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their chief glory is their duality of expression. Yet beyond the power of definition there is very little to diagnose from. Once it was said that a mark of distinction was the contagiousness of diphtheria; but now we know that diphtheria is not always contagious. Again, it has been said that croup was merely a local inflammation, whereas diphtheria was a special constitutional affection; now we have come to look upon croup as both constitutional and local in its relations. The albuminuria of diphtheria was characterized as diagnostic; but albumen has been found in the urine of the patient suffering from croup. The manifestation of asthenia, and the sequelae of paralyses and great depression characterize some cases of croup as uniformly as is the rule in diphtheria. A difference in the character of the exudation has been claimed, but is abandoned. I had an opportunity some time since of examining several specimens of sputa and false membrane removed from the throats of children dying of croup and diphtheria. Microscopical observation revealed but one difference; and that was that in diphtheria the exudation is planted firmly into the tissues, while in croup it is a superficial coagulation of lymph on the mucous membrane. In diphtheria the deeper tissues are destroyed, so that the membrane could not be peeled off. Another and a beautiful characteristic, microscopically revealed, relates to the presence of micrococci. In any partially decomposed mucus they are to be found scattered through the substance. This is the case in the croupal membrane and sputa, whereas in diphtheritic membrane these organisms appear only in collections or nests.
It seems, however, from all of the present data, that this question of diagnosis resolves itself into one conclusive ætiological truth, which, briefly expressed, is as follows: Croup is due to a constitution supported by blood of a certain condition, being acted upon by a certain condition of the atmosphere, which condition owes its peculiar influence to impalpable germs which might or might not be diphtheritic in origin. That germs procreating croup might originate from diphtheritic deposit is not necessarily hard to believe. In point of fact, it may be held that such germs might and doubtless do arise from other diseases than diphtheria. Measles or typhoid fever may furnish them just as readily. Until we come to know intimately the character of these germs, we can only estimate their value; yet there is every probability that their origin is from one fixed state, wherever placed. Interwoven with this remains the self-evident fact that germs born of the diphtheritic membrane have, by virtue of their birthright, more potent ability to produce a given character in the laryngeal membrane; which membrane, because of this relationship, manifests a disposition to put on a diphtheritic aspect.
Therefore it may be truthfully said that beyond question, those forms of croup which are somewhat asthenic, and manifestly of a diphtheritic nature, are due to the malignity of the influence of germs but recently derived from the condition of diphtheria, and only one remove from that disorder.
EXCERPTS FROM OPHTHALMIC PRACTICE.
H. C. ANGELL, M. D., BOSTON.
[From advance sheets of "Diseases of the Eye," sixth edition, now in press.]
THE more experience one has in granular or trachomatous conditions of the conjunctiva, the more one is inclined to prefer the milder to the so-called heroic treatment. Caustics and strong astringents are sometimes necessary, but their use should not be prolonged, and they may often be dispensed with to the advantage even of eyes that appear to tolerate them perfectly. Thus, I find myself of late years substituting a crayon of alum in cases where formerly I should have used a crayon of sulphate of copper.
Naturally, much depends upon the fact as to whether ciliary irritation exists to any great extent. If it does, caustic or astringent applications are not borne well, and do harm rather than good. Pain, photophobia, and lachrymation indicate ciliary irritation; and when considerable, contra-indicate astringents, apart from other considerations. In some of these cases one should carefully regard the condition of the iris. Atropine will sometimes be useful.
Recently, as an intercurrent application, I have found boracic acid, four to six grains to the ounce of water, serviceable. In acute or sub-acute cases the boracic acid, being a disinfectant as well as a very mild astringent, may be used freely several times a day. When used in a four-grain solution, in cases of even marked ciliary irritation, it is usually borne well, and is often decidedly beneficial.
PROPHYLAXIS OF INFANTILE OPHTHALMIA.
It is advised to wash the lids of the child in a one per cent solution of carbolic acid directly after birth. Possibly boracic acid, which is a milder and safer antiseptic, and could be used in a much stronger solution, would be equally efficacious. At the Lying-in Hospital at Leipsic the following prophylactic treatment is adopted: The eyes of the infant are immediately washed out with water, a drop of a two per cent solution of Argent. nit. is instilled, and the eyes are covered for twenty-four hours with
cool compresses moistened in a two per cent solution of salicylic acid. These measures were first adopted for the infants of diseased mothers only, but subsequently extended to all others. The result was, that for six months, in two hundred infants so treated, not one case of ophthalmia occurred. In one case where the application of the Argent. nit. had been accidentally neglected, a slight case of conjunctivitis appeared.
A much simpler treatment is employed at Halle; viz., for nine months the eyes of the infants were washed out, as soon as the head was born, with a one per cent solution of carbolic acid. This treatment reduced the percentage of ophthalmia from 12.5 per cent to 3.6 per cent, and the disease when it did appear assumed a milder form.
It would seem, in view of the above facts, that a grave responsibility for the condition of the eyes of the new-born rests upon the obstetrician. I recall last year an otherwise perfectly healthy infant, sent to me by the family physician for treatment: the child was four weeks old, and both cornea were wholly destroyed from purulent inflammation. Of course the child was totally blind, and was to go through life totally blind. Such cases would be almost impossible if the prophylactic treatment above suggested were generally observed. It is very feasible for a physician to carry out the treatment. A small bottle of a saturated solution of boracic acid could be conveniently carried about, and when used, diluted with an equal part of water. This would give a solution of fifteen to eighteen grains to the ounce. Or a fourgrain solution of carbolic acid might be used if preferred.
