NURSING EYE.EAR.NOSE AND THROAT DISEASES DAVIS-DOUGLAS DAV/S. NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland Gift of The New York Academy of Medicine from Mrs. Susie Hayword -/ ' U WITHDRAWN MAY 0 8 2009 THE NEW YORK ACADEMY OF MEDICINE LIBRARY I Eye, Ear, Nose, an d Throat Nursing A. EDWARD DAVIS, A.M..M.D. Professor of Diseases of the Eye in ihe New York Post-graduate Medical School and Hospital AND BEAMAN DOUGLASS, M.D. Professor of Diseases of the Nose and Throat in the New York Post-graduate Medical School and Hospital. "Offlitb 32 flllustrattons PHILADELPHIA F. A. DAVIS COMPANY, PUBLISHERS 1918 OCT -11951 OF MEDICINE 2812*4 COPYRIGHT, 1905, BY F. A. DAVIS COMPANY. [Registered at Stationers' Hall, London, Eng.] Philadelphia, Pa., U. S. A. The Medical Bulletin Printing-house, 1914-16 Cherry Street. PREFACE. While this little book has been written primarily for the use of nurses, students and general practitioners will, we believe, find it of great assistance to them also. It is not a treatise in any sense of the word, but is meant simply as a guide for the intelligent care and nursing of the various dis- eases of the eye, ear, nose, and throat, and to instruct the nurse as to her exact duties during and following operations upon these organs. Antisepsis and asepsis have received particular atten- tion, since, above all, the nurse should know the all-impor- tance of surgical cleanliness. The methods of preparing the numerous antiseptic and sterile solutions and dressings have been given in detail, while the various remedies required in the treatment and nursing of these special organs, their preparation, sterilization, and exact method of application, have been considered fully and most carefully. In fact, we have endeavored to show the nurse how to do things and cor- rectly, because, in treating such delicate organs as the eye, ear, nose, and throat, the good results obtained depend fully (iii) iv PREFACK as much upon the intelligent and painstaking care of the nurse as upon the work of the physician himself. A brief outline of the anatomy and physiology of the eye, ear, nose, and throat has been given, in order that the nurse might better understand the subjects under consider- tion. Dr. Davis has written the chapters on the eye; Dr. Douglass, those on the nose, throat, and ear. A. E. D. B. D. New York. CONTENTS. Pakt I.—Nursing of Eye Diseases. chapter I. Necessary Requirements for Special Nursing; Anatomy and Physiology of the Eye. page Necessary Requirements .................................... 1 Eyebrows ................................................. 3 Eyelids .................................................... 3 Lacrymal Apparatus ....................................... 4 Ocular Muscles ............................................ 5 Conjunctiva.................................._.............. 6 Cornea .................................................... 7 Sclera..................................................... 7 Aqueous Humor ........................................... 8 Vitreous Humor ........................................... 8 Crystalline Lens ............................................ 8 Uveal Tract............................................... 9 Choroid ................................................... 9 Ciliary Body ............................................... 10 Iris ....................................................... H Retina .................................................... H Optic Nerves .............................................. 12 Orbits ..................................................... I3 Eyeball .................................................... 14 Accommodation ............................................ 14 Binocular Vision ........................................... 14 CHAPTER II. Contagious Diseases of the Eye. Definition of Contagion and Infection........................ 15 Germ Theory of Disease..................................... 16 Epidemic and Endemic...................................... 1' Antisepsis and Asepsis...................................... 17 (v) vi CONTENTS. PAGE Catarrhal Conjunctivitis .................................... 18 Gonorrhceal Conjunctivitis .................................. 27 Ophthalmia Neonatorum ................................... 34 CHAPTER III. Membranous Conjunctivitis (Croupous and Diphtheritic). Membranous Conjunctivitis ................................. 37 Croupous Conjunctivitis .................................... 37 Diphtheritic Conjunctivitis ................................. 39 Traumatic Membranous Conjunctivitis....................... 43 CHAPTER IV. Noncontagious Diseases of the Eye. Hordeolum ................................................ 46 Blepharitis Marginalis ...................................... 46 Phlyctenular Conjunctivitis ................................. 48 Ulcerative Keratitis ....................................... 51 Iritis ...................................................... 54 Cyclitis ................................................... 55 Iridocyclitis ............................................... 55 Sympathetic Ophthalmia ................................... 56 Glaucoma................................................. 60 Panophthalmitis ........................................... 62 CHAPTER V. Remedies and their Application. Antiseptics ................................................ 64 Astringents ................................................ 69 Anodynes .................................................. 74 Irritants ................................................... 74 Counter-irritants ........................................... 76 Caustics ................................................... 77 Mydriatics ................................................ 77 Myotics ................................................... 82 Anaesthetics ............................................... 83 Miscellaneous Remedies .................................... 86 Bloodletting ............................................... 88 CHAPTER VI. Remedies and their Application (Concluded). Drops...................................................... 91 Lotions and Solutions...................................... 95 CONTENTS. vii PAGE Solids ..................................................... 100 Powders ................................................... 101 Ointments and Salves....................................... 102 Heat ...................................................... 102 Cold ....................................................... 104 Subconjunctival Injections .................................. 105 Mechanical Remedies ....................................... 105 Hypodermic Injections ...................................... 107 Diaphoresis ................................................ 107 Hydrotherapy .............................................. 108 Diet ....................................................... 109 Rest ....................................................... 110 CHAPTER VII. Operations on the Eye. Antisepsis and Asepsis...................................... 112 Arrangements for Operations................................ 113 Operating Room ........................................... 113 Instruments ............................................... 114 Dressings .................................................. 116 Suture Materials and Ligatures.............................. 118 Disinfecting the Hands...................................... 119 Preparing the Patient....................................... 120 Field of Operation........................................... 121 The Different Operations.................................... 123 CHAPTER VIII. After-nursing of the Different Operations on the Eye. Plastic Operations ...........,............................. 132 Operations where the Ej^eball is Opened...................... 134 After-care of Operations for Senile Cataract.................. 135 Local Complications ........................................ 13S General Complications ...................................... 142 CHAPTER IX. Dressings, Shades, etc. Dressings .................................................. 144 Bandages .................................................. 148 Application of Bandages.................................... 149 Special Bandages ........................................... 151 Masks and Shields.......................................... 158 Redressings ................................................ 159 Shades and Protective Glasses............................... 161 Artificial Eyes ............................................. 163 viii CONTENTS. CHAPTER X. What to Do in Emergencies. vkov: Injuries to the Eyes from Caustics and Burns................. 165 Contusions and Penetrating Wounds.....,................... 167 Infectious Materials in the Eyes............................. 168 Poisoning from Atropin, Cocain, and Holbcain................ 168 Part II.—Nursing of Ear Diseases. chapter I. Anatomy and Physiology. Anatomy of Ear............................................ 170 The External Auditory Canal............................. 170 The External Ear......................................... 170 The Membrana Tympani......................"............ 171 The Middle Ear.......................................... 173 The Internal Ear......................................... 174 Physiology of the Ear....................................... 175 Collection of Sound Waves................................ 175 Transmission of Sound Waves............................. 176 Balancing Power ......................................... 177 Ventilation of the Ear..................................... 177 CHAPTER II. General Methods of Nursing in Ear Case3. The Ear Douche............................................ 179 Method of Douching...................................... 179 Sterilization of Bag....................................... 179 Force of Stream.......................................... 180 Solutions ................................................ 180 Medication............................................... 180 Temperature ............................................. 181 Preparation of Patient.................................... 181 Unfavorable Results ...................................... 182 What is Accomplished..................................... 183 Ear Drops.................................................. 183 Temperature ............................................. 184 Position of Patient........................................ 184 Medication............................................... 184 CONTENTS. ix PAGE External Applications...................................... 186 Counter-irritants ......................................... 186 Ice Coil .................................................. 186 Poultice ................................................. 187 Leeches .................................................. 190 Method of Using........................................ 191 Dangers of Using....................................... 192 Method of Politzerization.................................... 192 CHAPTER III. Preparation for Operation. Sterilization of Ear......................................... 194 Arrangement of Table for Treatment of Ear Diseases.......... 196 Arrangement of Instruments................................ 197 Preparation of a Living Room for Operation.................. 198 Illumination ............................................. 198 Treatment of the Floor.................................... 199 The Improvised Table..................................... 199 Sterilization of Linen.................................... 199 Sterilization of Dressings ................................. 199 Sterilization of Basins .................................... 200 Sterilization of Instruments .............................. 200 Sterilization of Surgeon .................................. 201 CHAPTER IV. Treatment after Operation. Recovery from the Anaesthetic............................... 202 Powders ................................................... 202 Dressings after Operation on External Ear................... 203 Dressing after Paracentesis.................................. 204 Dressing after Mastoid Operation............................ 204 Sterilization ............................................. 204 Irrigation ................................................ 205 Packing with Gauze....................................... 206 Frequency of Dressings.................................... 207 Dressings after Furunculosis................................ 207 Dressings after Ossiculectomy .............................. 207 Dressings after Application of Leeches.......................208 CHAPTER V. Ear Nursing in Special Cases. Cerumen ................................................... 209 Cutaneous Eruptions ....................................... 210 Atresia of Auditory Canal................................... 210 x CONTENTS. page Foreign Bodies ............................................. 210 Paracentesis ............................................... 212 Chronic Catarrh of the Middle Ear........................... 213 Structure of the Eustachian Tube............................ 214 Acute Inflammation of the Middle Ear....................... 214 Chronic Purulent Inflammation of the Middle Ear............. 218 Treatment of Adenoids...................................... 220 Nursing of Deafness after Ear Discharge lias Ceased........... 220 Nursing in Mastoid Cases.................................... 222 At Operation ............................................ 223 After Operation .......................................... 224 Ear Polyps................................................. 227 Acute Hyperaemia of Labyrinth.............................. 227 Part III.—Nursing of Nose and Throat Diseases. CHAPTER I. Anatomy and Physiology. Anatomy of the Nose....................................... 229 The External Nose ....................................... 229 The Internal Nose........................................ 229 The Nasal Chamber ...................................... 230 The Turbinates .......................................... 230 The Nasal Meatus ....................................... 230 The Accessory Sinuses .................................... 232 Frontal Sinus .......................................... 232 Antrum of Highmore.................................... 232 Ethmoidal Sinus........................................ 233 Sphenoidal Sinus ....................................... 233 Anatomy of the Nasopharynx............................... 234 Anatomy of the Pharynx................................... 234 Anatomy of the Larynx.................................... 234 Cartilages ............................................... 234 Epiglottis ................................................ 235 False and True Cords..................................... 235 The Vestibule ............................................ 235 The Sinus of Morgagni.................................... 236 Physiology of the Nose...................................... 236 Secretion ................................................ 236 Respiration .............................................. 233 Filtration ................................................ 236 Heating ................................................. 236 Olfaction ................................................ 237 CONTENTS. xj PAGE Physiology of the Naso-pharynx ............................ 237 Physiology of the Pharynx .................................237 Physiology of the Larynx .................................. 237 CHAPTER II. Preparation for Operation. Local Anaesthesia........................................... 238 Heat .................................................... 23S Cold ..................................................... 239 Phenol-camphor .......................................... 239 Carbolic Acid ............................................ 239 Eucain................................................... 239 Cocain................................................... 239 Methods of Application.................................. 239 Strength of Solutions.................................... 240 Symptoms from Cocain.................................. 2 40 Poisoning .............................................. 241 Prevention of Poisoning................................. 241 General Anaesthesia......................................... 242 Nitrous oxid............................................. 242 Ether.................................................... 242 Chloroform .............................................. 242 Dangers from Inspiration of Blood......................... 242 Stripping the Larynx...................................... 243 Operation with Head over End of Table.................... 243 Degree of Anaesthesia..................................... 244 Position and Preparation of Instruments and Apparatus....... 244 Illumination ............................................. 214 Sterilization of Instruments............................... 245 Towels ................................................ 245 Vessels and Tray........................................ 245 Sheets and Splints...................................... 245 Hands ................................................. 245 Use of Wet Towel..................................... 216 Chlorid of Lime Method............................... 246 Permanganate of Potash and Oxalic Acid Method....... 246 Preparation of the Patient.................................. 247 Removal of Hair.......................................... 247 Washing................................................. 247 Shaving.................................................. 247 Treatment of Mustache.................................... 247 The Nasal Douche......................................... 248 Temperature ........................................... 249 Density ................................................ 249 Medication............................................. 249 Method of Use..........................................249 xii CONTENTS. page The Pharynx Douche...................................... 251 Protection of the Hair.................................... 253 Diet ..................................................... 253 Bowels................................................... 253 CHAPTER III. Care of Patient during and after Operation. Care of Patient during Operation............................ 254 Sponges and Pledgets of Cotton............................ 254 Reception of Pathological Material......................... 254 Mouth-gag............................................... 255 Care of Eyes.............................................. 255 Inspiration of Blood....................................... 255 Care of Patient after Operation.............................. 255 Haemorrhage ............................................. 256 Detection of Haemorrhage............................... 256 Treatment of Haemorrhage by Pressure and Ice............ 257 Plugging............................................... 258 Hot Water Douche...................................... 258 Peroxid of Hydrogen.................................... 258 Suprarenal Preparations ................................ 258 Complete Plugging ..................................... 258 Postnasal Plug ......................................... 259 Method of Use........................................ 259 Reaction............................................. 262 Treatment of Reaction................................ 262 Disturbance of Parts...................................... 264 Vomiting of Blood........................................ 264 Headache ................................................ 265 Stupor................................................... 266 Sepsis ................................................... 2o6 Forms ................................................. 266 Treatment of Sepsis..................................... 267 Of Frontal Sinus...................................... 2Ci8 * Of Antrum of Highmore............................... 268 After Septum Operation..............................•. 268 After Adenoid Operation.............................. 219 After Tonsil Operation................................ 270 After Cleft Palate Operation ......................... 271 CHAPTER IV. Diet after Operation. Diet after Operations........................................ 272 General .................................................. 272 Nose Operations.......................................... 272 Cleft Palate Operations.................................... 273 CONTENTS. xiii PAGE Tonsil and Adenoids........................................ 274 Amputation of Epiglottis..................................275 Intubation ...............................................275 CHAPTER V. Special Therapeutic Measures. Special Therapeutic Measures................................ 276 External Applications .................................... 276 Heat .................................................. 2'6 Cold ................................................... 276 Soothing Applications .................................. 277 Counter-irritations ..................................... 27/ Splints................................................. 2/7 Douching of Larynx...................................... 279 Douching of Pharynx..................................... 279 Douching of Nose ........................................ 279 Proper and Improper Methods........................... 279 Dangers ............................................... 280 Temperature of Douche.................................. 280 Specific Gravity of Solution.............................. 280 Position of Patient...................................... 2S1 Respiration while Douching.............................. 281 Blowing and Drying..................................... 282 Postnasal Syringe........................................ 282 Spraying.................................................. f* Internal Applications ..................................... £°<> Powders ................................................. 286 Vapor or Steam Inhalations---........................... 287 Fume Inhalations ......................•................. 288 Nebulizers ........................................-.......288 Gargles .................................................. 288 Lozenges................................................. ^oa CHAPTER VI. Nursing Methods in Particular Cases. External Diseases of the Nose................................ 291 Fracture of Nose.......................................... *JJ Internal Diseases of the Nose................................ *™ Acute Rhinitis ........................................... gj;j Diphtheria ............................................... 'ti6 Care of Patient......................................... gj* Isolation ............................................... Q^ Prevention of Contagion................................. ^ Care of Receptacles .................................... *Ji Care of Secretions and Discharges....................... *»>* xiv CONTENTS. PAGE Care of Bedding........................................ 294 Care of Eating Utensils ................................ 294 Disinfection of Physician................................ 295 Care of Nose and Throat................................ 295 Care of Hands.......................................... 295 Immunization of Nurses................................. 296 Duration of Infective Period............................. 296 Disinfection of Room................................... 297 Disinfection of Furniture ............................... 297 Sunshine and Fresh Air.................................. 298 Nourishment ........................................... 298 Rest in Bed............................................. 298 Croup Kettle........................................... 298 Local Treatment ....................................... 299 Calomel Fumigations ................................... 300 Intubation ............................................. 300 Antitoxin .............................................. 303 Hypertrophic Rhinitis .................................... 304 Operation on Accessory Nasal Sinuses...................... 304 Antrum of Highmore.................................... 304 Frontal Sinus .......................................... 305 Ethmoid Cells .......................................... 305 Peritonsillitis ............................................ 305 QCdema of Larynx......................................... 306 Tuberculosis of Larynx.................................... 306 Tumors of Larynx........................................ 307 Index ..................................................... 309 LIST OF ILLUSTEATIONS. FIG. PAGE 1. Child's Head in Surgeon's Lap for Cleansing the Eye...... 22 2. Showing how to Evert the Upper Lid Standing Back of the Patient .......................................... 25 3. Showing Method of Instilling Drops into the Eye.......... 92 4. Chalk's Eye-drop Bottle................................. 93 5. Andrews's Aseptic Eye-drop Bottle....................... 93 6. Galezowski's Eye-drop Bottle............................ 94 7. Stroschein's Aseptic Drop Bottle and Stand............... 95 8. Glass-Stoppered Aseptic Drop Bottle...................... 96 9. Showing how to Make Applications to the Upper Cul-de-sac. 98 10. Showing Method of Placing Retractor under the Upper Lid. 99 11. Alum Pencil and Holder................................. 101 12. Combination Hot Air, Hot Water, and Steam Sterilizer--- 117 13. Oval Eye Patch held on by Strips of Plaster.............. 146 14. Single Roller Bandage................................... 150 15. Double Roller Bandage.................................. 151 16. Figure of Eight Bandage for one Eye..................... 152 17. Figure of Eight Bandage for Both Eyes..................'. 153 18. Moorfields Bandage .....'................................ 154 19. Stephenson's Dumb-bell Bandage......................... 155 20. Ring's Mask........................................... 157 21. McCoy's Shield ......................................... 158 22. Andrew's Aluminum Shield.............................. 159 23. Position of Patient with Head Hanging over End of Table. 243 24. Method of Using a Nasal Douche........................ 248 25. Nasal Douche Given with a Bulb......................... 250 26. Applicators Wound with Cotton.........................251 27. Method of Making a Cap from a Towel................... 252 28-31. Postnasal Plug ...................................... 261 32. Stripping the Trachea and Larynx to Remove Clots of Blood or the Intubation Tube...................... 303 (XV) Eye, Ear, Nose, and Throat Nursing. PART I—EYE. CHAPTEE I. THE TRAINING AND REQUIREMENTS NECESSARY FOR OPHTHALMIC NURSING; A BRIEF SKETCH OF THE ANATOMY AND PHYSIOLOGY OF THE EYE. Necessary Requirements—Eyebrows—Eyelids—Lacrymal Ap- paratus—Ocular Muscles—Conjunctiva—Cornea—Sclera—Aqueous Humor—Vitreous Humor—Crystalline Lens—Uveal Tract—Cho- roid—Ciliary Body—Iris—Retina—Optic Nerves—Orbits—Eyeball- Accommodation—Binocular Vision. In nursing, as in medicine, a good general training is necessary before the special branches, or "specialities," can be taken up with advantage. It seems almost unnecessary, therefore, to make the statement that a nurse in order to become proficient in nursing diseases of the eye should first have had a thorough training in the care of general dis- eases. Without this general training she may not hope to attain success in special work of any kind. The first re- quirement, then, to become proficient in ophthalmic nurs- ing is a thorough grounding in general nursing. This may be had in the usual way at the numerous training schools » (1) 2 EYE NURSING. for nurses and the hospitals with which they are connected. Of late years some of the training schools have had arrange- ments with special hospitals (eye, ear, nose, and throat) by which they could give some of their students training for a few months in these special branches. While this arrange- ment is desirable and an advance over the old methods of no training whatever in special branches, except an oc- casional case, it is not adequate for present day require- ments. In order to become a proficient ophthalmic nurse at least twelve months' service in a special ophthalmic hos- pital is necessary, while double this length of time in such an institution would not be too much time in the majority of instances. Not only is a familiarity with the appearance of the different affections of the eyes obtained, but the proper methods of handling and caring for such disease is taught; also the preparations of the different dressings and bandages for the eyes is taught as well as the preparation of patients for the different operations on the eye. The art and technique of cleansing an eye, familiarity with the various instruments used upon the eye, the proper after-treatment of operative cases, a knowledge of the dif- ferent remedies used in the treatment of the eye are all to be had in these special institutions. It is urged upon those who are desirous of becoming proficient ophthalmic nurses, therefore, first, to ground themselves in the general train- ing; second, then in the special training in some ophthal- mic hospital. In fact, this must be the course pursued by most nurses. Occasionally, without this training, a nurse may "pick up" or "take up" the special nursing on her own initiative, or by the advice and assistance of some oculist, and become an expert special nurse. This is the exception, and such an instance, nowadays at least, is a rare occurrence. ANATOMY AND PHYSIOLOGY OF EYE. 3 A Brief Outline of the Anatomy and Physiology of the Eye. While the purport of this little volume will not allow of an extensive review of the anatomy and physiology of the eye, yet a very brief exposition of the subject is necessary for an intelligent understanding of the care and nursing of this most delicate organ of the body—the eye. eyebrows. The eyebrows are two thickened ridges of skin covered with short hairs, arched above the upper borders of the orbits. They serve to some extent to protect the eyes from light, dirt, and perspiration. EYELIDS. The eyelids, upper and lower, are two movable curtains which cover the entrance to the orbit and protect the eye- ball. The upper lid is larger and more movable than the lower lid and has a special muscle, levator palpebrce supe- rioris, to lift it. The lids proper are composed of dense connective tis- sues, known as the tarsal cartilage. They are attached to the margins of the orbits by means of connective tissue membranes — the tarso-orbital fascia?. Their free edges are straight and covered with a row of hairs, the eyelashes. These lashes serve for protection to the eyes. The outer surface of the lids are covered with delicate skin, loosely attached to the orbicularis muscle. The orbicular muscle lies between the skin and the tarsal cartilage and serves to close the eye. The inner surfaces of the lids are lined with a delicate membrane, the conjunctiva. Imbedded in the lids are some small glands, the Meibomian follicles. 4 EYE NURSING. These glands open on the free borders of the lids, and fur- nish a sebaceous material. The opening between the free margins of the eyelids is called the palpebral fissure. It is the width of this space, larger or smaller, that gives to the eyes the appearance of largeness or smallness, and not the actual size of the eye itself. The eyes of all adults are nearly of the same size, about 1 inch in all its diameters. The eyelids serve chiefly as a protection to the eyes, and by their constant motion the eyeball is kept moist and free from dust. The arteries to the lids are supplied in the main by the ophthalmic artery, while the veins empty into the temporal and facial veins. The lids are innervated by branches from the seventh, fifth, third, and the sympathetic nerves. The lymphatics in the lids are numerous. lacrymal apparatus. The lacrymal apparatus consists of two portions: a secreting—the conjunctiva and lacrymal gland; and a con- ducting—the lacrymal canals, the lacrymal sac, and the nasal duct. The gland, a small almond shaped body, lies in a fossa at the upper outer angle of the orbit. About twelve small ducts lead from it and carry its secretions to the surface of the conjunctiva at the upper outer end of the upper lids. This secretion keeps the inner surface of the lids moist. At the inner ends of the lids, upper and lower, are two small openings, puncta lacrymalia, from which small open- ings the lacrymal canals lead into the lacrymal sac. From the lacrymal sac a small duct (lacrymo-nasal) leads into the nose, opening on the floor of the same. Through these openings the tears drain into the nose. The tears drain into and through these very small lacrymal OCULAR MUSCLES. 5 canals (about 1 millimeter in diameter) by capillary attrac- tion, and not by force or gravity. This is a slow process, and when the tears are in excess, as in weeping, they run over the cheeks because of the inability of the tear-ducts to drain them through the nose. The lacrymal gland is supplied with blood from the ophthalmic artery, and in- nervated by the fifth and the sympathetic nerves. OCULAR MUSCLES. Six muscles, four straight recti and two oblique, give to the eye its varied motions. They are: the superior rec- tus, inferior rectus, internal rectus, external rectus, superior oblique, and inferior oblique. They are designated as the extrinsic muscles of the eye, while the ciliary muscle and the sphincter muscle of the iris are termed the intrinsic mus- cles of the eye. The four recti muscles arise immediately around the optic foramen, partly from a tendinous ring and partly from the optic foramen itself. From this origin they pass for- ward, diverging as they advance until they come in contact with the eyeball just behind its equator. Keeping in con- tact with it, they pierce its sheath (Tenon's capsule) from Vs to 1/3 inch back of the corneal margin to become in- serted into the sclerotic coat, by tendinous expansions— one above, one below, one to the inner side, and one to the outer side of the eyeball. The superior oblique muscle arises near the optic fora- men, passes forward through a pully attached to the upper inner angle of the orbit, and then is deflected backward be- neath the superior rectus muscle to become attached to the posterior outer surface of the eyeball. The inferior oblique arises from near the inner anterior angle of the orbit, passes outward and backward beneath the 6 EYE NURSING. eyeball, and becomes attached to the posterior outer surface of the eyeball. The recti muscles move the eye up and down, in and out, while the oblique muscles give to the eye a rotary motion. In many, in fact most, of the movements of the eyes, all of the muscles take part. The muscular branches of the ophthalmic artery supply blood to the extrinsic muscles of the eye. The venous blood is emptied into the ophthalmic and facial veins. The sensory nerves are from the fifth. The motor nerves to the muscles are: the third to the internal, supe- rior and inferior recti, and to the inferior oblique, muscles; the fourth to the superior oblique, and the sixth to the ex- ternal rectus. There are special centers governing the co-ordinate ac- tions of the ocular muscles, while their voluntary actions are governed by centers situated in the cortex of the brain. CONJUNCTIVA. The conjunctiva is the mucous membrane lining the inner surfaces of the eyelids and covering the anterior half of the eyeball. The epithelial layer of the conjunctiva is transparent and extends entirely across the cornea, forming the anterior layer of that structure. At the inner corner of the eye the conjunctiva forms a crescentic fold, plica semilunaris; and resting upon this fold is a small red mass of tissue, caruncula lacrymalis. The conjunctiva is richly supplied with blood from the branches of the oph- thalmic artery, while its nerve supply is derived chiefly from the seventh nerve. Besides assisting to retain the eyeball in position, the chief function of the conjunctiva is to form a smooth cover- ing for the inner surfaces of the eyelids and the outer sur- face of the anterior half of the eyeball, and by its secretion CORNEA AND SCLERA. 