Diseases and injuries of the eye : their medical and surgical treatment

Front matter

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Open Knowledge Commons and Harvard Medical School

MANUAL OF THE DISEASES

Preface

In this Manual is comprised a brief account of all the medical and surgical affections of the Eye, with the treatment essential for their relief. Each subject is discussed in a separate section, under its own peculiar heading.

In the description and treatment of the various diseases, I have not only given the results of my own experience, but I have carefully recorded special points in the practice of my colleagues at the Royal London Ophthalmic Hospital, and have made frequent reference to the labors of the Continental ophthalmic surgeons.

The scope of this work forbids profusion of detail. When, therefore, fuller information is required, I must refer the reader to the " Treatise on the Eye," by Mr. Soelberg Wells, or to the "Natural and Morbid Changes of the Human Eye," by Mr. Bader.

At the end of the book I have added a Formulary of Prescriptions, and also a page of Test-types, reduced from those designed by Dr. Orestes M. Pray, of New York, to aid in the diagnosis of astigmatism. In the

1*

VI PREFACE.

original, each letter is two inches square, and is composed of either vertical, horizontal, or oblique lines set at different angles.

To my friend Dr. Workman I return my warmest thanks for the help he has kindly given me in revising the proof-sheets before they passed through the press.

Chapter I. Diseases Of The Conjunctiva

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Catarrhal Ophthalmia — Chronic Ophthalmia — Pustular Ophthalmia— Purulent Ophthalmia of Newly-born Infants — Purulent or Contagious Ophthalmia — Gonorrheal Ophthalmia— Diphtheritic Ophthalmia — Granular Lids — Syndectomy — Pterygium — Pinguecula — Dermoid Tumors of the Conjunctiva — Cysts of the Conjunctiva — Warts of the Conjunctiva— Injuries of the Conjunctiva — Ecchymosis of the Conjunctiva — Lacerations of the Conjunctiva, . . 13-42

Chapter II. Diseases Of The Cornea And Sclerotic

Corneitis — Chronic Interstitial Corneitis — Strumous Corneitis — Diffuse Suppurative Corneitis — Hypopion — Onyx — Abscess of the Cornea — Marginal Corneitis — Phlyctenular Ophthalmia — Corneo-Iritis — Ulcers of the Cornea — Superficial Ulcers of the Cornea — Superficial Nebulous Ulcers — Superficial Transparent Ulcers — Deep Ulcers of the Cornea— Sloughing Ulcers — Crescentic or Chiselled Ulcers — Chronic Vascular Ulcers — Fistula of the Cornea — Nebula of the Cornea — Leucoma of the Cornea — Opacity of the Cornea from Lead — Conical Cornea — Kerato-globus — Staphyloma of the Cornea, partial and complete — Ciliary Sta-

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phyloma — Cyclitis — Episcleritis — Injuries of the Cornea and Sclerotic — Foreign Bodies on the Cornea — Abrasions of the Cornea — Penetrating Wounds of the Cornea and Sclerotic— Rupture of the Eye through the Sclerotic, . . 43-93

Chapter III. Diseases Of The Iris And Vitreous Humor

Iritis — Classification of — General Symptoms of — Syphilitic Iritis — Rheumatic Iritis — Serous Iritis — Suppurative Iritis — Traumatic Iritis — Cysts of the Iris — Cysticercus on the Iris — Melanotic Sarcoma or Carcinoma of Iris — Functional Derangements of the Iris — Mydriasis — Myosis — Calabar Bean — Operations on the Iris — Iridectomy — Artificial Pupil —1. With a Broad Needle and Tyrrell's Hook— 2. By Iridodesis or Ligature of the Iris — 3. By Incision of the Iris — 4. By Excision of a Triangular-shaped piece of Iris — Injuries to the Iris — Hemorrhage into the Anterior Chamber — Coredialysis — Prolapse of the Iris — Irido-Choroiditis — Choroido-lritis — Sympathetic Ophthalmia — Glaucoma — The Acute and Subacute Inflammatory Glaucoma — The Chronic or Simple Glaucoma — The Consecutive or Secondary Glaucoma — How to ascertain the Tension of the Globe — Tremulous Iris — Coloboma of the Iris — Diseases of the Vitreous — Hyalitis — Muscae Yolitantes — Opacities of the Vitreous — Sparkling Synchysis — Fluidity of the Vitreous — Foreign Bodies in the Vitreous — Hemorrhage into the Vitreous, 93-148

