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behind me gives the classification I would suggest. The medicines below the line in each group are such as I have not discussed in my lectures, but which should be mentioned in connection with the therapeutics of each region.
1. Conjunctiva.—As acting upon the mucous membrane of the ball and lids, with its glandular involutions, we have a list of twelve principal and six secondary medicines. Of these, eight correspond to catarrhal conjunctivitis of the ball—Arsenicum, Belladonna, Chloral, Euphrasia, Kali bichromicum, Mercurius, Sulphur, and Guarea. When acute, Euphrasia, Belladonna, Sulphur, Chloral, and Guarea are suitable, Euphrasia when much lachrymation is present (especially if it is acrid); Belladonna when the membrane is rather dry and burning; Sulphur when, with a slighter degree of the Belladonna symptoms, there is also itching, and when the subject is unhealthy; Guarea, in the presence of chemosis. The distinctive place of Chloral is hardly yet ascertained; it must be borne in mind as a possible alternative to any of these. Arsenicum, Kali bichromicum and Mercurius belong rather to chronic conjunctivitis. The discharges of the first are characteristically thin; but practically it is the remedy for almost every case of chronic inflammation of the ocular conjunctiva, Kali bichromicum and Mercurial preparations taking its place when that of the lids is more affected. The former is suitable when there is granulation of the membrane, leading to pannus; the latter when the Meibomian glands are more affected, thickening the eyelid, and causing profuse muco-purulent discharge. Under these last circumstances Hepar sulphuris also comes into action, its discharges being somewhat thicker; and Digitalis may find place. Hepar is also effective in inflammation of the palpebral margins (blepharitis ciliaris), where it finds an ally in Graphites when the symptoms are of a more passive character. Pulsatilla corresponds to the previously mentioned sphere of Hepar—its discharges being thick and bland; but is of especial use when the Meibomian inflammation is concentrated in a single gland, constituting hordeollum, or "stye." Staphisagria reinforces it here when this affection tends to be recurrent. When the prolongation of the conjunctiva into the lachrymal sac is inflamed (dacryo-cystitis), Silica has proved very effective; and in stillicidum lachrymarum, from obstruction of the lachrymal ducts, cure has been wrought by Graphites, by Sulphur, and by Mercurius corrosivus.
In true purulent ophthalmia, while some benefit is to got from Hepar sulphuris, from Mercurius, and from Pulsatilla, the most effective remedy is Argentum nitricum. In strumous ophthalmia any of the conjunctival remedies hitherto mentioned may find place, according to their respective indications; but when the phlyctenular character of this affection is very marked, they all yield to Rhus.
Ratanhia and Zincum correspond to that curious affection of the conjunctiva known as pterygium.
2. Cornea.—The drugs that act on the cornea are fewer in number, but their sphere is well-defined. Apis corresponds to its simple inflammation. Mercurius corrosivus and Arsenicum are suitable when the mischief is ulcerative, the choice between the two being determined by the lesser degree of inflammatory action which characterises the latter; and Hepar sulphuris where suppuration occurs. Euphrasia and Kali bichromicum are in place when the morbid process begins in the conjunctiva, and invades the cornea only secondarily. Aurum and Calcarea are suitable to a more chronic and interstitial keratitis, the former in both the syphilitic and the strumous forms of the complaint, the latter in the strumous only, where also Sulphur may do something. Several of these medicines, but chiefly Calcarea, are of avail to remove opacities of the membrane; and here we have also the aid of Cannabis.
3. Sclera.—For the affections of the sclerotic coat of the eye our dependance must be placed on the four medicines from our list which you see before you, and perhaps on Thuja, which is considered by Drs. Allen and Norton as exerting upon this membrane a more marked action than any other drug. Aconite is suitable in primary scleritis from exposure to cold, when the pain is diffused, and Spigelia, under like circumstances, when it is darting and shooting like neuralgia. Kali bichromicum is of great service when the conjunctiva is involved, and the cornea threatened. Sulphur (in the lower triturations) suits cases of a more passive and lingering character.