7 to keep the opposing surfaces moist and lubricated, allowing of free movement without friction. CORNEA. The cornea is a perfectly clear and transparent mem- brane forming the interior one-sixth of the external surface of the eye. It is about 1 millimeter in thickness and com- posed of five layers, from before backward, as follows: (1) epithelial layer, a continuation of the epithelium from the conjunctiva; (2) anterior limiting membrane (Bowman's); (3) true corneal tissue; (4) posterior limiting membrane; (5) endothelial layer. The chief function of the cornea is to transmit and refract rays of light entering the eye. The. nerve supply of the cornea is from the fifth nerve. The cornea has no blood-vessels and depends for its nutri- tion upon the lymph thrown out from loops of blood-vessels near its margins. - There are lymph-spaces in the corneal tissue for the circulation of this nutritious material. SCLERA. The sclera is a dense, white, fibrous membrane which together with the cornea forms the complete outer tunic or coat of the eyeball, the cornea forming the interior one- sixth and the sclera the posterior five-sixths. That portion of the sclera seen between the lids when open is commonly called the "white" of the eye. Owing to its density and firm- ness it protects the inner and more delicate coats of the eye, the choroid and retina. It also maintains the shape of the eye, being assisted in this, however, by the vitreous, which fills the interior of the eye.. The blood-vessels of the sclera are the ciliary arteries from the ophthalmic. 8 EYE NURSING. AQUEOUS HUMOR. The aqueous humor is a clear, serous fluid filling the anterior chamber of the eye. It is composed chiefly of water, with a small amount of albumin and chlorid of so- dium. It is secreted by the blood-vessels of the iris and ciliary body, and is quickly reproduced when evacuated by a puncture of the cornea. It fills both portions of the ante- rior chamber of the eye. The anterior chamber is the space between the posterior surface of the cornea and the anterior surface of the iris. The posterior part is the space between the posterior surface of the iris, near its periphery, and the anterior surface of the lens, near its periphery. The aqueous humor helps to maintain the shape of the eye and allows free movement of the iris. VITREOUS HUMOR. The vitreous humor is a transparent, gelatinous sub- stance filling the interior of the eyeball back of the crystal- line lens. It is surrounded by a very delicate, transparent membrane. The vitreous has no nerves or blood-vessels. It depends for its nutrition upon the lymph thrown out from the blood-vessels of the adjacent structures, the uveal tract and retina. The chief function of the vitreous body is to maintain the shape of the eye, and to keep the contiguous structures in position; that is, the retina from becoming detached, and the lens from dislocation. CRYSTALLINE LENS. The crystalline lens is a perfectly transparent lentil- shaped body surrounded by a transparent, elastic membrane (its capsule) and held in position just back of the pupil of the eye by means of a suspensory ligament, the zone of Zinn. It is composed of fibers held together by a delicate, trans- CRYSTALLINE LENS AND CHOROID. 9 parent, cement substance. Water, albuminous material, and a small amount of fat, with a trace of cholesterin, enter into its composition. In young subjects the lens and cap- sule are quite elastic in nature; but, as the subject gets older, the lens loses part of its watery element, the fibers become dryer and harder and lose elasticity, and at the age of 40 years or thereabouts old sight supervenes, due chiefly to a flattening of, and a lack of elasticity in, the crystalline lens. The lens, like the vitreous, is without nerves and blood-vessels, depending for its nutrition upon the lymph thrown out from the blood-vessels of the iris and ciliary body. The function of the crystalline lens is to assist in bringing rays of light to a focus on the retina. In conse- quence of its elasticity and the action of the ciliary muscle its refractive power is variable. UVEAL TRACT. The uveal tract forms the second, or middle, tunic of the eye. It is composed of the choroid, ciliary body, and the iris. CHOROID. The choroid is a thin and very vascular membrane, ex- tending from the entrance of the optic nerve into the eye, forward, between the sclera and retina, to where it joins the ciliary body. It is composed chiefly of blood-vessels. Its layers from without inward are: (1) lamina fusca, (2) tunica vasculosa, (3) membrana chorio-capillaris, and (4) lamina vitrea. The structure of the choroid being highly vascular, its chief function, together with the ciliary processes, is to sup- ply nutrition to the structures lying adjacent,—the lens, vitreous, and outer layers of the retina,—which are deficient 10 EYE NURSING. entirely or partially of blood-vessels. The large veins in the choroid are called vence vorticoso3. They pierce the sclera obliquely and empty into the ophthalmic vein. The nerve supply is from the fifth and sympathetic nerves. CILIARY BODY. The ciliary muscle forms the middle zone of the uveal tract, connecting the choroid behind with the iris in front. It is composed of the ciliary muscle and the ciliary processes. The ciliary muscle arises from the sclera just at the junction of the cornea and sclera; its outer longitudinal fibers extend backward to be inserted into the choroid, while its inner fibers take a circular course and form the circular fibers of Miiller. From the surface of the ciliary processes connective tissue fibers spring, forming the zonule of Zinn. These fibers are attached to the capsule of the crystalline lens, and it is by their aid that the lens is held in position. The ciliary muscle is the principal agent in adjusting or accommodating the eye to see objects distinctly at different distances. The accommodation of the eye is effected as follows:— In describing the crystalline lens we said it was elastic, and that it was surrounded by a capsule, likewise elastic. At- tached to the capsule are connective tissue fibers (zonule of Zinn), which are also attached to the ciliary processes and ciliary muscle. When the ciliary muscle is not acting these zonule fibers are stretched taut and draw on the lens capsule, which in turn compresses the lens. The lens in this way is flattened and the focus of the eye adjusted for distant objects. On the other hand, when the eye is to be accommodated for near objects the ciliary muscle contracts, drawing the zonule fibers forward, thus relaxing them; they in turn relax the tension on the capsule of the lens, and the lens, being elastic, IRIS AND RETINA. 11 expands, becoming more convex and in this way the eye is adjusted for seeing near objects. During the act of accom- modation, in addition to the lens becoming more convex, the pupil contracts, the pupillary margin of the iris moves slightly forward, being pushed by the anterior surface of the lens, which advances a little as it becomes more convex. The posterior surface of the lens becomes a little more convex, but does not move forward. The ciliary processes are very richly supplied with blood. A nutritious lymph is thrown out from them which nourishes the lens, and the anterior portion of the vitreous. IRIS. The iris is the third and anterior zone of the uveal tract. It is a thin membrane arising from the anterior sur- face of the ciliary body. It has a central perforation, the pupil. The layers from before backward are: (1) endothe- lial layer, (2) vascular layer, (3) muscle-fiber layer, (4) posterior limiting membrane, and (5) pigment layer. The iris aids in the act of vision by controlling the amount of light going into the eye, and by cutting off the marginal rays of light. It is supplied with blood from branches of the ophthalmic artery. Its nerve supply is from the fifth, the third, and sympathetic nerves. RETINA. The retina forms the inner tunic of the eye, and extends from the optic nerve entrance forward to the posterior ex- tremity of the ciliary body, where its nervous elements end in a serrated border, ora serrata. The pigment layer of the retina, together with its connective tissue elements, reduced to a single layer of cells, continues on the inner surface of 12 EYE NURSING. the ciliary body and on to the posterior surface of the iris even to the margin of the pupil. In the living subject the retina is almost transparent, having a whitish-gray, filmy appearance, when viewed by the ophthalmoscope. It is composed of ten layers; from within outward they are: (1) internal limiting membrane, (2) optic-nerve fiber layer, (3) ganglion-cell layer, (4) internal molecular layer, (5) internal nuclear layer, (6) external molecular layer, (7) external nuclear layer, (8) external limiting membrane, (9) rods and cones layer, and (10) pigment layer. The layer of rods and cones is the perceptive layer of the retina. Situated in the center of the retina in the posterior portion of the eye is a yellow spot, macula lutea. At the center of this spot is a depression, fovea centralis, which is the cen- ter of direct vision and is the most sensitive portion of the retina. The retina is supplied with blood by the arteria centralis retina, a branch from the ophthalmic which pierces the optic nerve just back of its entrance into the eyeball. The branches from this artery lie in the outer lay- ers of the retina, and terminate in free endings, no anasto- moses taking place. The retinal veins empty into the oph- thalmic vein. OPTIC NERVES. The optic nerves are nerves of a special sense, that of sight. They have their origin in the brain as the optic tracts which emerge from its under-surface at the posterior portion of the optic thalami by two roots. Fibers from these roots extend to the cortex of the occipital lobe of the brain, where the visual center of the brain is situated. The optic tracts decussate anteriorly; that is, about three-fifths of the fibers from the right tract cross over to the left optic nerve and three-fifths of the fibers of the left tract go over ORBITS. 13 to the right optic nerve. This crossing of the optic tract fibers forms the optic chiasm. The length of the optic nerves from their origin in the optic chiasm to the eyeball is about 1 inch. The optic nerves are surrounded by sheaths which are direct continuations of the membranes surround- ing the brain. The spot where the optic nerve enters the eye is known as the optic disc. The blood supply to the optic nerve, chiasm, and optic tracts is derived chiefly from the branches of the internal carotid and vertebral arteries. The function of the optic nerve and tracts is to transmit visual impressions to the brain. The conscious preception of the visual impressions gives sight. ORBITS. The orbits are the bony cavities in which the eyeballs are contained and by which they are protected. They are funnel shaped; the large end of the funnel is directed forward and the small end backward, terminating in the optic foramen through which the optic nerve enters the orbit and also the ophthalmic artery. Near the posterior end of the orbit is another opening, the sphenoidal fissure, through which pass the third, fourth, ophthalmic division of the fifth and sixth nerves, and the ophthalmic vein. The bony orbit is lined by a layer of dense connective tissue; fibers spring from this connective tissue which expand into sheaths. One of these sheaths surrounds the optic nerve and the eyeball, except the front portion, and in this cap- sule the eyeball turns as in a ball-and-socket joint. The posterior part of this membrane is called Bonnet's capsule, and the anterior portion Tenon's capsule. At the ap,ex of the orbit is a cushion of fat, which supports the eyeball. In wasting diseases, as consumption, when this fat is absorbed the eyes become sunken or hollow from lack of support. 14 EYE NURSING. EYEBALL; ACCOMMODATION; BINOCULAR VISION. The function of the orbits is to furnish protection to the eyeballs. The eye as a whole may be likened to a cam- era. At the front surface are the cornea and lens to focus the rays of light; and the iris with its central perforation, the pupil, which can be changed in size, to regulate the amount of the light; while the retina at the back of the eye is the sensitive plate upon which the images are re- ceived. As this plate cannot be moved backward and for- ward, as in a camera, the ciliary muscle is brought into use in order to have clear images of objects at varying dis- tances formed on it. By the action of this muscle and the elasticity of the crystalline lens itself the lens can be made to change its convexity. In this way the images of objects at different distances can be accurately focussed on the retina, and this is the act of accommodation. The impres- sions of these images are transmitted to the sight-perceptive center of the brain by means of the optic nerves and tracts. The images of all objects fall on the retina in an inverted position; that is, upside down; nevertheless they are in- terpreted by the brain as being erect, or upright. Moreover, the image of an object formed in each eye separately is fused into one and is seen singly. When the two eyes are not directed straight to an object, but one deviates so that the image of the object does not fall directly on the center of the retina, the macula lutea, double vision follows, as a rule. Just how the brain is able to perceive these inverted images on the retina as erect and single we are unable to understand, and it has resulted in much discussion and speculation. CHAPTER II. CONTAGIOUS DISEASES OF THE EYE. Definition of Contagion and Infection—Epidemic and En- demic—Germ Theory of Disease—Definition of Antisepsis and Asep- sis—Catarrhal Conjunctivitis—Gonorrhceal Conjunctivitis—Ophthal- mia Neonatorum. By contagious diseases of the eye we mean those dis- eases which can be transmitted either directly or indirectly from one eye to another. In all contagious diseases of the eye there is more or less discharge from the eye, and it is by some of this matter from the diseased eye to a healthy eye—from one eye to the other in the same person or to another individual—that the disease becomes communicable or contagious. In this matter are micro-organisms or bacteria, each disease having a germ peculiar to itself, as has been demon- strated in recent years in many diseases by means of the microscope. When a small amount of this pus is trans- ferred from a diseased eye to a healthy one, it usually pro- duces a similar disease in the healthy eye. In all of the contagious diseases of the eye, except one, trachoma, a specific germ has been found to be present peculiar to each disease. In trachoma no specific germ or microbe has been settled upon as a definite cause of the disease, although two or three observers (Michel, Sattler) claim a specific germ (a diplococcus) for its origin. Before the germ theory of disease was advanced it was difficult to explain just how a contagious disease was trans- (15) 16 EYE NURSING. ferred from one individual to another, but, since the dis- covery that each contagious disease has a specific germ causing it, it is easy to perceive in what manner such dis- eases are transferred and how produced. The contagious diseases of the eye are: catarrhal con- junctivitis, or pink eye; gonorrhceal ophthalmia; oph- thalmia neonatorum; diphtheritic ophthalmia; trachoma, or granulated eyelids. Of these diseases the first four are highly contagious, the smallest particle of secretion from an eye affected with any one of them when transferred to a healthy eye being sufficient to produce a similar disease in the latter. Usually in these diseases, when the second eye becomes affected in the same individual, the disease runs a milder course than in the first eye to become affected. Trachoma is only mildly contagious, and usually an eye has to be exposed to the contagion time and again before it becomes affected. When once contracted, however, the dis- ease is difficult to get rid of. By a few authorities these contagious diseases are thought to be infectious; that is, transmitted through the air. While it is possible to conceive of particles of the matter from eyes affected with these diseases becoming dried and then wafted through the air into healthy eyes and setting up a like disease, it is not at all probable. The danger from such source of infection is hardly worth while considering. For, as shown by the experiments of Piringer, these secretions, when dried, after thirty-six hours' time became inert and incapable of infecting healthy eyes. These diseases are highly contagious; that is, communicable when the pus from a diseased eye is brought in contact with a healthy eye by means of unclean fingers, handkerchiefs, towels, etc.; but they are slightly if at all infectious through the air, as measles, mumps, etc. Actual contact ANTISEPSIS. 17 of the germ, direct or indirect, is a necessary factor in the production of these diseases. The extreme importance of absolute cleanliness in such diseases on the part of the doc- tor, nurse, attendants, and the patient himself is self-evi- dent. Through uncleanliness and negligence these con- tagious diseases may become epidemic; that is, spread through a whole community temporarily. As, for example, through dirty public baths a great number of people may become afflicted with acute catarrhal conjunctivitis. In some instances these diseases are thought to become en- demic; that is, permanently fixed in certain localities. In Egypt, for instance, trachoma has been endemic for ages; and in the southern portion of the State of Illinois on the Wabash River in a small district, aptly enough called "Lit- tle Egypt," the disease is quite prevalent and always pres- ent; hence endemic. Having considered the causes of contagious diseases of the eye, it behooves us to say a few words here in reference to antisepsis and asepsis, a subject which will be treated more fully farther on. The word antisepsis means literally opposed to putrefaction or fermentation. Since micro-or- ganisms are at the seat of putrefaction and are the cause, as we know, of many diseases, any method or means to destroy these germs is termed antisepsis. Heat, dry or moist, where it can be applied, as in sterilizing instruments, is an effective antiseptic. Carbolic acid, bichlorid of mercury, alcohol, permanganate of potassium, etc., are common anti- septics with which we are familiar. They are antiseptic by reason of their power to kill germs, and are on this account also called germicides. Nitrate of silver, argyrol, and pro- targol are valuable germicides and they are frequently em- ployed in the treatment of the acute contagious diseases of the eye. a 18 EYE NURSING. Asepsis means literally the absence of putrefaction or fermentation, and also the micro-organisms upon which they depend. Hence any method or means used to keep a wound free from germs, as by sterile solutions, dressing, etc., is termed asepsis. In diseases of the eye strong antiseptic solutions can- not be used, the eye being such a delicate and sensitive or- gan. The solutions of carbolic acid and bichlorid of mer- cury should not be of greater strength than 1 to 5000. In this strength they are only weakly germicidal. If used in stronger solution they are very irritating to the eye and many times do actual harm. For this very reason in dis- eases of the eye, even in the contagious diseases, we depend on aseptic methods more than antiseptic means. That is, we endeavor to keep the eye clean by frequent bathing with aseptic or sterilized solutions, or mildly antiseptic solutions. In cases of wounds and after operations we pro- tect the eye with sterilized dressings, thus keeping the germs out. The old adage, "an ounce of prevention is worth more than a pound of cure," is quite applicable in the treatment of diseases of the eye, for it is much easier to keep these germs out than get them out when once in. This point can- not be too strongly impressed upon the nurse's mind, for an eye once infected, especially after operation, often means the loss of it. Acute Catarrhal Conjunctivitis. This is an acute contagious disease of the eyes, many times appearing in epidemic form. It is caused by a micro- organism, the Koch-Weeks bacillus. Atmospheric conditions evidently have some influence in its production, the damp, chilly days of spring seeming to predispose to it. The dis- ease is characterized in the beginning with redness, burn- ACUTE CATARRHAL CONJUNCTIVITIS. 19 ing, and itching of the eyes, the lids are swollen and red, and light hurts the eyes. After a few days' duration there is marked increased secretion of a muco-purulent nature, which sticks the eyelids together in the morning. In one or two weeks, according to the severity of the case, the dis- ease runs its course and the patient is well, if the eye has been properly taken care of. As a rule, the medicinal treat- ment in such cases is very simple, and consists, for the most part, in the application of silver nitrate, 2 per cent, solu- tion (10 grains to 1 ounce), to the lids once a day, or some other mildly antiseptic application according to the bent of the surgeon. Personally I prefer the silver nitrate appli- cation to all other remedies in this affection. The care and nursing of these cases is important, not only in knowing what to do with them, but what not to do. Sometimes we need to be delivered from our friends, and if there is one disease of the eyes more than another in which patients need to be delivered from "grandmother" reme- dies and quack nostrums it is this disease. The diagnosis given in such cases by these ignorant, dangerous, and free givers of advice is that of a "cold in the eyes," which may mean anything from a cinder on the cornea to the most virulent cases of diphtheritic conjunctivitis. The treatment recommended by these sometimes inno- cent, but always ignorant and presumptuous, practitioners of the healing art, to be applied to the most delicate organ of the human body, the eye, may be anything from bathing the eyes in breast-milk, the application of poultices, of tea- leaves, bread and milk, flaxseed, etc., raw meat, oysters, skin of egg, cow dung, a piece of the placenta of a parturient woman, and even to bathing the eyes in the patient's own urine, from which last practice more than one eye has been infected with gonorrhceal ophthalmia and the sight de- 20 EYE NURSING. stroyed. It seems hardly necessary for me to warn any intelligent person from carrying out such practices as the above mentioned, yet there are so-called intelligent people, and not a few of them apparently, who do practice them. A campaign of education is in order, therefore, and I know of no better time, place, or opportunity than now to start it. If called upon to write or formulate the two most im- portant precepts in ophthalmic nursing I should do so as follows:— 1. Thou shalt be altogether clean and gentle when caring for the eyes. 2. Thou shalt not apply poultices to the eye. I wish that these two short precepts might be indelibly impressed on the mind of every nurse and grandmother, or other person presuming to nurse, to the end that the sight of many eyes might be saved. Since Pasteur's discovery that fermentation and putre- faction are due to the presence of certain micro-organisms, or "germs," we have learned that most, if not all, contagious diseases (as well as many noncontagious diseases) are caused by germs and their toxins (their poisonous excretions). We know also that it is necessary to get rid of these micro- organisms before we are truly clean. The methods of get- ting rid of these germs, as by the use of heat, germicidal solutions, etc., are termed antisepsis, and were first intro- duced by Lord Lister. The means used to keep free of these germs, as by soap and water, dressings, etc., are termed asepsis. For full particulars in antisepsis and asepsis see Chapter VI. That poultices should never be applied to an eye af- fected with a contagious disease is self-evident to the sur- gical mind, and for two reasons; first, they retain the irritating secretion in the eye; secondly, they often strip ACUTE CATARRHAL CONJUNCTIVITIS. 21 the delicate epithelium from the cornea and conjunctiva, . leaving ulcerating surfaces open to the contagion, and not infrequently in this way causing the loss of the eye. The use of poultices, therefore, should never be resorted to in contagious diseases of the eye. They are dirty, dangerous, and altogether an abomination, as well as destructive to the sight of man. If heat and moisture must be applied to the eye, let it be in the form of hot water, with which the eyes may be bathed frequently; or applied by means of pledgets of cotton or old, soft, clean linen, dipped into the water and laid upon the closed eyes. In the mild cases of catarrhal conjunctivitis the pa- tient himself is usually able to care for his own eyes, but in the severer types, where the secretion is very abundant and accompanied at times with ulcers of the cornea and exceptionally with membranes on the lids and even with an iritis, the services of a nurse are called for. In any case the eyes should be cleansed with a warm (98° to 100° F.) sterilized solution sufficiently often to keep them free of the secretion. A teaspoonful "of boracic acid or of table salt to the pint of water, and plain sterile water (made so by boiling then cooled), are good for cleansing with. This should be done every half-hour, if necessary; and is the most important factor in the treatment of the disease. The technique of cleansing an acutely inflamed and sensitive eye is not so simple a matter as it seems. The "touch" of some nurses, also of some doctors, in manipulating these cases is as the tread of an elephant. So patients sometimes think and say. There is a certain aptness or deftness in the art of cleansing an eye gently and well that can be acquired only by the exercise of close attention and much patience. This deftness is natural to some and is never acquired by others. 22 EYE NURSING. DIRECTIONS FOR CLEANSING AN EYE. The nurse herself should have surgically clean hands, wear a pair of protective glasses (if she does not already wear glasses), and on her lap have a rubber apron. All solutions, cotton, cotton applicators, pus basins, etc., should be prepared and placed on a small table near a window or other source of light convenient to the nurse. If the pa- tient is a child, it should be wrapped in a sheet with the Fig. 1.—Child's Head in Surgeon's Lap for Cleansing the Eye. arms at its side, to prevent the child from interfering with the cleansing. Over the sheet and well up under the chin a towel should be placed for protection to the patient. The child is held in the lap of an attendant and with its back to the nurse who pulls the child's head backward and places it be- tween her knees, as shown in Fig. 1. With the head firmly fixed between the knees the lower lid is gently pulled down by placing the thumb on the cheek just beneath the eye, exposing the inner surface of the eyelid and the lower cul- de-sac (the deep fold of conjunctiva joining the lid to the DIRECTIONS FOR CLEANSING AN EYE. 23 eyeball). Then a stream of water squeezed from a pledget of cotton held in the free hand is directed on to the inner surface of the lid. This maneuver is repeated until all the loose pus is washed away. If any pus remains sticking to the lids or eyelashes, this may be gently wiped away with the moistened cotton. To cleanse the upper lid and cul-de-sac it is necessary to catch the eyelashes of the upper lid be- tween the thumb and forefinger of one hand, and pull the eyelid forward and away from the eye; pressure downward is then made at the upper edge of the cartilage, when, as a rule, the lid is everted and its inner surface and upper cul-de-sac are exposed to view. Then direct a stream of water squeezed from a pledget of cotton into the groove between the lid and eyeball and on to the lid surface, re- peated often enough to wash away the pus. If much pus should remain in the cul-de-sac, it may be wiped away by means of a moistened piece of cotton on an applicator. If the eyelids are so swollen that they cannot be lifted from the eye, it is much better that the surgeon perform a canthotomy (cutting the lids at the outer corner of the eye with a scissors), when the eyes can be readily cleansed after the manner just described. All rubber bulbs with narrow tips on them for inser- tion under the lids to irrigate the cul-de-sac should, in my opinion, be abandoned as dangerous. In using them, espe- cially in young children, we are apt to injure the cornea. With the simple cotton pledgets we are much less apt to do harm to the eye. If it becomes necessary to perform a canthotomy, no harm is done, but rather advantages gained, as follows: Pressure of the lids is taken from the eyeball, and the risk of ulceration of the cornea is less liable; the eyes can be cleansed more easily than before; local blood- letting is accomplished, which relieves the congested and 24 EYE NURSING. inflamed eye. The wound from such operation heals in about one week's time and leaves no scar. The fewer the instruments the less the danger to the patient, is a good surgical maxim, and it is especially ap- plicable to the eye. The second step in caring for a case of catarrhal con- junctivitis is the application of iced cloths or cold com- presses. Have by the side of the patient's bed a large bowl or dish in which place a cake of ice the size of a man's head. On this cake of ice place a half-dozen pledgets of old, soft, white linen or cotton about 2 inches square; or, better still, pledgets of absorbent cotton, moistened; allow them to remain on the ice till cold (ten minutes) ; then take one, or two, if both eyes are affected, and lay them on the closed eyelids. After two minutes take these pledgets off the eye, and place them back on the ice, then place two fresh pledgets on the eye. Keep changing the pledgets in this manner every two minutes for half an hour. This should be repeated four, five, or six times during the day, and, if the blennorrhcsa is very marked, even oftener. If ice is not to be had, these pledgets of cotton or cloth may be dipped in cold water and applied in the manner above indicated. The practice of putting cracked ice into a little rubber bag or wrapped in a towel or other cloth and laying the same on the eye is a bad one, for the reason that it puts too much weight and pressure on the sensitive eye. It often does harm rather than good. Cleansing the eyes and applying cold compresses are the two most important duties of a nurse in such cases. The physician in charge usually makes the necessary medic- inal applications. The most valuable remedy in these cases, at least it has been in my mands, is an application to the everted lids TREATMENT. 25 of a solution of silver nitrate, 10 grains to the ounce. The application is made as follows:— If the patient is a child the head is held between the knees as in cleansing the eye; after cleansing the eye, the lower lid is pulled down by placing the thumb on the cheek Fig. 2.—Showing how to Evert the Upper Lid Standing Back of the Patient. at the lower part of the lid. Then an applicator with a small amount of cotton wrapped smoothly on it and satu- rated with the silver solution is rubbed gently over the inner surface of the lid and deep into the lower cul-de-sac. The lid is then let loose to come back into position. Next, the lashes of the upper lid are caught between the thumb 26 EYE NURSING. and finger and the lid pulled gently forward away from the eye; then pressure is made with the blunt end of the ap- plicator or the tip of the finger at the upper edge of the cartilage (see Fig. 2) and the lid everted. The silver solu- tion is then applied to the exposed surface and cul-de-sac. It takes a certain amount of deftness to evert the upper eyelid gently and without pain, especially when it is swollen. It should be practiced frequently on the healthy eye before undertaken on the diseased organ. The ever- sion of an eyelid seems like a matter of exceedingly small importance to the surgeon and the nurse, but it is not so considered by a sensitive patient. I have known of more than one instance where the nurse lost charge of the case because she could not turn an eyelid properly. The essen- tial point in the technique is first to pull the lid well away from the eyeball, then make the pressure at the upper mar- gin of the cartilage downward and rather quickly. There is one other matter which should be spoken of here and that is the art of wrapping cotton on an applicator quickly, smoothly, and so that it will stick; also that it can be taken off when through with. Take a piece of cotton V2 inch wide, 1 or 2 inches long, and 1/18 (approximately) inch thick; catch one end of it between the thumb and fore- finger of one hand, place the extreme tip of the applicator on the cotton held between the thumb and finger, hold it firmly with the thumb and finger, then twist the applicator with the other hand (and not the cotton as is so often done), and the cotton will at once adhere to the tip of the ap- plicator. The tip should be covered completely first and to the depth desired, then the applicator should be pushed through the finger and thumb as it is turned so as to cover about from 1 to 11/2 inches of the applicator. At the upper end only, that is, nearest the handle of the applicator, GONORRHGEAL CONJUNCTIVITIS. 27 the cotton should be wound very tightly, the edge of the thumbnail being held against it for this purpose while the applicator is turned. This prevents the cotton from com- ing off when in use. When ready to take it off, hold the cotton firmly between the thumb and finger of one hand, and a slight reverse twist of the applicator is all that is necessary. Camel-hair brushes should not be used for making applications to the eyelids, because, unless disinfected after use on each patient, they are liable to carry infection. Cot- ton placed on an applicator as just described is much prefer- able, for this is used but once and is then destroyed. The "eye sponge" has been displaced by cotton, and the camel-hair brush is doomed to a like fate. The hygienic surroundings of the patient when af- fected with catarrhal conjunctivitis of the severer types is of importance. The room should be kept moderately darkened for these patients; the diet should be light, but nutritious; the bow- els kept freely open, and no smoking or stimulants allowed. The floor, which should be uncarpeted, should not be swept, but mopped up, and all dressings immediately destroyed after use. It seems almost unnecessary to warn the nurse that she should be very careful with her own person, washing and disinfecting her hands often, and never rubbing or touching her own eyes. A solution of bichlorid of mercury (1 to 1000) in a basin should always be near to dip her hands into after washing them with tincture of green soap. Gonorrhceal Conjunctivitis. The safety of an eye when affected with this frightful malady, causing as it does in adults and infants about one- fourth of all cases of blindness, depends more on the intel- 28 EYE NURSING. ligent and faithful care of a trained nurse than the minis- trations of a doctor. The disease is caused by infection with the germ or the micro-organism of gonorrhoea, the gonococ- cus, discovered by Neisser. The disease may affect adults or infants; in the former, it is usually designated gonorrhceal ophthalmia, and in the latter ophthalmia neonatorum. The two diseases are identical. The eyes of children, however, seem to withstand the disease better than the eyes of adults. In infants, when seen early (within the first twenty-four to forty-eight hours after infection) and before the cornea? are affected, the eyes are almost always saved with useful vision; but in adults, even when seen from the start, no promise can be given to the patient as to recovery with sight preserved. In adults, the disease for the first two or three days is characterized by redness and by marked swelling of the eyelids and conjunctiva, being so great in severe cases that the patient cannot open the eyes. The conjunctiva, both of the eyelid (palpebral) and the eyeball (ocular), is hot, dry, and swollen, and the ocular conjunctiva may become so swollen and cedematous as to form a ridge around the cor- nea, termed chemosis of the conjunctiva. There is intense pain in the eyes and over the orbits. This condition lasts for from two to four days, when the lids become softer and less swollen, and a purulent secretion flows from between them. This purulent stage of the disease lasts for from one to two or three weeks. Ulceration of the cornea may, and often does, take place, sometimes with loss of the sight. Inflammation of the entire eyeball and orbital contents (panophthalmitis) may supervene, with total loss of the eye. The nurse's first duty when called to take charge of a case of gonorrhceal ophthalmia is to protect the unaffected BULLER'S SHIELD. 