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126 marked, greyish-yellow concentric crescent, about one- sixth of an inch in length, midway between the centre and the outer margin. 0 I did not hesitate to pronounce the case to be one of genuine primary diphtheritic ophthalmia, and I, not un- willing, accepted the opportunity of putting to the test a plan of treatment that had some years before suggested itself to me as suitable in such cases. The treatment that had been previously prescribed was at once countermanded, and a lotion was ordered containing three grains of sulphate of quinine with a minimum quantity of diluted sulphuric acid to the ounce. Although the mother was informed that there was too much reason to fear that the eyes were lost, she was enjoined to keep compresses, well saturated with the lotion, constantly applied over the eyelids, and to wash out the conjunctival sacs freely at least every two hours with the lotion. These instructions were carried out with praiseworthy assiduity and zeal, and at the end of forty-eight hours the eyes were not only not worse, but appreciably better, the improvement being more noticeable on the left side. On the 22nd the lids were neither so hard nor so hot, and they were less swollen. The cornese were recovering their trans- lucency and smoothness, and the false membranes on the conjunctivse were considerably reduced both in extent and in depth. Three days later the conjunctivse were almost wholly free from false membrane; both cornese were clear and transparent, and no trace of the crescentic patch on the right cornea could be discovered, even with a strong magni- fying glass. The palpebral conjunctivas had again become red, vascular, and spongy. They had not, however, the ordinary villous appearance, but were coarsely wormeaten. The discharge was once more thick and purulent. The compresses were omitted, but the lotion was continued every three hours. On the 3rd of March a weak alum lotion was ordered to be used three times a day, in addition to occasional applica- tions of the quinine lotion. A week later there was scarcely any discharge, and the wormeaten irregularities of the con- junctivse were disappearing, and some of them were closing by very fine cicatrices. About the middle of the month of March the quinine and alum lotions were replaced by a weak perchloride of mercury lotion, one-tenth of a grain to an ounce, which was to be used twice a day. The child was seen at intervals of two or three weeks until the beginning of May. When last seen there was no discharge ; the corneae were bright, clear, and perfectly transparent; the palpebral conjunctival were smooth, but presented a delicate network of minute cicatricial bands. All treatment was stopped, and the case dismissed cured. There can, I think, be no reasonable doubt that the case was identical with those described by Graefe3 and others under the name of diphtheritic conjunctivitis. The three classical stages were well marked both as regards sequence and intensity. In addition to the early purulent stage, which may or may not have been essential, there were the exudative or pseudo-membraneous stage, the exfoliative and suppurative stage, and, lastly, the stage of cicatrisation. This peculiar sequence of phenomena separates the case from membranous conjunctivitis, which is, as I have already stated, merely a complication of ordinary purulent oph- thalmia. Indeed, the two diseases seem to me as dis- similar in their anatomical and pathological nature as in their clinical aspects. In the membranous form there is a greyish pellicle on the surface of the conjunctiva, whereas in the diphtheritic the pseudo-membrane is embedded, some- times deeply, in the substance of the mucous membrane. The pellicle in the membranous form may without much diffi- culty be stripped off entire, or in large shreds, exposing a red, spongy surface, which readily bleeds; but the pseudo- membrane of the diphtheritic form can neither be rubbed nor stripped off; at best it may be picked off in tiny bits with forceps, and then the underlying tissue is usually pale, and does not yield fluid blood. Again, the pellicular membrane involves only the epithelium of the conjunctiva, and does not effect any permanent change in the structure of the mucous membrane, whereas the exudation of diphtheria produces molecular disintegration of the parenchyma, which can only be repaired by cicatrisation. These anatomical differences are, I believe, constant. There is yet another i 3 Deutsche Klinik, 1853, No. 35 ; and Arch. fiir Ophthalmologie, Bd. i., Abt. i., p. 168 (Berlin, 1854); a translation of the latter ap- peared in Archiv. Belges de Medecine Militaire, t. xvii., p. 32; and in the London Medical Review for 1860. " particular in which the two diseases are unlike, and that if . is in their behaviour to treatment. Those who have had most experience in treating unequivocal cases of diphtbe- , ritic ophthalmia agree that caustics do harm, and that nitrate of silver especially, which generally agrees with membranous conjunctivitis is prejudicial in the genuine disease. (To be continued.) RINGWORM (OF THE HEAD): DIAGNOSIS AND TREATMENT. BY ALDER SMITH, M.B. LOND., F.R.C.S., RESIDENT MEDICAL OFFICER AT CHRIST’S HOSPITAL, LONDON. (Continued from p. 55.) The treatment of chronic ringworm.-There are some cases which no ordinary remedies, even under skilful hands, will cure. The treatment of these I now pass on to describe; as well as the treatment of those cases in which the dis. ease has been attended to until the hair has grown again, and then neglected for months, or even years (because it was supposed to be well), until some special reason has brought it under the notice of an expert. Here the difficulty is not to find some parasiticide that will destroy the ringworm fungus, but to bring the remedy into contact with it. In recent ringworm the conidia only penetrate a certain distance into the follicles, and therefore the disease is easily cured by almost any remedy; but after a time they _penetrate to the very bottom of the follicles, which it must be remembered are even below the true skin, and into the roots of the hairs. Therefore it is impossible to reach the fungus by any ordinary remedy applied to the surface of the scalp. Again, the stumps are so diseased that they cannot be extracted by epilation, but always break and leave the root part swarming with the fungus down to its very base (vide diagram, p. 53). One must therefore select a remedy that will penetrate deeply into the follicles, and Mr. Marshall’s preparation of oleate of mercury is certainly the best for this purpose, combined afterwards, if necessary, with the treatment I will call the artificial production of kerion. " I have seen oleate of mercury cure the most inveterate cases that have existed for many years, and on which all sorts of other remedies had been tried in vain. It does not cause much pain-very often none; and although I have used it most extensively for years, I have never seen even slight salivation caused except once, and that was in a child of four years of age. It is prepared as a thick solution in oleic acid, and sold as a 10 per cent. and 5 per cent. solution. I use the 5 per cent. for children under eight years of age, and the 10 per cent. to those over that age, if the skin will bear it without much irritation. It is advisable to have acetic ether mixed with it in the proportion of one part of ether to seven parts of oleate. This increases the penetrating power. The mixture must be kept in a stoppered bottle. The treatment is commenced by having the hair cut short, about a half to one inch long. The head should then be thoroughly washed with soft soap and water, and when dry the oleate should be rubbed well into the entire scalp, if the disease be at all extensive, with a small sponge mop. This must be done regularly, especially into any patches, night after night, and again in the morning into any well-marked diseased places. The caps before described should be worn at night, special care being taken that the oleate does not run on to the face or pillow-case, as it will produce much irri- tation, and even a rash. It is advisable to apply a thin towel, like a turban, round the head, as well as the cap, to prevent any oleate getting on to the face. It is most important that the head should not be washed more than once a fortnight. If water be constantly used, it tends to prevent the oleate from soaking to the bottom of the hair-follicles, which is so essential to the success of this remedy. Therefore, while the case is under treatment, which may be from three to six months, wash well every fortnight, cutting the hair again if necessary, removing all the scabs and yellow incrustations with the point of a pair 4 Wecker and Landolt : Traité complet d’Ophthalmologie, tom. i., p. 335. 1879.
