ON THE 
COMPARATIVE VALUE OF CAUSTICS AND ASTRINGENTS 
IN THE 
TREATMENT OF DISEASES OF THE CONJUNCTIVA, 
AND ON THE 
BEST MODE OF APPLYING THESE REMEDIES. 
BY 
HENRY W. WILLIAMS, A.M., M.D., 
PROFESSOR OF OPHTHALMOLOGY IN HARVARD UNIVERSITY. 
Extracted from the Transactions of the 
INTERNATIONAL MEDICAL CONGRESS, 
Philadelphia, September, 1876. 
PHILADELPHIA: 
1877. ON THE 
COMPARATIVE VALUE OF CAUSTICS AND ASTRINGENTS 
IN THE 
TREATMENT OF DISEASES OF THE CONJUNCTIVA, 
AND ON THE 
BEST MODE OF APPLYING THESE REMEDIES. 
BX. 
HENRY W. WILLIAMS, A.M., M.D., 
PROFESSOR OF OPHTHALMOLOGY IN HARVARD UNIVERSITY. 
Extracted from the Transactions of the 
INTERNATIONAL MEDICAL CONGRESS, 
Philadelphia, September, 1876. 
PHILADELPHIA: 
1877. PHILADELPHIA: 
COLLINS, PRINTER, 
705 Jayne Street. ON THE COMPARATIVE VALUE OF CAUSTICS AND ASTRIN- 
GENTS IN THE TREATMENT OF DISEASES OP THE 
CONJUNCTIVA, AND ON THE BEST MODE OP 
APPLYING THESE REMEDIES. 
The conjunctiva, one of the least in extent, but one of the most im- 
portant, of the mucous membranes, is the seat of affections singularly 
various in form and degree—from the simplest transient congestion to 
the most violent inflammatory processes and most persistent structural 
alterations. On the treatment of these depends, often, the preservation 
or the loss of the most important of our special senses, and the fairest 
prospects in life may be blighted by either mismanagement or neglect. 
In preparing the paper which I now offer to the Section on Ophthal- 
mology, I have avoided a recapitulation of every theory as to pathology 
and treatment, and offer simply a few practical suggestions, with no wish 
to unduly depreciate the value of other means and methods than those 
for which I express a preference. Skilful men will know how to use 
various instrumentalities to attain good results. Nevertheless, it is desi- 
rable, and important, to discriminate among the agencies at our com- 
mand, and to select such as practically prove best adapted to the cure, 
tuto, cito, etjucunde, of the diseases which wTe are considering. 
A considerable number of conjunctival affections require little or no 
treatment, and are injured rather than benefited by the use of other 
than the mildest remedies. The hypenemia caused by the presence of a 
foreign body subsides upon its removal; the injection depending on 
astigmatism, or other defects of refraction, disappears after the selection 
of suitable eye-glasses; the sub-conjunctival ecchymosis following a blow, 
or the rupture of a small bloodvessel, is re-absorbed, perhaps quite as 
rapidly, without our interference. If, in these cases, we prescribe a lotion 
or a collyrium, it should be quite unirritating. So also in traumatic 
injuries of a simple character, and after operations for strabismus or 
pterygium, the healing processes go on without assistance from applied 
remedies. Chemical injuries, because of their graver nature and the 
degree in which the cornea may be involved, oftener require our aid ; but 
even here, emollients and sedatives rather than active stimulants are 
most useful. 
With the above-named exceptions, and apart from certain complica- 
tions hereafter to be considered, diseases of the conjunctiva may be 
divided into two classes requiring essentially different management. The 
first includes a comparatively simple, limited, and benign, though some- 
times chronic, affection ; the second embraces several conditions of gene- 
ral and often severe conjunctival inflammation. The prominent feature 
of the first class is the development of small elevations or papulse, one or 4 
H. W. WILLIAMS, 
several in number, usually situated at or near the border of the cornea, 
though they may form elsewhere on the ocular conjunctiva. The sum- 
mits of these may be whitish, as if containing a minute quantity of pus; 
more frequently they are red; and they may vary in size, but are commonly 
about that of a hemp-seed. Usually a fasciculus of vessels runs to each of 
these papulae ; but there is no general injection of the conjunctiva, except 
as far as may be the result of friction of the papulae against the inner sur- 
face of the lid. Children are the most frequent subjects of this disease. 