29 eye, if but one is infected. This may be done in one of two ways: by Buller's protective shield or by bandaging the eye. Buller's shield is applied as follows:— Take an ordinary watch-crystal, which is about 11/a inches in diameter, and two pieces of adhesive plaster, one of which should be 2 inches square and the other 2 1/2 inches square; cut a hole 1 inch in diameter out of the center of each piece of plaster, paste the smaller piece to the concave (hollow) side of the watch crystal and the larger piece to the convex (elevated) surface of the watch crystal. The outside piece of plaster (which is on the convex surface of the crystal), being larger than the inside piece, leaves a half-inch margin of the adhesive plaster free. The watch crystal, concave surface inward, is now placed over the unaffected eye and the free margin of adhesive plaster fastened to the face, above the eye, on the nose and below the eye, the edges of the plaster being covered with flexible collodion to hold them more securely. The temporal side is not pasted to the face, but left free to give ventilation to the eye. There is but little danger of infection, by hav- ing the temporal side open; and if pasted down, moisture from the eye forms a mist on the glass crystal and prevents the patient from seeing with the eye, as well as preventing a view of the patient's eye by the physician. In infants and very restless patients, it is better to cover the well eye with a pad of gauze and a roller bandage, which is not so easily pulled off. (For method of applying a protective bandage, see Chapter IX.) This bandage should be removed twice every day, the eye washed, and then the bandage reapplied. Cleansing the affected eye, or eyes, as the case may be, is the next most important and urgent duty of the nurse. 30 EYE NURSING. For the first few days after the inception of the dis- ease there is, as a rule, but scanty secretion; but after the third or fourth day the secretion from the eyes is copious. This pus should not be allowed to remain in contact with the eye, as it becomes a source of irritation to the eyeballs, and may cause ulceration of the cornea, a complication we wish to avoid if possible. In very severe cases, where the pus collects quickly, it should be removed every twenty to thirty minutes, and in less severe cases every half-hour to one hour. The frequency with which an eye should be cleansed will depend upon the judgment of the doctor and the observation of the nurse. Pus should not remain in contact with the eye, and when enough is collected between the lids to be noticeable to the attendant it should be re- moved at once. A day nurse and a night nurse are neces- sary in such cases; at night the cleansing should not be as frequent as in the day,—perhaps about one-half as fre- quently. This is to allow the patient an opportunity to sleep. If the patient is kept awake too much, his general condition is weakened, and this in itself affects the eye in a bad way, and may hasten a breaking down or ulceration of the cornea. If the lids are so swollen that the eyes cannot be readily cleansed, a canthotomy (cutting of the outer angle of the lids) should be performed by the surgeon. As remarked above, this not only allows the eyes to be cleansed easily, but takes pressure off of the eyeball, and in this way lessens the danger of ulceration of the cornea. And it must ever be borne in mind that this is a complication we wish most ardently to avoid. In cleansing the eye the nurse should be very careful not to rub the cornea so as to abrade it, for this leaves an open spot for infection and is almost certain to result in an ulcer. TREATMENT. 31 When ulceration does take place, it should be reported at once to the surgeon, if not already observed by him, be- cause it necessitates the installation of atropin at once, and usually a change from cold to hot applications. The application of cold compresses is another impor- tant feature of the treatment in gonorrhceal ophthalmia, and the nurse should be prepared and know how to make such application, which may be clone in two or three ways, as already described when treating of catarrhal conjunc- tivitis (see page 24). Iced cloths should not be applied too frequently nor too long at a time, because they have a depressing effect on the circulation and nutrition of the eye. The circulation of the blood in the loops of blood- vessels at the periphery of the cornea is already much em- barrassed by the chemosis of the ocular conjunctiva, often present in the severer cases, and the cold further depresses this circulation. While, therefore, the cold compresses re- lieve the pain, they should not be used too freely, but only just enough to keep down the pain and to help reduce the swelling of the eyelids. The cold compresses are of much service in the beginning of the disease and should be used 15 to 30 minutes in each hour; but after the secretion has fully started, and in the later stages of the disease, they should be used less frequently. If ulceration of the cornea takes place, they should be stopped at once and hot appli- cations used in their place. Hot applications are applied in the following man- ner : Have by the bedside of the patient an open metal vessel which will hold a quart to half a gallon of water. Fill with water and place on two bricks so arranged that an alcohol lamp can be placed beneath. The temperature of the water should be raised to 110° F. Then pledgets of cotton or old linen are dipped into this, wrung out, and placed on the eye. 32 EYE NURSING. These pledgets should be changed every minute or two, for 30 minutes; then rest 30 minutes, or an hour, as the case may demand, when they should be repeated. This should be done several times a day according to the directions of the surgeon. If an alcohol lamp is not convenient, hot water may be taken frequently in a pitcher from a pot or kettle on the stove, and the pledgets of cotton dipped in this and placed on the eye. The objection to this method is that the water soon cools in the pitcher and is of variable temperature, while the alcohol flame keeps a constant temperature. The applications of remedies to the lids in these cases is usually made by the surgeon or his assistant in charge, but often the nurse is called upon to make them. In the very early stages of the disease we may modify it (and abort it as some claim) by the application to the everted lids and down deep within the culs-de-sac a strong solution of silver nitrate (from 40 to 50 grains to the ounce) solution. This is neutralized immediately with salt water solution. Usually not more than two such applications are made, and one day apart. When the purulent discharge sets in, about the third to fourth day, a solution of silver nitrate (10 grains to the ounce) may be applied to the lids once a day. Kecently some of the newer preparations of silver, protargol, argyrol, etc., have found favor with some surgeons. These solutions, of which I prefer argyrol, may be dropped into the. eye twice a day by the nurse. In the severe cases the argyrol should be in the strength of 250 grains to the ounce. It has the great advantage of being nonirritating. Protargol is moderately irritating and less effective. The silver nitrate solution is very irritating to the eye, unless salt solution is used immediately afterward, but, in my opinion, it is more TREATMENT. 33 effective than the newer preparations. For that reason, I depend upon it almost to the exclusion of the other prepara- tions. All dressings, cotton, linen, etc., used in connection with these cases of gonorrhceal ophthalmia should be burned immediately after use. The nurse herself cannot be too careful with her own eyes, always washing her hands each time after cleansing or touching the eyes of the patient, and then dipping the hands into a strong solution of bichlorid of mercury (1 to 1000). That the danger of in- fection of the nurse's eyes and also of the eyes of the family and friends of patients affected with gonorrhceal ophthal- mia is not an imaginary one, may be inferred from the fol- lowing quotation from Professor Fuchs, of Vienna:— "In the Vienna Foundling Asylum, during the years 1812 and 1813, there were for every hundred infants af- fected with blennorrhcea (ophthalmia neonatorum) more than fifteen nurses so affected, who had acquired their eye- disease from the infants. I have seen a whole family in- fected with blennorrhcea by a child having blennorrhcea neonatorum, and thus plunged into the greatest misery." ("Text-book of Ophthalmology," page 54.) I myself have seen more than one nurse's eyes infected with gonorrhceal ophthalmia contracted from the eyes of the patient whom she was nursing. Too much stress, therefore, cannot be laid upon this matter of prevention of infection of the attendants and the neighbors of the pa- tient afflicted with this highly contagious disease. Abso- lute cleanliness on the part of the nurse, protective glasses for her eyes, burning of all dressings, cotton, etc., used in cleansing the eyes, should be strictly followed out. The room or ward in which such patients are cared for should have but little furnishing, and that plain, with no 8 34 EYE NURSING. carpet on the floor; and should be well ventilated and mod- erately well lighted. The general condition of the patient should be care- fully attended to. Plenty of nutritious, fluid, diet, and tonics, if necessary, should be given. All company should be excluded, both for the comfort of the patient and the prevention of possible infection of the visitor. The room in which such cases have been taken care of should be thor- oughly disinfected before being occupied by anyone else. Ophthalmia Neonatorum. This disease is identical with gonorrhceal ophthal- mia, being caused by the same micro-organism, the gono- coccus. It occurs in infants; hence the name, ophthalmia neonatorum, — ophthalmia of the newborn. The symp- toms are the same as in gonorrhceal ophthalmia, but, as a rule, not as severe; furthermore, the eyes of infants withstand the inflammation better than the eyes of adults. Where ophthalmia neonatorum is seen in time, within forty-eight hours after infection, a favorable prognosis may be given. This is not so in adults when infected; no matter how soon the disease comes under observation or how energetic the treatment pursued, the vision of many eyes is destroyed by it, and the prognosis should always be a guarded one. For instance, I have known a nurse to lose her eyes as the result of gonorrhceal ophthalmia contracted from nursing an infant with ophthalmia neonatorum, the infant in the meantime recovering with good vision. Ophthalmia neonatorum is contracted from the genital organs of the mother during parturition, or immediately afterward when the child is bathed. Every obstetrical nurse should be taught this fact. If possible, the vagina of every parturient woman should be douched with a warm, anti- OPHTHALMIA NEONATORUM. 35 septic solution (1 teaspoonful of carbolic acid to a quart of water) just before delivery. After birth the child's eyes should be washed in water from a small bowl, and not from the tub in which the child's body is bathed. After the lids have been carefully bathed and dried, by direction of the doctor in charge, 1 drop of a 2 per cent, solution of nitrate of silver should be dropped between the lids into the eyes, as first suggested by Creole, and especially should this be done if there has been any vaginitis whatever in the mother. By this method, in the Lying-in Hospital of Leipzig, Crede reduced the number of cases of ophthalmia neonatorum from 10.8 per cent, (which prevailed before his method was used) to 0.2 per cent. With such a showing, it seems to me the doctor's duty to order and the nurse's duty to follow this method of treatment is imperative in every case of childbirth. And this, no matter whether there is a vaginitis in the mother or not. Even if there is no disease of the eye, 1 drop of a 2 per cent, solution of silver nitrate does no harm; and often, as shown by statistics, does a great deal of good by preventing the disease. The nursing of an infant's eyes affected with ophthal- mia neonatorum is about the same as that followed in the care of an adult with gonorrhceal ophthalmia, differing somewhat in but one or two particulars. When but one eye is affected, a protective bandage should be applied in- stead of the Buller's shield, which latter would likely be pulled off by the little patient. Again, the lids are very small and much more difficult to handle, and it is often necessary, on this account, to use a very small and delicate lid retractor to elevate the upper lid in order to cleanse the eye properly. To introduce this retractor under the upper lid without injury to the eye it is necessary to place the forefinger of one hand on the skin of the upper lid, about 36 EYE NURSING. V2 inch above its free margin, and make gentle traction. This lifts the free margin of the lid from the eyeball when the retractor can be gently introduced under it. Once under, the li(J can be held up out of the way while the eye is cleansed. If the swelling of the lids is so great that the retractor cannot be easily introduced, a canthotomy should be per- formed by the surgeon; after which it is quite an easy matter for the nurse to introduce the lid retractor, or ele- vator as it is commonly called. The canthotomy is of direct benefit also, as pointed above, by taking pressure of the eyelid off of the eyeball, and by reason of the local bloodletting. Complications, as ulceration of the cornea, should be treated in the same manner as when occurring in gonorrhceal ophthalmia in adults. Ninety-nine per cent, of all eyes affected with oph- thalmia neonatorum should be saved with useful vision, if only seen in time. Unfortunately many of the poorer classes in large cities are attended by midwives during con- finement, and the infant is often allowed to go for days or weeks with a "cold in the eyes" before the child is brought to a doctor. This so-called "cold in the eyes" only too often is ophthalmia neonatorum, and frequently the child's eyes are hopelessly lost or greatly injured when first seen by the doctor. For this reason, this disease, which is easily prevented when Crede's method is used, and which is so amenable to treatment, when seen in time, is the cause per- haps of one-sixth of all cases of blindness. A rather sad commentary in this day of antiseptic and aseptic surgery! In the State of New York a law has been passed mak- ing it a felony on the part of a midwife or other attendant, not a doctor, if sore or inflamed eyes in a newborn infant is not reported at once to a doctor. And the punishment may be a fine or imprisonment or both. CHAPTER III. MEMBRANOUS CONJUNCTIVITIS (CROUPOUS AND DIPHTHERITIC). Croupous Conjunctivitis—Diphtheritic Conjunctivitis—Trau- matic Membranous Conjunctivitis. Clinically we recognize two varieties of membranous conjunctivitis: croupous and diphtheritic. Considered from their microbic origin, however, the distinction or differ- entiation between the two forms is not so easily made; for the Klebs-Loeffler bacillus, which is supposedly the cause of every case of diphtheritic conjunctivitis, is some- times absent in the most virulent clinical forms of the disease, while the same bacillus is sometimes present in the mildest cases of croupous conjunctivitis. The history of the case and clinical appearances must be depended upon, therefore, in a large measure, in arriving at a correct diag- nosis in these cases. All such cases should be isolated from the start, and especially so if there is any suspicion of the diphtheritic form being present, since this latter variety is highly contagious. Every nurse should be familiar with the symptoms (both the local and general) of membranous con- junctivitis: first, for the benefit of the patient, and, sec- ond, for her own protection and the safety of the public. Croupous Conjunctivitis. The symptoms in the early stage of the disease are burning, pain, redness, and swelling of the eyelids, as in an ordinary purulent conjunctivitis. On the second or third day, however, a grayish-white membrane forms on the (37) 38 EYE NURSING. conjunctival surface of the lids and in the deeper folds (culs-de-sac) of the conjunctiva covering the eyeball itself. This membrane may be in small patches or cover the whole surface of the conjunctiva of the lids. As a rule, it can be wiped off easily with a pledget of cotton, leaving a raw surface beneath which sometimes bleeds. The superficial position of this membrane, it being confined to the epithe- lial layer of the conjunctiva, and the ease with which it can be removed, distinguishes this form of membranous con- junctivitis from the true diphtheritic variety. In the latter disease the membrane is really an exudate into the deeper layers of the conjunctiva and cannot be wiped off at all. Again, in croupous conjunctivitis, the lids, though swollen and red, do not become stiff and of a "leathery" hardness as in the true diphtheritic form of the disease. The general or systemic symptoms also are much milder in croupous than in diphtheritic conjunctivitis. Three or four days after the inception of croupous con- junctivitis, the membrane begins to loosen and come away, sometimes in small pieces and at times in a mass, when the disease assumes more or less the character of a purulent conjunctivitis, and is to be treated and cared for as such. The membrane may re-form one or several times. As the disease is contagious (the streptococcus usually being present), the patient is to be isolated, and, if but one eye is affected, the other is to be protected by a Buller shield or bandage. In the early stages of this disease, caustics or strong applications of any kind ,(as silver nitrate, bichlorid of mercury, etc., in strong solutions) are to be avoided, be- cause these preparations themselves, in concentrated form, are capable of forming membranes on the conjunctiva. All that is necessary for the nurse to do, after isolating the patient and protecting the eye, is to keep the affected eye DIPHTHERITIC CONJUNCTIVITIS. 39 clean with a saturated solution of boracic acid, and apply cold cloths to the eye in the very early stage of the disease. After the second day, if there is still pain, hot applications should be made in place of the cold, as the vitality of the eyes in these cases is reduced and cold has a tendency.to reduce it even further. The membrane should be wiped gently from the lids once a day. This can be done as fol- lows: Evert the upper lid; then, with a piece of cotton wrapped on an applicator and moistened in boracic acid solution, rub the membrane off of the palpebral conjunctiva, beginning at the border of the lid, and carrying the point of the applicator into the cul-de-sac so as to remove the mem- brane from that position. If the membrane does not come away fairly easily, do not persist too energetically, but let it alone till the following day, when a second attempt may be made. In fact, the membrane will loosen and -come away of its own accord after a few days. It is better, however, to facilitate matters if it can be done without injury to the eye. The use of peroxid of hydrogen, even in the weakest solution, should not be used to remove these membranes', as its use may cause abrasion of the corneal surface, with con- sequent ulceration and infection of that portion of-the eye, a mishap studiously to be avoided. When the disease passes into the purulent stage, it is to be cared for in ex- actly the same way as is a purulent conjunctivitis. Diphtheritic Conjunctivitis. In this variety of membranous conjunctivitis the symp- toms are much more severe than in the croupous form just described. The pain is much more intense and the lids are not only swollen and tender to the touch, but are dense and hard, and it is impossible to evert them. The membrane in this disease is really an infiltration into the conjunctiva, and 40 EYE NURSING. cannot be wiped off. It may affect only small areas of the conjunctiva, but may cover it entirely. The patches of infiltration have a grayish color, but when the entire con- junctiva is involved it assumes a very pale or "lardaceous" appearance, due to the infiltrate pressing on the blood- vessels and diminishing the normal blood supply. It is this very feature of the disease that makes it so dangerous. The cornea depends for its nutrition on the blood from the con- junctiva and subconjunctival vessels, and when the infiltra- tion is very extensive the cornea often sloughs, in part or in whole, despite all efforts to prevent it. Patches of the conjunctiva may slough away, leaving a granular surface and later scar tissue. The discharge from the eye in this disease is very slight: in the earliest stage of a watery or mucous nature, in the infiltration stage there is practically no discharge, while in the latest stages it may assume a purulent character. It should ever be borne in mind by the nurse that diphtheritic conjunctivitis is but a local manifestation of a systemic disease. Whenever she notices any membranous patches on the conjunctiva, patches of a similar nature should be looked for in the throat and in the nose, for the throat, nose, and eye are often affected simultaneously. The general symptoms in this affection are much more severe than in croupous conjunctivitis. The temperature is elevated, the pulse quicker, and the patient markedly depressed. These marked general symptoms, together with the local symptoms of intense pain in the eyeball and stiff, leathery condition of the eyelids should point to the nature of the trouble. In the very early stages of the disease, however, before infiltration of the conjunctiva has occurred and hardness and stiffness of the lids manifested themselves, it is difficult if not impossible to distinguish the graver TREATMENT. 41 from the milder disease. In every instance, therefore, where a nurse has charge of a child, or children, as they often have, and any membranous formation appears on the conjunctiva, it should be reported to the parents or those in authority, and the child in the meantime isolated. I have dwelt somewhat at length on the symptoms and manifestations of croupous and diphtheritic conjunc- tivitis, in order that the nurse may recognize or at least suspect the nature of these affections when she comes in contact with them, as she often does. The protection of the fellow-eye, if but one is affected, the isolation of the patient, and the institution of prompt treatment depend upon the early recognition of the nature of the disease. Only too often is the disease allowed to gain a firm hold and others exposed to the infection before the real nature of the affection is known. The nurse's first duty in a case of diphtheritic conjunc- tivitis, after the patient has been isolated, is to apply a pro- tective shield or bandage to the unaffected eye, if but one is involved. The method of doing this has already been described in a preceding chapter, and need not be gone into again here. The second important duty in these cases is the application of hot fomentations. Cold applications should not be applied in _ diphtheritic conjunctivitis. The vitality of the patient and of the eye is much reduced al- ready, and cold applications make matters worse. Heat, on the other hand, sustains the vitality, and at the same time relieves the pain, and in a measure softens the thickened and stiffened eyelids. Hot saturated boracic acid, or salt solutions, by means of pledgets of cotton soaked in them, should be applied to the eyes thirty minutes out of every hour during the day, and half this often during the night. The patient is not disturbed so frequently during the night, 42 EYE NURSING. in order that he may obtain a sufficient amount of sleep, for it is just as important for the patient to have rest and concentrated diet as local treatment; more so, perhaps. In fact, every measure that sustains vitality, general and local, is to be resorted to. Local remedies or applications, other than the hot fomentations just mentioned, are of but little value in the treatment of this malady. All irritating ap- plications of whatever nature are to be rigidly avoided, as they do harm rather than good. There is but little to be done in the way of cleansing the eye, as in the early and middle stages of the disease there is but scant secretion, and this is from the portion of the conjunctiva not infil- trated. The membrane, or, to be more accurate, the infil- trate, cannot be wiped off and is gotten rid of by absorp- tion. In the later stages of the disease there is more or less of a purulent secretion, and this must be washed away frequently, just as in purulent conjunctivitis, with boracic acid solution. Topical applications of silver nitrate, 10 grains to the ounce, solution may be used sparingly at this stage, being limited to that portion df the conjunctiva not affected by the infiltrate. Where ulceration of the conjunc- tiva has taken place, the lids should be separated from the eyeball several times a day, and, as this ulceration usually occurs in the later stages of the disease, the lids are usually pliable enough to be lifted away from the eyebill. The membrane may reappear in these cises, especially if irritating'applications have been made to the conjunctiva. Ulceration of the cornea, in part or the whole, fre- quently occurs in diphtheritic conjunctivitis. At the first appearance of such a complication, atropin is to be instilled, —of course, according to the surgeon's directions; hot fo- mentations persisted in, and the general condition of the patient sustained by fluid diet, tonics, etc. TRAUMATIC MEMBRANOUS CONJUNCTIVITIS. 43 Incidentally, it may be remarked that no cauterization of the corneal ulcer by means of the actual cautery, carbolic acid, nitric acid, or other destructive agents should be un- dertaken, especially in the early stages, since the ulceration is due to a lowered vitality and cutting off of nutrition to the cornea by the infiltrate, and not to infection. In the later stages such measures may be cautiously used. Diphtheritic conjunctivitis is met with most frequently in babies and young children, though occasionally in the adult. In the latter instance, it is often contracted by doc- tors, nurses, and attendants, from children suffering with faucial diphtheria, by having the membrane or parts of it coughed into the eye while attempting to cleanse the child's throat. If active measures are at once adopted, usually infection can be prevented, and I have prevented it on one occasion where a doctor had a large piece of membrane coughed directly into his eye. The eye is cleansed thor- oughly with a solution of bichlorid of mercury (1 to 5000), then 2 or 3 drops of a 1 per cent, solution of silver nitrate is dropped into the eye, and finally 4 or 5 drops of sweet oil are dropped into the eye. As to the general care of the patient and nursing con- nected with faucial diphtheria, the administration of the antitoxins, etc., see the chapter on faucial diphtheria in Part III. Traumatic Membranous Conjunctivitis. This may result from applications of caustics to the conjunctiva, strong solutions of silver nitrate or the solid stick, carbolic acid, nitric acid, or to dusting the powdered jequirity bean into the eye in the treatment of trachoma, and always occurs after the operation of "expression" of trachoma, if the operation is at all thorough. 44 EYE NURSING. Where the membrane is the result of caustics, the only treatment and care necessary is to discontinue the caustic and keep the eye cleansed with boracic acid solution. Sweet oil may be dropped between the lids and the eyes protected with a shade or patch. Care should be taken that no adhe- sions occur between the lids and the eyeball. Where the powdered jequirity bean is dusted into the eye, in the treatment of old trachoma with pannus, the eye- lids become markedly swollen and cedematous, the con- junctiva intensely congested, and the eye very painful in about twelve hours after the powder is put into the eye and lasts from forty-eight to seventy-two hours. Iced cloths are applied thirty minutes out of every hour, and the secretion, which is very scanty, is to be washed away with boracic acid solution. At the end of the second or third day a dirty-grayish membrane is formed covering the entire conjunctiva and even the cornea. This breaks down and comes away a piece at a time, or occasionally a cast of the entire lid is removed. As this membrane loosens it should be washed away with boracic acid solution and rubbed off gently with cotton wrapped on an applicator. Usually the membrane is entirely cleaned away in ten days' to two weeks' time. Iced cloths are not to be used after the pain and intense swelling are gone. The patient is to be put to bed and the eyes looked after as carefully as if the patient had croupous or purulent conjunctivitis. The membrane that follows "expression" of trachoma is to be treated exactly in the same manner as indicated above. For the first few days after the operation is per- formed, iced cloths are to be applied; then, when the membrane begins to loosen, it should be washed away or rubbed off with cotton. If this is not done, the membrane organizes, forms dense connective tissue (scar tissue), and TREATMENT. 45 leaves the lids in a very undesirable condition, which may result in curving of the lids inward toward the eye (en- tropion) with the lashes sweeping the cornea. Where the membrane cannot be removed readily, a few drops of 1 per cent, solution of pyrozone may be dropped on to it, which loosens it at once. Care in the use of this solution must be exercised, and, if there are ulcers on the cornea, it should be used only by dipping cotton wrapped on an applicator into it and its action limited to the lids. Sweet oil or vase- lin should be applied to the conjunctiva after cleansing the eye; this prevents adhesions and protects the surface of the cornea and conjunctiva. CHAPTER IV. SOME OF THE NONCONTAGIOUS DISEASES OF THE EYE CALLING FOR THE SERVICES OF A NURSE. Hordeolum—Blepharitis Marginalis—Phlyctenular Conjunc- tivitis—Ulcerative Keratitis—Iritis—Cyclitis—Irido-cyclitis—Sym- pathetic Ophthalmia—Glaucoma—Panophthalmitis. Hordeolum (Stye). This is one of the commonest affections of the eyes. A stye is not of serious import in itself, but often gives the patient acute pain and much annoyance. It is nothing more or less than a little boil or abscess at the root of an eyelash. Any treatment that aborts the process or alleviates the pain is very grateful to the patient. When seen early, epilation or pulling of the eyelash, at the root of which the abscess is forming, and the application of hot fomentations relieve the pain and frequently abort the disease. If the stye is not aborted, the hot applications should be continued sev- eral times a day until the stye is "ripe" for opening, when it should be lanced by the surgeon, the contents gently pressed out with the fingers and hot applications applied a day longer. Where a person is subject to frequent re- currence of styes, the eyes should be examined for glasses, a refractive error sometimes being the exciting cause. Blepharitis Marginalis. Inflammation of the borders of the lids is a very com- mon affection of the eyes. It presents itself under two forms: blepharitis squamosa and blepharitis ulcerosa. In the squamous variety the edges of the lids are reddened and (46) BLEPHARITIS MARGINALIS. 47 covered with dry scales; in the ulcerative, the edges of the lids are not only reddened, but the eyelashes are tufted together with dried crusts. When these crusts are removed small ulcers are found beneath them, around the roots of the eyelashes. If the disease has lasted for a long time it may cause: a chronic conjunctivitis; irregularity of the lashes (wild hairs, or trichiasis), causing them to sweep the cornea; total loss of the eyelashes (baldness of the lids, or mada- rosis); thickening of the edges of the lids, and eversion of the lower lid (ectropion). The exciting causes of the disease are: much weeping; bright light; smoke; dust; closure of the lacrymo-nasal canal, causing tears to run over the eyelids; astigmatism, and excessive use of the eyes. General causes leading to the disease are scrofula, tubercular affections, etc. When only one eye is affected we should look for a local cause, as stop- ping of the tear-duct. Treatment.—The local treatment consists, first, in cleansing all scales and crusts from the edges of the lids. This may be done by bathing the lids with a warm solution of carbonate of soda (2 drachms of soda to the pint of water) for ten minutes, rubbing the crusts off with a piece of cotton saturated in the solution. In the very severe cases, where the lids are thickened, the eyelashes should be pulled out with cilia forceps, and the little abscesses at their bases touched with a solution of nitrate of silver (4 per cent.). After the lids are thoroughly cleansed in the manner just described, an ointment of some kind should be rubbed on the edges of the closed lids. Of the various ointments, the yellow oxid of mercury (Pagenstecher), 1/2 to 1 per cent, (the base of vaselin or lanolin), perhaps is the best. In very sensitive eyes the ammoniated mercury 48 EYE NURSING. ointment, the same strength as the yellow oxid, may be used. As a base for these ointments, equal parts of vaselin and lanolin is to be preferred. In obstinate cases the red oxid of mercury ointment and tar preparations may be used, but they are usually too irritating. As a rule, the milder the ointment, the less irritation and the quicker the cure. In these mercurial ointments, too, it is altogether essential that they be well made, the mercury finely pulverized, and no grains left in it. A few drops of sweet oil added to the powdered mercury and rubbed with it before it is added to the base facilitates this and makes a smoother ointment. No more than 1/2 ounce of ointment should be prescribed at one time, as it soon becomes rancid, when it should be renewed. The general treatment consists of placing the patient in better hygienic surroundings, which unfortunately can seldom be done, as usually the patients are from the poorer classes; building up the system with tonics, as the syrup of the iodid of iron, syrup of hypophosphites, codliver-oil, etc.; and placing the patient on a simple nutritious diet,— milk, bread and butter, oatmeal, fresh meat once a day, eggs, etc. All sweets and pastry should be excluded from the diet. Phlyctenular or Lymphatic Conjunctivitis. Phlyctenular keratitis may be discussed under this heading also, as it is essentially the same disease, the con- junctival epithelium extending over the cornea and forming its anterior layer, the one chiefly affected in this disease. The disease occurs most frequently in young children and up to puberty—rarely before 1 year of age or in adults. Children in poor hygienic surroundings with inadequate nourishment and scrofulous and tubercular taint are most LYMPHATIC CONJUNCTIVITIS. 