iiltbical QBffitcrs nf grlgunls fi ssuriatiun .

SCHOOL OPHTHALMIA .

A P AP ER R EAD B EFO R E T H E AS S O C IAT I O N

O n Febr u a r y 25th , 1897 .

S ! D N E ! S T E P H E N S O N,

O P HTH A L M I C S UR G EON TO TH E NOR TH EA STER N H O S P ITA L FO R C H I LDR EN ;S U RG EON TO TH E OP HTHA L M IC S C H O OL

,H A N ‘VE L L

,W .

l

/ S i éy z.

ILLUSTRATED WITH M ICRO - PHOTOGRAPHS .

P u blis hed by O rder qf the A s s ovin l io -

n,

H . A LD I Z R S M IT H .

110 11 . S nc s( 3 . E . SH EL L ! .

1 0110011

! . A . CHURCH ILL , 7 , GREAT M A R L B O R O UGH STREET .

1897 .

R E M

5 9 3

I L L U S T R A T I O NS .

1 . GONOCOCC I O F PURULENT OPHTHALM IA . (COVER

GLASS PREPARATION .) x

2 . DIPHTHERIA B ACILLI FROM CUL TIVATION O N

SERUM . x 1,000.

O C C I FROM CULTIVATION O R UM .

001 . x

6. Z ER O S I S B ACILLI . x 1,000.

G ONOCOCCI x 1000 .

From a c a se o f puru len t oph tha lm i a : x3 th day o f d iseas e . C oxer -

gla s sprepa ra t ion ma de from d isc ha rge from eye . (C a s e

B ACILLUS DIPHTHER I/E x 1000 .

C over - gl a s s prepa ra t ion from c u l t u re on b lo od - serum in o c u la te i

ea sed c on j un c t iva .

\! ERK’S B A CILLI x 1000 .

C ou r - gla s s prepa ra t ion from di>c ha rge from a c onj un c t iva “ i t h a c u te muc opu ru len t oph tha lm i a : t s t day o f d lsea se . (C a se

T R A C H O M A C O C C I x 1000.

O b ta ined from a c u l tiva t ion u pon b lood - s e rum, whic h had been in oc u la ted

from m a te ria l squeezed from a c onj un c t iva w i t h tra c hom a . Sta in ed by G ram ’

s

me thod .

I ’N I‘Z UM O C O C C I x 1000 .

A c o ver - g la s s prepa ra t io n from disd mrge from in flam ed eye . (C a xn

Z ICR O S IS B A C H L I x 1000 .

A C o ve r- gla ze s impres s io n ma de from c o n iu n c tiva w i t h epi the l ia l zen -s ix

S ta in ed by G ram'

s me t hod . (C a se

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6 S C HOOL OPHT HALM IA .

must needs be d islocated . In the poorer school s,

particularly the parochial , th e eff ects are even more serious .There l arge sums of money may have to be expendedbefore the pest can be stamped ou t ; the education of

a ffected ch ildren may be brought to a standstil l for manymonths together ; sight may be damaged ; and , last butnot l east , the victims of the epidemic may be handicappedby the disease for years after they have passed into the

‘

outside world . Their economic value is in th is wayreduced

,while there is the ever - present risk that they may

communicate their ma lady to those about them .

'

Thequestion of ophthalmia and its prevention in parochialschool s

,therefore , involves interests of the widest poss ible

kind . So important , indeed , i s the matter now deemed bythe Local Government Board that they h ave directed aninquiry into the state as regards ophthalmia of every P oorL aw ch ild in London , as a first step towards some plan forrooting ou t the evil .So far I have spoken of “ Ophthalmia in a broad and

general sen se as meaning any inflammation of th econ j unct iva . In the pres ent paper I propose deal ing withacute aff ection s of that membrane only

, a s being mostl ikely to fall under the notice of Members of thi sAssociat ion . From a practica l point of view it i s necessaryto di stinguish carefully between the various specificai lments , a t least three in number , included under acuteOphthalmia . Some o f these aff ect ions a re of li ttle moment ,whereas others are exactly the reverse . But they are a lldistingui shed by on e feature— namely , the power of

becoming epidemic under certa in condit ions of which wecannot as yet speak w i th scientific exactitude . For

convenience o f descr iption , they may be classified asfol lows

(1 ) Purulent Ophthalmia .

(2 ) Muco - purulent Ophthalmia .