The tendency of this affection is towards a disappearance of the symp- 
toms at the end of a few days, even when no treatment is employed. 
Therefore, no active remedies of caustic or astringent nature are needed, 
and they tend to delay rather than hasten the recovery. Calomel or other 
insufflations are similarly useless. All annoying remedies are moreover 
objectionable on account of the age of the majority of the patients. Simple 
lotions, cold or tepid, with water, or milk and water, may be used. Two 
or three times a day, a few drops of a solution of ten grains of borax in 
an ounce of water, or of camphor water, may be dropped into the eye 
from a teaspoon or a drop-tube. This usually proves a soothing and 
refreshing collyrium, grateful rather than painful to the patient, and 
appears to have a sufficiently astringent and stimulating effect to pro- 
mote absorption of the papulae. Although the ordinary duration of these 
small pimples rarely exceeds ten days, it is not uncommon, whatever 
treatment has been employed, to find successive crops of them, at inter- 
vals of a week or two. This disposition seems to be best obviated by 
continuing the use of the borax collyrium, once or twice a day, for some 
time after recovery, so as to modify the condition of the conjunctiva. 
"Where the papulae are slow in disappearing, the application of a crayon 
of alum, once in a day or two, to the inner surface of the lower lid, is 
often useful and is nearly painless. The astringent reaches the affected 
spot as the lid returns to its place, and seems sometimes to excite a more 
rapid resolution. The papulae themselves should never be directly touched 
with caustic or astringent crayons or solutions. 
Very rarely, the disease takes a more chronic form, the papulae being 
as large or larger than a split pea, and sometimes umbilicated at the 
centre". Though persisting longer, and for a time intractable to treatment, 
the prognosis is always favorable. Tonic general remedies, and some- 
times change of air, are useful adjuvants to the mild local applications. 
Solutions of atropia have of late been too much in vogue in the treatment 
of this form of disease. Though far less dangerous than the strong caus- 
tic remedies which were formerly indiscriminately employed, yet an 
unnecessary resort to them has grave disadvantages. In cases of corneal 
ulceration the}r may be of much service, in lessening the irritability and 
photophobia; whilst in these less serious conjunctival affections their 
action upon the pupil does but increase the intolerance of light, and, 
by exciting strong contractions of the lids, creates a disposition to cor- 
neal ulceration as an effect of friction. 
The second class of conjunctival affections comprises catarrhal con- 
junctivitis in its acute and chronic forms, trachoma, purulent and 
gonorrhoeal conjunctivitis, ophthalmia of new-born children, and diph- 
theritic conjunctivitis; each of which conditions has an importance 
claiming distinct consideration. 
When the conjunctiva becomes affected from exposure to cold, dust, 
or other simple causes of irritation, the first symptom is injection with 
an increased ffovv of tears—soon followed by a velvety thickening of the DISEASES OF CONJUNCTIVA. 