Chapter IV. Diseases Of The Crystalline Lens

Cataract — Causes of — Classification of — Hard and Soft Cataracts— Congenital or Infantile Cataract — Involuntary Oscillations of the Globe — Operations for Soft Cataract — Operation by Solution — Linear Extraction — Suction Operation

CONTENTS. IX

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— Hard Cataracts — Varieties of — Nuclear, Striated, Black, and Senile Cataracts — Operations for Hard Cataracts — Flap Extraction Operation — Accidents which may happen in Flap Extraction of Cataract — Remarks on Flap Extraction — The Traction Operation — Yon Graefe's modified Linear Extraction — Mooren's Extraction Operation — Jacobson's Extraction Operation — Pagenstecher's Operation for extracting the Lens in its Capsule — Macnamara's Operation for Cataract — Treatment of the Eye after an Extraction of the Cataract— The Casualties which may occur after an Extraction of a Hard Cataract — Capsular Cataract — Capsulo- Lenticular Cataract — Diabetic Cataract — Fluid Cataract — Traumatic Cataract — Secondary Cataract — Capsular Opacities— Treatment of — Dislocations of the Lens — 1. Into the Anterior Chamber — 2. Into the Vitreous — 3. Beneath the Conjunctiva — Partial Dislocations of the Lens, . . 149-195

Chapter V. Diseases Of The Retina, Choroid, And Optic Nerye

Hyperemia of the Retina — Retinitis — Retinitis Albuminuria — Retinitis Syphilitica — Retinal Apoplexy — Retinitis Pigmentosa— Detachment of the Retina — Embolism of the Central Artery of the Retina — Tumors of the Retina — Glioma of the Retina — Cysts of the Retina — Diseases of the Choroid — Disseminated or Exudative Choroiditis — Sclerotico-Choroiditis Posterior — Suppurative Choroiditis — Deposits of Bone on the Choroid — Tubercles in the Choroid — Hemorrhage from the Choroid — Injuries of the Choroid — Hemorrhage between the Choroid and Retina — Hemorrhage between the Choroid and Sclerotic — Hemorrhage into the Vitreous — Tumors of the Choroid — Sarcoma of the Choroid — Medullary Cancer of the Choroid — Diseases of the Optic Nerve — Descending Optic Neuritis — Neuro-Retinitis — Atrophy of the Optic Nerve — Amaurosis — Causes of — Amblyopia— Hemeralopia — Snow-blindness — Color-blindness — To ascertain the Field of Vision — The Ophthalmoscope — How to work with the Ophthalmoscope — Lateral or Focal Illumination of the Eye, ...... 195-260

CONTENTS.

Chapter VI. Anomalies Of Refraction And Diseases Of Accommodation

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Accommodation — Myopia — Ophthalmoscopic appearances of a Myopic Eye — Treatment of Myopia — Degree of Myopia — General Rules for Selection of Glasses — General Directions for Myopic Patients — Hypermetropia — Treatment of Hypermetropia — To ascertain the degree of Hypermetropia — Peculiarities of the Hypermetropic Eye — Presbyopia — Treatment of Presbyopia — Astigmatism — Irregular Astigmatism— Regular Astigmatism — Asthenopia — Causes of — Treatment of Asthenopia, 260-282