(3 ) Acute Trachoma .

A brief account may next be given of the lead ing featureso f each o f thes e three forms o f acute inflammation of th econjunctiva .

S C HOOL OPHT HALM IA . 7

( l ) P u ru len t O phtha lmia .

— This formidable a ilment wasonce common enough in the large school s o f this country .

For in stance,S ir P atrick M a cGregor

l h a s given a graphicaccount o f an outbreak that occurred in the early part ofthis c entury at the C helsea M il itary A sy lum ,

wherechildren were lodged . In November

,1809 , about 2 40

patients were under treatment , and we are told that th eepidemic res isted all remedia l measures until s ix month slater , when the whole of the children s n fi er in g fromophthalmia we re removed to a detached hospital at somedistance . From that time the disorder gradually decreased

,

so that a few months la ter five case s only remained undertrea tment . C hrist ’s Hospita l , again , su fi

'

er ed severelyabout the same t ime , and a n interest ing account of thefacts has been given by L loyd , 2 the th en surgeon to theschool . Sir Thoma s Watson , in his c la s s ical Lectures

,

speaks o f Purulent Ophthalmia having broken out in alarge school in ! orkshire , with the result tha t b lindnessof on e or both eyes , or other seriou s consequences , followedin nearly twenty case s . One o f the bes t recorded ou t

breaks of comparatively recent t imes was that at theHanwell School in 1862 . The late Sir Will iam Bowman ,

wh o was cal led in by the managing body of the inst itution ,

divided the cases into fou r groups of varying inten sity ,and spoke of there being 800 chi ldren with the worst type ,i . e .

, with Purulent Ophthalmia . He found that severa l ofthe younger lads had lost on e or both eyes .O f l ate l itt le has been hea rd of purulent ophtha lmia

e ith er in Parochial or in P rivate School s,so that it may be

asser ted wi th almost absolute certainty tha t it i s now a s

r are under the Poor Law a s elsewhere . There is l ittle ,however , to prevent it from again becoming epidemic insome of the se institut ions i f rigid precautions be n ot

enforced to keep it from gaining an entry .

Purulent Ophthalmia. i s always due to infection of theconj unc tiva by a particular micro - organi sm , th e gonococcus .which may be demonst rated w ith the microscope both inth e discha rges from th e eye and al so in exc ised fragments

‘3 Fo r l is t o f Referen c es , s ee page 2 3 , p 08 !

8 S C HOOL OPHT HALM IA.

of mucous membran e . Its signs a n d symptoms are ofsuch a nature that they cannot b e over looked . Thedisease makes its appearance , as a rule , with in three daysafter the eye has been infected . Stiffness of the l id sand pain

,photophobia and lacrymation , are constantly

present,and bear a direct r elationsh ip to th e intensity o f

the virus . T h e l ids are glossy , red , and shining , and inmarked cases so much swol len that the patien t is altogether unable to open his eye . The di scharge , at firstthin and whey - l ike

,when fully establ i shed may run from

the eye in great quantity i t has an alkaline reaction,and

exactly resembles pus,such as that of an ordinary abscess .

The palpebral conj unctiva , when it can be exposed fo rexamination , i s found to be swollen , rough , of crimsonlake hue , and arranged in fold s that Spring forward a s

soon as the l id s are everted . The inner surfa ce of theupper l id i s not infrequently Shaggy enough to recal l thepile of red velvet , wh il e the retro - tarsal folds are ladenwith p u s . Slight haemorrhage s from the conj unct ivareadily occur , even when the parts are handled withthe utmost gentleness . The ocular con j unctiva i soften gr eatly swol len

,so that it may overlap the cornea on

every side or even protrude from between th e tumifi ed l ids,

and appear upon the cheek as a reddi sh , semi - transparentmass . The cornea suff ers in c ertain ly on e - third of thecases

,the commonest condition being on e of marginal

ulceration , which comes on early , spreads rapidly, andperhaps leads to perforat ion of th e membrane and loss o f

the eye . These corneal lesion s are thought to be due todirect invasion by the spec ific organisms

,which gain

a dmission to th e s troma. through a Spot from which theprotecting epithelial investment has been detached . However thi s may be , I have more than once succeeded incultiva ting ordinary pyococc i from scrapings taken fromthe ulcers . Then , the swollen l id s and conj unct iva havesomething to do with the re sult

,possibly by mechanically

interfering with the nutrit ion o f the cornea . M y own

exper ience teaches me that corneal compl ications arel ikely to occur in proportion to the amount of chemosis

,

S C H O O L OPHTHALMIA . 9

although that obs ervation , perhaps , means that both swel

l ing of the conj unct iva and corneal ulceration stand inrelation to the number an d potency of the spec ificorganisms . L a stly , the preauricular glands are enlargedand tender ; and synoviti s of the larger joint s has been metwith .