palpebral conjunctiva and a slight mucous secretion. These phenomena 
may occur so suddenly that the patient feels sure that something has 
been blown into his eye ; but the scarlet, velvety appearance of the lining 
of the lids, as distinguished from the mere vascular hypersemia excited 
by the presence of a foreign body, renders the differential diagnosis suffi- 
ciently easy. At this stage, caustics and strong astringents are alike to 
be avoided, or used with great reserve. Frequent bathing with cold or 
tepid water according to the sensations of the patient, with applications, 
four or five times a day, of a few drops of a solution of ten grains of 
borax in an ounce of camphor-water, or of five grains of alum or one grain 
of sulphate of zinc in an ounce of water or rose-water, will generally cut 
short even a sharp attack and remove the symptoms within three or four 
days. Occasionally this form of conjunctivitis is epidemic, large numbers 
of persons being attacked within a short time. Similar, with perhaps 
somewhat more active, means, are here called for; one or two touches 
inside the upper lid with a crayon of alum, or, very rarely, a single light 
touch with a crayon of sulphate of copper, acting as useful auxiliaries in 
arresting the symptoms in an early stage. If neglected or if too actively 
treated, the thickened conjunctiva assumes a more or less granulated 
aspect, and a chronic phase of disease is established which requires more 
active measures. The lining of the lids, especially the upper, from 
hypertrophy of the conjunctival follicles, now resembles in appearance 
the surface of a raspberry, and the sub-conjunctival tissues become so 
infiltrated that the lid-movements are difficult. The secretions are 
greatly augmented, causing abundant flow in the daytime, and aggluti- 
nation of the lids at night. Here, as in another affection next to be 
described, the mild remedies, sufficient for the lesser degrees of inflamma- 
tion, are of little avail. Caustics or astringents, of considerable potency, 
seem to be our only resource. 
Trachoma differs widely, pathologically,from catarrhal conjunctivitis, 
though often coexistent with and complicating it. It consists essen- 
tially in a neo-plastic formation ; at first in small, oval-shaped, semi-trans- 
parent masses, resembling grains of tapioca; and sometimes increasing 
until the conjunctiva, with its subjacent textures, is largely transformed 
into a dense, nearly structureless mass, which, as recovery takes place, 
is not replaced by normal tissue, but is followed by contraction of the 
conjunctiva and incurvation of the tarsal cartilage.* Here, the prognosis 
is less favorable, the recovery slower, and the danger of secondary lesions 
of the cornea much greater than in the catarrhal form of conjunctivitis. 
But the local treatment of the two affections has much similarity, and 
may be either caustic or astringent, or both. 
of silver is the caustic most relied on in the treatment of con- 
junctival affections, though other means have from time to time been 
tested and enjoyed ephemeral reputation. The methods of using it, and 
the means employed to limit its effects, vary with different ophthalmolo- 
gists. The crayon of pure nitrate and the nearly saturated solution, 
formerly much used, are now rarely employed, but have given place to 
the lapis mitigatus, as it is termed, in which one part of nitrate of silver 
and two parts of nitrate of potassium—or two parts of silver and one of 
potassium—are fused together; or to solutions of nitrate of silver of 
from ten to forty or more grains to an ounce of water. The caustic is 
applied, in most cases, to the surface of the everted, upper lid, more or less 
lightly or extensively, the stick of lapis mitigatus being preferred by 
some, the solution of nitrate of silver by other authorities. When 6 
H. W. WILLIAMS, 
thought advisable, the action of these substances is limited by the imme- 
diate application of a neutralizing solution of salt and water, or pure 
water, or both of these, to the cauterized surface. The frequency of the 
repetition also varies greatly, in the practice of different individuals: 
once, twice, or thrice a week, daily, or oftener, according to the intensity 
of the symptoms or the preferences of the practitioner. Moreover, some 
rely wholly on this means; others employ auxiliary treatment. Theories 
as to therapeutic effect also vary with different observers, some seeking 
to destroy the apices of the granulations, while others, deprecating such 
an effect, use the caustic with more reserve, and, virtually, as a strong 
stimulant only. 
In the class of astringents employed as topical applications by the 
physician himself, may be named, crayons of sulphate of copper ; the lapis 
divinus, composed of equal parts of sulphate of copper, alum, and nitrate 
of potassium moulded into sticks ; crayons of alum ; and strong solutions 
of tannin in glycerine. Of these, the crayon of sulphate of copper forms 
the best type; as combining the several qualities of convenience, effi- 
ciency, and safety. The alum crayon has an excellent effect in mild 
forms of conjunctivitis, but is inefficient in the severer and chronic affec- 
tions. The lapis divinus seems less reliable than the crayon of pure 
sulphate of copper. Tannin and other vegetable astringents, from which 
theoretically we should expect so much, have always proved, in my 
hands, in whatever proportion or combination, inferior to the mineral 
astringents; whether as a means of energetic action upon the conjunc- 
tiva, or as used in collyria to produce milder continuous effects. 
