantity of the salve should be thoroughly rubbed into the lid margins and hair follicles. This may be repeated twice daily. This remedy should never be used in the eye while the patient is taking any form of the iodides internally.

ZINC SULPHATE.—I use this remedy but little. There is one condition, however, which resists other lines of treatment very stubbornly but responds readily to zinc sulphate. I refer to an infection by the Morax-Axenfeld diplobacillus. This may be recognized microscopically with little difficulty. Clinically it resembles ordinary acute catarrhal conjunctivitis, but is more persistent and inclined to chronicity unless treated by zinc. One symptom aids materially in the diagnosis; this is an erythema of the skin just at the lid margins, particularly at either angle of the palpebral fissure. One grain of sulphate to an ounce of boric solution, is the strength ordinarily prescribed. Of this solution two drops are used in the eye three times a day.

ESERIN.—Eserin solution, one-half grain to the ounce, is used to lower the tension of the globe when this is increased from any cause. It may also be used to draw the iris toward the pupillary space, where there is danger of perforation in marginal ulcer of the cornea. Use one drop every three to six hours. It is a remedy to be relied upon in chronic simple glaucoma. In acute inflammatory glaucoma, it will prevent injury to the nerve head until an iridactomy can be performed. It is often used to prevent prolapse of the iris into the wound during the first twenty-four hours; following the various operations necessitating the opening of the eye-ball.

The use of constitutional remedies in diseases of the eye often resolves itself into treating gout, rheumatism, nephritis, syphilis, anaemia, etc. It is a very important part of the daily work of the oculist and one too often neglected. Thorough examination should be made and the indicated remedy prescribed.

Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.