Chapter VII. Strabismus

Strabismus — Causes of — To ascertain the Degree of — Convergent Strabismus — Causes of — Divergent Strabismus — Causes of — Treatment of Strabismus — The Moorn'elds Operation for Strabismus — Von Graefe's Operation for Strabismus— Liebreich's Operation for Strabismus — Treatment of Strabismus after the Operation — Divergent Strabismus following division of the Internal Recti Muscles — Operation for bringing forward the Internal Rectus Muscle — Paralysis of the Ciliary Muscle — Spasm of the Ciliary Muscle — Diplopia— Homonymous Diplopia — Crossed Diplopia — The Action and Uses of Prisms— To ascertain the presence of Binocular Vision — To test the Strength of the Muscles of the Eye — To wear as Spectacles to correct Diplopia — Paralytic Affections of the Muscles of the Eye — Causes of — Paralysis of the Third Nerve — Paralysis of the Fourth Nerve — Paralysis of the Sixth Nerve — Treatment of Paralytic Affections of the Muscles of the Eye, . . . 282-312

CONTENTS. XI

Chapter VIII. Special Injuries Of The Eye

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Foreign Bodies within the Eye — Injuries of the Eye from Escharotics — Injuries from Mortar, Lime, and Plaster — Burns and Scalds of the Eye — Injuries from Strong Sulphuric and Nitric Acid — From Vinegar, dilute Acetic Acid, or any of the weak Acids — Injuries from Percussion Caps, Gunpowder, and Small Shot — Excision of the Eye — Artificial Eyes — Directions for wearing Artificial Eyes, . 313-326

Chapter IX. Diseases Of Lachrymal Apparatus

Epiphora — Causes of — Chronic Inflammation of Lachrymal Sac — Treatment of — Stricture of Lachrymal Canal — Sites of Stricture of — Treatment of — Acute Inflammation of the Lachrymal Sac — Treatment of — Fistula of the Lachrymal Sac — Epiphora from Mechanical Obstruction by Tumors — To slit up the Canaliculus — Obliteration of the Lachrymal Sac — Removal of the Lachrymal Gland — Diseases of the Lachrymal Gland — Inflammation of the Lachrymal Gland — Cysts of the Lachrymal Gland— Fistula of the Lachrymal Gland — Chronic Enlargement of the Lachrymal Gland — Treatment of, . . . . . . . . 327-341

Chapter X. Diseases Of The Eyelids

Tinea Tarsi — Hordeolum — Eczema of the Lids — Trichiasis — Distichiasis — Operation for the Removal of the Eyelashes — Entropion — Spasmodic Entropion — Chronic Entropion — Causes of — Treatment of — Ectropion — Causes of — Treatment of — Paralytic and Spasmodic Affections of the Eyelids — Ptosis — Complete and Partial — Paralysis of the

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Orbicularis Muscle — Blepharospasm — Ulcerations of the Eyelids — Syphilitic Ulcers of the Eyelid — Treatment of — Rodent Cancer of the Eyelid — Epithelial Cancer of the Eyelid— Treatment of Epithelial and Rodent Cancer — Tumors of the Eyelid — Tarsal Cysts — Nsevus of the Eyelid — Sebaceous or Dermoid Cysts — Epicanthus — Injuries of the Eyelids— Ecchymosis of the Eyelid — Abscess of the Eyelid — Wounds of the Eyelid — Results of Injuries and Ulcerations of the Eyelids — Ankyloblepharon — Treatment of — Symblepharon — Treatment of, 342-378

Chapter XI. Diseases Of The Orbit

Abscess of the Orbit — Acute and Chronic — Treatment of — Fractures of the Bones of the Orbit — Foreign Bodies in the Orbit — Effects of — Treatment of — Penetrating Wounds of the Orbit — Periostitis of the Orbit — Treatment of — Necrosis and Caries of the Orbit — Aneurism of the Orbit — True and False Aneurism of Orbit — Diffuse or Consecutive Aneurism of Orbit — Aneurism by Anastomosis of Orbit — Exophthalmic Goitre — Treatment of — Tumors of the Orbit — 1. Those which originate within the Orbit — 2. Those which commence within the Eye — 3. Those which have their Origin beyond the eye or Orbit — Treatment of Tumors of the Orbit — Acute Inflammatory Exudation into the Orbit — Distension of the Frontal Sinus — Anatomy of Frontal Sinus — Causes of Distension of Frontal Sinus — Treatment of Distension of Frontal Sinus, . . . 379-414

Formulary of Prescriptions, ....... 415

Page of Test-Types for Astigmatism, 427

MANUAL

OF

DISEASES OF THE EYE.