The sulphate of copper cannot be fused in moulds, like nitrate of silver 
and lapis divinus, but the crayons have to be shaped from crystals of 
the substance. Unfortunately, these are generally much broken at the 
laboratories in packing for the market, but if good crystals can be found 
it-is easy to cut from them crayons of convenient size. The harder parts 
of the crystal, free from pores or water of crystallization, are to be chosen. 
Nothing would be needed to obtain ample supplies of the crystals, or of 
crayons already shaped from them, but the knowledge that there was a 
demand for them, as they are easily made from crystals obtainable at the 
laboratories, and they require no care in keeping, being little changed 
by exposure to air or light. A single crayon lasts a long time, and may 
be used, like a silver probe or a bistoury, for successive cases, care being 
of course taken to wipe the crayon after every application. The crayon 
of sulphate of copper should be applied, as a rule, rather lightly to the 
conjunctiva of the everted upper lid; this lid, in which the circulation 
is more readily congested, being usually more diseased than the lower 
lid. It is rarely necessary to touch both lids, as a portion of the remedy, 
dissolved by the moist surface over which it is passed, is carried by the 
movements of the lids to every part of the conjunctiva. In sluggish 
cases the crayon may be applied more heavily, or may be more frequently 
repeated. 
Used as above described, the crayon of sulphate of copper does not act 
on the conjunctiva as a caustic, but only as an energetic astringent and 
stimulant. In the more acute cases, the pain, after the first or even after 
several applications, may continue for some time; though it is much less 
severe and enduring than when caustic has been used. Bathing the eye 
with water shortens and mitigates the smarting. AVhile the pain is 
much prolonged, the crayon should be used lightly and perhaps less 
frequently than after the eye has become more tolerant of the remedy. DISEASES OF CONJUNCTIVA. 
7 
The touch may then be harder, and may be repeated daily or less often, 
according to the judgment of the physician. When the crayon is well 
borne, cases often improve the more rapidly according to the greater 
frequency of its application; this being especially observed in many 
chronic cases, trachomatous, and other. 
That many cases of muco-pnrnlent or trachomatous forms of conjunc- 
tivitis may be successfully treated with nitrate of silver, pure or combined, 
does not admit of a doubt. Its action requires to be carefully watched, 
and good judgment must be exercised in determining the frequency and 
severity of its application, and‘in neutralizing at once any excess of the 
caustic. More benefit is obtained from its moderate than from its too 
free use. Care must also be taken not to continue it too long, as not 
infrequent instances have occurred in which the conjunctiva has acquired 
an indelible, olive stain, or even become quite black, from the prolonged 
instillation of a moderately strong solution. If employed, caustics should 
not be solely relied on, but should be supplemented by other milder 
remedies of stimulating or astringent nature, which may be more or less 
frequently applied by the patient or his friends. 
The use of caustic as an application to the eye is not without its 
dangers. Its active properties render it a destructive agent in unskilful 
hands; and it sometimes disappoints even the most experienced oculist. 
*The application of the crayon of sulphate of copper involves no such 
consequences as are inseparable from the use of nitrate of silver. If it 
happens to be injudiciously employed, no special harm is done and no 
immediately destructive effects ensue from its use. It is, therefore, a far 
safer agent in inexperienced hands. 
It remains to consider whether the general results of treatment will 
be more successful under the one or the other plan. 