It wil l be perceived from this sl ight sketch that P urulentO p

-h th a lmia is a serious complain t , exceedingly dangerousa s

'

r ega rd s sight . Wh ile thi s i s undoubtedly the case, on e

must be prepared to r ecogn is e the fact that great ind ividualdifferences are met with . In newly - born children

,for

in stance , the s tres s falls upon the palpebral conj un ctiva ,and injuries to sight are relatively rare , espec ial ly whenth e case i s treated ea rly ; in o lder subj ects , on th e otherh and , chemosis i s great, pain i s a promine n t feature , andthe cornea suff ers in perhaps one half of those affe c ted .

Between individual s of much the same age,somewhat

s imilar d ifferences are to be observed , and these must beexplained in one of two ways , namely , (1 ) by vari ationsin the virulence of the d isease - germs

,or (2 ) by idiosyn

c r a sy on th e part of th e pati ent .A marked ca se of Purulent Ophthalmia cannot be mis

taken , but on e o f milder type might be confounded withmuco -

p uru lent con j un c tiviti s o f unusual severity , althoughit would n everthe les s be capabl e of communicating to asecond person a form of Ophthalmia that might end inloss o f s ight . Fortunately there i s an unfailing test asto the nature of th e disease , v iz th e bacteriological on e .

This is so s imple that there can be no excuse for n eglectin git. A clean cover - glass (No . 1 ) i s smeared with a l ittle pustaken from the conj unct ival sac , and , after allowing thepreparation to dry , i t i s passed two or three times over aspirit flame or Bunsen lamp . If the specimen appea rsunduly thick it may be floated for a few minute s in a strong

(15 per cent. ) sol ut ion of acetic acid , which i s afterwards tobe careful ly wa shed away by means of dis ti lled water . Thenext step is to pour a few drops of almos t any anil in e basicdye over the cover - glass , and , after waiting five minutes

,

to wash the spec imen once more with distil led water .

10 S C H OOL OPHTHALMIA .

The stain that,in my exper ience , gives the best al l round

result i s L offi er '

s alkal ine methylene blue , ! but Ki’

ih n e’

s

carbol ic methyl blue , ! or methyl or gentian violet (1 percent . ) answer admirably . The last step i s to dry thep reparation

,and to mount it in xylol - balsam . E xamina

tion with a 112inch oil immersion lens and Abbé con

denser will show that the germs of Pu rulent Ophthalmiaare usua lly arranged in pairs — that is to say

,in d iplo

coccus form . They l ie s ingly or in groups either free in thed ischarge

,or (much more commonly ) with in the protoplasm

of the polynucleated leucocytes that go to make up themas s o f the specimen ; the lat ter arrangement must beregarded a s character istic . If any doubt be stil l enterta in ed as to th e exact na ture o f th e organisms , recou rsemay be h ad to Gram

’s methodf" with or wi thout cou nter

stain ing by means o f c os in e . It would l ie beyond mypresent purpose to describe the detail s of this well - knowndifferentia l process ; I wil l merely s ay that

,while

ordinary pus cocc i retain the gen tian violet when thustreated

,gonococc i become decolor is ed . A gl ance at th e

prepara tions sho wn this afte rn oon w .ll do more than pagesof mere verbal descrip tion to render the subj ect intell igibl e .

I t i s impossible to leave th e question w ithout sayingsomething w ith regard to negative bacteriological result s .It i s obvious that gen o c oc c i may not be found w ith them icro s cope , and yet the case may b e one of PurulentOphthalmia This failu re may be expla in e l in s everalw a r s . Thus . the organisms are likely to be so s canty ata t an early stage of disease that the ir existence may beoverlooked

,a thing easy enough to do , as wi l l b e

acknowledged by everybod v who h a s worked w ith highpowers o f the micro scope . Again

,the prepa rat ion may

h ave been overheated , when ba c illi are apt to stain w ithdi ffi culty or not at al l ; o r

,l as tly

,there may be some other

fa ult in the method o f investigat ion . We may conclude ,therefore

,that the d iscovery of gonococci j ustifi es the

diagnosis o f Purulent O ph thalmi a ,apart from other s ign s

S ee A ppen d ix , pa ge 2 1 , pos t.