Chapter I. Diseases Of The Conjunctiva

Catarrhal Ophthalmia — Acute Conjunctivitis — is an inflammation of the conjunctiva covering the eye and lining the lids. It may come on without any apparent cause, or it may be produced by rapid alternations of temperature, or by exposure of the eye to cold. Catarrhal ophthalmia will sometimes assume an epidemic character, and large numbers in the same locality will suffer from it ; or it will attack every member of a family in succession, notwithstanding that due precautions have been taken to prevent its spreading by direct communication.

Symptoms. — A feeling of grittiness, as if dust or line sand were in the eye, with some stiffness of the lids. The conjunctiva becomes red^ and this increase of vascularity generally commences from the circumference of the globe, and fades as it approaches the cornea. In the advanced stage of this affection the white of the eye becomes of one uniform red color. The redness is superficial, and of a brighter and darker shade than that caused by inflammation of the deeper structures of the eye, for which it can hardly be mistaken. There is an increased secretion from the surfaces of the eye and lids ; at first only of mucus, but afterwards of muco-pus, small quantities of which will collect in little beads over the caruncle at the inner angle of the eye, or form little scabs on the edges of the lids by caking on the eyelashes. If the lower lid be drawn down by the finger, one or two streaks of pus or lymph will be often seen in the oculo-palpebral fold. The patient complains that the lids are sticky, and that in the morning they are gummed together by dried secretion. On looking at the eyes, there is a peculiar sticky and gummy appearance which is quite characteristic of the disease. There is often associated with these symptoms chemosis of the conjunctiva and swelling of the lids. The conjunctiva looks blown up from the serous effusion into the subjacent cellular tissue, sometimes to an extent sufficient to make the cornea appear sunken below it. The cornea is clear, and the pupil is active. The rapid action of the pupil will at once decide that the inflammation is superficial, and that the iris is not affected by it.

Catarrhal ophthalmia usually commences in both eyes simultaneously, or one eye may be attacked a little in advance of the other, but it is seldom that this disease is limited to only the one eye. In this respect catarrhal ophthalmia offers a marked difference from gonorrhoeal ophthalmia, which is generally, in the first instance, strictly confined to the one e}re. (See Gonorrheal Ophthalmia, page 22.)

Prognosis, — This affection is usually very amenable to proper treatment, and the eyes will recover without a trace of the disease remaining. But if no treatment be adopted, or unsuitable remedies be used, the conjunctival inflammation may extend to the cornea, and corneitis, with superficial or deep ulcerations, may follow.

CHRONIC OPHTHALMIA. 15

Treatment. — The eyes should be bathed every two or three hours, or oftener if the case is severe, with a lotion of alum, or sulphate of zinc and alum (F. 38, 39, 40), taking care that with each application a little is allowed to flow into the eyes. In the intervals between the times for using the lotion, the eyes may be bathed with cold water, to keep them free from the discharge. A solution of nitrate of silver, gr. 1 or gr. 2, ad aquae ^ 1, is very useful in catarrhal ophthalmia, and especially in those cases where there is chemosis of the conjunctiva and swelling of the lids. Two or three drops should be dropped into the eye twice a day, and every two or three hours, or oftener if necessary, the eyes should be cleansed from discharge by bathing them with cold water. To prevent the gumming together of the eyelids during sleep, a little unguent, cetacei should be smeared along their tarsal borders every night. At the commencement of the attack the bowels should be acted on by some purgative ; and if the patient is hot and thirsty, an alkaline or effervescing draught (F. 53, 55) may be prescribed, but, as a rule, tonics, such as bark, quinine, or iron, will be required; and these are given with most benefit after the first febrile symptoms which often usher in an attack of catarrhal ophthalmia have passed away.

Chronic Ophthalmia may be consequent on catarrhal ophthalmia, the acute disease subsiding into a chronic form; but this is quite exceptional. Chronic ophthalmia generally occurs in patients who are below the standard of health, and in those who have to earn their living by the long-continued use of their eyes at fine work.