49 subject to it. Unlike the other forms of inflammation of the conjunctiva, which are diffuse in character, this affection is circumscribed, or focal, in nature; that is, small spots of the conjunctiva or cornea are affected while the rest remains in a quiet state. The favorite location of these phlyctenules is at the limbus of the conjunctiva; that is, where the conjunctival epithelium incroaches upon the cornea. From one to a half dozen small, red, somewhat elevated spots, about the size of a pinhead (sometimes larger, sometimes smaller), appear on or near the limbus of the conjunctiva. Small leashes of blood-vessels, triangular in shape, run to each phlyctenule, or rather nodule, as there is, in fact, no vesicle, but simply an elevation of the epithelium by an exudate of round cells beneath the epithelium. After a few days' time (from one to three) the epithelium at the top of the elevation breaks down, leaving a small, grayish ulcer. This heals under favorable conditions in from one to two weeks' time. The same holds true when they are on the cornea, and without leaving opacities. When neglected and the ulcer extends into the true corneal tissue, opacities are left which never clear away, and the sight is impaired. Sometimes these small ulcers take on a serpiginous character; that is, extend across the cornea, drawing a leash of blood-vessels after them, and leaving a bandlike opacity when they heal. Phlyctenulae may appear on the conjunctiva (ocular) alone, when they are large and usually few in number; they may appear on the cornea proper, or at the limbus of conjunc- tiva, as they do most frequently. They may be very small and surround the cornea entirely. The most marked symptoms of phlyctenular conjunc- tivitis, outside of the phlyctenules themselves, is the great fear of light (photophobia) which is present in almost 50 EYE NURSING. every case; and, second, the spasm of the orbicular or lid muscles. Children will hide their faces in dark corners, in the bedclothes to avoid the light, and they shut the eye- lids tightly for the same reason and on account of the irri- tation of the cornea and conjunctiva. Often accompanying this disease the edges of the eyelids are inflamed, and even the outer surface of the lower lid and the nasal mucous membrane and the upper lip have an eczematous eruption, which must be treated along with the eye affection. Treatment.—Locally, the best and most frequently used remedy is the Pagenstecher ointment of the yellow oxid of mercury (1/2 to 1 per cent.), which is placed on the everted lower lid with a small spatula or with the tip of the finger, then the lid is allowed to close and the oint- ment is rubbed into the eye with the tip of the finger over the closed lids. This is done once a day. Calomel dusted into the eye once a day with a camel's-hair brush is an- other favorite remedy in these cases. If there is marked inflammation of the eyes and the ulcers are rather deep, it is better to treat the eyes for a few days with atropin and hot water fomentations until the inflammation is reduced somewhat, when the above remedies may be applied. The eruption on the outer surface of the lids and about the nose is treated by having the scales washed off and the yellow oxid of mercury salve rubbed on the affected surfaces. Painting the surface about the nose with a solution of nitrate of silver (10 grains to the ounce) often is of great benefit. For relief of the spasm of the lids and to make the patient open the eyes, dipping the face into a basin of cold water three or four times a day is the best remedy. Small children are wrapped in a towel or sheet, held under one arm, and their faces pushed into the water and held there ULCERATIVE CONJUNCTIVITIS. 51 twenty to thirty seconds with the other hand. Usually the child holds the eyes open for an hour or two after this duck- ing. If the photophobia is intense, a solution of sulphate of eserin (1/2 grain to the ounce) may be used twice a day, and dark glasses or a shade worn. Under no circumstances should the child be allowed to hide in dark corners or its face in the bedclothes. General treatment consists in building the patient up with tonics, as the syrup of iodid of iron, syrup hypophos- phite compound, codliver-oil, etc.; placing the patient in the best hygienic surroundings; and, when it is possible, getting the patient into the open air two or three hours a day. The food should be simple; milk, bread and butter, rich soups, eggs, fresh meat once a day, etc., while all sweets are discontinued. The eyes of these patients usually get well in from one to four or five weeks' time, but unfortunately there is a marked tendency to recurrence of the disease, and, when once affected, the patient is liable to fresh attacks until puberty is reached, and exceptionally even later in life. The sight may be greatly impaired if many attacks occur or if treatment is neglected. Ulcerative Keratitis. Three of the severer types of ulceration of the cornea will be spoken of here; in particular, serpiginous ulcer (ulcus serpens); perforating ulcer; and rodent ulcer (ulcus rodens). The subjective symptoms of ulceration of the cornea are: pain, fear of light, tearing of the eyes, closing of the lids to keep the light out, and more or less interference with vision. Objectively, in the early stage of ulceration, a facet, smaller or larger as the case may be, is seen on the cornea. If the ulcer is a clean one, the bottom and edges 52 EYE NURSING. of the facet is very slightly grayish and there is but slight infiltration of the neighboring cornea. If it is a foul ulcer, the bottom and edges of the ulcer are covered with grayish matter, and the cornea next the ulcer is infiltrated and of a grayish color. Sometimes pus forms in the anterior cham- ber, which is called hypopyon. Usually there is an iritis present when this complication happens, with intense pain and circumcorneal injection. In serpiginous ulceration of the cornea the ulcer is clean on one side and dirty or foul on the other. On the clean side (which is nearest the periphery of the cornea) blood- vessels are thrown out to it from the corneal limbus and it heals; while on the other side the grayish infiltrate keeps extending into the cornea, the corneal tissue breaking down (ulcerates), and this ulceration may creep or extend en- tirely across the cornea. The blood-vessels which were thrown out to the clean side of the ulcer follow in the wake of the ulcers and heal it. When the ulcer finally heals, a band or ribbonlike opacity is left, which, though it may not extend deep into the corneal surface, often impairs vision very much on account of its extent. Rodent ulcer of the cornea affects the superficial layers of the cornea and is marked by severe inflammatory symp- toms. It usually starts at or near the margin of the cornea with edges that are undermined and of a dirty-grayish color. This undermining and breaking down of the rim of cornea immediately surrounding the ulcer progresses interruptedly (for often the edges of the ulcer clear up as if healing were about to take place, and then it starts again) until fre- quently the entire surface of the cornea is affected. A diffuse opacity covering the entire cornea results and useful vision is destroyed. Unfortunately both eyes may become affected. The disease occurs in old people. ULCERATIVE CONJUNCTIVITIS. 53 Treatment.—Local treatment consists in protecting the eyes from bright light, the instillation of atropin, the application of hot fomentations, and, chiefly and most effi- cient, cauterization of the ulcer by the surgeon with the actual cautery, the galvanocautery, or with pure carbolic or nitric acid. In ulcus serpens the foul side of the ulcer only should be cauterized. The general treatment is directed to toning the patient up with tonics, concentrated fluid diet, rest, massage, and, what often proves of marked benefit in these cases, a series of hot baths. Care should be exercised in giving hot baths, especially if the patient has a weak heart. The bowels should be kept in order. Perforating Ulcer.—Ulceration of the cornea following violent inflammation of the conjunctiva, as after gonorrhceal ophthalmia, diphtheritic ophthalmia, etc., often results in perforation of the cornea with prolapse of the iris into the wound, and sometimes with entire destruction of the cornea with loss of the lens and vitreous, and followed at times even with panophthalmitis. Perforating ulcer of the cornea is a serious disease, the iris often falling forward into the opening, becoming adherent, and when the wound heals leaves a dense, white opacity (leucoma) interfering greatly with vision. Sometimes this leucoma is so thinned that it bulges forward, forming a staphyloma of the cornea. When hypopyon complicates ulceration of the cornea and is not resorbed quickly, paracentesis of the cornea should be prac- ticed and the pus evacuated; because, if allowed to organ- ize, it blocks the pupil and may bind the cornea to the iris, and does great damage to vision and the eyeball in this way. The nurse is required to apply hot fomentations (moist) thirty minutes out of every two hours, and the instillation of a mydriatic as directed. Often a bandage is indicated, 54 EYE NURSING. when it has to be changed frequently to allow the applica- tion of hot water. The general condition of the patient and the giving of baths all come under the nurse's immediate direction. Iritis, Cyclitis, Irido-cyclitis, Sympathetic Ophthalmia. Iritis is an inflammation of the iris; cyclitis is an inflammation of the ciliary body (ciliary muscle and proc- esses), while irido-cyclitis is an inflammation of both the iris and ciliary body. Irido-cyclitis, when transferred from one eye to the other, as after an injury to the one eye, is called sympathetic ophthalmia. Iritis, cyclitis, and irido- cyclitis may be primary or secondary in nature. When primary, they are usually due to some general disease, as syphilis (acquired), rheumatism, infectious diseases, etc.; or they may be due to traumatism, and the second eye may be affected sympathetically. When of a secondary nature, they most commonly follow inflammations of the cornea. iritis. The objective symptoms of iritis of the plastic or exu- dative type (following syphilis, and about 65 per cent, or more of all cases are such) are: (1) discoloration of the iris, in blue eyes to a greenish or greenish-yellow hue, and in dark eyes to a "muddy" or lighter brown, as compared with the fellow-eye; (2) at times yellowish-red nodules appear on the borders of the iris, 1 to 4 or 5 millimeters in diameter, and varying in number from one to a half dozen or more; (3) contraction of the pupil and immobility of the iris; (4) redness of the eyeball, especially that part of it immediately back of the cornea; (5) cloudiness of the aqueous humor and, at times, in severe cases, the presence of pus in quan- CYCLITIS AND IRIDO-CYCLITIS. 55 tity in the anterior chamber (hypopyon) ; (6) a gray exu- date filling the pupil (occlusion of the pupil); (7) impair- ment of vision; (8) lacrymation. Exudates may be formed on the posterior surface of the iris binding it to the ante- rior surface of the lens capsule, which are called posterior synechiae. If these synechias bind the entire pupillary mar- gin to the lens capsule (seclusion of the pupil) it is called posterior annular synechias. This is seen only in the latest stages of the disease, and manifests itself by a "ballooning" of the iris; that is, the papillary margin of the iris being bound to the lens capsule, the secretions back of the iris, being unable to escape into the anterior chamber, push the middle zone of the iris forward. The subjective symptoms of iritis are: (1) pain in the eye, as a rule most severe at night; (2) photophobia (fear of light) ; (3) pain in the temple and side of the head on the corresponding side as the affected eye. cyclitis. Cyclitis without a complicating iritis, except in a chronic form (described as serous iritis), is a rare affection. The symptoms of inflammation are very mild; the pupil is dilated, the anterior chamber is deep, the aqueous humor is a little hazy, and often there is a deposit of small, grayish spots on the posterior surface of the cornea, and at times the eye has a plus tension. irido-cyclitis. Irido-cyclitis, being an inflammation of the iris and the ciliary body, has the symptoms of an iritis, which have been enumerated above, and, in addition, the following symptoms may be present: (1) oedema of the upper lids; (2) ex- cessive tenderness of the eye to the touch, especially over 56 EYE NURSING. the ciliary region; (3) excruciating pain, which may be attended in severe cases with vomiting and elevation of tem- perature; (4) marked disturbance of vision, due to opaci- ties in the vitreous and deposits on the posterior surface of the cornea; (5) increased depth of the anterior chamber due to binding down of the entire posterior surface of the iris to the lens capsule; (6) increased tension of the eye, followed in the latest stages of the disease by diminished tension. sympathetic ophthalmia. This disease, irido-cyclitis, may be transferred from one eye to the other (especially if it is due to a traumatism), when it is called sympathetic ophthalmia, or sympathetic irido-choroiditis. Sympathetic ophthalmia is a very serious disease of the eye, and when once thoroughly established rarely subsides until the sight of the sympathizing eye is entirely destroyed. It follows most frequently an irido- cyclitis which has been produced in the injured eye by a penetrating wound of the ciliary region or by a foreign body being lodged in the eye. The disease may appear as early as the second week, but usually not until from four to six weeks after the injury to the offending eye, when the in- flammation in the injured eye is at its height. It may ap- pear, however, years after the injury, especially when for- eign bodies have been lodged in the eye. These may be- come loosened, set up a fresh inflammation of the injured eye, and a sympathetic inflammation in the other. No wound in the ciliary region of an eye, or a foreign body lodged in an eye, is to be regarded as free from inciting sympathetic ophthalmia in the fellow-eye, even years after the traumatism has occurred. Sympathetic ophthalmia is characterized by a prodro- mal stage and by its marked tendency to recur. Failure of SYMPATHETIC OPHTHALMIA 57 the power of accommodation (in the sympathizing eye) is one of the very first signs of the disease. The patient, though he may be a young subject, finds he has to hold read- ing matter farther from his eyes than usual in order to read; secondly, the eye becomes sensitive to light or even painful; thirdly, there is lacrymation; and finally some redness of the eye. This is termed sympathetic irritation. As a rule, unless this condition is speedily relieved by quieting the inflammation in the injured eye, it develops into an irido-choroiditis, marked by circumcorneal injection, contraction of the pupil, clouded aqueous humor, but rarely with hypopyon; there are also pain, photophobia, and re- traction of the iris in severe cases. This condition may last from two to several weeks, and then subside, but almost without exception the attack is repeated and repeated until the sight is totally destroyed. In fact, if the sight is not entirely destroyed in the injured eye, it may retain more vision than the sympathizing eye. The surest method of preventing sympathetic inflammation is to enucleate the injured eye before the inflammation is well established in the uninjured eye; that is, when the symptoms of sym- pathetic irritation set in; for when once fully developed enucleation of the injured eye rarely relieves it. The Treatment of Iritis, Irido-cyclitis, and Sym- pathetic Irido-cyclitis.—In iritis the first and most im- portant step in treatment is to dilate the pupil, if that can be done. A solution of the sulphate of atropin (varying in strength from 1 to 3 per cent.) is the drug most relied upon. A drop of the solution, usually 1 per cent., should be put into the eye every five minutes, extending over a period of thirty minutes. If the pupil does not dilate easily, a drop of cocain solution (1 per cent.) should be dropped into the eye along with the atropin, or a few drops of adrenalin chlo- 58 EYE NURSING. rid solution (1 to 1000) may be supplemented. The cocain and adrenalin solutions (and atropin to a slight extent) aid in the dilatation of the pupil by contracting the blood-ves- sels of the iris and driving the blood from it. In stubborn cases where the adhesions are firm, Fuchs advises dropping a small granule of atropin in substance in the conjunctival sac. A powerful mydriatic of comparatively recent use is scopolamin, which is to be used in the same manner as the atropin, but in much weaker solution: from 1/10 to 1/5 of 1 per cent, solution. The nurse should always be careful to press with her fingers on the lacrymal sac at the inner cor- ner of the eye for two or three minutes after instilling a mydriatic or myotic into the eye, to prevent an excess of the drug going into the nose, where by rapid absorption into the general system it may cause annoying and sometimes alarming symptoms of poisoning. The patient also should be shown how to press over the inner corner of the eyes to prevent the above complication. If the pupil does not dilate by the use of these meth- ods, from two to six leeches should be applied to the temple on the side of the affected eye (for the method of applying leeches see page 88), or the artificial leech may be used. If the pupil still does not yield, a hypodermic injection of the muriate of pilocarpin (V10 to 1/s grain) causes profuse sweating and often aids in dilating the pupil. Hot, moist compresses to the eye and hot baths also assist in dilating the pupil, as well as alleviating the pain, as does also the leeching. In fact, the nurse's chief duty after instilling the medicines into the eye will be the application of hot fo- mentations. These should be kept up thirty minutes out of every two hours during the day and half as often during the night if there is much pain. TREATMENT. 59 The eyes (both) should be shaded from light with a light patch or shade, or dark glasses, or the room should be darkened. After the pupil is once dilated atropin should be used once or twice a day to keep it dilated. The bowels should be kept open. The diet should be light, no liquors being used, and in severe cases the patient should be confined to bed. In fact, in iritis of any severity the patient is much better off in bed than out, and the disease runs a quicker course. The general treatment is directed to removing the cause. In syphilitic iritis the inunctions of mercury are begun at once, using the oleate of mercury (20 per cent., Squibbs), 1/2 to 1 drachm being rubbed into the patient every night by the nurse with rubber gloves. This should be continued until the iritis subsides. Care should be taken not to salivate the patient. Potassium iodid in saturated solution may be given at the same time, the dose being in- creased from 5 drops, 1 drop a dose, until the effects of the medicine is manifested by watering of the eyes, and small pimples on the face, when the dose should be lessened. It should be given in a full glass of water or milk after meals. In rheumatic iritis the salicylates are given and hot baths resorted to. The treatment of irido-cyclitis is much the same as that of iritis. Mydriatics are not so well borne sometimes, espe- cially if there is elevation of the tension. In sympathetic irido-cyclitis the best treatment is prevention, and the best prevention is early enucleation of the injured eye before actual inflammation starts in the uninjured eye. Once started, no treatment is of much avail, though mercury in full doses and sweating by means of pilocarpin injections may prove of benefit. 60 EYE NURSING. Glaucoma. A brief description of acute and inflammatory glau- coma is given here that the nurse may not confuse this dis- ease with iritis, and that she may not make the great mistake of instilling atropin into eyes affected with this disease. Glaucoma is a complex disease of the eye, characterized by hardening of the eyeball, from which hardening or ele- vation of tension (plus tension) all the other symptoms of glaucoma follow. It may be primary in nature, or sec- ondary following injury or disease of the eyeball. In the former case it affects both eyes always, but not necessarily at the same time, while in secondary glaucoma but one eye is affected. In primary glaucoma there is usually a prodromal stage, which may extend over days, weeks, months, or even years before the disease manifests itself in violent form. During this stage the patient has attacks of dimness of vision, sees rings round lights, rainbow colored, and has a sense of fullness in the eye extending often to the forehead and temple. The pupil is slightly dilated and sluggish, the tension of the eye is elevated (plus), and there is slight redness of the eyeball. These attacks may last for hours, completely disappear, and not return again for months per- haps. The eye in the meantime resumes the normal condi- tion. Then the attacks become more frequent, last longer, and finally develop into a full-fledged inflammatory glau- coma. The eyeball becomes intensely hard to the touch of the finger through the closed lid, feeling like a stone; the eyeball is dusky red in color, with marked oedema of the conjunctiva often extending to the eyelids; the pupil is widely dilated and does not react; there is a greenish re- GLAUCOMA. 61 flex from the pupil; the cornea has a steamed appearance and is insensitive to touch; the anterior chamber is very shallow, while the pain is unbearable. Pain extends to the temple and head, and is of the intense neuralgic type, the patient often mistaking the disease for neuralgia. At times there is rise of temperature and vomiting. The field of vision is much contracted and the sight greatly reduced, and may be totally destroyed in a few hours' time in the worst cases. Such an attack may last for days or weeks, when the eye becomes quiet, the pain and redness disappear, and the tension much reduced if not entirely normal. If active treat- ment is not instituted, as eserin in oily solution (2 grains to the ounce) or pilocarpin solution (4 grains to the ounce) instilled, or iridectomy performed, the attacks recur and the eyesight is slowly, but surely, destroyed. It is altogether important that this disease be not mistaken for iritis and atropin instilled, as it is frequently done (even by doctors) to the great detriment of the eye. Dilatation of the pupil blocks the canal of Schlemm and increases the trouble. The important points of differentiation between glaucoma and iritis are as follows: 1. In glaucoma the tension is in- creased and the eyeball is hard. In order to detect hard- ness of the eye, palpate the eyeball over the closed lids with the tip of the index finger of each hand; then palpate the unaffected eye, and any difference in tension of the two is apparent. In iritis the tension is normal. 2. In glaucoma the pupil is dilated; in iritis the pupil is contracted. These two points of differentiation should be well fixed in the mind of the nurse. The cause of primary glaucoma is little understood. Some (von Graefe) attribute it to increased fluid in the eye, some (Donders) to irritation of the ciliary nerves, some (Stellwag) to increased blood pressure in the blood-vessels 62 EYE NURSING. inside the eye, while others (Weber and Knies) to dimin- ished outflow of fluid from the eye. Predisposing causes are: old age, hardening of the blood-vessels, obstinate constipation, sudden increase of blood-pressure; while women are more frequent sufferers than men. The form of the eye itself seems to have some effect, as myopic eyes are seldom attacked by glaucoma, while the flat hypermetropic eye is. Treatment. — When seen early the instillation of eserin solution (2 grains to 1 ounce of sweet oil), 1 drop every ten minutes for an hour, may prevent an acute attack, or, if at its height, may reduce the tension, relieve pain, and leave the eye in better condition for performing iridectomy. Iridectomy has proved to be the quickest and surest relief and even cure of this frightful disease. Panophthalmitis. As the name indicates, panophthalmitis is an inflam- mation involving all the tissues of the eyeball, and even the cellular tissue of the orbit and the lids are involved. The disease originates usually from an acute traumatic purulent choroiditis, or retino-choroiditis; or it may follow a perforating ulcer of the cornea. It may be metastatic in nature, following pyaemia, measles, scarlet fever, diph- theria, influenza, small-pox, meningitis, etc., when it may affect both eyes. The two most prominent symptoms are: (1) intense pain; (2) marked swelling of the eyeball, the tissues of the orbit and lids participating in the process. After the first few hours the pain becomes unbearable, unless relieved by hot fomentations, opiates, or lancing of the eyeball. The pain radiates to the head and is often accompanied by rise of temperature and vomiting. The eyeball becomes promi- PANOPHTHALMITIS. 63 nent; the conjunctiva intensely congested, cedematous, and a purplish red; the cornea hazy; the anterior chamber filled with pus; and the lids swollen and red, and tender to the touch. The nurse's duty in such cases is the application al- most continuously of hot fomentations, either in the form of linseed poultices or hot, moist applications (water 115° F.) by means of pledgets of cotton. Where the eyeball has perforated or has been split open by the surgeon the wound should be syringed every two hours with a solution of bichlorid of mercury (1 to 2000) or of carbolic acid (1 to 150), seeing that the solution gets inside the eyeball. The pain usually subsides quickly after the eyeball is once opened. The general condition of the patient is to be carefully looked after by the nurse, and the pulse, temperature, bow- els, etc., charted. The progress is always unfavorable in panophthalmitis: the eyeball shrinks and the sight is totally lost. The dis- ease is due to infection, and various micro-organisms have been found by microscopical examinations, as the staphy- lococcus aureus and albus and the streptococcus pyogenes. CHAPTER V. REMEDIES AND THEIR APPLICATION. Antiseptics—Astringents— Anodynes—Irritants—Counter-irri- tants—Caustics — Galvanocautery—Actual Cautery—Cycloplegics, Mydriatics, and Myotics—Anaesthetics—Miscellaneous Remedies— Vehicles—Bases—Solutions—Ointments—Powders. The nurse should be familiar with the various reme- dies and measures used in the treatment of eye diseases and have some knowledge of the nature of their actions, for in this way only will she be able to apply them intelligently. Antiseptics. Antiseptics are a class of remedies used for the pre- vention of septic decomposition or inflammation, or for arresting the process if already begun. Their efficiency depends upon their power to kill the micro-organisms which cause the inflammation. Boracic acid is a mild astringent powder. It is slightly antiseptic in action and causes no irritation whatever to the eye. It is used in a solution of from 1 to 4 per cent, for cleansing and irrigating the eyes in the various inflamma- tory affections. For this purpose it has almost superseded all other solutions, and, although only mildly antiseptic in action, on account of its unirritating property, it is used largely for irrigating the eye just before operations on that organ. After the eyeball has been opened, as in cataract extraction, iridectomy, etc., it is to be used in preference to all other solutions. An equal amount of borax added (64) ANTISEPTICS. 65 to it makes it more soluble. It is sometimes used in the form of an ointment (10 per cent.), and is valuable in the various inflammations of the conjunctiva and cornea. In solution it is often used as a vehicle for eye drops and in the preparation of surgical dressings which are dipped into it and then dried. Carbolic Acid.—This is used in very weak solutions (1/2 per cent.), as it is irritating to the eye when first applied. It is used chiefly for cleansing the eye and for its antiseptic properties in septic cases. The pure phenol, and not the commercial form, should be1 used in making the solution, as it is less irritating. Carbolic acid may be ap- plied in the form of an ointment (2 to 5 grains to the ounce) to rub between the inflamed lids of the eye. In a strength of 1 to 20, the solution is often used for disinfect- ing instruments by immersing the instruments in it for five or ten minutes. Mercuric bichlorid is one of the best antiseptics we have. It has a limited use about the eye, however, as it is highly irritating when used in sufficient strength to be germicidal in action. It has the further disadvantage of being a poison and of coagulating the albumin in the tissue, thus limiting its action to the surface of the tissue. For cleansing and irrigating the eye, it is used in solution of 1 to 5000, but never stronger than 1 to 3000. In the latter strength it is highly irritating. When cocain is dropped into the eye, as for cataract operation, and then the eye irrigated even with 1 to 5000 bichlorid of mercury solution, haziness of the cornea is produced and permanent opacities may result. The solution is not to be recommended in such cases. Simple sterilized water or boracic acid solution is much to be preferred. In the form of an ointment, 1 to 5000 (vaselin as a base), bichlorid is often used for its 66 EYE NURSING. antiseptic properties. In the treatment of trachoma a solu- tion of 1 to 500 or even 1 to 250 is at times applied on the everted lids. It should be strictly limited to the lid, how- ever, and no excess allowed to run on the eyeball. For dis- infecting the hands a solution of 1 to 1000 may be used, the hands being immersed for two or three minutes in the solu- tion. On account of its corrosive action it is never used on instruments. Surgical dressings of gauze, dipped into a solution 1 to 5000 or 1 to 3000 of bichlorid of mercury, then dried and prepared, are sometimes used about the eye. As a rule, however, simple sterilized dressings are the best for the eye. Biniodid of mercury, in very weak solution, is sometimes used for irrigating and cleansing the eye. The late Profes- sor Panas used a solution of 1 part of biniodid of mercury, 4 parts of alcohol, and 20,000 parts of water for cleansing the eyes before operating. Its efficiency in such weak solu- tion has been doubted and its chemical compatibility ques- tioned, since what little mercury is present is precipitated, it is claimed. Oxycyanid of mercury, in solution of 1 to 500 or 1 to 1000, has decided antiseptic properties and is less irritating to the eye than the bichlorid of mercury. It has the further advantage of not injuring instruments when they are dipped into it. Calomel, dusted into the eye, acts as an irritant and antiseptic, probably by being changed into the bichlorid of mercury by the action of the salt tears. Potassium permanganate, in solution of 1-500 to 1-100, is a strongly antiseptic agent of a purplish hue, which is somewhat irritating to the eye when used in strong solution. On account of its staining properties it is more or less ob- jectionable. ANTISEPTICS. 67) Formalin contains about 35 per cent, of formic alde- hyd. In solution of 1-5000 to 1-2000 it is astringent, irri- tant, and strongly antiseptic in action. It has highly pre- servative properties. In the weaker solution it is used to cleanse and disinfect the eye before operations, but should not be used in those cases where the eye is to be opened, as in cataract operations, as it is too irritating and causes too much congestion of the parts. In the stronger solutions, 1 to 2000, it is used as a cleansing solution and as an ap- plication to the lids of the eye in the contagious inflamma- tory diseases. Formaldehyd, in solution 1-3000 to 1-1000, is strongly antiseptic, but very irritating to the mucous membranes, and for that reason is seldom used about the eye. Chlorin water, the official, which contains 3/10 of 1 per cent, of chlorin gas, is astringent and antiseptic in action, and where used in dilution of 3 drachms to the pint of water is but slightly irritating to the eye. It is used for cleansing the eye before operations and also in the acute con- tagious inflammatory diseases. The solution rapidly dete- riorates, and for that reason must be freshly prepared and kept away from the light in a dark-colored, glass-stoppered bottle. Hydrogen peroxid, in 3 per cent, solution (the usual strength as it comes in the original bottle), is a strong anti- septic, being both germicidal and disinfectant in its action. It may be used in full strength, or, if too irritating, may be diluted one-half, when it may be used freely in the eye, provided there is no ulceration of the cornea, when it should be used with great caution and its action limited to the lids by being applied with probe and cotton. For removing the membrane from the lids that follows the operation of "ex- pression" for trachoma, and for cleansing and disinfecting 68 EYE NURSING. the eye occasionally in purulent inflammation of the con- junctiva, it is an excellent preparation. It should not be used too frequently, however, for cleansing the eye, as it becomes an irritant. When it comes in contact with pus or blood it breaks up the corpuscles through oxidation and causes a froth or foam. This foam should always be washed away with boracic acid solution or plain, sterilized water. As the solution quickly deteriorates it should be kept in a glass-stoppered bottle and in a cool place. The preparation known as pyrozone (3 per cent, solu- tion) is less acid than some other preparations of peroxid of hydrogen on the market, and for that reason its use is to be recommended in the eye, as it is less irritating than the others. Pyoktanin (pus-killer), or methyl violet, in solution of 1-5000 to 1-2000, is antiseptic and unirritating in action. On account of its staining properties it has never had wide use. Stilling recommended it a few years ago, and it has been used in purulent conditions of the conjunctiva for cleaning and disinfecting, but its use is almost wholly given up now. Iodoform is but slightly antiseptic in its action. It is highly offensive in odor. It and its substitutes, aristol, iodol, etc. (which latter have not the offensive odor of the former), are used chiefly in dressing wounds. They may be dusted on the wound or applied in the form of an ointment (10 per cent.). Corneal ulcers requiring stimulation are sometimes dusted over with iodoform with benefit. Gauze impregnated with iodoform (10 per cent.) is much used as a dressing for wounds. Zinc chlorid, in weak solution (1-1000 to 1-300), is antiseptic, astringent, and stimulating in its action. It is seldom used for irrigation of the conjunctiva because of its ASTRINGENTS. 