DIAGNOSIS OF IRITIS.
This is made comparatively easy by a careful observance of the objective symptoms already mentioned; still, in certain cases, some of these are more or less masked by the great injection of the conjunctiva, and some may be absent. Thus, the pinkish zone around the edge of the cornea may be hidden from sight by the vermilion redness of the congested conjunctiva. In such cases a general practitioner, I have observed, may mistake the disease for a conjunctivitis, and this may lead to the prescription of an astringent eye-wash, which is always contra-indicated in an iritis, and always aggravates the severity of the affection; or it may lead to the neglect of the use of Atropine or some other mydriatic, an event too often deplored after an eye is lost. But in these doubtful cases, if the physician will take his patient near a window and test the movement of the pupils, he will find a sluggish movement of the iris if it be inflamed; but if the movements of the pupil in contraction and expansion are active and natural, he may be quite sure that he has not an iritis. When
there are elements of uncertainty in the case, avoid all irritating applications, and then, at least, no harm will ensue. If it is an iritis, it will develop unmistakably in a short time.
The operation of sclerotomy is finding considerable favor with many ophthalmic surgeons as a substitute for iridectomy. It does not appear to reduce tension so effectually as iridectomy, nor is it so reliable for most forms of glaucoma. It is to be commended for chronic glaucoma simplex, in which iridectomy is sometimes of little service, and may perhaps be advised in cases of absolute glaucoma, where, sight being gone, an operation for the relief of pain is indicated. The operation is usually done with the narrow cataract knife, which is entered near the corneal margin of the sclera as if to make a small flap, some two or three mm in height. When the imaginary flap is about two thirds finished, and the aqueous humor has escaped, the knife is slowly withdrawn. The operation is difficult, and there is not unlikely to be a prolapse of the iris; in which case the iris is cut off, and the operation results in an iridectomy. In order to avoid this prolapse of the iris, it is advised to drop a one per cent solution of eserine into the eye before operating, and to fix the eye both above and below during the operation. On no account should the knife be withdrawn before the complete escape of the aqueous humor. The after treatment is similar to that of iridectomy.
THE CAUSE OF CATARACT
Is probably faulty nutrition of the lens. This may be due to old age, as in senile cataract; to disease of the kidney, as in diabetic cataract; or to abnormal change in the deep structure of the eye, as in secondary cataract. There is also a congenital cataract, dating from birth, and a traumatic cataract, from injury.
Recently, investigations, chiefly by Michel, in regard to the influence of the general circulation upon the nutrition of the eye, go very far to prove that cataract is generally caused by sclerosis of the carotid arteries. Thus, in the course of ten months, fiftythree cases of cataract observed showed a sclerosis of the carotid in every case. In some, where one eye only was affected, there was sclerosis of the carotid on the same side only, or it was more highly developed on that side; while in double cataract the opacity of the lens was most advanced on the side corresponding to that in which the sclerosis of the carotid was greatest. In addition to the sclerosis, there was also in some of the cases an enlargement of the thyroid gland. The ages of the patients varied from eight to eighty-one years. It is supposed that the diminution in the supply of blood to the eye produces, after some
time, an opacity of the lens, due to insufficient nutriment. It is not probable that every case of cataract will show a sclerosis of the carotid. There may be senile marasmus, or a feebleness of circulation after exhaustive disease, congenital insufficiency of the arterial circulation, abnormal growths pressing on the carotids, any of these may also cause opacities of the lens.
SUPPURATING INTERSTITIAL KERATITIS.
This outline of a case of apparently total destruction of the cornea from suppuration, as I at first considered it, may be instructive as showing the value of paracentesis combined with the application of heat in desperate cases.
On June 7, 1879, Capt. B— aged sixty, master of a whaling vessel, was brought directly from his ship to my office. He had sailed some weeks previously, with good sight; but off the coast of South Carolina had been attacked with inflammation of the eyes, had gradually become blind, and was obliged to bring his vessel back to port. He was led to my house as a blind man, but I found vision, left eye, right eye entirely blind; he thought he could distinguish the direction of a window in the sunlight, but failed to detect the presence of a sheet of white paper moving directly before the affected eye.
There was diffuse cloudiness of the whole cornea in the left eye, but it was not sufficiently dense to completely hide the iris and pupil. The conjunctiva was moderately injected around the corneal edge. The right eye presented a very different aspect. There was deep, dark injection of the entire ocular conjunctiva, with chemosis; the cornea was yellow and opaque; the infiltration of pus between its layers was so marked a feature that I looked for its disintegration very shortly. The patient was assured that the left eye would probably be restored to fair sight, but was told that the right was inevitably lost. I instilled Atropine into both; bandaged them; gave orders for a hot fomentation to each, of fifteen minutes, three times a day. Gave him Quinine, five-grain doses, three times a day. The Quinine was suggested by his general health, which, although not specially bad, was not up to his usual robust standard. For a sea captain, he was pale.
June 9. Left eye better, cornea clearing a little. The right eye is not changed in appearance. He cannot see a white paper moving before it. Made a small opening into the anterior chamber at the lower corneal margin with a Beer cataract knife, which I consider the best instrument for this purpose if used cautiously. There was a discharge of aqueous, followed by aqueous turbid from pus; showing that hypopion probably existed also, but undetected owing to the complete corneal opacity. Same local and internal treatment continued.