Symptoms. — The eye has a reddish and irritable appearance ; it will not face the light without a sense of discomfort and watering. The caruncle and edges of the lids often look red and prominent, and the secretion of the mucous surfaces of the lids and globe is slightly increased. Reading or fine work soon tires the eye, and causes it to flush up. The patient is generally more or less out of health; oftentimes used up from want of rest.

Treatment. — When there is reason to believe that over-use of the eyes has been the exciting cause of the disease, rest must be strictly enjoined. Close reading, the casting up of figures, and all fine work should be forbidden. The state of the patient's health should be improved, and any irregularity in the discharge of the functions of the different organs of the body should be, as far as possible, corrected.

Local Applications. — When there is any extra secretion from the mucous surfaces of the lids or eye, mild stimulating drops or lotions do good. Two or three drops of the guttse argenti nitratis (F. 16), or of zinci sulphatis (F. 20), may be dropped into the eye twice a day. Lotions with alum, or with alum and sulphate of zinc combined (F. 39, 40), are very efficacious. A weak solution of the acetate of lead (F. 42), provided there is no abrasion of the cornea, will be often found very useful. The tarsal edges of the lids should be anointed at night with a little unguent, cetacei, to prevent their gumming together ; or if there is much secretion from the Meibomian follicles, the unguent, hydrarg. nitratis dilut. (F. 102) may be advantageously used. When there is much dread of light, stimulating applications to the eye fail to do good, and are apt to excite considerable irritation. In chronic ophthalmia, counter-irritation will be frequently found beneficial. A small blister of emplast. cantharidis, or a piece of Brown's blistering tissue of the size of a shilling, may be applied to the temple, or behind the ear, and repeated in two or three nights if necessary.

If the remedies named fail to afford relief, a seton in the temple of a single or double thread of thick corded

PUSTULAR OPHTHALMIA. 17

silk will occasionally do good. The seton should not be allowed to remain more than three or four weeks, or the ulceration at the entrance and exit of the thread may cause an unsightly scar. In cases of persistent chronic ophthalmia the lids should be everted and carefully examined for granulations, as, if the conjunctiva has become granular, the ophthalmia will continue until the granulations are cured. (See Granular Lids.)

Pustular Ophthalmia is a mild form of inflammation of the conjunctiva, characterized by the formation of small elevations about one or two lines from the margin of the cornea. They are generally of a reddish color at their base, and of a yellowish-white on their somewhat flattened summits. They have been called pustules, but they do not really contain pus ; if pricked, only a little watery fluid will exude from them. The conjunctiva in their vicinity is more or less reddened, and sometimes one or two small red vessels may be seen coursing towards them. There may be only one of these so-called pustules, or there may be as many as three or four of them. There is no intolerance of light, and the patient seldom complains of more than a feeling of grittiness in the eye. One peculiarity of pustular ophthalmia is that it is very apt to recur. This affection is quite distinct from the true phlyctenular ophthalmia described in the chapter on Diseases of the Cornea.

Treatment. — Attention must be paid to the general health of the patient, and, if necessary, a mild aperient prescribed. As a local application, any mild stimulant will do good. A little calomel, dusted into the eye on to the pustules with a camel's hair brush every or every other day for a few times, will be found a very efficient remedy. It has also the credit of preventing a recurrence of the disease. Lotions of the acetate of lead (F.

2*

42), or of sulphate of zinc, may be also used with good effect.

Purulent Ophthalmia of Newly-born Infants — ■ Ophthalmia neonatorum — is one of the most important diseases of the eye which the surgeon can have under his care. When rightly treated it is one of the most remediable, but when neglected, or, what is often worse, when unsuitable and improper remedies are used, it is one of the most disastrous of all the inflammatory affections of the eye. The responsibility of any one undertaking a case of purulent ophthalmia who is not thoroughly acquainted with its nature and treatment is very great. Many a useful life has been blighted in the first month of its existence by irreparable blindness, which might have been prevented if the simple means, which seldom fail to arrest this formidable disease, had been rightfully applied. Purulent ophthalmia usually commences from the second to the seventh day after birth. Both eyes are commonly affected simultaneously, but to this there are occasional exceptions ; thus one eye only may be involved, or the first eye may suffer twelve or twenty-four hours in advance of the second.