69 irritating properties. In 1/2 to 1 per cent, solution it is frequently used as an application to the lids in chronic in- flammation. Lysol is a tar-oil dissolved in fat and then saponified with alcohol. It is antiseptic, disinfectant, and deodorant in action. In a 1 to 2 per cent, solution it is excellent for cleansing the field of operation, hands, and instruments. Chinosol, in solution of 1-3000 to 1-2000, is mildly antiseptic in action, and is used for cleansing the conjunc- tiva. ASTRINGENTS. Many of the antiseptics are also astringent in action. This class of remedies contracts the blood-vessels and tissues (especially mucous surfaces) when brought in contact with them. In this way the blood supply to the part is lessened and the secretions from mucous membranes diminished, partly by depleting the tissue of blood and partly by coagu- lating the albumin in the tissue. Silver Nitrate.—Of all the astringents used about the eye, nitrate of silver is the most efficient and the one most commonly employed. It is not only strongly astringent, but when used in strong solution or in solid form acts as a caustic. It is also a valuable antiseptic and germicide, and is often employed in the acute contagious diseases of the eye. Acting in its double capacity of astringent and germi- cide, it is the most valuable remedy we have in such affec- tions. Solutions of the drug are soon decomposed and ren- dered inert when left exposed to light; hence they should be kept in dark-colored bottles, and, when not in use, in a dark place. The strength of the solutions used varies from 5 to 20 grains to the ounce, exceptionally 40 to 60 grains to the ounce, for astringent and antiseptic purposes. Solu- tions stronger than this are used for their caustic action. 70 EYE NURSING. When brought in contact with mucous surfaces silver nitrate coagulates albumin and forms an insoluble precipitate, which renders its action superficial. For this reason it must be reapplied to the conjunctiva, in the acute microbic diseases of that membrane, especially in gonorrhceal ophthalmia, every twenty-four to forty-eight hours, according to the severity of the reaction, in order to kill the fresh supply of micro-organisms which appear on the surface from the deeper tissues. Solutions of nitrate of silver of 5 to 10 grains to the ounce may be dropped into the eye without harm, unless there is ulceration of the cornea. Where there is ulceration of the cornea a precipitate of silver may form an opacity at the site of the ulcer. Crede's method of pre- venting ophthalmia neonatorum in the lying-in hospital at Leipzig was to drop 1 or 2 drops of a 10 grain to the ounce solution of silver nitrate into the eyes of all infants imme- diately after birth. In this way he reduced the percentage of such cases enormously. In solution stronger than 10 grains to the ounce silver nitrate should always be applied to the everted lids by means of cotton on a probe, and the excess immediately washed away with a salt water solution. In stick form, or strong solution, silver nitrate is used to remove granulation tissue, polypi at the base of ulcers on the lids, etc. It may be fused with other drugs, as nitrate of potassium, and used as a caustic. The solutions of silver nitrate when used for too long a time on the conjunctiva cause it to turn to a slate color (argyria). This point should be borne in mind. Silver Substitutes.—Various substitutes for silver ni- trate have been tried in the last few years. They contain a certain percentage of silver nitrate, are organic in com- position, but little irritating, and do not coagulate albumin, and for this latter reason are supposed to penetrate deeper ASTRINGENTS. 71 into the tissues. They are germicidal and astringent in their action also. The most valuable one of these prepara- tions and the one containing the largest percentage of silver (30 per cent.) is argyrol (silver vitellin, Barnes & Hille). It is especially useful in the acute contagious diseases of the conjunctiva, and is used in solution varying from 25 to 250 grains to the ounce. Protargol contains about 8 per cent, of silver, is more irritating than argyrol, and is used for the same purpose, in solutions varying in strength from 5 to 30 grains to the ounce. Argentamin contains about 10 per cent, of silver, and is a slightly irritating as- tringent, and antimicrobic in action. It may be used in a 5 to 25 grain to the ounce solution. Argonin may be used in solution of from 5 to 30 grains to the ounce, and in the same cases as argentamin. Aktol (lactate of silver) and collargol (argentum colloidale, Crede) are used in solutions for disinfecting the conjunctiva. Itrol (citrate of silver) is used in the form of a dusting powder for infected wounds and in the contagious diseases of the eye. It is nonirri- tating and is to be applied from an insufflator, so as to drive the substance into the affected tissues (Meyer). Alum.—The sulphate of alum in crystal form, shaped into a pencil or stick, is frequently used in the milder in- flammations of the lids. It acts as an astringent and ex- siccant and coagulates albumin. At times it is used in solu- tion (1 per cent., as alum curd) in relaxed conditions of the conjunctiva. Alumnol, a preparation of aluminum (naphthol disul- phonate), is mildly astringent and sedative in action; most commonly it is used in powder form, 1 part of alumnol to 5 or 10 parts of boracic acid, bismuth, or talcum, to dust over wounds. It is soluble in water and may be used in solution (5 per cent.) for irrigation. 72 EYE NURSING. Acetic acid, in solution (3 per cent.), acts as a mild astringent and sedative and is occasionally used in mild in- flammations of the conjunctiva. In case of lime burn of the eye, especially when seen early, it is most useful, acting as a chemical antidote. Weak solutions of vinegar may be used for the same purpose. Tannic acid, in solution (1 to 20 per cent.), is mark- edly astringent and tonic in action on mucous membranes, is slightly irritant in weak solution, moderately so in strong solution, and coagulates albumin. It is one of the most frequently used drugs in inflammatory conditions of the conjunctiva. It is often used in the form of the aqueous solution (Agnew) :— B Acidi tannici, Sodii biborati............................aa gr x. Glycei ini................................. 3j. Aquae camph..........................q. s. ^j. M. et ft. sol. Sig. : Two drops in each eye three times a day. This solution is extensively prescribed at the Manhat- tan Eye and Ear Hospital, New York. In the treatment of trachoma, in which it is very beneficial, tannic acid may be used in from 10 to 20 per cent, solution of camphor water, to which 1 drachm of glycerin is added. The old preparation of glycerole of tannin (120 grains of tannin to 1 ounce of glycerin) is rarely used now, as tannin is much more irri- tating in pure glycerin as a vehicle than when mixed with camphor water. Zinc sulphate, in solution (1 to 2 per cent.), acts as an astringent. In the stronger solutions it is applied to the conjunctiva with probe and cotton. If dropped into the eye it should not be stronger than 1 to 3 grains to the ounce of water. The strong solutions act as mild caustics. ASTRINGENTS. 73 Zinc oxid is used most frequently in an ointment (20 per cent.) with benzoinate of lard as a base. It is mildly astringent and sedative in action. The dry powder is some- times used in place of the ointment. Oxid of zinc is used chiefly in eczematous conditions of the lids, being both sooth- ing and protective in action. Copper sulphate, in weak solution (1/5 to 1/2 per cent.), may be used as a stimulating tonic in chronic inflammation of the conjunctiva, as in trachoma. Lead subacetate (liquor plumbi subacetatis) acts as a mild astringent and sedative; in a weak aqueous solution it was formerly used frequently as a wash (1 to 2 per cent.) for the eyes, but, on account of its causing dense white opaci- ties on the cornea when the least abrasion or ulcer on that membrane was present, its use has been almost entirely abandoned, and wisely so. Suprarenal extract and its derivatives act as pure as- tringents and haemostatics, with but little irritation or re- action following. They are all used in solution, and where dropped into the eye cause marked blanching of the mucous surface in from one to two minutes' time. This lasts from one to two hours and is not followed by hyperaemia, unless used in excess and for a long period of time. The extract itself is but little used now; its alkaloids, which are more stable and more convenient for use, have displaced it. Adrenalin chlorid, in solution (1-1000 to 1-5000), is the widest used of all the derivatives. Hemostatin solution (1 to 1000), suprarenin solution (1 to 1000), and suprarenatin (1 to 1000) are all of a similar nature to, and act like, adrenalin. As remedies for the cure of disease these drugs are of but little value. They markedly increase the effect of cocain, however, and are very useful in operations on the eye to prevent the flow of blood. 74 EYE NURSING. They should not be combined in solution with cocain or atropin, but each drug dropped into the eye separately. When combined in solution with cocain it seems to cause irritation of the eye. anodynes. Cocain, holocain, eucain, and all of the local anaesthet- ics are anodynes; but these will be described under anaes- thetics. Heat and cold also are, in the true sense of the word, anodynes, and the method of their application may be found under their proper headings (pages 102 and 104). Tincture of opium as a local application has been and is still used for its anodyne and sedative effect. It has been largely replaced, however, by the simple cold and hot ap- plications and the local anaesthetics. Poultices of various substances were once much used for their anodyne and seda- tive effect on the eye, but they, too, have been almost wholly abandoned by the profession, and fortunately so, for, while soothing at first, their ultimate effect was often fatal to the sight of the eye. Irritants. Such remedies cause a moderate amount of inflamma- tion, and are used to promote absorption and to stimulate indolent ulcers, etc. The mercury preparations furnish the greatest number of irritants used in the eyes. Yellow oxid of mercury (hydrargyri oxidum flavum) in the form of a salve or ointment (Pagenstecher's), vary- ing in strength from 1 to 3 per cent., according to the effect desired, is the most valuable of all these preparations. Some eyes are much more susceptible to its action than others, and it may have to be reduced to 1/2 or 1/4 per cent, before it is tolerated. Furthermore, unless prepared with the greatest IRRITANTS. 75 care, the mercury being reduced to an impalpable powder, or, better, precipitated from solution, before being added to the base (which may be vaselin and lanolin or benzoinated lard) it causes too much irritation, and does actual harm rather than good. This yellow ointment (1/2 to 1 per cent.) is a specific in blepharitis marginalis and in phlyctenular keratitis and conjunctivitis. In 3 per cent, strength it is valuable as a stimulant and irritant in chronic and indolent ulcers of the cornea, as in pannus. In molluscum con- tagiosum it often effects a cure in a few days, if well rubbed into the diseased spots. Ammoniated mercury (white precipitate), in the same strength ointment as the yellow oxid, is often used in blepharitis and phlyctenular keratitis, when the yellow oxid proves too irritating. Red oxid of mercury, in the form of an ointment (1 to 2 per cent.), is highly irritating to the eye and is but seldom used. Mild chlorid of mercury (calomel), in powdered form, is often dusted into the eye for its stimulating effect where there is superficial and indolent inflammation of the cornea. The tears are supposed to convert part of it into the strong bichlorid of mercury, and it is to the latter that the stimula- tion is chiefly due; though part of it may be due to the mechanical irritation of the powder rubbing on the eye. Iodids should not be given internally at the time calomel is being used. Bichlorid of mercury, in solution (1-2000 to 1-3000), may be used in similar conditions as those where calomel is used for an irritant. It is not so desirable, however, as it does not remain in the eye so long as the calomel. Sulphate of copper, in the form of a crystal, pure, or mixed with equal parts of alum and nitrate of potassium 76 EYE NURSING. (lapis divinus), mounted in a wood holder for convenient use, is one of the most frequently used stimulating irritants used in ophthalmic practice. In chronic inflammation of the eyelids (trachoma) it is the sheet anchor when operative procedure is not resorted to. Sulphate of zinc, in solution (2 to 3 per cent.), is some- times used as an irritant. Tincture of opium, once much used as a stimulant and irritant in the eye, has been given up almost entirely. Its action was due to the alcohol contained in the solution. Counter-irritants. These are substances used to produce a violent inflam- mation at some distance from the eye. Their use is indicated only in the deep-seated and chronic inflammations of the eye accompanied with severe pain. The temple and the back of the ear over the mastoid region are the points usually selected for counter-irritation. Cantharides, in plaster, cut to the desired size, may be placed on the temple or back of the ear and allowed to re- main till a blister is raised, when it is removed, the blister punctured and dressed with vaselin; or, if continued effect is desired, it may be kept open with a stimulating ointment, as resorcin. Cantharides collodion may be painted on the temple or back of the ear and the same effect secured as when the plaster is used. Tincture of iodin may be painted on the temple or back of the ear, where a mild counter-irritant is desired. The nurse should be careful to protect the eye when paint- ing the temple with iodin or cantharides collodion. Setons, issues, etc., are no longer used as counter-irri- tants in ocular affections, as they are too severe. Other means more pleasant and more efficacious may be employed. CAUSTICS AND MYDRIATICS. 77 Caustics. These are substances used to destroy diseased tissues. Silver nitrate, "mitigated," that is, mixed with nitrate of potash, in stick form, is much used. Copper sulphate, zinc sulphate, and alum, in solid stick form are all used as mild caustics. Bichlorid of mercury in concentrated solu- tion (1 to 250) may be used with an applicator and cotton for the same purpose. Actual Cautery.—This may be applied by heating a probe in a spirit flame and the diseased tissue burned, or the galvanocautery or Paquelin's cautery may be used. The actual cautery is used chiefly to check the progress of in- fected ulcers, to destroy diseased tissue, and, at times, to destroy and close the tear-sac. Mydriatics. These are drugs which dilate the pupil, and the ma- jority of them at the same time paralyze the ciliary or focus- ing muscle, thereby suspending the accommodation. Their action is local, that is, when dropped into the eye, they act directly on the iris and ciliary muscles, and their action is confined to the eye in which they are dropped. A secondary effect, an elevation of tension, or slight hardening of the eye, is sometimes noticed after the use of mydriatics. This is due to the dilatation of the pupil and crowding the iris against the canal of Schlemm, partly closing it, thus pre- venting a free exit to the natural secretions of the eye. On this account mydriatics are never to be used in glaucoma. Atropin sulphate is the most widely used of this class of remedies. It is the active principle (alkaloid) of bella- donna, and its salts are used in solutions of from 1 to 15 grains to the ounce. The usual strength is 4 grains to the 78 EYE NURSING. ounce in adults. In special instances, as for breaking adhe- sions between the iris and the lens capsule, a 15 grain to the ounce solution may be used, but with caution, as poisonous, or "toxic," effects may be caused. The symptoms of atropin poisoning consist in dryness of the throat, difficulty in swal- lowing, redness and swelling of the conjunctiva and even of the lids, widely dilated pupils, flushed and burning skin, rapid pulse, dizziness, and, in extreme cases, delirium and convulsions. Death may ensue through paralysis of respira- tion and coma. This poisonous train of symptoms may be due to an idiosyncrasy of the patient for the drug, 1 drop sometimes being sufficient to cause both local and general symptoms of poisoning. Or poisoning may be caused by the careless use of the drug, allowing it to run over the cheeks into the mouth of the patient, or by not holding the fingers over the puncta at the inner angle of the lids, allowing an excess of the drug to go into the nose, where it is rapidly absorbed. Hence the precautions necessary in the use of this drug. When a solution of atropin (4 grains to the ounce) is dropped into the eye the pupil is first affected, beginning to dilate in ten or fifteen minutes and is widely dilated in thirty to forty minutes. The ciliary muscle is not affected so quickly, and the accommodation is not suspended for an hour or two. In fact, for complete suspension of the accommoda- tion it is necessary to instill 1 drop of the solution every five minutes for the space of thirty minutes, then wait for from one to two hours, when the paralysis is complete. Atropin is used in this way (coup sur coup) to tear away adhesions of the iris from the lens capsule, or to dilate the pupil and relax the ciliary muscle in acute iritis. Usually atropin is in- stilled but two or three times during the twenty-four hours after the eye is well under the influence of it. It requires MYDRIATICS. 79 about from ten days to two weeks to recover from its effect and sometimes longer. For its quieting effect, by placing the ciliary muscle at rest, in a splint, as it were, atropin is used in many inflam- matory conditions of the eye. In iritis it answers a double purpose: first, to dilate the pupil and prevent adhesions (synechiae), or to break up the adhesions if they exist; sec- ondly, to place the ciliary muscle at rest and relieve pain. In ulceration of the cornea, and in the deep-seated in- flammations of the eye, as well as in injuries, atropin is used for its quieting and sedative effect. It is contra-indi- cated in glaucoma, and should be used with great care in all aged people, as it sometimes induces glaucoma. In in- flammations limited to the conjunctiva and lids it is also contra-indicated. As a cycloplegic, to place the ciliary mus- cle at rest, in order to adjust glasses to the eye, it has had extensive use, but is used less and less for this purpose since the introduction of instruments of precision, rendering its employment unnecessary for this purpose, except in children and where spasm of the ciliary muscle is present. Scopolamin hydrobrornate is the active principle of Scopolia atropoidea and is much more powerful in its action than atropin. It is used in solutions of from 1/2 to 1 grain to the ounce (1/10 to 1/5 per cent.) and in exactly the same way as atropin is used. Its action is much quicker than that of atropin, and its effect wears off sooner. One drop instilled at intervals of five minutes for one-half hour (1 grain to 1 ounce in adults and half to one-fourth this strength in chil- dren) places the ciliary muscle completely at rest in one hour's time from the beginning of the instillations. The effect wears off in from three to four days' time. On ac- count of its rapid and powerful action, and the earlier dis- appearance of the effect, it is used in preference to atropin 80 EYE NURSING. for the adjustment of glasses. The tension of the eye is believed not to be increased by its use, as is the case with atropin, making it safer for use in elderly people. Great care must be exercised in its use, as any excess flowing into the nose or mouth quickly produces alarming toxic effects. Hyoscin hydrobromate and hydro chlorate, which are isomeric with atropin, but much more poisonous, are some- times used in solutions of from 1/2 to 2 grains to the ounce, in the same conditions in which atropin is indicated. On account of its poisonous effects it is rarely used, and then usually when atropin cannot be employed. Hyoscyamin, the active principle of Hyoscyamus niger, is used in solution of from 2 to 4 grains to the ounce. When instilled into the eye it dilates the pupil widely in ten min- utes, which continues thus for from thirty-five to forty hours, and does not return to normal for eight or ten days. It paralyzes the focusing muscle in about two hours' time. Duboisin sulphate and hydro chlorate, the active prin- ciples of Duboisia myoporoidea, act in the same manner as atropin, but more powerfully, and the effects wear off sooner —in five or six days' time. They are used in place of atropin when there is an idiosyncrasy for the latter. From 2 to 4 grains to the ounce solution is the proper strength. Daturin, the active principle of stramonium, in solution of from 2 to 4 grains to the ounce, acts very much like duboisin and is used under similar conditions. Euphthalmin hydro chlorate, in 5 per cent, solution, is used for dilating the pupil for diagnostic purposes solely, since it has but little effect on the ciliary muscle. A few drops instilled into the eye causes a maximum dilatation of the pupil in from sixty to ninety minutes, which state is maintained for two or three hours; the pupil gradually re- turns to the normal size in about twenty hours' time. MYDRIATICS. 81 Homatropin hydrobromate, a synthetic preparation, is often used in solution (2 per cent.) to dilate the pupil for diagnostic purposes. The pupil begins to dilate in from eight to ten minutes after the first instillation, and with six instillations, at five-minute intervals, the pupil is widely dilated in from one to one and one-half hours' time, return- ing to the normal in twenty-four to forty-eight hours' time. In 4 per cent, solution it is used as a cycloplegic as an aid in adjusting glasses, 1 drop being instilled every five min- utes for thirty minutes, then waiting one hour before the test for glasses is begun. It is not reliable for this purpose, however. Ephedrin and mydrin are other mydriatics used much in the same way and for the same purposes as the weaker solutions of homatropin. They have but little effect on the ciliary muscle. Ephedrin is used in 2 per cent, solution and mydrin in 10 per cent, solution. Cocain hydrochlorate, in from 2 to 4 per cent, solution, is often used as a mydriatic for diagnostic purposes, its effect on the ciliary muscle being but slight. Its action as a myd- riatic is brought about by contraction of the blood-vessels of the iris, lessening the volume of that membrane, and per- haps by stimulation of the dilator fibers supposed to exist in the iris. In this respect it differs from the action of at- ropin, which paralyzes the circular muscle fibers of the iris. Two or 3 drops of a 4 per cent, solution dropped into the eyes cause the pupil to dilate in four or five minutes, reach- ing the highest effect in from fifteen to twenty-five minutes, and gradually passing off in from four to eight hours. When used in conjunction with atropin it is found to increase the effect of the atropin paralysis, as shown by the pupil becom- ing wider if atropin is first used until it produces its fullest effect, and then the cocain instilled into the eye. This un- 6 82 EYE NURSING. doubtedly is caused by constricting the blood-vessels and lessening the volume of the iris, so that it can be crowded still farther into the iris angle. Myotics. These are remedies employed for contracting the pupils. They are also used to reduce the tension of the eye, as in glaucoma, or in threatened perforation of a corneal ulcer, especially if the ulcer is at the margin of the cornea, to lessen the danger of perforation and of prolapse of the iris into the corneal wound should the ulcer perforate; in serous iritis (cyclitis of Fuchs); and at times to counteract the effect of mydriatics. Eserin sulphate and salicylate (physostigmin), in solu- tion of from 1 to 2 grains to the ounce (a/5 to 2/5 per cent.), when dropped into the eye causes the pupil to contract in from four to five minutes, and the ciliary muscle is stimu- lated to action at the same time. The full effect of the drug on the iris and ciliary muscle is attained in about one-half hour. The effect on the ciliary muscle wears off in about two hours, while the pupil may not return to the normal size for from twelve to forty-eight hours. Eserin has no effect on a pupil widely dilated with atropin, but contracts to a slight extent a pupil dilated from paralysis of the third nerve. Eserin when used in strong solution (4 to 5 grains to the ounce), as is often done to obtain quick results, e.g., in glaucoma, may cause marked circumcorneal injection, spasm of the ciliary muscle, a feeling of tension, and a dragging pain in the eye, with at times neuralgic pains in the temple. It is said to be less irritating when used in oily solution. When eserin is to be used for a considerable time the solutions must be quite weak, from 1/2 to 1 grain to the ounce; and, when the weak solutions are not tolerated, pilo- ANAESTHETICS. 83 carpin is used instead of it. If there is any tendency to iritic inflammation, pilocarpin should be used from the first. Eserin finds its chief use in glaucoma to reduce the tension, and, at times, in ulcerative keratitis, especially where there is tendency to perforation and atropin has not proved bene- ficial. The solution should be kept in a colored bottle and in a dark place; after exposure to light for some time the clear solution changes to a red one. The efficiency of its action is but little affected, however, by this change in color. Pilocarpin hydrochlorate, the active principle of jabo- randi, is used in solutions of from 1 to 2 per cent. Its action on- the iris and ciliary muscle is not as strong as that of eserin, but it has the great advantage of not irritating the eye as does the eserin solutions. Where eserin is not toler- ated, and for prolonged use, as in chronic noninflammatory glaucoma, for reducing the tension, it is very useful in solutions of from 4 to 8 grains to the ounce. In detachment of the retina, choroiditis, rheumatic paralysis, and tobacco amblyopia the drug is often used hypodermically (1/10 to 1/5 grain) to produce sweating. Great care must be exercised in giving hypodermic injections of pilocarpin that the solu- tion be sterile, the syringe absolutely clean, and the injection given deeply into the muscle of the arm or leg, as abscesses are prone to follow its use. Anesthetics. The local anassthetics used in the eye are: cocain, holo- cain, and eucain. They produce anaesthesia by paralyzing the sensory nerve-fibers with which they come in contact; hence their action is strictly a local one. Cocain muriate is the active principle of Erythroxylon coca, and is used in solution, as a rule, 2 to 8 per cent., though it may be used in the crystal or powdered forms when 84 EYE NURSING. intense and quick effect is desired. Its anaesthetic proper- ties were discovered by Roller (1884). It is largely em- ployed as a local anaesthetic for most operations upon the eye and its appendages, even enucleation of the eyeball hav- ing been performed under cocain anaesthesia. As a rule, however, enucleation of the eyeball, or evisceration, and the graver plastic operations about the eye should be performed with the patient under the influence of a general anaesthetic. When a few drops of a 4 per cent, solution of cocain is dropped into the eye it causes slight irritation, blanching the conjunctiva in from two to five minutes, constricting the blood-vessels, loss of sensation in the cornea and conjunctiva beginning at the same time and reaching its greatest effect in from six to eight minutes. If the instillations are re- peated two or three times at five-minute intervals, in from ten to fifteen minutes from the time of the first instillation, the anaesthesia becomes sufficiently complete for operations on the eyeball. The pupil is moderately dilated and the pal- pebral fissure made wider, both brought about through stimulation of the sympathetic nerves to these structures (Fuchs). If the instillations of cocain are continued too long and too frequently, especially when used in strong solu- tions, the corneal epithelium is peeled off, an effect wh\ch is not desired. Oily solutions (1/2 to 1 per cent.) of the drug are sometimes used in corneal affections. In operations upon the inner surface of the eyelids the crystals, reduced to a powder, are dusted on to the lid and a more marked anaes- thesia is thus obtained. Adrenalin chlorid solution used in conjunction with cocain seems to increase the anaesthetic action of the cocain. The anaesthetic effect of cocain dis- appears in from twenty to thirty minutes, but the pupil may remain dilated for as many hours. The accommodation is but mildly affected, being slightly suspended. Toxic effects ANAESTHETICS. 85 may result from the too free use of cocain, especially if allowed to drain into the nose or mouth. They are: diz- ziness; faintness; very rapid, feeble, and irregular pulse; rapid and irregular respiration, and at times delirium. The patient, under such circumstances, should be laid flat and stimulants applied: whisky, strychnin, etc. Holocain hydrochlorate, a synthetic preparation, is a more powerful local anaesthetic than cocain, and in less con- centrated solution, a 1 per cent, solution equaling a 5 per cent, solution of cocain in anaesthetic effect. The solution lias antiseptic properties, kills pus-organisms, and acts as a protoplasmic poison, checking fomentation and putrefaction. When dropped into the eye, a 1 per cent, solution causes smarting for a few seconds, anaesthesia beginning in from three to five minutes and continuing for fifteen or twenty minutes. Eepeated in five minutes, operations may be com- menced in ten minutes after the first instillation. The drug is more penetrating than cocain and is very desirable when the iris is to be cut. It allows freer bleeding, however, than when cocain is used, as it does not contract the blood-vessels. It does not peel the corneal epithelium as does cocain, and is said not to increase the tension of the eye. The pupil and ciliary muscle are affected but very slightly by way of dilatation of the former and suspension of action in the latter. On account of its toxic effect when injected hypo- dermrcally it is rarely used in that manner. Eucain hydrochlorate is a synthetic preparation, and comes in two forms: eucain A and eucain B. The latter only is used in ophthalmic practice, as the former proves to be too irritating to the eye. Eucain B is used in 2 per cent, solutions, and, when instilled into the eye, anaesthesia begins in two or three minutes, continues for eight or ten minutes, and totally disappears in from fifteen to twenty- 86 EYE NURSING. five minutes. It does not dilate the pupil, affect the ciliary muscle, or blanch the conjunctiva. It is not as effective an anaesthetic as either cocain or holocain, and for that reason is not extensively used for operations on the eye. Miscellaneous Remedies. Jequirity is a preparation first introduced into oph- thalmic practice by de Wecker for the treatment of chronic trachoma complicated with pannus, that is, where the cornea is covered with blood-vessels and opaque epithelium. It may be used in the form of an infusion, as recommended by de Wecker; or, better yet, in the form of a powder, as recom- mended by Cheatham. The infusion is made by macerating 3 to 5 per cent, of the powdered bean in cold water for six or eight hours, and is applied to the everted lids with cotton on an applicator once every twenty-four hours, until a violent inflammation is started. Simply dusting the powdered bean over the.front of the eye and on the everted lids, as first recommended by Cheatham, of Louisville, is much the better method of application. Within from twelve to twenty- four hours after the powder is dusted into the eye, a violent inflammation, accompanied by marked swelling of the lids, heat, burning, and intense pain, is incited. To control the swelling and relieve the pain the nurse must apply iced cloths frequently, just as in a case of gonorrhceal ophthal- mia. In from forty-eight to seventy-two hours a membrane is formed on the lids and the cornea, which must be gently washed and rubbed off as it separates from the underlying tissue. In fact, it is to be treated as a croupous or mem- branous conjunctivitis, which it is, in effect. At the end of a week's time the violent inflammation rapidly subsides, but the clearing away of the blood-vessels and opaque epithe- lium through inflammatory reaction may continue for MISCELLANEOUS REMEDIES. 87 weeks; consequently the drug should not be reapplied within four weeks after the first application. Jequirity is contra-indicated unless there is pannus covering the cornea. I have seen some most excellent results from the use of this drug, in fact, useful vision restored, in old trachoma cases with pannus where sight had been reduced to counting fingers. Owing to the violent inflammation which it pro- duces when dusted into the eye, these cases should be taken into the hospital and treated as house cases, and should not be treated as outdoor cases, since there is danger of destroy- ing the eye if it is not properly cared for. I have used the drug often and have seen it used in many cases and have never had any bad results from its use. It is where the cases are not properly cared for after the drug is used that the greatest danger lies. Fluorescin is a coal-tar derivative, a staining fluid (2 per cent, solution), used for diagnostic purposes only. When dropped into the eye it stains any ulcerated spot of the cor- nea a greenish hue, thus indicating the position and extent of an ulcer or abrasion. A drop of cocain used just before the fluorescin is instilled increases the effect of the latter. Msorcin, also a staining fluid (10 per cent, solution), is used for diagnostic purposes only, just as fluorescin. It stains ulcerated surfaces on the cornea red. Salt (chlorid of sodium), in solution (a teaspoonful to the pint), is used for cleansing the eye and for neutralizing the excess of nitrate of silver when the latter is applied in strong solution to the eyelids. Collodion (flexible) is used for dressing small wounds about the lids. At times it is painted on the lower lids to prevent inversion of them, when such inversion is due to spasmodic contraction, as sometimes happens after opera- tions on the eyeball, e.g., cataract extraction. 88 EYE NURSING. Vaselin is obtained from petroleum by distillation. There are two preparations: the yellow and the white. If properly made there is little choice between them. Vaselin is used largely as a base for eye salves and as a dressing after operations on the lids; also frequently to prevent the lids from sticking together. It may be obtained in tubes which is most convenient for use about the eye, and is also the best way of keeping vaselin sterile. Lanolin is obtained from the grease of wool, and is used extensively as a base for ointments. It is rather stiff when used alone and for that reason is often combined with vaselin or rose water. It has one advantage over vaselin as a base—that is, it mixes with watery solutions. Glycerin, in solution (10 per cent.), is frequently used as a vehicle for various eye drops, especially where the drops are used in chronic inflammation of the lids, as in trachoma. Camphor water as a vehicle for drops is frequently used in the eyes. Boracic acid, sterilized, in saturated solution, and steril- ized distilled water are commonly used as vehicles for eye drops. Bloodletting. Local bleeding is at times employed in deep-seated in- flammations of the eye, as in iritis and irido-cyclitis. This may be accomplished by cupping the temple or back of the ear, or by applying leeches to the temple or side of the nose, preferably on the temple. At times an artificial leech is used, which is nothing more or less than "cupping" with a special instrument devised by Heurteloup. The object of leeching is to draw away the blood from the inflamed tissues, thereby relieving pain and lessening the inflammatory proc- ess. The bloodletting may be repeated at two or three days' BLOODLETTING. 