S C H OOL OPHTHALMIA . 1 1

an d symptoms that may be presented by the case . Onthe other hand

,a failure to find th ese organisms cannot

be acc epted as excluding the existence o f the dis ease . Inorder to avoid error

,i t i s advisable to make repeated exam

in a tion s of the discharge , unti l the presence or absence ofspecific germs i s rendered reasonably ce rtain . T o sum u pi f the discharge from an eye with acute conj unctiviti s befound to contain diplococci in the protoplasm of theleucoc yte s , and if those organi sms stain with the ordinaryaniline dye s and are decolori sed by Gram ’s method

,the

surgeon need fee l no hesitat ion in making a diagnosi s of

P u rulent O phthalmia . Otherwi se , I should recommendh im n ot to commit h imself to a definite opinion on e wayor the other .

(2 ) A c u te M a c e -

pu ru len t O ph tha lmia .

— Acute catarrhalOphthalmia

, or muco - pu rulent co nj unctiviti s , is on e of th ecommonest eye diseases met with in this country . It s contagiou sn es s and epidemic tendency endow it with considerable practical importa nce , e specially to those in charge o f

schoo ls . Its symptoms , no les s than its treatment , areknown to every practitioner of medicine , but there aren everthele ss , poin ts in both that wil l repay further study .

In good - clas s English school s it would seem that outbreaksof ophthalm ia practically always belong to this type of

disease , although we may hope for expressions of Op inionfr om M embers of the As soc iation upon this point . Thea ilment is certainly far from uncommon in Poor L awschool s , even when the latte r happen to be of good construct ion and under excellent man agement , both lay andmedical . The malady does l it tle harm , but its signs n ow

and then appear most formidable,especially to one not

accustomed to the affect ion . It seldom damages sight , atl east in y oung persons

,and n ever leaves any trouble some

s equ el s beh ind , except in the presence of a super - addedcontagion , as for inst ance , that of trachom a .

This d i sea se must be regarded as due to a specifi cmicro - organism . This fact was fir st po inted out by Koch ,

3

who, during a visit to Egypt in 1 88 3 ,

examined bacterio3 For l is t o f Re feren c e s

,s ee page 2 3 , pos t

12 S C H OOL OPHTHALMIA .

l ogical ly s ome fi fty cases of the ophthalmia that prevail sepidemical ly in that country . He found two microbesin th e eye discharges— the on e assoc iated with severe

,and

the other with mild,symptoms of the disease . The former

appeared to be identical with Ne isser’ s gonococcus

,while

th e la tter he described as a very smal l bacil lus . In 1886

! ohn E . Weeks , of New ! ork , publi shed a carefu l memoir4

upon the subj ect . He claimed that small,wel l - defi n ed

bacill i were always present in the secretion of catarrhalophtha lmia , and he succeeded in setting up the di s easewhen the specific pus was implanted o n the human con

j u n c tiv a . He failed to obtain a pure culture o f the organism,

as he found a small , club - shaped bacillus in al l h is pre

pa r a tion s . In s ix in stances inoculat ion with the mixedgrowth gave ris e to a cute inflammation of the conj unct ivath e c lubbed b a c il lus was proved to possess no pathogenicpropert ies . In the fo l low ing year Ka rtu lis

5 described thesame organ ism in ca se s of E gyptian Ophthalmia . Out ofs ix inocula tions of the human eye that ob server set u p

the d isease twic e .

M orax 6 ( 18 94 ) concluded from h is investigations thatthe smal l bacillus wa s constantly present in th is form of

ophthalmia . Al though inoculat ion o f a pure culturefailed to produ ce any apprec iable result in animal s , yet itsucceeded upon his own eye . Somewhat later Mr . H . E .

! uler 7 mentioned the fact that he h a d come acros s th esame organism in many , but not in all , cases o f catarrha lO phthalmia .