Symptoms. — The first indication of the disease is usually detected by the nurse, who notices that there is a slight discharge from the eyes, and that the edges of the lids are glued together during sleep. In a short time, often within a few hours, the discharge increases greatly in quantity and changes in quality ; it first becomes mucopurulent, and ultimately, if the case is severe, is converted into almost pure pus. The eyelids now become red and swollen, and their tarsal margins, caked together, pen up the discharge, which accumulates behind the lids, and streams over the cheeks when the eyes are opened. The quantity of pus which literally pours from between the

PURULENT OPHTHALMIA OF INFANTS. 19

eyelids in a bad case, and the rapidity with which it is secreted, are very remarkable.

In the slight cases of purulent ophthalmia the discharge is of a whitish color with scarcely a tinge of yellow, and it is not very abundant in quantity. In the very severe forms of the disease the discharge is of a deep yellow color and very profuse. Between these extremes there are many gradations.

Prognosis. — When a child suffering from purulent ophthalmia is seen sufficiently early, and proper remedies are rightly applied, recovery is almost certain. It should, however, be remembered that cases occasionally occur of so severe a nature that all treatment is unavailable to arrest the progress of the disease, and one or both eyes are rapidly and irrecoverably destroyed. In such instances it will generally be found that the discharge was of a deep yellow color, very copious, and that it commenced on the first or second day after birth. It will also be probably ascertained, on inquiry, that the mother had gonorrhoea at the time of her confinement, or leucorrhoea of so severe a type that the discharge was yellow and puriform.

Treatment. — The indications for treatment are to wash away the discharge from the eye as often as it collects, and to use some astringent lotion to arrest the re-secretion of the purulent matter. Lotions of alum, or of sulphate of zinc and alum (F. 38, 40), and drops of nitrate of silver, are the most useful astringents in purulent ophthalmia. The lotion which I generally use is one of alum (F. 38). The mode, however, of applying the remedies is of as much .importance as the remedies themselves. The lotion should be gently squirted into the eye with an India-rubber syringe with an ivory nozzle, or with a small glass syringe, every half-hour or hour, according to the severity of the case, the object being to thoroughly cleanse the eye from all discharge as often as it is re-secreted. This treatment should be pursued by night as well as by day. The intervals between the use of the lotion may be increased as the discharge decreases in quantity. The carrying out of these instructions should be intrusted solely to the nurse, as the mother, so soon after her confinement, is unfitted for the duty, and rest is also essential for her in order to insure a due supply of milk for the child.

The easiest way of applying the lotion is as follows : The nurse should lay the child on her lap, turning its head a little to one side or the other, according to the eye she is going to wash out. With the thumb and finger of her left hand she gently separates the lids, whilst with the right hand she squirts a stream of the lotion into the eye from the nasal side, allowing it to run away from between the lids on to a soft napkin, which she has placed under its head to receive it.

If the case is very severe, the surgeon should see the child once or twice a day himself, and having washed the eye thoroughly from all discharge with a stream of cold water, he should drop into it two or three drops of a solution of nitrate of silver gr. 2 ad aquae § 1, and order the alum lotion to be continued as directed during his absence. In some cases, where the nurse is very awkward, and cannot rightly use the lotion with a syringe, it may be efficiently applied by means of a soft camel's-hair brush. From time to time a little unguent, cetacei should be smeared on the edges of the lids, to prevent their sticking together.

Evil Results of Purulent Ophthalmia. — The great danger in this disease is lest the inflammation, which was originally confined to the conjunctiva of the lids and globe, should extend to the cornea. When this happens, acute corneitis follows; the cornea becomes at first hazy,

PURULENT OPHTHALMIA. 21

then ulcerates either superficially or deeply, or, if the case is very severe, a large portion of it may slough. As the result of such casualties, we get nebula, leucoma, or staphyloma of the cornea. Each of these subjects will be found fulty treated of under their respective headings.