89 interval. To apply the natural leech, the nurse should first wash the spot to which the leeches are to be applied, then holding the larger, bulkier end of the leech in a towel apply the smaller end of the leech, which is the head or biting end, to the temple; or the leech may be placed in a small glass tube and held to the temple. If the leech does not "stick," a drop of blood can be drawn with the prick of a lancet at the site desired, when, as a rule, it at once takes hold. Two to six leeches may be applied at one sitting. They should be al- lowed to remain on till they drop off and subsequent bleed- ing encouraged by the application of warm, sterile water. It is sometimes difficult to stop the flow of blood after leech- ing. A small pledget of cotton soaked with perchlorid of iron applied to the seat of bite and gauze placed over this and a pressure bandage applied is effective in stopping the bleeding. Leeches should be used but once. A supply may be kept on hand indefinitely in black earth. The artificial leech or cup is applied by first rendering the site of application clean, then scarifying and placing the cup on and allowing it to draw. Subsequent bleeding may be encouraged by warm applications as after the natural leech. Not only is local bloodletting of value in relieving the congestion and allaying pain in iritis, but frequently is of great service as an adjuvant to mydriatics in dilating the pupil and breaking up synechiae between the iris and lens. The withdrawal of the blood by lessening the bulk of the iris allows the mydriatic to act more forcibly. Leeches should not be applied to the lids or the con- junctiva, as they cause local irritation at times, and the bleeding would be most difficult to stop, since there is no firm surface beneath to make pressure against, the only method of stopping the flow quickly and efficiently. 90 EYE NURSING. Poultices are no longei used in ophthalmic practice except by ignorant and uninformed individuals. The laity are prone to use poultices, but fortunately are being edu- cated to dispense with these unhygienic and dangerous ap- plications. In hopeless cases, as in panophthalmitis, where there is no chance of saving the sight, a poultice may be used to alleviate the pain. Under no other conditions should it be at all considered. CHAPTER VI. REMEDIES AND THEIR APPLICATION (Concluded). The Application of Drops—Lotions and Solutions—Solids— Powders — Ointments—Cold—Heat—Massage—Pressure—Hypoder- mic Injections of Strychnin—Mercury—Pilocarpin, etc. Drops. These are applied to the eyes and lids for varying pur- poses, e.g., to dilate the pupil and paralyze the ciliary mus- cle, as in iritis; to contract the pupil in glaucoma; for in- flammatory conditions of the cornea and conjunctiva; and to produce local anaesthesia preparatory for operation. For convenience of use and in order to keep these' drops sterile they are kept in bottles which are closed with pipettes or droppers ground at their upper extremities in the shape of a stopper, which fit air-tight into the neck of the bottle. The upper end of the dropper has a rubber nipple which serves to close the opening, and also, by exhausting the air from it and releasing the pressure, to draw a few of the drops from the bottle, which may be instilled one by one into the eye by gently squeezing it again (see Fig. 3). Chalk's eye-drop bottle has a thin sheet of India rubber tied across the upper, cup-shaped end of the dropper, and the drops are drawn into it by first pressing the finger on the rubber, then re- lieving the pressure when the drops are drawn into the tube, when they may be dropped into the eye (see Fig. 4). An- drews's aseptic eye-drop bottle is shown in Fig. 5, and Galezowski's in Fig. 6. Stroschein's aseptic bottle is shown in Fig. 7. It is made of thin glass, is flask-shaped, and the solutions can be sterilized in the bottle by boiling. This (91) 92 EYE NURSING. makes it very convenient for operations and where fresh solutions cannot be had frequently. The pipette is made with a constriction in it just above the stopper part (C1), and above the constriction there is another stopper-shaped bulb (C2), and on the end of this second stopper is an olive- tipped bulb over which the rubber nipple fits. The pipette Fig. 3.—Showing Method of Instilling Drops into the Eye. is constructed in this manner so that the rubber nipple may be removed and the pipette reversed and inserted into the bottle when the solution is to be sterilized. The flask is then held over a flame (gas jet or alcohol lamp) for three minutes, bringing the solution to a boil, thus sterilizing it. The steam escaping through the pipette and around the EYE DROPS. 93 loose-fitting upper bulb of the pipette serves to sterilize these. The flask may be held on wire gauze supported by a tripod while over the flame, or with a clamp. The rubber nipple may be sterilized by boiling, or by dipping into strong bichlorid of mercury solution and rinsing with sterile water. One minute after sterilization, the pipette can be reversed (with aseptic fingers^ of course), the nipple attached, and Fig. 4.—Chalk's Eye-drop Fig. 5.—Andrews's Aseptic Bottle. Eye-drop Bottle. the drops are ready for use. In order that the solution may not be made stronger from evaporation through boiling a few drops of sterilized water may be added before boiling the drops. The usual method of instilling drops into the eye is to sit in front of the patient, the patient also being seated; pull the lower lid down with the index or middle finger; 94 EYE NURSING. have the patient look up, and gently instill one or more drops on the inside or mucous surface of the lower lid near the outer corner of the eye. The lid is then released, and by "blinking" the eyelids the patient distributes the fluid over the eye. If the patient is an adult and not nervous, the upper lid may be raised with the thumb or forefinger, the patient told to look down, and 1 or 2 drops of the solution dropped directly on to the cornea. Refractory patients should be made to lie down, or the patient's head taken between the knees, the lids gently held apart with the thumb and forefinger, or both hands used, while a second attendant instills the drops. When drops are used for af- fections of the lids, these must first be everted (see page Fig. 6.—Galezowski's Eye-drop Bottle. 95) and the drops applied freely, any excess being taken up with absorbent cotton. In the application of drops to the eye the dropper should not be allowed to touch the eye, neither should it be held too far from the eye, especially if the drops are to fall on the cornea, as they cause the patient to jump, and often shock a nervous patient. After applying drops to the eye the nurse must never fail to place the finger over the tear-sac at the inner canthus, holding it there for two or three minutes and by pressure prevent the excess of fluid from running into the nose; or the lids may be held from the eyes for a few moments, thus preventing drainage into the lacrymal ducts and into the nose. Particular care should be exercised when strong solutions of atropin, sco- polamin, cocain, or any of the powerful alkaloids are em- APPLICATIONS OF LOTIONS AND SOLUTIONS. 95 ployed. It must be remembered that it takes but a very few drops of a 1 per cent, solution of atropin (the ordinary strength used in the eye) to contain the maximum dose of that drug as administered internally. By allowing several drops of such a solution carelessly to drain into the nose of a child or weakly adult it is easily understood how poisonous symptoms could be brought about. I presume it is almost unnecessary to say that the nurse should wash her hands Fig. i.—btroscheins Aseptic Drop Bottle and Stand. after instilling such drugs, if she wishes to avoid apply- ing some of the same to her own eyes by rubbing them. Application of Lotions and Solutions. In order properly to apply lotions to the eye the lids must be everted. To evert the lower lid place the thumb or index finger on the lower lid just below the lashes and near the center and pull directly downward. To evert the upper 96 EYE NURSING. lid have the patient look down, catch the lashes between th.e thumb and index finger of one hand, and pull the lid gently forward from the eyeball, while sudden pressure downward is made at the upper edge of the cartilage with the index finger of the free hand. Unless there is marked swelling of the lids, or we have an unruly patient, the lid is easily everted by this simple manipulation. With children we may be compelled to place the child's head between the knees before it can be accomplished successfully and without harm to the eye. Once the lids are everted, all cleansing lotions are easily applied by squeezing the solution out of a pledget of cotton APPLICATION OF LOTIONS AND SOLUTIONS. 97 on to the lids; any remaining secretion not washed away in this manner must be wiped away from the lids with the moistened cotton, care being taken not to touch the cornea. Solutions not meant for cleansing, but as a local medication to the lids, are best applied with cotton wound smoothly on an applicator, saturated in the solutions, and rubbed on to the surface of the everted lids. The lower lid and cul-de-sac are easily treated in this manner. To reach the upper cul- de-sac with probe and cotton or solid stick of blue stone or alum is a.more difficult matter, unless the following ma- neuver is used, which renders it easy and safe: First release the lower lid; after the application is made to that part, have the patient look down, evert the upper lid, and make pressure on the upper edge of the everted lid with the thumb; then tell the patient to shut the eye (usually un- necessary, especially with children who try to close the eyes). The pressure at the upper edge of the everted cartilage throws the everted upper lid outward over the lower lid, which latter is squeezed upward under the everted upper lid and at the same time protects the cornea from injury. The appli- cation is now carried far up into the upper cul-de-sac, where it should go, and without any danger whatever to the cornea, as the lower lid effectively protects that part of the eye. The applicator (or pencil if solids are being used) is held horizontally and the whole length of the cul-de-sac is touched at once. The tighter the lids are squeezed, the farther down is the cul-de-sac brought and the more easy and thorough the application (see Fig. 9). I have found the above method of technique so simple and so valuable, particularly so with children, that I have ventured to give it in detail. All the writers I have consulted say that no attempt, except by an expert, should be made to reach the upper cul-de-sac because of the danger of injury to the cornea. By this method any 98 EYE NURSING. competent nurse can do so with safety. I am firmly con* vinced that many cases of chronic inflammation of the lids are much prolonged because of inefficient and insufficient application of the intended remedy to the upper cul-de-sac where it is most needed. Fig. 9.—Showing how to Make Applications to the Upper Cul-de-sac Rubber-tipped bulbs or rubber bulbs with rubber nip- ples, syringes, atomizers, etc., should never be used to apply lotions to the eye. They are inefficient, dirty, and danger- ous, both to the patient's and the operator's eyes; to the patient by injury to the eye, to the surgeon and nurse by squirting infectious material into their eyes. APPLICATIONS OF LOTIONS AND SOLUTIONS. 99 Where the lids are very much swollen, as in gonorrhceal ophthalmia, a retractor may be required to lift the lid from the eyeball (see Fig. 10), in order to properly cleanse the eye and make the necessary application. This is to be done carefully, the edge of the lid being lifted slightly from the globe by traction at the upper part of the lid with one hand and the edge of the retractor slipped beneath the lid and pulled upward and backward to expose the eyeball for cleans- ing and for the application of remedies. There has been. de- Fig. 10.—Showing Method of Placing Retractor Under the Upper Lid. vised a hollow retractor with a rubber tube attached to the handles with perforations in the "curved" portion, so that a solution may be transmitted through it while in situ, thus cleansing the eye. Its use is not satisfactory, solutions squeezed from pledgets of cotton being more efficient and less dangerous to the eyes, both of the patient and of the operator. Camel-hair brushes should never be used to apply liquids to the eye, as they are difficult to keep clean and the danger of infection being transmitted by them is too great. Cotton wrapped on an applicator, dipped into the solution, is by far 100 EYE NURSING. the best method of making such applications, for the cotton is used but once and immediately destroyed. Eye-cups are sometimes prescribed for patients with which to apply healing lotions to the eyes where the serv- ices of a nurse are not required, as in the milder inflamma- tion of the eyelids. They are also at times used as a means of applying hot or cold water to the eyes. They are used in the following manner: The cup is filled to within from an eighth to a quarter of an inch of the top with the solution to be applied, the head is bent forward, the cup applied firmly over the closed eye, then the head is raised and held slightly backward and the eye opened and closed several times. The head is leaned forward again and the cup re- moved. The second eye may be treated in a similar manner. Each patient should have his own eye-cup, otherwise infec- tion might be transmitted. Application of Solids. Pencils of sulphate of copper (bluestone), alum, miti- gated silver stick (made by fusing 1 part of nitrate of silver and 2 parts, of nitrate of potassium), lapis divinus (equal parts of bluestone, alum, and nitrate of potassium, with 2 per cent, of camphor added), are the solid preparations commonly applied to the eyelids in the treatment of tra- choma and chronic affections of the conjunctiva. Peneils of these preparations are mounted in holders which have caps to cover them when not in use (see Fig. 11). When applied to the lids they should first be dipped into clean water, then the lower lid everted, and the pencil, held in the horizontal position, applied the full length of the lid and into the cul-de-sac. The lower lid is then released, the upper lid everted, and the patient told to close the eyes, when the upper lid, by slight pressure at the upper edge of the everted APPLICATION OF POWDERS. 101 lid, is slid down over the lower lid, which covers and pro- tects the cornea. The pencil in the horizontal position is applied to outer surface of the lid and then into the upper cul-de-sac. If there is any pus or muco-pus in the eyes, this should be washed away before the pencils are applied. Any excess of the remedy, as coagulated material after application of the silver stick, may be wiped away with a pledget of cotton moistened in boracic acid or salt solution and squeezed as dry as possible. Where the bichlorid of mercury solution (1 to 500) is applied with cotton and applicator, as it is in trachoma, or silver solution in acute ophthalmia (10, 20, or 30 grains to 1 ounce) the excess may be washed away with sterile water, or salt solution (1 per cent.) in case of silver. Fig. 11.—Alum Pencil and Holder. The nurse should sit in front of the patient, or stand back of the patient (the patient sitting in each instance), when the solid applications to the lids are made. In case of children they may be held in the lap of a second nurse, and the head of the child between the knees, as shown in Fig. 1. Application of Powders. The various powders, such as calomel, iodoform, and boracic acid, are best applied to the lids or the eyes by means of a camel-hair brush. The patient's head should be held tilted backward, and the lids opened with the thumb and forefinger of one hand, while a little of the powder is flipped on to the cornea from the brush, being careful not to touch the cornea with the brush. Where the remedy is to be ap- 102 EYE NURSING. plied to the lids, they should be everted and the powder dusted on them. Application of Ointments and Salves. Ointments are best applied to the eyeball by means of a very narrow short spatula or by means of a small glass rod. The lower lid is drawn downward with the finger, and the spatula or rod, with a little of the ointment on it, is rubbed on to the everted lid. When it is allowed to go back into position and the eyeball massaged for a minute or two with the tip of the index finger over the closed lids to thor- oughly apply the ointment. The spatula, of course, is to be cleansed before using on a second patient. To apply ointment to the edges of the lids, as in blepha- ritis marginalis, the lids are first thoroughly cleansed of all scales and scabs with a warm solution of boracic acid or soda, then dried, and the ointment rubbed on the edges of the lids, which are closed, with the finger. In case of chil- dren it is best to place the child's head between the knees, both for cleansing the eyes and applying the ointment, pow- ders, or other remedies. Where inunctions of mercury are given, the nurse should be careful to protect her hands with rubber gloves, so as not to medicate herself. Mercurial ointment may be rubbed into the temple or on any other portion of the body, preferably under the arms and inside the thigh, and is de- signed to remove constitutional disease which causes certain diseases of the eye, as iritis, scleritis, etc. Application of Heat. Heat is applied to the eyes for the purpose of relieving pain, preventing inflammation, the promotion of absorption of inflammatory products, and to hasten the formation of APPLICATION OF HEAT. 103 pus in the later stages of inflammation. It may be applied in dry or moist form. The application of heat is especially indicated in inflammations of the cornea, of the iris, and deep-seated inflammations of the eyeball. Dry Heat.—1. This may be applied to the eye by means of the electric heated pads, which can be attached to any incandescent lamp by a cord which is supplied with the pad. These pads can be had at most drugstores and electrical sup- ply houses. They are very convenient, light, and easily ap- plied. Of course, electricity in the house or hospital is a necessary requisite to its use. 2. Pads of cotton wool or several layers of gauze heated in an oven and placed on the closed eye and covered with oiled silk and held on by a band- age is a convenient method of applying dry heat. 3. A thin layer of rubber protective may be placed over the closed lids and hot wet compresses of absorbent cotton or wool may be applied over this. The rubber keeps the eye dry, and the effect of dry heat is thus obtained. 4. A very small hot- water bag may be used upon the eye, but this has the disad- vantage of being heavy and causing pain by its weight. Moist Heat.—This is best applied by means of pledgets of absorbent cotton or wool. The lids of the eye are greased with vaselin that the skin may not be blistered. A basin of sterilized water (made so by boiling and allowing to cool, 115° F.) is placed on a tripod or a couple of bricks, near the bed, and a spirit lamp or gas jet placed under it and so regulated as to keep the temperature at about 115° F. The pledgets of wool or cotton, which should be rather thick, are dipped into this, wrung out, and placed on the eye. They should be changed every two minutes and this should be kept up for fifteen minutes to half an hour, according to directions of the surgeon. If the pledgets become soiled from secretions they should be destroyed and fresh ones used. 104 EYE NURSING. Application of Cold. Cold is used on the eyes and its appendanges to relieve pain and to prevent and relieve inflammatory symptoms. In inflammatory conditions of the lids and conjunctiva, as in purulent and gonorrhceal conjunctivitis, it is indicated par- ticularly in the early stages. In the later stages hot appli- cations are indicated, especially if the cornea becomes in- volved. In injuries of the eye cold is also indicated. Cold may be applied in dry or moist form. Dry Cold.—1. This may be applied by putting finely cracked ice in a small rubber bag and placing it on the eye. This method is objectionable because of the weight of the ice. 2. The Leiter coil, which consists of metal tubing of small caliber, coiled, as its name implies, so as to form a disc, is a convenient way of applying dry cold to the eye. One end of the tubing is connected by means of a rubber tube with a large basin of iced or cold water, and this is al- lowed to drain through the coil, which rests upon the closed eyelids. A thin layer of gauze may be placed over the lids that the coil may not come in direct contact with the lids. The water from the coil is caught in a second basin, and poured again into the first basin if the application is to be made for a long while. As a rule, twenty to thirty minutes at one sitting is quite long enough to apply cold. The objection to the Leiter coil is its weight, which is often un- comfortable to the eye. Moist Cold.—The best method of applying moist cold to the eyes is by means of pledgets of absorbent cotton moist- ened and placed on a large cake of ice, allowing them to get thoroughly cold, then applying them to the closed eyelids. The cake of ice should be large enough to have room for four or six pads of cotton on it at once, so that some of the MECHANICAL REMEDIES. 105 pads are cooling while those on the eye are in use. The pads should be changed on the eye about every minute, or two ■ minutes at the furthest, and this should be kept up for from twenty minutes to one-half hour at a time. This may be repeated every two or three hours during the day. Subconjunctival Injections. In recent years subconjunctival injections of bichlorid of mercury have been recommended in certain eye diseases, such as scleritis, episcleritis, irido-choroiditis, etc., with the claim that the remedy has a more direct and specific action than when given by other methods. The conjunctiva is first anaesthetized by a few drops of a 4 per cent, solution of cocain; then the ocular conjunctiva near the equator is picked up with a fine pair of forceps and 8 to 12 minims of a 1 to 1000 solution of bichlorid of mercury and 4 to 6 minims of a 4 per cent, solution of cocain are injected with a hypodermic syringe under the conjunctiva. There is always reaction from this injection; sometimes it is very marked, causing much pain. It should not be repeated until the reaction has subsided. This mode of treatment has not met with much favor in this country. A less severe injection under the conjunctiva is a simple normal salt solution, which has been found to be equally efficacious as the bichlorid solution, the inference being drawn that the benefit secured is from the stimulation of the lymph chan- nels, thus increasing the elimination and hastening the cure. Mechanical Eemedies. Mechanical remedies, such as pressure and massage, are frequently used in diseases of the eye. The pressure band- age is used in ulceration of the cornea as a means of pro- tection and to keep the eye and the lids quiet; also to pre- 106 EYE NURSING. vent a perforation of the cornea in deep ulcers of that mem- brane; to prevent staphyloma (bulging forward) of the cor- nea; to promote the absorption of extravasations of blood in the lids; also fluid effusions inside the eye, as in detach- ment of the retina; to prevent excessive swelling of the lids after the operations of "expression" or "grattage" for trachoma; and to prevent haemorrhage. For the method of applying a pressure bandage, see Chapter IX. Where there is marked secretion from the conjunctiva bandaging is contra-indicated, unless the bandages are removed fre- quently to allow the eye to be cleansed. Massage of the eyeball and the eyelids is sometimes practiced with benefit. That which the nurse will be called upon to give will be massage of the eyelids, and occasionally massage of the eyeball indirectly through the lids. The lid affections calling for massage are: (1) blepharitis, in which the yellow oxid of mercury ointment is rubbed into the edges of the lids by a horizontal motion of the finger-tip over the lids; (2) in chronic conjunctivitis, simple massage of the lids by horizontal or rotary strokes improves the conditions by stimulating the blood and lymph flow and getting rid of inflammatory products; (3) in deposits of blood under the skin of the lids, after blows, etc., massage is of service in hastening absorption; (4) spasm and twitching of the orbicular muscle are often relieved by massage over the lids and the brow. The diseases of the eyeball which have been benefited by massage are: (1) phlyctenular keratitis, in which a small portion of yellow oxid of mercury ointment is placed between the lids and then massage of the eyeball is made by rubbing the lids over the globe for a few moments; (2) in non- inflammatory glaucoma, where treatment by medicines or operation is of little avail, massage of the globe through the DIAPHORESIS. 107 lids is of benefit in reducing the tension. Eapid rotary movements with the finger-tip are first made over the upper lid, the lower lid being pushed firmly against the eyeball below to steady it; then like movements are made over the lower lid, the upper one being held firmly against the eye- ball above. Instead of rotary movements, backward strokes from the center of the lids may be made. Unfortunately the reduction of tension in the eye by this method of treat- ment remains but a short time. Massage of the globe by means of a stream of hot water, 115° to 120° F., to remove corneal opacities of a superficial nature, has been recommended, but in my experience, after trying it faithfully, the method proved of but little value. Hypodermic Injections. In deep-seated affections of the eye, as in the choroid, retina, and optic nerve, hypodermic injections of strychnin are frequently required. The nitrate of strychnin is pre- ferred to the sulphate for injecting under the skin, as it is less irritating. In optic atrophy due to the use of alcohol and tobacco the nitrate of strychnin in increasing doses, beginning with 1 minim of a solution of 1 grain to the drachm, and increasing the dose 1 minim a day until phys- iological effect is reached, is of marked benefit. The use of tobacco and alcohol is to be stopped during the treatment. Diaphoresis. Hypodermic injections of muriate of pilocarpin, in dose of Vio to Vs gram> are °ften employed hypodermically where there is serous exudates in the eye, as in detachment of the retina, to produce excessive sweating. It is also em- ployed in some forms of optic atrophy. The nurse cannot be too particular in preparing the site for the injection, also 108 EYE NURSING. in the care of the syringe, needle, and solution in giving these injections, as abscesses are liable to follow the injec- tion. The injection should be given deep in the muscle of the arm or leg, and a little gentle massage made for some moments over the spot to promote the absorption of the drug. When profuse sweating has been caused, the night- clothes should be changed for dry ones. In some syphilitic and rheumatic affections of the deeper tunics of the eye, sweating is of pronounced benefit, and this may be accomplished without the use of drugs, as by the dry pack. Here the nurse wraps the patient in a blanket and covers him warmly in bed, at the same time giv- ing the patient free draughts of hot water. If the sweating is not free enough the patient may first be given a hot bath, then wrapped in blankets, and jaborandi added to the hot water which the patient drinks. Hot-air baths may be used for causing profuse sweating. Hydrotherapy. In addition to local hydrotherapy general hydrotherapy is employed in many affections of the eyes, as in ulcerations of the cornea, phlyctenular conjunctivitis, episcleritis, and in the various rheumatic and syphilitic diseases of the eye. The beneficial effects are produced, no doubt, by improve- ment in the general condition, increased elimination, and the tonic and sedative effect brought about by the bathing. I have seen, in more than one instance, the steady advance of a destructive ulceration of the cornea checked by Turkish baths, and this after all other means of relief had failed. For the various methods of giving hot baths, cold baths, foot baths, etc., the nurse must be referred to books on general nursing and hydropathy, as the space in this small volume is too limited to delve into those subjects. DIET. 109 Diet. In many diseases of the eye the proper regulation of the diet of the patient as to the kind and the amount of food to be given is of great importance. The nurse will be called upon to look after the diet in operative cases especially. Where the disease of the eye is dependent upon some con- stitutional trouble, as it is in albuminuric retinitis, diabetic retinitis; and in iritis, episcleritis, etc., of gouty origin; the diet of the patient must be suitable to combat the gen- eral disorder. In certain diseases of the eyelids, as blepha- ritis marginalis, and in some affections of the eyeball, phlyc- tenular keratitis and conjunctivitis, diseases most often seen in children of a scrofulous diathesis, diet is of the utmost importance in effecting a cure. Without exception, in these latter cases, sweets and pastries of all kinds should be with- held, while a simple plain diet should be insisted upon, such as milk, bread and butter, oatmeal, hominy, rice, eggs, fresh meat once a day, as lamb chops, turkey, chicken, etc.; vege- tables, potatoes, string beans, peas, tomatoes, lettuce, chicory, and ripe fruit in limited quantity. Tea and coffee, as a rule, are not good for such patients. In ulceration of the cornea and other affections due to malnutrition, especially in old and in feeble patients, a mild stimulant, as a weak milk punch, may be added to the diet. In fever patients a fluid diet is to be given, such as milk, soups, etc., or a semifluid diet, as oatmeal, mush, or soft-boiled eggs. After operations on the eyeball where the anterior chamber has been opened, as after cataract extraction, not only is a special diet de- manded for a few days, but the nurse is required to feed the patient, since the eyes are bandaged. In such cases, in order to prevent chewing and thereby disturbance of the wound, the patient is fed milk, broths, soups, etc., in the recumbent 110 EYE NURSING. position and through a tube or from a spoon or a special cup, fluids constituting the main source of diet for a day or two; after which soft-boiled eggs, milk toast, shredded lean meat, oatmeal, etc., may be added to the diet. Great care must be exercised by the nurse, when feeding a patient in the recumbent position, not to feed him too fast or to give too large a morsel of soft food at once, because, if the patient is choked and thrown into a fit of coughing, great harm may be done the eye, especially after cataract extraction. As a rule, no fruits or food of a laxative nature should be given to cataract patients until two or three days after the operation, as it is desirable to keep the bowels from moving and the patient from straining at stool for at least that length of time after the operation. Quiet, Rest, and Sleep. In the serious inflammatory diseases of the eye, espe- cially those attended with much pain, and after operations, it is essential that the patient be in a quiet place that he may secure the proper amount of rest and sleep to sustain his vitality and thus hasten the cure. The nurse should talk to the patient only as in the course of her duty demands, and should allow the patient to talk but very little. On no account should friends be allowed to sit and talk for a long time to a patient who is very ill or shortly after an operation on the eyes. Only recently a lady under my care with chronic inflammatory glaucoma was thrown into an acute attack lasting for a period of twenty-four hours be- cause the nurse allowed a friend of the patient to sit and talk to her for two hours. The patient told me that she was so utterly exhausted and so much irritated by the long visit that she could hardly contain her self-control and that her SLEEP. Ill eye began to pain shortly afterward, though she had had no pain in it for a number of days previously. Sleep is essential to the healing process. If there is much pain an opiate must be given: morphin, 1/s to 1/i grain. If there is no pain, trional, in 15 grain doses, is a reliable hypnotic. Where the eye has to be looked after and cleansed every half-hour, as in gonorrhceal ophthalmia and purulent ophthalmia, it is essential to increase the intervals between times for cleansing during the night, say, from one to two hours; because, if the patient is kept awake con- tinuously for two or three days, the general strength is re- duced and the vitality so lowered that evil consequences result from lack of general nutrition and rest as well as from the local disease. CHAPTER VII. OPERATIONS ON THE EYE. Asepsis and Antisepsis—Preparation of the Operating Room— Operating Table—Sterilization of Instruments, Ligatures, and Dressings—Preparation of the Patient—Anaesthesia, General and Local—The Different Operations. Asepsis and antisepsis as practiced in general surgery are to be followed in the same manner with some modifica- tions in ophthalmic surgery. In preparing the patient, op- erating room, instruments, dressings, solutions, etc., the same rigid antiseptic methods as in general surgery are fol- lowed, as is also by the surgeon, assistants, and nurses in disinfecting and making their own hands clean. In pre- paring the field of operation, especially when the eyeball is to be operated upon, the strong antiseptic solutions should not be used, as the eye, being such a delicate organ, is much irritated by their use and the success of the operation often imperiled. If used at all, it should be the day previous to the operation and the eye bandaged, and a mild, aseptic solu- tion or sterile water used to bathe the eye just before the operation. Antisepsis and Asepsis. Antisepsis, in the broadest sense, as it pertains to sur- gery and surgical dressings, may be defined as the means and methods employed to destroy disease and pus-producing germs, while asepsis is the art and science of keeping free from such germs. Antisepsis may be accomplished in various ways: by means of: (1) soap, water, and scrubbing; (2) the use of (112) ARRANGEMENTS FOR OPERATIONS. 113 the chemical antiseptics, as solutions of bichlorid of mer- cury, carbolic acid, cyanid of mercury, formalin, alcohol, ether, etc., or by heat, dry or moist. Dry heat and steam are employed largely for sterilizing dressings, bandages, towels, aprons, and gowns, while instruments and solutions are quickly and efficiently sterilized by boiling. Asepsis is surgical cleanliness. After a wound is made the greatest care must be exercised to keep it clean and free from germs. This may be done during or immediately after the operation by irrigating the operated surface with some sterile solution, a plain, sterile water or boracic acid solution. After the operation sterile dressings are applied, and at subsequent dressings the same care in asepsis must be fol- lowed until the wound is entirely healed. If the wound becomes infected from any cause, antiseptic solutions may be required to cleanse it, but they should not be strong enough to produce any sloughing of the tissue. Where wounds are septic from the beginning, as in abscesses, anti- septic solutions must be used until the wound is free of pus. Arrangements for Operations. Operating Room.