Weeks 8 h a s l ately (1895 ) reviewed th e state of ou r

knowledge concerning th is microbe . From the examinationof between one and two thousand cases of acute contagiouscon j unctivi tis

,he i s enabled to affi rm that the bacil lus in

question i s con stantly to be found in the secretion . Duringlas t ye ar Morax a n d Beach 9 publ i shed a ful l account of

t he ir experiments w ith this micro - organism , which theymanaged to cult ivate upon agar - agar , with or without theaddition of human blood serum . These a uthor s expressthe definite opinion that acute catarrhal oph thalmia

4 5 6 7 3 9 For l ist o f Referen c e , s ee page 23 , pos t.

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14 S C H O O L OPHTHALMIA .

In severe catarrhal ophthalmia the short bacill i occur ingreat numbers after the lapse of the first day ; I haveseen cases of th is sort where scarcely a leucocyte in th eSpec imen was free from one or more organisms . In mildtypes of disease , on the other hand , they may be so scantythat a careful search has to be made to find a S ingle one .

Here , as elsewhere , negative resu lts possess merely anegative value , and do not exclude the existence of a sl ightor commencing catarrhal Ophthalmia . The pathogenicorganisms become progressively fewer and fewer with s u b

s iden c e o f the disease , but , in my exper i ence , persist tos ome extent so long as di scharge i s g iven off by the con

j u n c tiva .

There are two types of acute conj u nctivitis in which Ihave found the short baci llus

(a ) C lass ical catarrhal ophthalmia . th e leading featureso f which are great and rapid infect ivity , profuse yel lowishwhite discharge

,more o r l es s oedema of the l ids , and a

bloodshot eyeball, wi th o r without h aemorrha gic patches .

The bacill i appear to be constantly present in th is , thecommonest , type o f disease .

(b) A variety in which foll icular enlargement i s superadded to th e signs of acute or s u b - acute inflammation .

The small growths that mark the cond ition occur chieflyupon the lower l ids , are round or oval , disposed in one ormore rows

,and better ma rked towards the outer canthus .

The upper lids , as a rule , show l itt le change , being merelycongested or s lightly roughened by t iny elevations . Theoutbreak recently recorded by M r . S imeon Snell11 ashavin g occurred in a good - class school at ! ork was almostc ertainly o f th is kind . So far as my experience goe s , it isth e most commo n type of a cute O phthalmia met with inwell - mana ged school s o f the upper and middle class . Itsmain interest to us th is afternoon li es in the l ikelihood of

i ts bein g mistaken for the far more serious condit ion ,

Trachoma, to which we may next turn .

(3 ) A c u te T r a c h vc n a x This formidable affection , s o

far a s I kn ow,i s nowaday s met with on ly in crowded Poor

For l ist o f Referen c es,see page 28 , pos t.

S C HOOL OPHTHALMIA . 1 5

Law schools and other places of that kind , b u t even thereit i s by no means common . It i s distinguished by it spowers o f rapid spread under bad sanitary conditions , as ,for instance , overc rowding , imperfect vent ilation , andn eglect of isolat ion . A bove all it is cha racteri sed by thefact that it always en tail s a chronic disease of thepalpebral conj unct iva

,which has received the singularly

unfortunate name of G ranular L ids . Although thereare many points abo u t th is aff ection that sti ll remainobscure , we may , I th ink , take i t a s certain that it arise sin one way

,and in one only

,namely

,by contagion . As to

it s specific c on tagiam,there i s c ons iderable confl ict of

opinion . Many organisms have been described , but itcannot yet be asserted with certainty which of th em is thecau se o f the di sease . For my own part , I have somereason for believing that the diplococci shown u nder themicro scope thi s afternoon may be the causal agents .At al l event s these organisms may general ly be demons tr a ted in sections cut from diseased conj unct iva ; theymay , furthermore , be obtained , although not in everyinstance , by inoculat ing tubes of blood - serumwith materialsqueezed from the mucous membra ne of an eye affectedwith chron ic Trachoma . They range from O

‘

6,u to 1 ‘ O

,u

in diameter,stain with methy lene blue

,& c .

,&c .

, and don ot lo se their colour when the preparation is treatedby Gram

’s method . Whether they be the actual c ause ornot

,there can be n o reasonable doubt that Trachoma is

d u e to some kind of micro - organ ism .

The symptoms of Acute Trachoma present a widediversity . T h e affection , as a rule , i s b ilateral , but it i squite common for one eye to be attacked 3 to 10 days beforeth e other , in which case the first generally suff ers morethan the second . This may probably be explained on theas sumption that the virus has undergone some alterat ion

before passing from on e eye to the other .