My own experience, which has included careful personal observation of 
the practice of nearly eveiy European oculist who has had celebrity 
within the last thirty years, has satisfied me that better and quicker 
results, with far less danger and suffering, are obtainable from the use 
of astringents than from the use of caustics. Many years since, I made 
comparative tests of the value of these two classes of remedies in severe and 
chronic forms of conjunctivitis, on a large number of patients. Selecting 
cases where both eyes were equally diseased, I treated all the right eyes 
with nitrate of silver, and all the left eyes with sulphate of copper. Of 
course, no differences of constitution could influence the effect produced, as 
might, perhaps, have been alleged had merely a certain number of patients 
been chosen for each mode of treatment and the same remedy used in 
both their eyes. The uniform result was a more rapid gain in the eyes 
treated with the crayon of sulphate of copper. Some of the eyes treated 
with nitrate of silver went on tolerably well, though slowly; but others 
did so badly that, after vain attempts to succeed by varying the strength 
of the caustic applications, I was at last compelled, in order to avert 
threatened loss of the eyes, to substitute the use of the sulphate of 
copper, under which they recovered. In no instance ivas it necessary to 
abandon the sulphate of copper and resort to another remedy. 
A very important adjuvant to treatment, either by caustics or astrin- 
gents, as applied by the physician himself, consists in combining with 
these the more or less frequent use, at home, of a milder astringent or 
stimulating collyrium. Of these, the mineral seem to be superior to the 
vegetable astringents, as also to the purely stimulating class of collyria, 
such, for instance, as those containing wine of opium or corrosive subli- 8 
H. W. WILLIAMS, 
mate. Many substances have been employed with more or less advan- 
tage. Among those most in use may be mentioned solutions of nitrate 
of silver, sulphate of zinc, acetate of zinc, sulphate of copper, sulphate of 
cadmium, alum, and borax. Of these, the sulphate of zinc seems by far 
the best for the forms of conjunctivitis which we are considering, as it 
appears to have a more astringent with less irritant action than either 
of the other remedies. The silver, copper, and cadmium solutions, are too 
actively stimulating, with less of astringent effect; the alum and borax 
are too mild. The sulphate of zinc solutions may vary from half a- grain 
to four grains to the ounce of water or rose-water ; and a few drops may 
be poured into the eye from a teaspoon, a drop tube, or otherwise, two, 
three, or four times a day. In cold wmather the spoon may first be 
dipped into hot water for a moment, so as to wTarm the collyrium, if the 
eye is sensitive as to the temperature of the drops. I have found the 
sensations of the patient a useful guide in determining the strength of 
collyrium likely to be of most benefit to him. If a solution of a given 
strength, say of two or of three grains to the ounce, causes smarting for 
more than five minutes, it should be diluted one-half, or until it no 
longer gives more than a few minutes’ pain. Thus graduated, the colly- 
rium should be used often enough to keep up a moderate remedial influ- 
ence. 
Acetate of lead, in substance or solution, formerly much in favor even” 
with the profession, and still in common popular use, should never be 
put into the eye. It has no special remedial value to warrant its em- 
ployment; and whenever the conjunctivitis is, or becomes, complicated 
with corneal ulceration, great harm is done; the acetate being decom- 
posed, and an indelible deposit formed on the ulcerated surface, causing 
permanent opacity of the cornea. It is therefore better to erase it from 
the list of ophthalmic remedies. 
More actively virulent forms of conjunctivitis are found under the 
designations of purulent conjunctivitis, gonorrhoeal conjunctivitis, and 
the conjunctivitis of new-born children. Purulent conjunctivitis, some- 
times termed Egyptian Ophthalmia or Ophthalmia of Armies, is marked 
by far more rapid sequence and violence of symptoms than the catarrhal 
or trachomatous affections. In pauper asylums, schools, and barracks, 
it may speedily extend to a large number of persons by direct infection 
of healthy eyes with the purulent discharge from those which are dis- 
eased. This is largely conveyed through the promiscuous use, in such 
institutions, of articles of toilet, wash-basins, towels, etc.; and is some- 
times purposely introduced ; the fearful risk of blindness being incurred 
for the sake of avoiding military.or other duty, or of obtaining some 
hospital privilege. Enormous tumefaction of the conjunctiva and of the 
entire lid, and copious muco-purulent discharge, characterize this dis- 
ease. Serous or even phlegmonous chemosis of the subconjunctival 
cellular tissue often forms a dangerous complication, interfering with 
the proper nutrition of the cornea ; and ulceration of that structure may 
result from the direct pressure of the swollen lid, or from the continued 
maceration in the copious purulent secretion. 
