REMARKS ON THE NEED OF SEDA- tives, as morphine, codeine, bromide or TIVE TREATMENT IN OPHTHAL MIC SURGERY.1 BY JOHN HENRY OHLY, M. D., Asst. Ophth. Surg. Brooklyn Eye and Ear Hos- etc. On every operative ophthalmic case much care and time is spent upon the examination of the ocular lesion for which the patient seeks relief. The previous history is carefully noted as it might have an important bearing on our results and the methods employed. The present state of the condition is most carefully studied so that our technic may be correct for the individual case. If our operation is one of an intra ocular character, especially in cataract extractions, we are inclined to devote some time in training the patient to keep his ocular movements under control and not to shift the position of the eye in the various directions with undue force and especially to train the opening and closing of the lids so as not to squeeze excessively. When a general anesthetic is necessary the general physical condition as to heart, lung and urine is carefully examined. To all these conditions mentioned we devote much time, but how much time do we devote to the nervous condition of our patients and how much attention do we pay to this? Most text-books on ophthalmic surgery devote at the most a few lines to this subject, possibly stating that nervous. patients are generally benefited by seda 1A paper read before the Ophthalmological Section of the Med. Society of the County of Kings, Brooklyn, N. Y., Oct. 26, 1909. chloral. Probably in no branch of surgery is the thought of an operation more terrible to the average patient than in operations on the eye. As we do the majority of our work under local anesthesia the patient being aware that the operation is going on and the mortal terror of moving or twitching causes a severe strain upon his nervous energies. Then again he is in constant fear that he may at any moment feel some pain. These patients have been told, by kind friends, previous to operation, of the many cases that have lost their eyes because such patients did not hold still and this factor produces a distinct fear in each case. A patient knowing an operation to be impending is naturally rather excited and the majority of such cases sleep poorly and are very restless some days and nights before the same. This is especially true of the more intellectual class of people who seem to have a keener sense of appreciation as to the gravity of the procedure, and who as a rule are somewhat more nervously high strung than the less intellectual class. Also certain races are especially excitable as, for instance, the Hebrews and Italians. Again after an operation, where it is desirable to have the patient remain quietly on his back for 24 hours or longer, as is the case after cataract extraction, or where they are to be confined to their bed for a longer period, such patients become restless and especially so should they have any slight ache or pain in the operated part. Lying in one position often causes intense backache and the patients often will turn over and roll about, despite protest and warning. , 1910 , Vol. V., For a patient to lie quietly in bed with both eyes bandaged, as is usual after cataract extraction, for 24 to 48 hours and even longer, is quite an ordeal, and often it happens that such cases show signs of intense restlessness, raving and even dementia, which is generally relieved when the eyes are uncovered, this in itself shows the strain on the nervous system. To overcome these mentioned nervous manifestations I think it advisable, and in some cases essential, to give to our patients ready for ocular operations nerve sedatives and mild hypnotics so as to help them over these trying periods. With this in view I have given such treatment, especially to subjects for cataract operation. Nine out of ten of these cases are under a severe nervous strain even if they control themselves well in our presence, and in questioning the family or those about them we can get valuable information on this point. My results in general seemed most gratifying and although I could not know how these patients would have acted had they not had such treatment, they seemed more composed and calm compared to others who have not had nerve sedatives. No doubt the additional sleep obtained was most gratifying. Especially after intra ocular operations they seemed less uncomfortable and restless while in bed and possibly less conscious of pain and other annoyances, the intense backache was rarely complained of. Morphine and codeine are often used with good results, however, I feel these should only be used where the pain or restlessness is very great and when we know these drugs are well borne by the patient. These drugs often produce nausea and vomiting, and this by the cerebral congestion, restlessness and strain may do grave damage to the eye. There are also many cases where morphine produces great excitability and delirium. This happened in one of my recent cases of extraction producing a large iris prolapse despite a good large preliminary iredectomy. The bromides answer the purpose well, alone or in combination with chloral, or the valerinates may have the desired results. However, bromide often upsets the stomach and produces the characteristic rash which I have observed several times. Some of the mild newer preparations of bromide have helped me in many of these cases. My attention was called to a preparation well spoken of by several New York Ophthalmologists, which I tried repeatedly and have