In severe instances inflammatory symptoms are somarked as almost to suggest that one i s d eal ing w ithP u rulent O phthalmia . There are two points

,howeve r ,

the one negative and th e other positive,bv which Acute

1 6 S C H OOL OPHT HALMIA .

Trachoma may be recogn ised : fi rst,the absence o f the

gonococcus in the discharge from the eye ; second ly , th estate o f the palpebral conjunct iva

,which presents many

deeply congested r idges a n d depress ions,over which are

scatt ered numerous opaque , reddi sh - grey trachoma grainsor bodies . U lc erations of the cornea are now and thenmet with , but it i s to be n oted that extens ive lesions ,such as are Common in Purulent O phthalmia

,are the

except ion in Acute Trachoma . The preauricular glandsare n early always swollen and tender .

The violent inflammatory symptoms soon subside . Thed is charge grows smal ler and smaller , a n d a t the same timechanges its character from a pus - l ike fluid to on e that is

more or less gleety . Within a month or so from the beginning of the attack external s ign s wil l h ave di sappeared

,

except a sl ight d ropping o f the upper l ids,a n d what i s

commonly described as a weak look about the eyes . O n

evert ing the l ids , however , the conj unctiva will be foundextensively disea sed . It wil l b e markedly reddened andth ickened , fold upon fold springing into prominence whenthe lower l id is pulled down . It w il l be studded by numerou s sage - grains , wh ich bleed rapidly

,and often by red ,

punctate spots upon th e tarsa l conjunct iva of the upper lid .

The superior cul - de - s a c wil l be fil l ed with semi - tran sparentfolds o f infil tra t ed membrane that can usually be broughtinto Vi ew by directing the pat ient to look down while hisupper l id is raised by the surgeon ’s finger . This is the cond ition known nowadays as Trachoma

,a dise ase that in it s

chron ic form has proved the bane and curse of certainPoor Law schools , where it has remained endemic for years .We have next to enquire whether epidemic forms of

ophthalmia a re ever a s so : ia ted with microbes other thanthe three already mentioned . Th i s question mu st now bean swered in the affirmative . A xenfeld ! in 1896 described

! For th e s ak e o f h istoric a l a c c u ra c y it sh ou l d b e n oted th a t Mora x( T hese d c P a r is , 1894 , p . 88 ) wa s th e fi rs t to dra w a tten tion to c a s es o f

a c u te c on ju n c tivi t i s d u e to pn eumo c o c c i . H e reported fou r mi l din s ta n c es in c h i ld ren u n der th ree yea rs o f age . Pa rin a u d a n d G a spa rin i ,to o , h a ve re c o rded examples . Axen fe l d

,h owever , wa s th e fi rs t to des c ribe

a n yth in g approa c h in g a n ou tbreak o f th is pn eumo c o c c u s - oph th a lmia .

S C HOOL OPHTHALM IA . 1 7

an outbreak 12o f acute Ophthalmia, that had aff ected

twenty - fi ve ou t of the n inety - four inmate s of a school .

Pus from the eyes was found in every instance to contain

th e pneumococcus — a h organism , i t n eed scarcely beremarked

,now acknowledged to be the commonest cause

of croupous pneumonia and o f some of i ts compli cation s ,as pleu r is v and pericarditis . The a ff ection , in Axenfeld

’

sexperience

, wa s nearly always b ilateral , and theinflammation completely subsided with in e ight days .

He succeeded in cultivating th e organism , but failed to

s et up any reaction by applying a pure culture to hi s own

eye . A xenfeld maintains the propri ety of di stinguishinga pneumococcus - ophthalmia , sinc e in al l h is cases thesame c lin ical appearances coincided with the sameorganism . Grifz

'

for d ,1 3 in an exc ellen tpaper , h a s s ince then

gone ful ly into the question . He has been abl e to examinesome forty cases— samples , so to speak, of several d istinctou tbreaks that have taken plac e durin g th e last eight yearsin Omaha and the distr ict . The pneumococcus was foun din all save four patients , while it s cau sa l rela tion wasproved b v inoculating th e human con j unctiva with purecultures . The ophthalmia it sel f pre sented n o appearancessuffi ciently dist inct ive to al low one to separate it off - handfrom ordinary catarrhal ophtha lmia , u n les s it were thefrequent ex i stence upon the conjunct iva of a thin pell icle offibrin that could be easily wiped aw ay . G ifford noted c a s e sin adults as wel l a s in chi ldren .