—If in a hospital, it should be made antisentically clean, of course, as for a general surgical op- eration. The operating table should be placed near a win- dow in order to get side light, if daylight is to be used. If artificial light is to be employed, the table is to be placed near and to the side of the source of light. Light coming from above, as from a skylight, is bad for operations on the eye, as it casts confusing shadows on the field of operation. If the operation is to be performed in a private house, the nurse may have to improvise an operating table, as a lounge, library table, kitchen table, etc. On this table should first be placed blankets, over this a rubber sheet, and over this a 114 EYE NURSING. cotton or linen sheet. The pillow should be covered with a piece of rubber sheeting and over this an antiseptic towel may be spread. Near the operating table and on the side opposite from the light should be a small table to hold the instruments, tray, dressings, solutions, towels, etc. This table should be washed with soap and water and an anti- septic solution, and finally antiseptic towels spread on the top of it. A second small table may be necessary to help hold the dressings and solutions. In hospitals one small table made of iron and glass and having two shelves is quite sufficient. If a general anaesthetic is to be given a small table should be provided to hold the anaesthetic, inhaler, tongue forceps, mouth-gag, hypodermic syringe, solution of nitroglycerin, whisky, camphor, nitrate of amyl, a pus basin for vomited matter, pads of sterile gauze or towels for wiping the patient's mouth, and a galvanic battery. All hangings and articles of furniture unnecessary for the op- eration should be removed from the operating room. This is meant especially in private houses, since in regularly ap- pointed operating rooms unnecessary articles of furniture are not permitted. It is always to be remembered by the nurse that the operating room should be warm, from 76° to 80° F., especially where a general anaesthetic is to be given, as the patient is lightly clad and entirely relaxed while under the anaesthetic. The room should be well ventilated. Instruments.—In all well-regulated hospitals there are dust-poof, air tight, iron and glass instrument cases with convenient shelves and racks for holding instruments and ligatures. It is the nurse's duty to keep the instruments clean, dry, and well arranged in these cases, and before an operation it is necessary for her or a house surgeon to pick out the necessary instruments for the operation. If knives, knife-needles, or keratomes are to be used, a test-drum should STERILIZATION OF INSTRUMENTS. 115 be convenient and handed to the assistant or the surgeon to test the sharpness of the instruments before they are steril- ized. Eye instruments are so small and delicately made, espe- cially knives, knife-needles, and fine-pointed scissors, that they are often dulled or ruined by the nurse in handling and sterilizing them, unless she has had special directions and warning in the matter, and I speak feelingly on the matter, having suffered both in temper and pocket from such source. The larger instruments, as speculum, enucleation scissors, tenotomy hooks, needle-holders, etc., may be boiled for from four to five minutes in a 1 per cent, solution of soda, or they may be sterilized by steam. After taking the instruments from the boiling water or steam they are placed in a 3 per cent, solution of carbolic acid for five minutes, then placed in an instrument tray or rack ready for use near the oper- ating table, a sterile towel being spread over them. Or, after boiling, the instruments may be placed in a 1 per cent. solution of cyanid of mercury for five minutes before use. Some surgeons prefer to have the instruments dipped in alcohol (95 per cent, pure) immediately after boiling, which dries them quickly. Cataract knives, keratomes, and knife- needles should only be dipped into boiling soda solution (1 per cent.) for about one minute, holding them with forceps and not allowing the instrument to touch the sterilizing basin for fear of dulling them. They are then dipped into alcohol for one minute, rinsed in sterile water, and placed in special trays or racks, ready for use, being careful not to touch the blades on the rack or tray. Some surgeons prefer to have these finer instruments simply dipped in 95 per cent, pure alcohol and dried just before using, while others have them dipped in boiling water only and dried just before using. 116 EYE NURSING. Soft, sterile gauze or soft, old linen should be used for drying instruments, and not cotton, as is sometimes done. If cotton is used, fine shreds are apt to cling to the instru- ments and be introduced into wounds or into the eyeball itself. Needles should be stuck in a piece of gauze before being put into the sterilizer to prevent their being lost. Instruments with ivory handles should not be boiled, but dipped into boiling water just for a moment, then im- mersed in a 5 per cent, solution of carbolic acid for five minutes, and dried with sterile gauze. Syringes may be sterilized by soaking in carbolic solu- tion, 5 per cent., for twenty minutes, then boiling water drawn into them and emptied several times to have them ready for use. Immediately after operation, cataract knives and kera- tomes should be dipped into boiling water and cleansed, then into alcohol, dried, and placed back in the case. The teeth and catches of forceps, joints of scissors and needle holders, needles, and cystitomes should be cleansed in a hot 1 per cent, soda solution and with especial care, a fine brush being used for this purpose. They are then dipped into alcohol, dried, and put away. Dressings. — Bandages, eyepads, cotton and gauze sponges (mops), gauze and gauze strips, towels, and gowns for the surgeon and attendants are best sterilized by steam. Several sterilizers for this purpose have been invented, one of the best being that of Schimmelbusch. In this there is a compartment below for boiling the instruments and com- partments above for sterilizing dressings by means of the steam. It takes but four or five minutes to sterilize the in- struments, but the dressings should be allowed to steam for at least one-half hour. The large hospitals have hot-air sterilizers, in which towels, bandages, dressings, gowns, STERILIZATION OF DRESSINGS. 117 etc., are sterilized at a temperature of 300° F. for the space of one hour. For private use, the Rochester combi- Fig. 12.—Combination Hot Air, Hot Water, and Steam Sterilizer. nation sterilizer shown in Fig. 12 is excellent. It is very much like the Schimmelbusch sterilizer: Any of the three 118 EYE NURSING. sterilizing agencies, dry heat, steam, or boiling water, may be utilized at will. The sterilizing chamber, by the simple turning of a valve, may be filled with either steam or hot air, and in this way instruments or dressings may first be subjected to dry heat, then steam, sterilized, then thoroughly and quickly dried by hot air. The apparatus consists of a double-walled chamber. The outer wall rests in the groove of a removable base, which forms a water-joint. This base may be used for sterilizing instruments with boiling water (1 per cent, soda solution), if desired, and dressings, gowns, etc., may at the same time be steam sterilized in the cham- ber above. With the sterilizer there are two removable wire- cloth racks: one for dressings, the other for instruments. The instrument rack is built to fit either the chamber or base. The Rochester combination sterilizer is made in vari- ous styles and sizes for both hospital and physicians' use, and special sizes are made to order. The bottom is heated by means of a stove, spirit lamp, or gas jet. The apparatus is very simple, efficient, and cheap, and can be carried easily in the hand. Suture Material and Ligatures.—Silk is the most common suture material used in operations about the eye, and this is usually the iron-dyed, so that the stitches can be readily seen when it is time for their removal. Occasionally catgut is used, but this comes sterilized ready for use. For that matter, silk sutures most often come in tubes or on spools in bottles, sterilized ready for use. Silk sutures may be sterilized by dry heat, one hour, or simply by boiling for a few minutes in 1 per cent, soda solution, or in a solution, 1 to 1000, of bichlorid of mercury. A small glass spool or reel is convenient for wrapping the silk on while sterilizing. After sterilization the material is kept in small bottles im- mersed in alcohol until ready for use. DISINFECTION. 119 All dishes, trays, racks, bowls, etc., intended for hold- ing instruments and dressings, should either be boiled for ten minutes or boiling water poured over them and in them, then rinsed in carbolic solution (1 to 20) and dried with a sterile towel. Bottles, droppers, and receptacles intended for solutions may be sterilized in the same manner. The solu- tions themselves intended for use in the eye, except the anti- septic solutions, must be sterilized before use. Solutions of cocain, atropin, eserin, etc., should be made sterile by boiling, if not sterilized by the apothecary when compounded. This may be done by placing the solution in the Stroschein flasks, already described on page 91 and boiling for two or three minutes, not longer, when, after cooling for a few moments, the solution is ready for use. If these flasks are not con- venient, an ordinary test tube may be used to boil the solu- tion in; or the original bottles may be unstopped, set in a basin of boiling water, and boiled for five minutes. The Nurse's Hands.—Just as the hands of the sur- geon and attendants must be made thoroughly aseptic before an operation, so must the hands of the nurse. This may be accomplished in one of several ways. As a preliminary measure in every instance, the nails should be cut short, and carefully cleansed with a nail file. The method of disin- fection may then proceed. One commonly followed by many of the surgeons at the New York Post-graduate Hospital is as follows: (1) the hands and arms are first thoroughly scrubbed with soap and water with a brush; (2) dipped into alcohol (95 per cent.) for one minute; (3) dipped into permanganate of potash solution (2 per cent.) for from three to five minutes; (4) bleached in a saturated solution of oxalic acid until all the stain from the permanganate is gone; (5) dipped into a solution of bichlorid of mercury (1 to 1000) for one minute. The hands are then dried with 120 EYE NURSING. a sterile towel. A thorough scrubbing of the hands with soap and water and brush, and immersing the hands in a solution (1 to 1000) of bichlorid of mercury for ten minutes, is quite sufficient, as a rule, for complete asepsis. Some sur- geons are very careful in regard to the nails, and depend for sterilization of the hands upon scrubbing them very thor- oughly with soap and water and brush, using no other antiseptic. Preparing the Patient.—In all major operations, whether a general anaesthetic is to be given or not, the pa- tient should have a cathartic given the night previous to the operation, to be followed the next morning by a saline or enema if not effective. If the operation is to be performed -• at a hospital, the patient should be sent to the hospital the night previous to the operation to get accustomed to the bed and surroundings. A full bath should be given the morn- ing of the day of the operation. Just before the patient is brought to the etherizing or operating room the day clothes should be changed for nightclothes, over which a bathrobe or dressing gown is to be worn until the patient is placed on the operating table, when he should be covered warmly with a blanket. Special inquiry as to artificial teeth should be made, and the patient should be instructed to empty the bladder just before going on the table to avoid involuntary micturition. Where chloroform is given, the lips and nose should be greased with vaselin or cold cream to prevent blis- tering. Patients who are to have a general anaesthetic given should have nothing to eat on the day of the operation, and not until some hours after the operation, and then only fluid diet, as tea, milk, and broth in small quantities at a time. This precaution on the part of the nurse is very important, because with solid food in the stomach vomiting is almost sure to come on during or immediately after the operation, FIELD OF OPERATION. 121 and the patient's life is endangered from having some of the food lodged in the larynx. Furthermore, the success of the operation is greatly imperiled, especially if the eyeball has been opened. Even the contents of the eye may be extruded if the vomiting is very violent, and the sight totally de- stroyed. In weakly patients a little clear broth or stimulant may be given three hours before the operation, but no solids under any circumstances should be given within the six hours preceding "the operation. The surgeon himself or an assistant makes a physical examination of the patient as to the heart, lungs, intestinal tract, some time before the operation; and also gives direc- tions to the patient as to looking "up" or "down" just before the operation is begun. Field of Operation.—In case the operation is on or near the eyebrow, this should be shaved before the patient is brought to the operating room. Placed on the operating table, the patient is covered with a blanket, and over this and well up under the chin is placed a rubber sheet. Towels should be laid over the pillow of the patient and over this a rubber sheet. On the patient's head is adjusted a sterilized rubber cap or towel to effectively keep the instruments and hands of the operator from contact with the hair. The skin about the both eyes and the outer surface of the lids is now washed thoroughly with soap and water, the edges of the lids and eyelashes receiving special care. The skin surface may then be mopped in turn with alcohol and a solution of bi- chlorid of mercury, 1 to 5000. The lids are now everted and the eye and cul-de-sac thoroughly flushed with warm sterile water or boracic acid solution squeezed from a pledget of cotton. Some operators wrap a little cotton on a cotton car- rier, saturate it in the sterile water or boracic acid solution, and carry it along the cul-de-sac above and below to insure 122 EYE NURSING. complete cleanliness. Other surgeons direct that the nurse or assistant wash the eyes thoroughly the day before the op- eration, and bandage the eyes, which bandage is left on until just before the operation. Unless there is some mucous discharge from the con- junctiva, no antiseptic solutions should be used on the eye itself as they are quite irritating; and, if there is any con- siderable discharge from the conjunctiva or lacrymal sac, no operation with a view of opening the eyeball should be undertaken until this discharge has been relieved by means of appropriate treatment. In case of septic operations, as abscess, antiseptic solutions may be used on the eye, such as bichlorid of mercury solution, 1 to 5000, or formalin, 1 to 5000. The nurse will rarely be called upon to prepare the field of operation, most surgeons preferring to do this them- selves, but she may, and should be able and ready to do it as directed. The anaesthetic, if general, is usually administered by an assistant, but the nurse is occasionally called upon to do this in emergency cases. Local anaesthesia, described in a previous chapter, is produced by means of cocain and holocain, and is begun five to ten minutes before the operation begins, the nurse usually putting the first drop in the eye in the anteroom. The eye not to be operated upon, after cleansing, should have 1 drop of cocain in it and a patch held on by narrow strips of ad- hesive plaster. This keeps the eye quiet, and the patch pre- vents the patient seeing every motion of the surgeon or assistants. And this leads me to remark that but few spec- tators should be allowed in the operating room, and entire silence must be insisted upon. I suppose it is unnecessary to say that nurses and assistants should not speak unless spoken to. THE DIFFERENT OPERATIONS. 123 The Different Operations. After preparing the operating room, table, instruments, dressings, and the patient for operation, it is the nurse's duty to assist in the different operations, and to care for the patient and to assist in the dressings after the operation. The operations upon the appendages of the eye, lids, and lacrymal apparatus will be considered first, and later the operations upon the eyeball itself. In the minor operations, such as opening styes, open- ing and curetting chalazia, and passing lacrymal probes, no special preparations are required. For a stye all that is necessary is a bowl of hot boracic acid solution and a small bistoury, which should be sterilized. For a chalazion are required hot boracic acid solution, a small bistoury, chalazion curette, 4 per cent, sterilized solution of cocain, and a hypodermic syringe sterile ready for use. The eye is washed with boracic solution. A few drops of cocain are dropped on to the mucous surface of the everted lid. After five minutes the lid is again everted and from 2 to 4 drops of cocain injected into the tumor by the surgeon. After eight minutes' wait the cyst can be opened and curetted without the least pain. The after care of styes and chalazia may be attended to by the patient himself, and consists in bathing the eye with hot boracic acid or salt solution. operations on the tear-passages. For slitting the canaliculi and passing probes are re- quired hot boracic acid solution, and, if pus is present, hot bichlorid of mercury solution (1 to 5000), a tube of vaselin, cocain, 4 per cent, solution (except in children and weakly patients, when a general anaesthetic is given), a .lacrymal knife, a full set of lacrymal probes, and where an abscess is 124 EYE NURSING. present, a bistoury. All of the above are to be made sur- gically clean, of course. Except in the cases where a gen- eral anaesthetic is given, such cases require no special prepa- ration, and are operated on in the outdoor department of hospitals and in the private office. EXCISION OF THE LACRYMAL GLAND; THE LACRYMAL SAC; THE PLASTIC OPERATIONS ON THE EYELIDS, AS FOR ENTROPION (TURNING INWARD OF THE LID), ECTRO- PION (TURNING OUTWARD OF THE LID), AND PTOSIS (DROOPING OF THE UPPER LID). These operations are usually performed with the patient under a general anaesthetic. Here the patient must be pre- pared for the anaesthetic and all arrangements for an anti- septic operation complied with. Antiseptic and sterile solu- tions are to be prepared, bichlorid, carbolic, sterile water, plenty of hot water, absorbent cotton, pledgets or balls of cotton for sponging, bandages, gauze, strip gauze (plain and iodoform), iodoform and iodol powder, and the following instruments more or less varied according to the direction of the surgeon: a Beer knife, bistoury, scissors (straight and curved), fixation forceps (small and large), dressing forceps, retractors, hard rubber spatula, needle holder and needles, sutures, etc. expression; grattage. The "expression" and "grattage" operations for tra- choma are both performed under general anaesthesia. After the patient is prepared the only instruments necessary in the first operation are two pairs of expression forceps, and, for grattage, a multiple knife and a stiff toothbrush. Solu- tions of hot, sterile water and bichlorid of mercury (1 to TENOTOMY AND ADVANCEMENT. 125 500) should be prepared; also plenty of cotton mops for sponging, a tube of vaselin, dressings, and a bandage. Some operators put no dressing on the eyes after these operations, but have the nurse apply iced cloths frequently, thirty min- utes at a time, for two or three days. The eyes are to be kept thoroughly cleansed with boracic acid solution several times a day, and when the surgeon comes to examine the case a stiff conical pointed probe (No. 8 Theobald lacrymal probe is excellent) should be at hand, with which he sepa- rates the folds of conjunctiva in the culs-de-sac. This is necessary because of the adhesions which take, place after the above operations. A membrane forms on the lids within forty-eight hours after the above operations. The lids should be everted and this membrane gently rubbed away with cotton wrapped on an applicator. This maneuver should be repeated daily until the adhesions and membrane cease to form. TENOTOMY AND ADVANCEMENT. Many times these operations are performed under a general anaesthetic, especially in children, when the patient' must be prepared in the usual way. When cocain is used it is generally in 4 to 10 per cent, solution. The instruments necessary are: speculum, two fixation forceps (narrow and broad), and for the advancement operation some surgeons have a special forceps to hold the cut muscle (Prince), two tenotomy hooks, curved and blunt-pointed scissors, needle holder, and threaded needles. Solutions of boracic acid, or plain sterile water, oval patches of gauze and cotton, a roller bandage, and pledgets of cotton for sponging complete the arrangement for the operation. During the operation the nurse will have little to do. Most surgeons in America bandage the eyes for from twelve to twenty-four hours, and 126 EYE NURSING. some for four or five days, changing the dressing daily. After the first day iced cloths are usually applied, three or four times a day, and the eye kept clean with boracic acid or other bland solution. OPERATIONS ON THE EYEBALL WHEN THE EYE IS NOT OPENED. Corneal ulcers are sometimes curetted, and then cauter- ized with pure carbolic acid (95 per cent.). The nurse should get ready a 4 per cent, solution of cocain, a small curette, carbolic acid, a gauze pad, and bandage. Sometimes the actual cautery is used, when a spirit lamp and blunt-pointed probe are to be ready. Often the surgeon uses a Paquelin cautery or the galvanocautery; a solution of atropin (gr. iv to §j) should be at hand. ENUCLEATION. The patient must be prepared for a general anaesthetic. The instruments required are large and small blunt-pointed, curved scissors, two fixation forceps, a tenotomy hook, and a speculum. In case of exenteration of the orbit a perios- teum elevator must be had also. Solutions of bichlorid of mercury, 1 to 5000, and boracic acid, saturated, and very hot water should be ready, also cotton sponges, plain, steril- ized gauze in pads, and iodoform gauze and plain sterilized gauze in strips and bandages. In case of much bleeding the orbit is douched with hot boracic solution, or plain hot water, the orbit packed tightly with strip gauze, and a firm bandage applied. Should bleeding come on some time after the operation, the nurse should apply a bandage tightly over the other bandages, and if this does not control the bleed- ing the dressing should be removed, the orbit washed with very hot boracic acid solution, packed tightly with gauze, THE MULES OPERATION. 127 and rebandaged tightly. Of course, this must be done under strict antiseptic conditions, and the surgeon notified. Some- times great difficulty is encountered in removing the first packing from the orbit after an enucleation or exentera- tion. If necessary, this packing should be soaked with hot boracic acid for half an hour rather than cause the patient great pain. This is done by removing the outer dressing and squeezing a small stream of the boracic acid solution from a pledget of cotton, holding the lids apart with the other hand. The dressings are changed daily for four or five days, when they may be discontinued, and an artificial eye introduced at the expiration of one week or ten days. In the Mules operation, a substitute for enucleation, the front of the eye (cornea) is cut off; the contents curetted out to the sclera; a glass, silver, or gold ball inserted, and the wound closed with many sutures. The additional instru- ments required are a Beer knife or small scalpel, straight scissors, Mules's instrument for inserting the balls into the sclera, a sharp curette, glass or silver balls, and several threaded needles. Carbolic acid (95 per cent.) and alcohol (95 per cent.) should be provided. The strictest antiseptic precautions are necessary in this operation. Some American surgeons apply a firm bandage for twelve hours, followed by iced cloths, while others begin the application of iced cloths shortly after the operation. There is always intense reaction following this operation, redness of the lids; chemosis of the conjunctiva, protruding between the lids at times; redness, pain, and often rise of temperature. The patient is always put to bed after an enucleation or Mules's operation, is given fluid diet for twenty-four hours, and the temperature and pulse are charted at least twice a day. 128 EYE NURSING. OPERATIONS WHERE THE EYEBALL IS OPENED. It may be stated here that in all operations where the eyeball is opened the strictest antisepsis and asepsis must be practiced. Even in the simple operations of paracentesis and needling (keratonyxis), where but one or two instru- ments are used, just the same care must be exercised as in preparing for a cataract extraction. Tepid, sterile warer and boracic acid solutions are the best for cleansing the rye where the eyeball is to be opened. Bichlorid of mercvry solution certainly should not be used after the eye is 07 ce opened, as it tends to cloud the cornea. PARACENTESIS. The instruments necessary for this operation are a nar- row Graefe knife, a speculum, and fixation forceps. Warm boracic acid solution, 4 per cent, solution of cocain, patches of gauze and cotton for each eye, a bandage, and narrow strips of adhesive zinc oxid plaster are to be made ready. NEEDLING OPERATION. For a needling operation, a knife-needle, fixation for- ceps and speculum, in addition to warm, sterile, boracic acid solution and dressings for each eye and a bandage, are required. In removing thick membranes from the pupil (membranous cataracts) it is necessary to open the eye as for iridectomy. The instruments required are: a speculum, fixation forceps, angular keratome, iris scissors, iris forceps, and a narrow spatula or iris replacer. The pupil should be dilated with atropin before the operation, and a solution of atropin (gr. iv to §j) should be at hand for instillation im- mediately after the operation. Dressings for both eyes and a bandage are necessary. EXTRACTION OF CATARACT. 129 SCLEROTOMY. For sclerotomy, the instruments required are a cataract knife, fixation forceps, and speculum; and iris forceps and scissors may be needed, so should be ready. The same solu- tions and dressings are necessary as for the needling opera- tion. IRIDECTOMY. For iridectomy, the same solutions and dressings are necessary as for sclerotomy, but more instruments are re- quired. In addition to the speculum, fixation forceps, and narrow spatula (iris replacer), an angular keratome is usu- ally preferred to the Graefe knife; iris forceps and iris scissors are also needed. After sclerotomy or iridectomy is performed for glaucoma a sterile solution of eserin (gr. ij to §j) or pilocarpin (gr. iv to %]) should be on hand for instillation into the eye immediately after the operation. OPERATION FOR EXTRACTION OF SENILE CATARACT. The patient should be sent to the hospital the afternoon previous to the day of the operation, that the patient may become accustomed to the bed and surroundings, the bowels opened with a cathartic, and the morning of the day of the operation a general bath given. If a general anaesthetic is to be given, which is rarely the case, the patient should fast for at least six hours before the time for the operation. Even where cocain is employed as the anaesthetic, which is usually the case, the stomach should be empty or only liquid food given, and this not nearer than three hours before the op- eration. Vomiting may be caused by the shock of the operation, and a full stomach may be put down as a predis- posing cause. Of this I have had sad experience in one case • 130 EYE NURSING. of cataract extraction at a private house. The lady was given the usual instructions as to the bath and cathartic the night previous to the operation, and was told to eat a very light lunch at 12 o'clock (operation to be at 3 p.m.). Instead of eating a light lunch she ate very freely and took some brandy to fortify her nerves. Immediately after the extraction, and before the bandage could be applied, she began to vomit, continuing for some half-hour, the bandage being applied in the meantime as well as possible. On inspecting the eye the next day the retina was found detached and protruding from the wound. I cite this case to emphasize the necessity of taking every precaution to insure quiet and rest during and after the operation in cases where the eye is to be opened. The instruments required are: speculum, fixation forceps, Graefe cataract knife, cystitome, Daviel spoon, shell spoon, iris replacer or spatula, wire spoon or vectis, iris forceps, and iris scissors. Some surgeons have in readi- ness also a suction syringe (Teale's) or irrigating tube (Lip- pincott's), in case of much cortical matter, to assist in its removal. Warm solutions of boracic acid (saturated), ster- ile water, normal salt solution, and a 4 per cent, solution of cocain, all sterile, should be freshly prepared. Cotton balls for sponging, oval eyepads (cotton between layers of gauze), bandage, strips of adhesive zinc oxid plaster, and eye-shield (Ring's) should be in readiness. The instruments should be on a tray by themselves, while the dressings should be on a separate tray. A double-shelved table may hold both and the necessary solutions, or a second small table may be re- quired. Just before and during the operation the nurse should be ready to hand the surgeon the cocain solution, or bowls containing the cleansing solutions, cotton balls, etc. Immediately the section is made, the knife should be taken in charge by a nurse and cleansed and dried, not allowing it EXTRACTION OF CATARACT. 131 to be knocked about with the other instruments. After the operation the nurse is to hand the tray with the dressings to the assistant, and, when both eyes are bandaged (even if but one is operated on) and the shield applied, is to assist in getting the patient off of the table and into the bed with the least possible straining or jarring of the patient. In bed the patient is to be placed on his back, or on the side op- posite to that operated upon, quiet enjoined, and the patient warned not to pick at the dressing or to move for anything whatsoever, but to call the nurse when anything is wanted. In a private case the nurse will be by the patient's side most of the time, but in a ward an electric push bell, the handle of which is attached by a cord to the bed and the patient's hand placed on it to show him where it is, serves to call the nurse for every want, as for a drink, to turn in bed, the urinal or bedpan, etc. CHAPTER VIII. AFTER-NURSING OF THE DIFFERENT OPERATIONS ON THE EYE Plastic Operations—Operations on the Eyeball—Operations where the Eyeball is Opened: Paracentesis; Needling; Sclerot- omy; Iridectomy; Extraction of Senile Cataract—Complications: Delayed Union of the Woimdj Infection; Iritis; Entropion; Shock; Vomiting; Delirium. It is in the management of cases after operations, espe- cially in private cases, that the ability and capability of the nurse is thoroughly tested. In carrying out instructions she must be resourceful, but tactful; gentle, but firm; never losing her temper, but ever patient, bearing in mind always that she is dealing with sick people. Truly efficient nurses, like poets, it may be said, are born, not made. Training may do wonders for her as far as arranging for and assist- ing at operations and nursing in a hospital ward, but for private nursing, to be successful, there must be an innate aptness not furnished by any amount of training. Many nurses, in fact, shrink from this work just on account of the difficulty of "managing" such patients. Plastic Operations. In the various plastic operations upon the eyelids and especially where a general anaesthetic has been given, the nurse is to accompany the patient to the ward or private room, as the case may be, and remain by the bedside until the patient is out from under the influence of the anaesthetic. In cases of children who have a tendency to pull off the (132). PLASTIC OPERATIONS. 133 dressings their hands should be tied to the sides of the bed. Unless there is some complication, as shock, haemorrhage, vomiting, etc., which will be spoken of later, the nurse's chief duty for the first twenty-four to forty-eight hours is to see that the patient gets the proper diet at the right time and sufficient rest and is not allowed to suffer too much pain. Where both eyes are bandaged, the patient must be fed by the nurse and assisted with the urinal and bedpan, unless the patients are able to walk, when they are to be led to the closet and back to the ward or room. After »a general anaes- thetic" no solid food should be given for at least four hours, but hot soups, broth, or milk may be given in limited quan- tity, and a little at a time, two hours after the operation, and repeated in from one-half to one hour if the first amount is retained. There should be no hurry about feeding the patients after an operation, even with "slops," unless the patient is very weak. The nurse should also be very careful how she gives water to patients shortly after general anaes- thetics have been administered, although the patients may be very thirsty. The best plan is to let them suck small pieces of ice. After the first twenty-four hours semisolid food may be given, as eggs, oatmeal, and mush; and after forty-eight hours usually a solid diet may be given, unless there is some contra-indication, in which case the surgeon directs just what is to be given and what not. The pulse and tempera- ture should be charted for a few days, especially when there is any febrile reaction. The bowels should move on the second day after the operation. In all redressings following operations the nurse is to be just as careful in her antiseptic and aseptic methods as when preparing for the operation. In the first place, all bowls, basins, solutions, and dressings must be strictly asep- tic, as must also all dressings, forceps, or other instruments 134 EYE NURSING. to be used in redressing the cases and for removing stitches. And, of course, the nurse's and the attendant's hands must be aseptic. The after-nursing of operations upon the eyeball where the anterior chamber has not been opened has been indicated already in Chapter VII under the description of the dif- ferent operations themselves, and need not be repeated here. Operations where the Eyeball has been Opened. In simple paracentesis of the cornea the after-care is usually very simple. The wound, being small, is healed at the first inspection. Of course, all antiseptic and aseptic precautions are to be observed in redressing the wound. Two or three dressings, consisting of an oval gauze and cotton pad, held in position with strips of plaster, are all that are required. The needling Operation for membranous cataract fol- lowing the extraction of a senile cataract, if no complica- tions ensue, requires but little after-care. The eye is in- spected daily after the operation, the dressings (patch and adhesive strips) changed under strict antiseptic precautions, and a drop of a solution of atropin (gr. iv to f,j) is instilled. The patient may be confined to the house for four or five « days before being discharged with smoked glasses. Where needling is done to remove soft cataract in the young, the eye is inspected daily, the dressings changed under strict antiseptic precautions, and a drop of atropin instilled. If all goes well the patient is ready to leave the hospital in five or six days' time. Occasionally after needling a soft cataract the lens swells so rapidly that it causes marked plus tension or hardening of the eyeball, accompanied by intense pain in the eye and redness of it; that is, it produces secondary glaucoma. Leeches applied to the temple and hot moist AFTER EXTRACTION OF CATARACT. 