Gonorrhoeal conjunctivitis is even more intense in its symptoms and 
rapid in its course. Caused by infection with gonorrhoeal matter or with 
the discharge from an already diseased eye, it is more common in men 
than in females, the fingers being often the medium for conveying the 
urethral discharge to the eye. One eye only is usually affected at the 
outset. The frequency of phlegmonous chemosis, and consequent danger 9 
to the cornea, is greater than in the simple purulent affection. So rapid 
is the course of the disease, that an eye may be lost by sloughing of the 
cornea within twenty-four hours from the moment of infection. 
Active cauterization of these forms of conjunctivitis, especially the 
gonorrhoeal, was formerly practised as an abortive treatment, in the hope 
of substituting a less dangerous traumatic inflammation for the specific 
infection. This idea has been generally abandoned, and the modern 
treatment is in all respects milder. As general means, tonics, instead of 
copious depletion, are in favor; and, as regards local treatment, great im- 
portance is to be attached to the frequent use of mild detergents, injected 
beneath the swollen lids, to remove the abundant purulent secretion. If 
caustics are used, the applications should be neither too strong nor too 
frequent, and should be at once neutralized—as otherwise they tend to 
increase the phlegmonous chemosis and perhaps destroy the cornea. They 
should not be continued if corneal ulceration has begun. If the crayon of 
sulphate of copper is applied at all during the active stages of the disease, 
it should be lightly used; but it is most serviceable in removing the 
granulations which remain after the active symptoms are abated. The 
application of cold compresses, constantly renewed, to the lids; frequent 
removal of the fast accumulating secretions; and the keeping up an influ- 
ence on the diseased conjunctiva by means of mild astringent collyria, 
appear to form the most reliable treatment. Solutions of five grains of 
alum or ten grains of borax to an ounce of water may be injected several 
times a day, and a solution of half a grain to two grains of sulphate of 
zinc may be used three or four times in twenty-four hours. The appli- 
cation of a crayon of alum to the inside of the lid, once or twice a day, 
is sometimes of great apparent benefit, and is safely and easily applied 
as an auxiliary to the astringent solutions. It is nearly painless, and 
has little stimulating action as compared with its astringent qualities. 
It should be used by introducing it beneath the lid without everting it. 
If the case is seen early, these means are generally effectual; but unfor- 
tunately the vitality of the cornea is in many instances already destroyed 
when the patient first applies for advice, and the prognosis is then un- 
favorable. 
DISEASES OF CONJUNCTIVA. 
Ho disease of the eye imposes greater responsibilities upon the general 
practitioner than ophthalmia neonatorum, the conjunctivitis of new-born 
children. Occurring within a few days after birth, under circumstances 
which, in a large proportion of cases, preclude a consultation with any 
practitioner of special experience, the preservation or loss of sight must 
depend on the skill of the family physician. A slight conjunctival injec- 
tion and tumefaction, with some mucous discharge, is not uncommon in 
infants, and yields to simple means of cleanliness. But true ophthalmia 
neonatorum, preceded perhaps only by a slight reddish hue along the 
skin of the upper lid, becomes within a few hours an intense inflammation. 