Speak ing for myself , I am familiar with sporadic cases o fmild inflammation o f th e con j unctiva in the discharge fromwhich pneumococci may be found . The disease i s general lyb ilateral , and , s o fa r , I have obse rved it only in ch i ldren ,

although I should n ot be inclined to lay much s tres s uponthe latter fact , as I see many more children than adults .

The symptoms a re generally mild,but n ow and then sl ight

chemosi s and a few s u b - conj unctival haemorrhages arepre sent , together with a fair amount of muco - purulent di scharge . The palpebral conjunctiva is covered by a del ica tegrey ish fi lm of coagulated secretion

,usually makin g its

'3 For l is t o f Referen c es,see pa ge 2 3 . P 03 t~

1 8 S C HOOL OPHTHALMIA .

appearance from on e to s ix days after the first sign of ih

fi amma tion h a s been noticed . C orneal compl ic ations areextremely ra re , a n d th e ailment , as a rule , is soon over .There yet rema in s on e other form . With in the la st few

months G elpke“ has had a n opportunity of inve s tigat ing a

w ide—sprea d inflammation o f the eyes th a t p reva i l ed as anepidemic in two sma l l vil lages near C arlsruhe . It affectedschool children in the first instance

,and later grown—u p

people . It commenced w ith feverishness,lass itude

,and

headache - a group of symptoms speedily followed by photophobia

,swell ing o f th e lids

,a n d an abundant secretion o f

pus from the eyes . The oedemato u s palpebral conj unctivawas folded

,fol licular

, of purple hue , and fi ec ked over withmany small h aemorrhages ; the bulbar conjunctiva wa s

chemotic . It i s n ot surprising that th i s severe maladyo ften entailed corn eal comp l ications . Gelpke succeeded in

cultivating an organism from the con j unctival secretion .

This he described as a bacil lus,w ith pointed ends , a veraging

1p. in length . It could be stained by the usual dyes , a n dalso by G ram ’s method . It contained highly refract ingspores , and presented the unusual feature of being dividedinto two pa rts by a l ighter zone . This microbe appears tore semble in certain respects the s o - ca lled Z eros is bacillusor spiril lum , which i s associa ted w ith some forms of nightblindness . Gelpke , however , bel ieves the two to be different ,a n d preposes to name the on e described by h im B .

S epta tu s .

A few words o f rec api tulation . Outbreak s of a cuteOphthalmia ! may be associated with the fol lowing diseas egerms

(1 ) Gonococc i .

(2 ) W'

eek ’s bacill i .

(3 ) Pneumococci .

(4 ) T r a c h oma c oc c i .

(5 ) Ba c illus S epta tu s .

‘4 For l is t o f Referen c es,see page 23 , post .

T h e foregoin g l is t in c lu des on ly su c h mi c rob es a s a re khown to b epres en t in th e va riou s forms o f epidemic oph th a lmia . T h e c on j u n c tiva ,

h owever, may re a c t to s ome o th er orga n isms, pa rtic u la rly th e K leb s

L effi er ba c i l l i,S ta phyloc o c c i a n d S i r eptoc c c c i Pyogen es .

S C HOOL OPHTHALM IA . 19

The evidence i s conclu sive in respect of the two microparasites n amed first ; fairly convincing as regards th epneumococc u s ; whil e as to the others , the chain of proofcannot yet be regarded as a ltogether complete . It mayfall to th e lot of s ome M ember o f T he M ed ic a l Ofi c er s ofS c hools A s soc ia tion to supplement and perfect our know

ledge o f th e latter microbes .

I wou ld urge that the forms of acute Ophthalmia des

c r ibed in the foregoing pages diff er not so much in degreeas in kind . They are , in my opinion , Spec ific ailments ,due to distinct and sepa rate causes . If this fact be n ot

fully recog n i sed and acted upon,the ri sks of multip le

infection will be ever - present . T o mix in on e sleeping ward

M uco - purulent Ophthalmia and Acute Trachoma wo ii ld

be to commit a blunder o f no small magnitude . Thelesson to be drawn from the increased etiological knowledgenow at ou r disposal i s to sort ou t ou r eye cases with thesame care that would be observed in deal ing with suchdifferent disorders as d iphtheria , small - pox , scarlet fever ,and measle s . In truth , a detail ed cla ssification of theacute oph th a lmiae would seem to form a first step towardstheir rational treatment .The term Ophth almia lies open to s everal obj ection s .