been satisfied with its action. Have given 5 grains of bromural (alphamonobrom-isovalery-urea) every 4 hours and ten grains at night 4 to 5 days before operation, especially in cases for intra ocular operation, and the day of the operation and a day following a little larger dose, continuing for a week. The drug is mild, there was no depression or any apparent drowsiness but the patients seemed more quiet and certainly sleep was more natural. The gastro-intestinal tract was never upset despite the somewhat disagreeable taste of the drug. The results were satisfactory inasmuch as the patients were benefited. In those cases where the milder preparations of bromide and valerian do not quiet. the patient and produce sleep I have found trional and veronal, given in 10-20 grs. doses repeated if necessary, to act well. It makes little difference what drug we use as long as we get the desired result, but some nerve sedative given a short time before ocular operation and after the same, certainly have their indication in many more cases then we have been accustomed to use them. 22 Schermerhon St., Brooklyn. THE URTICARIA OF INFANCY.1 BY UDO J. WILE, M. D., Chief of Clinic in Dermatology and Syphilis at the Beth Israel Hospital, New York. The subject about which I have elected to speak this evening has been chosen with a two fold purpose. First it seemed wise. that I should select a subject which should be of general interest, secondly because from the study of a large number of these cases I am about to describe, I am fully convinced that they belong to the realm of internal medicine or pediatrics rather than to that of dermatology. That the subject will prove of interest, I infer from my clinical experience at the Beth Israel Hospital Dispensary, where about 15% of the total number of cases treated during the past spring and summer have been cases of urticaria in infants. Such cases then must indeed be frequent in your practices. In order to make entirely clear the clinical picture of my essay, let me say that it goes under several different names in the dermatological literature. Bateman, the English clinician, to whom we are indebted for the first clear description of the disease, called the affection Lichen Urticatus; following him, Bayer and Biet described the condition as Lichen Strophulus; Hebra, the great Vinnese dermatologist, called it Urticaria Papulosa, indeed each of the earlier students of this disease, seems to have singled out a name for himself, and so in addition to the above mentioned names, we find this subject mentioned in the literature variously as Urticaria Chronica, Prurigo Infantum, Varicella Prurigo, Vaccinia Prurigo, Prurigo Simplex, etc., etc. Let me ask you at once to consider all these names as including one and the same clinical entity; the great 1 Read before Eastern Medical Society, Dec. 10, 1909. divergence in nomenclature being in part due to the different stages of the disease when studied, on the one hand, on the other, to the modifications of the clinical picture resulting from complicating factors. To Dr. T. Colcott Fox of London, we owe the really first clear logical classification of the subject; indeed after reading his admirable paper, it was with some hesitancy that I began this article, since there is little to be said on this subject which is unsaid in Dr. Fox's monograph. The urticaria of infants does not produce the same clinical picture as the urticaria of adults; Dr. Fox in fact, considers acute urticaria as seen in adults to be very rare in infants, and while it does occur perhaps even more frequently than he believes, nevertheless it is a thing quite apart in its clinical features from the disease under discussion. The urticaria of infants is essentially a chronic disease; it may occur alike in breast fed, or in artificially fed infants, in those poorly nourished, or in those apparently well nourished. In one hundred cases, I have seen it begin as early as the fifth week of life, as late as five years; by far the largest number of cases, however, occur during the first two years of life. Sex seems to be no determining factor, season, however, has a marked influence, for the disease is most frequently seen during the summer months. Heat and cold are important determining factors, exposure to either may cause a fresh outbreak of wheals in an already suffering infant, indeed often enough one can actually see the new lesions form, when the child is undressed for inspection. Men tion must also be made of vaccination even as a direct cause; the introduction of the vaccine in a few cases seems to be followed by an almost immediate explosion of urticarial lesions in a previously healthy , 1910 , Vol. V., child. Such cases, however, result obviously from the introduction into the system of toxic material from without, and in this, while clinically like the majority of cases they differ etiologically from them. Clinically, the urticaria of infants is characterized, first, by an intense pruritus, as evidenced by scratch marks, secondly, by loss of sleep and night crying, and thirdly, by a polymorphous eruption. The latter consists of wheals, deep seated papules, excoriated papules, vesicles and at times even bullae and pustules may be present. The extremities are more frequently attacked than the body, the face and head seldom. The soles and palms are very frequent sites of papules and bullae, but rarely of wheals. The wheals when first seen are quite different from those of ordinary acute urtiIcaria in adults. They are almost