The lids are tumefied, livid, sometimes projecting much beyond the 
supra-orbital ridge, or even completely everted from the enormous swell- 
ing of the conjunctiva. The chemotic infiltration of the cellular tissue 
beneath the ocular conjunctiva often causes this to overlap the cornea or 
even to hide it. The secretion is exceedingly abundant. This disease is 
one of the most destructive, but happily also one of the most manageable, 
of the affections of the eye. If neglected, or if treated with inert domestic 
remedies such as injection of breast milk, or with more harmful means 
such as the application of poultices, the result is too frequently the loss 
of one or both eyes. Equally baneful consequences follow the use of 10 
H. W. WILLIAMS, 
harsh measures. The great danger attending the use of caustics, in any 
form, or of very strong astringents, and the needlessness of resorting to them, 
cannot be too strongly insisted on. The symptoms invariably yield to a 
mild treatment, if reasonably begun and faithfully carried out. If, as is 
sometimes the case, the cornea has already become more or less cloudy 
before the attention of the physician is called to the eyes, this furnishes 
an additional reason for refraining from strong caustic or astringent 
remedies, which are never well borne when the cornea has become in- 
volved. 
The first indication is to insure the utmost attention to cleanliness. 
The copious, muco-purulent secretion should be washed from the eyes 
every two hours, every hour, or even every half hour if necessary. 
Should the great tumefaction of the lids prevent their being readily 
opened so as to permit free discharge of the pus, the nozzle of a small 
syringe should be passed beneath the swollen upper lid, and an injection 
thrown in to completely wash out the conjunctival cavity. For this 
purpose tepid water may be used in the milder cases ; in those of more 
severity a solution of alum, five grains to the ounce, may be alternated 
with the injections of water. These injections should be repeated hourly 
or oftener, according to the severity of the case, during the day, and two 
or three times during the night. They are nearly painless, and the 
nurse or mother should be taught how to make them. In a few days 
the discharge lessens and the swelling of the lids diminishes; but the 
treatment must be kept up, though with less frequency. The physician 
should not fail to assure himself, by daily inspection, as to whether the 
cornea retains its normal appearances ; and where the swollen condition 
of the lid prevents a view of the cornea, an elevator should be carefully 
used to draw up the lid. If the cornea is seen to be even slightly cloudy 
at its centre, a drop of a solution of sulphate of atropia, two grains to an 
ounce of water, should be put into the eye twice daily, to lessen the 
danger of hernia of the iris in case corneal ulceration and perforation 
should occur. This haziness and ulceration may come on very early in 
the disease, as a result of the continuous pressure of the lid upon the 
cornea, or as the effect of its constant immersion in the purulent secre- 
tion ; but this threatening condition may also supervene at a later stage, 
and after marked amelioration of the active symptoms ; so that the phy- 
sician, unless on his guard, may lose the battle in the moment of ap- 
parent victory. 
The use of the nitrate of silver or of lapis mitigatus, is still recom- 
mended by some of 'the continental European oculists ; but the milder 
plan above described has been, for many years, almost exclusively in use 
at the ophthalmic hospitals of London, and especially at the Moorfields 
Royal London Ophthalmic Hospital, probably the largest institution 
in the world for the treatment of eye-diseases, and certainly the most 
distinguished for the celebrity of its medical staff. In my own experi- 
ence, success has always attended the mild plan of treatment; and I 
have seen so many examples of the destructive consequences of harsher 
methods, that I cannot Regard them otherwise than as unnecessary and 
injudicious. 
Two classes of complications of conjunctivitis are worthy of our atten- 
tion, in their relations to the questions of remedial action which we are 
considering. In one of these classes the conjunctivitis results from other 
morbid processes; in the other class the morbid conditions are the con- 
sequence of pre-existing conjunctivitis. In the ffrst class, including 11 
DISEASES OF CONJUNCTIVA. 
cases where conjunctivitis appears as a symptom in keratitis, iritis, or in 
other inflammations of the interior structures of the eye, the conjunctival 
injection is not to be regarded as a disease, and its treatment, if any, 
must be subordinate to or modified by that of its primary exciting cause, 
the removal of which often suffices for the cure of the secondary con- 
junctival symptoms. In most of these conditions the use of caustics and 
astringents is contra-indicated. Instead of relieving, they excite yet 
further congestion of the external membrane, and increase rather than 
lessen the deeper seated inflammation. Tepid, unirritating lotions, and 
collyria containing a few grains of borax, may be used as sedatives, if 
the patient finds them agreeable. Active use of either caustics or astrin- 
gents is also to be avoided in conjunctivitis accompanying corneal 
ulceration, or the presence of papules on the epithelial layer of the cornea, 
in children; as also, especially, in ulcerations of the cornea in adults, 
occasioned by debility, in old age, or as a sequela of smallpox or other 
depressing disease. 