Purulent Ophthalmia — Contagious Ophthalmia. — To this disease very many names have been applied, but the two mentioned are sufficient to indicate its nature. This form of ophthalmia is both purulent and contagious. It has been called Egyptian Ophthalmia ,. from its being ever present in Egypt, where the severest types of the disease are to be constantly found.

In its mild form it closely resembles catarrhal ophthalmia, for which it may be mistaken ; but in the worst cases it almost equals in severity the gonorrheal affection of the eyes.

Purulent ophthalmia commences with a slight discharge from the eye and swelling of the lids. The discharge soon increases in quantity and becomes puriform, the conjunctiva gets chemosed, and the lids grow red, shining, and edematous. If the disease progresses unchecked, the cornea first becomes cloudy, then ulcerates, or portions of it slough, and the eye is destroyed. The peculiar tendency of purulent ophthalmia is to attack masses of people who are congregated together, and living without due attention to cleanliness and ventilation. Hence it is that the disease has frequently broken out amongst soldiers in barracks, amongst the poor in workhouses, and in large pauper schools in the country.

Although purulent ophthalmia is undoubtedly propagated by inoculation, yet there is abundant evidence to show that it may be epidemic, and spread without any direct conveyance of the purulent secretion from eye to eye.

I think rr^self that the ordinary catarrhal ophthalmia may, and frequently does, assume a contagious form, and that it is liable to do so whenever it attacks members of a community who are living in violation of the laws of health.

Treatment. — A mild case of purulent ophthalmia should be treated in the same way as catarrhal ophthalmia, page 13 ; but if the case is severe the plan of treatment recommended for gonorrheal ophthalmia, page 23, should be adopted. After the severity of the disease has been arrested, there is apt to remain a muco-purulent discharge, which will obstinately resist all treatment for many weeks, or even months. Upon everting the lids, it will be often found that this chronic discharge is due to a granular condition of the palpebral conjunctiva induced by the disease. (See Treatment of Granular Lids, page 32.)

In all outbreaks of the disease sanita^ precautions should be taken to prevent it spreading, and the bad cases should be kept apart from the others. A daily inspection should be also made to treat each fresh case as soon as the early symptoms show themselves.

Results of Purulent Ophthalmia. — 1st. If the disease resists all treatment, the eye may be lost from ulceration or sloughing of the cornea. 2d. The eye may recover, but with a nebula of the cornea, or a leucoma, to the inner surface of which the iris is frequently attached, causing a distortion of the pupil. 3d. A granular state of the lids, with a chronic muco-purulent discharge.

Gonorrheal Ophthalmia is an acute specific inflammation of the conjunctiva of the lids and globe, induced by the inoculation of some gonorrheal matter into the eye. It is characterized by a profuse purulent discharge from between the lids, which is of a yellow color, and ex-

GONORRHEAL OPHTHALMIA. 23

actly corresponds in appearance with that which flows from the urethra. The disease is rapid in its progress and very destructive ; unless it is soon checked, the eye is lost.

Symptoms. — Acute inflammatory action usually commences in from six to eighteen hours after the inoculation has been effected. The early symptoms resemble those of catarrhal ophthalmia, but they are more severe. A slight thin discharge first begins to ooze from between the lids, accompanied by a sense of heat and fulness of the eye. The conjunctiva of the globe grows red, swollen, and chemosed, often rising above the level of the cornea, which will appear as if it were partially buried below it. The lids are swollen, red, and shining, and completely closed over the eye. The discharge has now become excessive in quantity, of a thick consistence and yellow color, and streams over the cheeks from between the lids. The cornea is almost certain to become involved ; and if the inflammation be not quickly subdued, ulceration and sloughing of its structure will surely follow. The patient suffers severely from the pain in the eye and around the orbit, with an oppressive feeling of heat and fulness of the lids and globe. The disease is usually confined to the one eye. When the second becomes affected, it is generally on account of due precaution not having been taken to shield it from the danger of inoculation.