135 applications to the eye may relieve this condition, but if the pain persists and the tension of the eye remains much ele- vated, the surgeon usually performs linear extraction of the soft cataract, for which see below. After the operations of sclerotomy and iridectomy usu- ally both eyes are bandaged, and the patient put to bed for a few days and fed on slops for the first day. Great care is taken to prevent the patient from straining or exerting him- self in any way. The eye is inspected under the strictest antiseptic precautions daily, and the dressings reapplied. If the operation has been performed for the cure of glau- coma, as is often the case, a sterile solution of eserin (gr. ij to 5J) or of pilocarpin (gr. iv to 5J) should be in readiness to be instilled at each dressing. After-care of Operations for Senile Cataract. The after-treatment of cataract operations varies some- what with different surgeons. As a rule, however, both eyes are closed after the operation with oval cotton or cotton-wool pads, inclosed between a single layer of gauze on either side of the cotton, which are held in position with narrow strips of adhesive zinc oxid plaster. Over this, most ophthalmic surgeons place a roller bandage (of flannel or gauze 11/2 inches wide) to make the dressing more secure, and the whole is covered with a shield to prevent injury to the eye. Some surgeons use simply the pads held in position with adhesive strips, and over this a protective shield; others have advised a strip of isinglass plaster (1 by 11/2 inches) to close the lids with, and no other dressing; while a few surgeons use no dressing whatever on the eye. In my opin- ion, without question, after cataract extraction, a dressing of some kind affording support and protection to the eye during the healing process should be used. The oval pads 136 EYE NURSING. on each eye, held in position by strips of adhesive plaster and protected by a Ring papier mache mask is about the best dressing, and I believe it to be a good practice to place a bandage over the pads on both eyes before the mask is applied. The objection to the bandage that it causes "drag- ging" on the dressings is overcome by the strips of adhesive plaster which hold the dressings (pads) in position. The patient is placed in a moderately lighted room in bed and on his back or on the side opposite to the eye operated upon. He should stay in bed at least twenty-four hours, and it is better to have him remain in bed two or three days until the wound is healed, after which he may be al- lowed to sit up in an armchair for part of the day, or all day, if he is more comfortable sitting up. When confined to bed the urinal and bedpan should be used. If the bowels do not move on the second day after the operation an enema of warm water and soapsuds should be given. The patient should be cautioned not to strain at stool, as great harm can result to the eye as a result. The diet should be fluid for the first day, and semisolid the next two or three days, after which the usual diet may be given, with care not to overfeed or upset the stomach. Mild stimulants may be required in some cases, especially if the patient has been accustomed to them. The nurse must feed the patient as long as both eyes are bandaged. Highly seasoned foods, and fruits and pastries, except in limited quantities, are contra-indicated. For the first few days after extraction of senile cataract there is usually some smarting and burning in the eye and a "sore feeling" complained of, but not a sharp or aching pain. This wears off in three or four days' time, and the patient is able to rest. If these symptoms continue and the patient is unable to sleep an anodyne should be given. If a shooting or decidedly hard pain should persist, the surgeon should AFTER EXTRACTION OF CATARACT. 137 be notified, the dressing removed, and the eye inspected and redressed. Sometimes a faultily applied bandage, or an eyelash loosened and caught between the lids, may cause the pain, or, if a simple extraction has been performed, a pro- lapse of the iris into the wound may cause acute pain. Acute persistent pain demands inspection of the eye and redress- ing, even within five or six hours after the operation. If all goes well, however, the first dressing should not be made until twenty-four hours after the operation, some surgeons waiting two or three days before making a change. If a simple extraction is done, that is, without iridectomy, the dressing should be changed in twenty-four hours, and the eye looked at to see if any prolapse of the iris has occurred. The lower lid is pulled gently downward, a little warm, sterile, boracic acid solution squeezed from a pledget of cot- ton into the eye, the lower lid and face bathed with the same solution, and the eye bandaged. The dressings are to be changed daily under the strictest antiseptic precautions, espe- cially until the wound is healed. On the third day after the operation, most surgeons instill a drop of atropin into the eye, and repeat the instillation daily until the eye is quiet and white. Both eyes are kept closed for five or six days, when the unoperated eye is left uncovered and protected by a double shade covering both eyes. About the eighth or tenth day all dressings may be left off and the eyes protected with a shade or smoke-coquilles. From the tenth to the fourteenth day the patient may be allowed to take a little exercise out of doors. The above description applies to the normal, uncom- plicated course of healing following extraction of senile cat- aract. Several complications, both of a local and a general nature, may occur to mterrupt and retard the healing process or even jeopard the success of the operation altogether. 138 EYE NURSING. LOCAL COMPLICATIONS. First, the local complications which may ensue will be considered in turn; they are: delayed union of the wound, infection of the wound, iritis, deep infection, panophthal- mitis, meningitis by extension, pseudo- or false erysipelas from atropin, etc. Delayed Union of the Wound may result from im- proper apposition of the wound surfaces, or from lack of nutrition in old or debilitated patients, and at times with- out any apparent cause. Where apposition of the wound sur- faces is not good the surgeon readjusts them, and, in the cases due to lack of nutrition, tonics and concentrated fluid diet are resorted to. The eye must be kept bandaged until the wound closes, even if it is as long as two weeks, the dressings being changed infrequently; that is, at two or three days' interval; so as not to disturb the wound any oftener than is absolutely necessary. Infection of the Wound is manifested by pain, lac- rymation, and more or less muco-purulent discharge from the eye. In such case the simple eyepad held in position with adhesive strips and covered with the Ring protective shield, which can be removed readily, is the best dressing. The eye should be inspected two or three times during the day, bathed with hot boracic acid solution, and atropin instilled. The surgeon usually cauterizes the wound with pure carbolic acid, the galvanocautery, or the actual cautery, any one of which the nurse should have in readiness according to the direction of the surgeon. A local application of a 50 per cent, solution of argyrol has proved of great service in some of the cases, and it has the advantage of being nonirritating. A 4 per cent, solution of cocain should be ready for producing local anaesthesia before cauterization is done. Dusting the wound with iodoform is of benefit in some cases. LOCAL COMPLICATIONS. 139 Deep Infection of the Eye may extend from the wound infection, or occur within the eye while the wound heals. It is manifested by severe pain, cloudiness of the aqueous humor, discoloration of the iris, pus in the anterior chamber perhaps, and marked redness of the eye. If not checked, the conjunctiva becomes chemotic, the eyelids swollen and cedematous, all of the tissues of the eyeball be- come inflamed, and there is excruciating pain, with intense suffering, accompanied by rise of temperature, rapid pulse, and at times with vomiting. Cases of death from meningitis by extension of pus from the eye to the meninges have been reported. Where infection occurs deep in the eye, the symptoms (which may not be present till the third or fourth day after the operation) indicate to the nurse that a serious compli- cation is taking place. This should be reported at once to the surgeon. When certain that infection has taken place, the wound should be opened, the anterior chamber irrigated with a warm, sterile, salt solution, the edges of the wound cauterized, atropin instilled, and hot fomentations applied for twenty minutes every two hours. Some favorable results have been reported where the infection has been checked and the eye saved by injecting a few drops of a 25 per cent, solu- tion of argyrol into the anterior chamber (Webster). Where the inflammation results in a panophthalmitis (all the tis- sues of the eye becoming involved), poultices must be ap- plied, anodynes given, the wound opened and irrigated with antiseptic solutions, and the patient made as comfortable as possible. The nurse will find plenty to do in infected cases in keeping sterile solutions and dressings on hand, in cleans- ing the eyes, or assisting, and in making hot applications. Antiseptic precautions are to be observed, of course. 140 EYE NURSING. Infection of the eye may result from the needling op- eration for membranous cataract. In fact, infection is more apt to occur after a needling operation than after the pri- mary operations, if antiseptic methods are not rigidly fol- lowed. Germs carried into the eye with the needle remain in it, the opening made by the needle being so small they cannot easily escape; whereas, after section of the cornea, germs, if not too many are introduced, may be washed away by the aqueous humor and by irrigation with sterile water or boracic acid solution. It is altogether essential, therefore, that the needle be absolutely aseptic, and, for that matter, all other instruments connected with the delicate operation for need- ling. Iritis.—This complication may be of a very mild na- ture, accompanied with but little or no pain, redness, or irri- tation, yet of sufficient intensity to cause adhesions to form between the iris and the remains of the lens capsule. To obviate this, most surgeons instill a drop of atropin into the eye on the third day after the operation and for a few days following. This dilates the pupil and prevents the adhe- Bions. Severe iritis of an exudative nature sometimes follows extraction of senile cataract, especially if the iris has been bruised at the time of the operation. It usually manifests itself on the third or fourth day following the operation by redness of the eyeball; pain of a severe nature, worse toward night; lacrymation; discoloration of the iris; contraction of the pupil, and an exudate may be thrown out blocking the pupil. In such an unfortunate complication the nurse will be required to apply leeches to the temple, change the dress- ings several times (three or four) during the twenty-four hours, to apply hot, moist fomentations to the eye, and at the same time to instill a drop of atropin solution (gr. viii-xij LOCAL COMPLICATIONS. 141 to ^j) into the eye. The bowels should be opened thoroughly with calomel and soda, and inunctions of the oleate of mer- cury rubbed on the body. At times, sweating the patient freely seems to give relief. The patient must be kept on fever diet. Sympathetic Inflammation of the Fellow-eye may follow the operation for the extraction of senile cat- aract, especially if the iris or lens capsule is caught in the wound and retained there during the healing process. It is truly an unfortunate complication and often results in total blindness. Its symptoms and method of treatment have been described previously (see page 56). Hemorrhage may follow the operation of iridectomy for glaucoma, or operation for cataract, and is always a most serious complication, the sight many times being lost as a result. It occurs most frequently in arthritic patients, usu- ally without warning, and little can be done to prevent it. Bleeding may take place from one of the iris vessels or from some of the deeper vessels in the eye. It has a tendency to occur in glaucoma. If a sharp and intense pain strikes the eye suddenly a few hours after the above operations, espe- cially if accompanied by nausea and sickness at the stomach and depression, the nurse should report such facts at once to the surgeon or assistant. Removal of the dressings may show them to be wet with blood, or the blood may be clotted between the lids or in the lips of the wound itself. The blood-clots should be removed, very hot wet compresses ap- plied for a while, to try to stop the haemorrhage, and a compress held firmly with a roller bandage applied. The patient may be propped up in bed, perfect quiet enjoined, and sedatives may be administered by direction of the sur- geon. Whatever is done the eye is usually lost through in- fection, or later by shrinkage of the globe. 142 EYE NURSING. Spastic Entropion (turning inward) of the lower lid is an annoying complication occasionally following opera- tions on the eyeball. Painting the skin surface of the lid and the face just below the eye with flexible collodion gives relief many times. If this is not effective, a stitch placed in a vertical direction through the skin of the lid and cheek and tied firmly usually gives the desired effect. GENERAL COMPLICATIONS. Complications of a general nature which may follow operations on the eye and its appendages are: shock, vomit- ing, and delirium. Shock as a complication after ophthalmic operations is rare. It should be dealt with as after other operations, the patient put to bed, hot-water bags applied to the feet and sides, and stimulants given. Vomiting following operations upon the eye where the eyeball has been opened is a very undesirable complication and one to be avoided if possible. Before the discovery of cocain by Koller, when these operations were performed with the patient under the influence of a general anaesthetic, espe- cially after ether, vomiting was a frequent complication. Thanks to the genius of this great man, we have been given the boon of a local anaesthetic, after the use of which the pa- tient is freed of pain during the operation, and the dangerous complication of vomiting made much less frequent than after ether or chloroform anaesthesia, to say nothing of the danger to life from the exhibition of the latter two. At the very first indication of sickness at the stomach or nausea, the patient should be placed flat on the back, if not already in that position, all pillows removed from the head, and a mustard leaf applied to the stomach. A tea- spoonful of hot water, tea, or coffee sometimes allays the GENERAL COMPLICATIONS. 143 trouble, or even a small piece of ice in the mouth may be of service. Many, many remedies have been advised for vomit- ing, and any one of these, according to the direction of the surgeon, may be given. During the paroxysms of vomiting the patient's head should be supported by the nurse, taking care not to disturb the dressings any more than can be helped. If the dressing should be soiled, the outer bandage may be renewed and fresh dressings applied. Delirium, leading at times into acute mania, some- times follows operations upon the eyes, particularly after the operation for the extraction of senile cataract and iridectomy for glaucoma where both the eyes are bandaged and the pa- tient thus placed in total darkness. It is usually manifested in from twenty-four to seventy-two hours, but it may be four or five days after the operation. The patient becomes rest- less, with inclination to talk, or laugh or cry perhaps; some- times terror or fright seizes the patient, and he imagines some one is trying to injure him. With such symptoms coming on, the nurse should notify the surgeon at once, and remain constantly by the patient's side to prevent him from tearing off the dressings, injuring the eye or perhaps himself. In many instances freeing one eye (the unoperated one) gives entire relief. At times both eyes may have to be freed, and if this does not give relief, it may be necessary to use force in restraining the patient. If in a hospital, the patient should be allowed to return home at the earliest possible moment. Sometimes the familiar surroundings of home as- sist in clearing up the hallucinations and illusions of the patient. Where the patient becomes violent and delusions are present, sedatives, such as opium, bromids, etc., should be given. Until the wound is entirely healed the nurse must be constantly in attendance. CHAPTER IX. DRESSINGS, BANDAGES, SHADES, PATCHES, PROTECTIVE SHIELDS, PROTECTIVE GLASSES, AND ARTIFICIAL EYES. Antiseptic Dressings—Bandages—Application of Roller Ban- dages—Special Bandages—Masks and Shields—Redressings—Shades and Protective Glasses—Artificial Eyes. Dressings. The nurse will be called upon to prepare many of the dressings, bandages, and shades used about the eyes, and for that reason should be ready and able to do such work when it is necessary. All dressings to be used about the eyes should be aseptically clean, while some of the dressings are rendered antiseptic by being impregnated with antiseptic remedies, such as bichlorid of mercury, carbolic acid, iodoform, etc. Dressings for the eyes are needed chiefly after operations upon the eye, to support and protect the wound and to keep it free from septic material. They are required at times in the treatment of diseases of the eyes. For example, in de- tachment of the retina, the pressure bandage is used to pro- mote absorption of the fluid beneath the retina. It is also used to promote absorption of inflammatory material in the lids, or to prevent swelling of the lids, as after the operation of expression in trachoma, or after the Mules operation. Or a dressing may be used to support the cornea and prevent its rupture when thinned by ulceration; or, when thinned by malnutrition, to prevent staphyloma or conical cornea, etc. The materials of which eye dressings are made are ab- sorbent cotton, cotton wool, gauze, or cheese cloth prepared in such way that they are absorbent. They may be sterilized DRESSINGS. 145 and used plain or impregnated with some antiseptic material, as stated above. For convenient use on the eye the cotton and cotton wool and gauze are cut into oval pads or patches about three inches long by two inches wide. The cotton as it comes prepared in the rools from the druggist is in layers of from 1/2 to 1 inch in thickness. Thin patches may be made from a single layer of this, or, if the surgeon wishes, they may be made of two layers. On each side of this patch of cotton or wool is placed a single layer of gauze of the same size as the cotton patch. This prevents the cotton or wool fibers from getting into the eye or the wound itself. In hospital operating rooms a great number of these patches are prepared, sterilized, and stored in dust-proof glass jars. Pads of several thicknesses of gauze, cut in the same shape and size as the above, are preferred by some surgeons. Again, pads of gauze, 8 inches long by 4 inches wide, with a notch cut in one edge for the nose, form a very convenient dressing when both eyes are to be covered, especially after plastic operations upon the eyelids or about the orbit. Over this wide pad is placed loose gauze to level out the depres- sions over the orbits so as to give uniform pressure and sup- port to the wound. For packing the orbit and for drainage purposes, the gauze is cut into narrow strips, 1 inch wide by 3 yards long; this may be left plain or it may be impregnated with iodo- form, aristol, or other antiseptic remedies. This strip gauze is sterilized and packed snugly in test tubes and sealed ready for use. The best way to sterilize plain dressings is to place them in a hot-air sterilizer (temperature, 300° F.) for one hour. The receptacle for storing them may be treated in the same manner, or scalded with boiling water and later washed with 10 146 EYE NUKSING. a solution of carbolic acid (1 to 20) and dried, when they are ready for use. The bandages for holding these dressings on the eye should be sterilized in the hot air at the same time as the dressings. Dressings thus prepared are thoroughly asep- tic, and, except in septic cases, are preferable to dressings incorporated with antiseptic materials, which latter are apt to prove more or less irritating. Fig. 13.—Oval Eye Patch held on by Strips of Plaster. Where the oval eyepads are used, which are the most widely employed of all dressings for the eye, they should be held in position on the eye by two narrow strips, 1/2 inch by 4 inches long, of adhesive zinc oxid plaster for each pad. The strips are put on in a vertical direction extending from the brow down and slanting slightly outward to the cheek below (see Fig. 13). This zinc plaster is prepared antisep- tically and comes in convenient narrow rolls. Plain, adhe- ANTISEPTIC DRESSINGS. 147 sive plaster should not be employed, as it often causes irrita- tion of the skin. Over this pad and strips of zinc plaster a bandage should be applied. If the zinc plaster strips are not used, the bandage is applied directly over the dressings. In my opinion the strips should be used in every case where the eyepads form the dressings, for they prevent the pads from slipping or becoming displaced and at the same time obviate the "dragging" of the dressings by the bandage. These two advantages outweigh by far the small disadvantage and an- noyance of removing the plaster. If the patient is warned and the plaster gently removed (using a little ether if neces- sary in very nervous or sensitive patients, which renders the process absolutely painless) most patients do not complain. But, even if they do, a little annoyance with the chance of a good result is much to be preferred to entire comfort and the risk of a bad result. antiseptic dressings. These are made from the sterilized plain dressings by incorporating into them antiseptics of various kinds, as iodo- form, carbolic acid, bichlorid of mercury, or others, accord- ing to the desire of the surgeon. Messrs. Van Horn & Co., 307 Madison Avenue, this city, have kindly furnished me with the exact methods of prepar- ing these dressings, and I append them. I may add that this firm makes and has on hand at all times antiseptic and aseptic eye dressings. Bichlorid Gauze.—Impregnate absorbent gauze with a solution of bichlorid of mercury 1 to 1000 containing 10 per cent, of glycerin. Wring it out, roll it up, and put it up in paraffin paper. The addition of the glycerin renders the gauze less irritating. It is well to tint the solution with fuchsin, as this enables the manufacturer to note whether 148 EYE NURSING. the solution has been distributed uniformly throughout the gauze. Iodoform Gauze.—Dissolve 4 parts of iodoform in 16 of ether. Then add 16 parts of alcohol, 2 parts of tincture of benzoin, and 2 parts of glycerin. To make a 10 per cent. gauze. Weigh out 100 parts of the above solution, which contains 10 per cent, of iodoform; also weigh out 88 parts of gauze, and make the latter absorb the whole of the former. On drying, the gauze will retain the 10' parts of iodoform and the 2 parts of glycerin, and it will therefore be a 10 per cent, iodoform gauze. Carbolized Gauze.—This is prepared in the same man- ner as the bichlorid gauze. The strength of the solution used should be 1 to 40. Borated Gauze.—Saturate the gauze with a 10 per cent, solution of boracic acid, made with boiling water. Tincture of benzoin is added to this solution to make the medicament adhere more firmly to the gauze. It is impor- tant to hang the gauze up in a horizontal position, as in any other position the solution would be apt to drain off un- evenly. An antiseptic dressing may be made by applying an ointment, made from any one of the above remedies, to the plain gauze, or directly on the wound. For example, 1 to 5000 bichlorid of mercury vaselin, 10 per cent, iodoform vaselin, 1 per cent, carbolized vaselin, or 3 per cent, borated vaselin. Or iodoform, aristol, boracic acid, etc., may be dusted on the eye or wound and a plain dressing put over this. bandages. The materials for bandages are gauze, flannel, and white and unbleached muslin. The width commonly employed is 1 x/a inches, and the length varies from 3 to 5 yards. Sev- BANDAGES. 149 eral bandages may be made at once by having the material the requisite length, nicking the end at 1 x/2 inch distances, and pulling the alternate strips in opposite directions. These strips are rolled by hand or machine into a firm, even, neat roll, freed of shreds, and covered with a protective paper to keep them clean. An excellent material for bandages is a loose-woven muslin known as "water dressing," which may be had bleached or unbleached. It is very elastic, free from shreds, and conforms smoothly and neatly to the dressing and the head. It is used exclusively by some surgeons in this coun- try. All bandages should be sterilized by dry heat (300° F.) for one hour before they are used. APPLICATION OF ROLLER BANDAGES. The art of properly applying a roller bandage to the eye; so that it will protect and support the wound or pro- duce even pressure, as the case may be; so that it'will stay on; so that it will look neat; requires no little practice. The nurse should practice the single and double roller and the figure of 8 bandages, for one and for both eyes, many, many times on a healthy subject before trying to apply them on a patient. To apply the single roller bandage to one eye—for ex- ample, the right—the nurse, standing in front of the patient, holds the free end of the bandage on the middle of the fore- head with the thumb of the left hand, while she makes a complete turn round the head, going from right to left (pa- tient's) just above the ears, covering the free end as she brings the bandage across the forehead. The bandage is con- tinued half round the head again, but a little lower than on the first turn, so that it comes under the occiput and under the right ear and up over the right eye to the center of the 150 EYE NURSING. forehead, where it may be fastened with a safety pin and the remainder cut off. This is a very convenient bandage, as the end that comes up over the eye may be unpinned, the dressing removed, the eye examined and redressed, and the end brought up and again pinned (if unsoiled) without dis- turbing the patient even to move his head from the pillow Fig. 14.—Single Roller Bandage. (see Fig. 14). Where the left eye is to be bandaged, the free end of the bandage is held with the thumb of the left hand, but the bandage is carried from left to the right (pa- tient's) round the head, half round again and under the occiput, under the left ear, and up over the left eye to the center of the forehead and fastened with a safety pin. Where both eyes are to be covered with a single roller, instead of cutting off the bandage when one eye is covered, after the safety pin is fastened at the center of the forehead, the band- BANDAGES. 151 age is reversed and carried downward in front of the other eye and under the corresponding ear, under the occiput, and forward above the opposite ear to the center of the forehead. A second complete circular turn is taken around the head and the bandage fastened in front with a second safety pin (see Fig. 15). Fig. 15.—Double Roller Bandage. To apply the figure of 8 bandage to one eye (right eye), the free end of the bandage is held on the center of the fore- head with the left thumb and the bandage carried to the left (patient's), making one complete turn round the head just above the ears; the bandage is then continued round the head on a little lower level under the occiput and under the right ear up over the right eye to the forehead; a second circular turn of the bandage is taken round the head directly over the first circular turn; then a second diagonal turn is 152 EYE NURSING. made, the bandage being a little higher (l/2 inch) on the side of the head above the ear on the left side, slanting down under the occiput, coming forward under the right ear and up over the right eye, on a little lower level (1/2 inch) than the first lap, to the forehead. A third circular turn may be taken and also a third diagonal, this time being 1/2 inch higher on the left side of the head than the previous turn, Fig. 16.—Figure of Eight Bandage for one Eye. slanting down under the occiput under the right ear and 1/2 inch lower on the right eye than the former turn, to the forehead; then a fourth circular turn is taken to make the bandage entirely secure (see Fig. 16). Safety pins are used to fasten the bandage: one at the center of the forehead, one above the left ear, and one below the right ear. Only slight tension on the bandage should be used when the diagonal turns are made, but enough tension should be made on the BANDAGING. 153 circular turns to hold the bandage well in position. If the left eye is to be bandaged the bandage should be carried from left to right (patient's), or in the reverse direction to what was followed in bandaging the right eye. To apply a figure of 8 bandage to both eyes, a circular turn of the bandage above the ears as for a single eye is first made, then the first diagonal turn as for a single eye Fig. 17.—Figure of Eight Bandage for Both Eyes. (say, the right), then a second complete circular turn is made; then the roller should be carried down over the left eye, under the left ear, and up under the occiput, slanting upward above the right ear to the center of the forehead. A third circular turn is now made, then a second diagonal over the right eye, a fourth circular, a second diagonal over the left eye, and so on, the circular turns alternating with the diagonal ones (see Fig. 17). Safety pins are used to fasten 154 EYE NURSING. the bandage, at the center of the forehead and at each side of the head. If well applied, a single pin at the center of the forehead suffices to hold it on. SPECIAL BANDAGES. A number of special bandages for the eyes have been devised, the most useful of which are the "Moorfields," Stephenson's "dumb-bell," and von Alt's "strips." The Fig. 18.—Moorfields Bandage. Moorfields bandage (see Fig. 18) consists of a double fold of linen, rectangular in shape, 8 inches long by 3 inches wide, out of one edge of which a notch is cut so that the bandage will fit over the nose and eyes snugly. To each corner is sewed a tape; the tapes on each end are brought together so as to form a loop, leaving one free end of tape, however. When the bandage is in position the loops of tape fit over the ears, while the free ends are carried beneath the occiput behind and brought forward and tied over the fore- head. SPECIAL BANDAGES. 155 The Stephenson1 dumb-bell bandage, according to the author, "can be made in a few minutes from a piece of Saxony flannel or domette. As shown in the figure (Fig. 19), its shape resembles a dumb-bell, the handle of which passes over the nose, while the expanded ends fit over the eyes. This covering piece is fitted with two tapes, an inch in width, which are passed above the ears and round the head, to be tied together on the forehead." Fig. 19.—Stephenson's Dumb-bell Bandage. Von Alt's strips are really not bandages, but are used for the same purpose as the narrow strips of zinc oxid plaster to hold the dressings from slipping or becoming disarranged on the eye, while a bandage is placed over them just as over the adhesive strips. They consist of narrow strips of cheese cloth, 1 x/2 inches in width by 5 or 6 inches in length, which are placed diagonally over the eyes, from the right frontal eminence across the left eye to the left cheek, from the left frontal eminence across the right eye to the right cheek. 1 "Ophthalmic Nursing," second edition, page 111. 156 EYE NURSING. The ends are fastened to the face by means of adhesive plas- ter or zinc oxid plaster. These "strips" possess no special advantage over the simple narrow strips of zinc oxid plaster and are not so easily managed. In children and unruly patients, after the ordinary roller bandage is applied, a few turns of a moistened starched bandage applied over it, or a bandage soaked in a solution of silicate of potassium or soda (40 per cent.), known as "water glass," and wrung out, may be used. These harden when dry and effectually hold the dressings in position and also protect the eye. The tie-patch is made of an oval piece of brown paper, 3 by 2 inches, covered on each side with black silk. To each end a tape is sewed. This patch is very convenient for hold- ing temporary dressings (an eyepad) on the eye after re- moval of cinders from the eye or after slight injuries. Masks and Shields. Numerous masks or shields have been devised to place over the eye and dressings after operations upon the eye, where the anterior ch amber has been opened, as after ex- traction of cataract, to give greater security. The shield protects the eye from rubbing by the patient or accidental knocks, especially at night when the patient is half asleep and does not know just what he is about. Ring's'mask (Fig. 20) is the best of all the masks or shields with which I have had any experience. It is made of papier mache, about 8 inches long by 4 inches wide, is lined on the inside with white muslin and on the outside with black muslin. It is shaped to fit the average sized nose, and protuberances come forward in front of each eye so as to give space for dressings. At each corner tapes are sewn, longer on one end of the mask, so that they may be carried MASKS AND SHIELDS. 157 round the head one above and one below the ear and tied on one side of the head. If it is desirable for the patient to see with one eye, a piece can be cut out of the mask directly in front of that eye. Where no pressure or support is to be made on the eye, the eyepads may be held in position with the strips of zinc plaster, and this mask placed directly over these. It thus takes the place of a bandage, leaves the eyes cool, and gives security at the same time. This mask has Fig. 20.—Ring's Mask. many advantages: it is light, comfortable, cool, and cheap (costing but 25 cents), and is destroyed when soiled or the patient is well.1 McCoy's shield (Fig. 21) is made of wire in two cir- cular frames, held together by a loop and shaped somewhat like a rat-trap, the bases being about 3 inches across. It 1 They may be had of E. B. Meyrowitz, of this city. 158 EYE NURSING. can be made aseptic by boiling. It is applied over the eye dressings and held in position by means of tapes. Stephenson's wire gauze shield is made in three sizes; it is pliable, and can be molded to fit the face and dressings. Fig. 21.—McCoy's Shield. It takes the place of a bandage and is useful for protection in case of children or restless patients to prevent them from pulling off the dressings. It is held in position by means of tapes, which are attached to eyelets at the ends of the shield. It can be made aseptic by boiling. REDRESSINGS. 15