It is vague and elastic , and connotes many different th ings .Then , there is the odium that attaches to the name in thepublic mind , so that on th is account alone the medicalofficers of important school s may well shrink from printingtheir experiences , no matter how valuable . ! et i t i salmost imposs ible to over estimate the usefulness of suchrecords , especially when attention has been paid todiagnosi s and to cause . Indeed , th e time appears tobe now ripe for repl acing the old designat ions withothers more in keeping with the state of presentknowledge . Thus , we might altogether drop the termspurulent , ma ce - purulent , &c . , & c . , &c and speak of

acute con j unct ivitis as due to gonococci,to Week ’ s

bacill i , to pneumococci , and so forth . This plan wouldhave the obvious advantage o f ensuring uniformi ty inou r descriptions of d isease , and thereby allow exact

20 Sw ee t. O PHTHALM IA .

conclusions to be drawn from the publish ed records ofoutbreaks .A part from quest ions of nomenclature

, a s practicalsurgeons we must , I th ink , admit that even in wellmanaged school s outbreaks o f acute Ophthalmia wil l nowand then occur . When these ep idemics belong to th eM uco - purulent type they are really o f no great moment ,although often alarmin g enough to a casual observer .That disorder brings about no after - consequences , andif clas s ification be rigorously carried ou t, can never lead toTrachoma . So far as we

'

kn ow, th is form o f conj unctiviti sdoes not arise apart from contagion , but for all that it i soften diff i cult , or impossible , to trace ou t the origin o f

first cases . It spreads rapidly , a n d may affect'

a h ost o fch ildren unl ess prompt steps be taken . It must be metby r igid i solation and other measures into which I have nopresent intention of entering . So much for the in flammation due to Week ’s bac illus

,and possibly , al so , to the

pneumococcus . With regard to the forms of ophthalmiaassociated with gonococci and tr a c h oma c oc c i, however,the case is very different . Those disorder s

,as we have

seen,give ri se to grave immediate or remote results ,

and their recurrence in epidemic form must be regarded ass o many evidences of bad management or lax medi caladministrat ion .

In conclusion , l et me insist upon the necess ity ofa n accurate d iagnosi s of any form of epidemic ophthalmia .

To do that with even tolerabl e c ertainty the surgeon mustneeds resort to bacteriol ogy. The methods of investi

ga tion are n ot diffi cult : th e making o f cover - glas spreparations generally suffi ce s for the end in view,

andcultivation tests a re n ot essential , at al l event s in thosetypes of acute ophthalmia that are l ikely to be common lymet with in schools .

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5 . KA RT UL I S .

B EA -C H .

R EFER ENC E S .

T ra n s . o f a S oc iety f or the improvemen t o f M edic a l

an d C h iru rgic a l Kn owledge . L on don , 1812 .

A T rea tise on S c roph u la . L on don , 1821 .

Wien er M ed . Woc h en s c h rift . Dec . 29,1883 .

A rc h ives o f O ph th a lmology. 1886. No . 4, p . 44 1 .

C en tra lbl . f u r B ak . u n d P aras iten k . 1887 . p . 289 .

R ec h erch es ba c té r . su r l’

étio logie d es c o n jon c tivites

A iqu'

é s . P a ris , 1894 .

B rit. M ed . ! ou rn a l . S ept. 15 , 1894.

New ! ork Eye a n d Ea r I n fi rma ry R eports

! a n . 1895 . p . 24 .

!A rc h ives of O ph th a lmo logy . ! a n . , 1896 . p . 54 .

10. S T EP H ENSO N. Epidemi c O ph tha lmia . 1895 . (! ou n g ! . P en tland,

11. S NE L L .

12 . A XB NFE L I ) .

13 . G IFFO R I ) .

l -f . O s L P K i-z.

L ondon Edin bu rgh . )

B rit . M ed . ! ou rn a l . Nov . 17 , 189 -1 .

C en tra lb l. f . p . A u gen . Feb . 1896. p 52 .

A r ch ives o f O ph th a lmo logy . 1896.

A rc h iv f u r O phth . 1896. p . 97, ab . i v .