invariably surmounted by a central papule or a tiny vesicle; the wheal in subsiding leaves the papule in its place. This persists for weeks and even months and so is the chronicity of the the disease established. If seen early, the children may otherwise seem healthy looking and well nourished, indeed many seem especially so; later however, after many sleepless nights, the child becomes peevish, fretful, does not nourish well, the face becomes pasty, and a fair degree of emaciation may be present. If we analyze our cases in the hope of bringing to light the possible etiological factors of this disease, two points stand out as very suggestive: First, on close questioning, a very large percentage of the mothers of infants confessed to giving almost anything to the children to eat. It was not at all infrequent to hear of a child of one or two years being given meat, soup, pickles, coffee and tea, raw fruit, candy, and all kinds of food totally unsuited to such young digestive tracts. This is a very suggestive point but it does not explain the presence of the disease among the breast fed infants of whom there were many. I believe, however, the explanation here lies along exactly the same lines; in no such single instance could it be established that the child was fed at regular intervals of time, and what I believe is of greater import, is the fact that in practically all instances the diet of the mother was wholly unsuited to her nursing functions. From the study of the cases, I believe one can say definitely that the urticaria of infants is a vaso-motor disturbance of the skin, primarily the result of circulating toxins generated in the gastro-intestinal tract, and as I shall attempt to show later, this hypothesis is substantiated by the results of treatment tending to correct these evils. Granting the presence of an unbalanced vaso-motor system in an infant, it is easy to see how external influences such as bites of insects, fleas, bed bugs, or scabies, may be the inciting factors in causing an outbreak of urticaria in a child, the balance of whose vascular system is already upset by causes from within. Last, but not least in predisposing factors, let me mention the habit of swaddling the infant with a superabundance of clothes, particularly those made of coarse. wool. The child's body thus covered during the warm months is in a constant sweat, and the maintenance of an even body temperature so essential to the normal vascular balance, is manifestly under these conditions impossible. The clinical picture of the infant brought to us for urticaria is a very varied one. As a rule the patient's body is covered, with especial predilection for the extremities, much clothing in the children, especially in the summer; this point I believe to be of particular importance. Drugs are of minor importance; in most cases the removal of the cause removes the disease, yet there are a few suggestions which may be of help. The bowels should be kept open, and the stools rendered as neutral as possible. For this purpose the administration of the rhubarb and soda mixture in 1⁄2 to I drachm doses t. i. d. will be found useful. Where the vaso-motor upset is very marked, that is, in those cases characterized by numerous easily incited acute exacerbations, some vaso-motor tonic may be indicated, such as small doses of the tincture of jaborandi; in general, however, the balance is well restored when the exciting cause has been removed, and the vascular system, except in a few cases, is better not tampered with. Locally for the with erythematous patches, wheals with with central papules or vesicles resembling much the ordinary flea bite, with deep seated and scratched papules, perhaps with bullae and pustules, making a picture which is readily enough diagnosed. Yet at times this picture is so complicated, that it may be very difficult to determine the underlying cause of the eruption. The complications are almost without exception the result of scratching and subsequent infection, and SO may they obscure the original picture that it is frequently impossible to say, is the eruption the result of an urticaria or does it follow eczema, scabies or other insect bites. The secondary infections complicating urticaria. in infants, are impetigo and ecthyma, induced in every case by scratching. The condition and length of the finger nails is a suggestive factor here to be noted. Treatment. A brief word is in order itching, alkaline baths are to be recomas to therapeutic measures. In other disease should the axiom, treat the patient and not the disease, be observed more closely than in the urticaria of infancy. One is not dealing with the primary dermatological condition, but with the direct effect on the skin, of an intestinal disorder. The first thing therefore to be looked into, is the diet of the infants, not forgetting in the case of a nursing infant to probe carefully into the diet of the mother, and equally important, the regulation of the number and time of the feeding per diem. Too often the children are overnursed, and indeed many look overfed, too plump as it were. Secondly, in an infant suffering with urticaria insist on, as nearly as possible, an aseptic condition of the finger nails, and so avoid distressing suppurative complications; thirdly insist on on the avoidance of too no mended; the simplest being the addition of mine ap or In concluding, let me emphasize the necessity for perseverance in the treatment of this most obstinate and distressing affection of childhood. Let me urge again |