The second class of complications embraces those conditions resulting 
from conjunctivitis, usually from its chronic duration, as seen for instance 
in paunus and secondary keratitis. Here, the attention must primarily 
be directed to the removal of the original disease, by such remedies as 
have been already indicated ; but we must be careful vto make such modi- 
fications of treatment as may be required by the secondary symptoms or 
structural changes, while we avoid the error of regarding these as the 
essential morbid conditions and directing our treatment solely to them. 
For example, in the affection styled pannus, where the epithelial layer of 
the cornea has become so thickened and vascular as to resemble a piece 
of red flannel, it is useless to attempt to remove this vascularity by divi- 
sion Or scarification of the vessels. The abnormal condition of the exter- 
nal layer of the cornea is the result of constant friction by trachomatous 
or other granulation of the lids, and is to be cured through the removal 
of these by the patient use of astringents. After the friction has ceased 
to irritate the corneal surface, the injection and cloudiness gradually fade 
away. If ulcerative or exudative processes have begun in the cornea 
itself, caustics are not admissible, but the use of atropia should be com- 
bined with the astringent remedies, the continuance of which in modera- 
tion is necessary for the removal of the granulations. A certain degree 
of vascularity is essential to the absorption of the cloudy transformations, 
and disappears as these fade away. 
Some other more exceptional complications should be briefly referred 
to. When chronic conjunctivitis accompanies obstruction of the lachry- 
mal passages, mild astringent collyria may be combined with the appro- 
priate means for the removal of this obstruction. When it is coincident 
with disease of the Meibomian glands or ciliary bulbs, these collyria may 
be used in connection with diluted citrine ointment, or other suitable, 
topical applications, along the edges of the lids. When it appears during 
an attack of herpes zoster ophthalmicus, or ensues after paralysis of the 
orbicularis, caustics are scrupulously to be avoided as being likely to pro- 
mote ulceration of the cornea, to which, in these circumstances, there is 
always a predisposition; only the mildest astringents should be used. 
In chronic thickening of the conjunctiva and eversion of the lids in old 
people, commonly called “ blear eyes,” attention should be given to the 
lachrymal passages, and the everted lid should be brought to its place by 
a frequent but mild use of astringents, patiently followed up. These 
should not be applied, nor should caustics be used, upon the everted and 12 
H. W. WILLIAMS, DISEASES OF CONJUNCTIVA, 
dry portion of the conjunctiva, as they only serve to harden, and, as it 
were, tan the surface; but the crayon of sulphate of copper or of alum 
should be applied, very lightly, to the non-everted portion of the con- 
junctiva. As this part becomes more healthy, the everted lid is drawn 
more and more to its proper place, the remedy can be applied more 
largely, and the improvement finally extends to the whole of the affected 
tissue. 
The conclusions which seem to be warranted by the facts presented in 
the foregoing paper, may be summed up as follows: 
I. In a considerable number of essentially transient affections of the 
conjunctiva, and in pterygium or other growths, no active treatment by 
caustics or astringents is required. 
11. When disease affects only a limited portion of the conjunctiva, as 
in phlyctenular inflammation, the mildest stimulating or astringent 
remedies are usually sufficient. 
111. In the acute and chronic forms of general conjunctivitis, astrin- 
gents are, as a rule, safer as well as more efficacious than caustics, and are, 
therefore, better adapted to the requirements of the general practitioner.