4. Iris.—It is of the iris as a part susceptible of inflammation that we have now to speak: as a contractile curtain it must be considered among the muscles of the eye. The only drug which has proved its power of inflaming it is Physostigma, as we have seen reason to put Mercury out of court in this respect; but the other members of my group have attained unquestioned credit in the cure of iritis. Belladonna seems effective in its simple form, such as may come on from traumatism. In rheumatic iritis, if the effusion be serous only, Mercurius may suffice, though Euphrasia and Terebinthina must not be forgotten, and Physostigma may prove the best remedy of all. In the syphilitic form, our chief reliance must be placed on Clematis and Kali bichromicum, though Thuja may be useful (as stated by Dr. Norton) in removing the deposits of lymph. Bryonia and Sulphur find place, if anywhere, in the rheumatic form, the first in the painful stage, the second to wind up the case satisfactorily.
5. Choroid.—For simple choroidal congestions, Digitalis, Ipecacuanha, Phosphorus and Santonine claim consideration. Their differential indications are hardly known, but the choice of the third would be determined by the constitutional condition. For serous choroiditis, Gelsemium seems facile princeps, and for the plastic (disseminate) form, Aurum and Kali iodatum. Rhus is reported very effective when choroiditis becomes suppurative, and constitutes the affection known as panophthalmitis.
6. Retina and optic nerve.—For simple retinal congestion, as from over-use of the eyes, we need not go farther than Santonine. In retinitis simplex, and optic neuritis before exudation has taken place, Belladonna is the great remedy; later, Mercurius and Picric acid are indicated. In albuminuric retinitis, our reliance should be placed on Mercurius (best in the form of the corrosive sublimate) and Plumbum; in syphilitic, on Kali iodatum. Strychnia corresponds to retinal hypersesthesia, Lithia and Tabacum to the opposite condition.
7. Lens.—The choice of remedies for cataract must depend rather upon the general condition and the anamnesis than on any differences in the opacity itself. The indications thereby afforded for Calcarea, Sepia, Silica and Sulphur are obvious enough; and in their absence, the other remedies mentioned may be tried in order.
8. Muscles.—Of the medicines classed as acting on the muscles of the eye, Physostigma and Jaborandi would correspond to their irritable condition, Aetata to their involvement in rheumatism, Rhus and Senega to their paralysis. Ruta and Natrum muriaticum are most effective in asthenopia.
8. Nerves.—The sensory nerves of the eyes are affected by Aconite, Colocynth, Prunus and Spigelia in the direction of neuralgia, by Belladonna and Conium in that of hypersesthesia. Its motor nerves are excited to spasm by Agaricus and Lilium, depressed to paralysis by Argentum, Conium, Gelsemium, Causticum and Senega.
TWENTY CONSECUTIVE CASES FROM DISPENSARY PRACTICE.
By John H. Clarke, M.D.
The following twenty cases, with a single exception —that of a boy who only attended once—are taken from my note-book in the order of their occurrence, beginning with the first. I have thought that by thus presenting the cases as they came, without any attempt at selection, a very fair picture might be given of what the work is like that is done at institutions of the kind. I am quite aware that much of the work here recorded is imperfect, and might have been much better done, but in spite of this, it is, as regards treatment, much more satisfactory than any I have ever seen at dispensaries under the old system—if, indeed, that can be called a "system" which is the negation of system—with which I have been from time to time acquainted.
It is, then, primarily with this object—of presenting a mirror of dispensary practice—that the cases are related. But it is also hoped that the individual cases may be found not uninstructive. To some I have appended a few explanatory remarks.
The words of my note-book have been as closely as possible adhered to. Where the medicines given were indicated by particular symptoms, these have been italicised. Where the medicines have been selected as applicable more to the general state, no note has been made. Brevity has been studied as far as consistent with clearness. The following contractions are used :—p. pulse; t. tongue; b. bowels; app. appetite; reg. regular; and cat. catamenia.
Case 1. Bronchial irritation in phthisical subject; heart disease.—Sep. 19th, 1882. Hy. H—, aet. 10, dark, florid, puny. His mother says he is wasting. Flushes frequently; has short, troublesome cough during the day. No worm symptoms. Has had night perspiration, but not now.