EPIDEMIC OPHTHALMIA: ITS SYMPTOMS,

DIAGNOSIS, AND MANAGEMENT.

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As well known, ophthalmia flourishes place where People are brought together in large groups. Thus, it invades schools, orphanages, ships, penitentiaries, workhouses, hospitals, prisons, and barracks, where it gives rise to endless trouble, annoyance, and

expense.

Although epidemic ophthalmia was known to the ancients, yet it failed to attract serious scientific attention until the earlier part of the present century. At the latter period the disease prevailed in the English and French armies, which had lately been engaged in the Egyptian campaigns. It attacked Our own troops with great severity, and on their return home, quickly spread to the civil population. It was sown broadcast among the inhabitants of towns and villages in which soldiers were billeted, and in some cases a whole family was infected through housing a discharged soldier. The malady next invaded the large schools-such as, for example, the Royal Military Asylum and Christ's Hospital, and before long ophthalmia assumed the dimensions of a national calamity.

The subject of "Egyptian ophthalmia,"* as it was then termed, attracted a widespread interest, both on the part of the press and of the public. A host of books, monographs, and papers, written

* A few authors still maintain that epidemic ophthalmia and trachoma were unknown in this country before the return of our troops from Egypt. The fallacious character of such a statement, however, may be shown by a glance at the earlier literature, which will be found epitomised in the following places:-Ann. d'ocul., Bruxelles, 1859, p. 219 (J. Sichel); ibid., tome xli, p. 233 (Vlemincks); Arlt's "Clinical Studies of the Diseases of the Eye," translated by Ware, p. 55-57 ; "Description de l'ophthalmie Purulente observée de 1835 à 1839 dans l'hôpital militaire le Saint-Pétersbourg," par Pierre Florio: Paris, 1841.

chiefly by army surgeons, poured forth from the publishers. The disease became widely recognised among the profession as one of the most formidable maladies known to medical science. As a result of all this agitation, stringent measures were taken at any rate as regards the army-to stamp out the mischief.

It would be beside the present purpose to trace the onward progress of ophthalmia in these islands, or to tell of the different steps that have been taken to free the army from the pest. It may, however, be stated in general terms that the amount of the disease has been materially lessened, and that modern epidemics are, as a rule, far milder in type than those of sixty or seventy years ago.

There are two reasons why so much has been heard of epidemic ophthalmia during the last half-century. In the first place, the press, keenly alive to the value of sensational matter, rarely neglects an opportunity of drawing attention to the subject. So that now-a-days every newspaper reader is familiar with the headline, "Ophthalmia in a Pauper School," and also with the kind of report that usually follows such an announcement. Secondly, numerous schools have sprung into existence, many of them built and conducted in defiance of the elementary laws of hygiene. Dormitories and classrooms, for instance, are overcrowded and badly ventilated, and there is often a common use of washing utensils. In many cases no provision is made for isolation, which, it need hardly be remarked, is a first necessity in the preventive treatment of ophthalmia. Moreover, some schools make no attempt whatever to stay the admission of diseased children from outside, the gravity of which statement is apparent when we reflect that a single case of ophthalmia may become the starting point of a widespread outbreak. In a word, these imperfectly arranged schools form hotbeds for the growth and spread of this and of other contagious maladies.

Latter day epidemics of ophthalmia vary much in severity. They range from a simple inflammation, entailing no further damage, to a severe condition that may speedily terminate in loss of sight. They differ, moreover, not only in their immediate, but also in their remote results. Some of them, for example, are unattended by

sequelæ, while others give rise to chronic ailments that may burden. their owners literally for a lifetime.

Apart from injury to sight, school ophthalmia is the cause of much indirect trouble and loss. As a rule, it brings the education of those affected to a standstill, and the internal administration of a school is, for the time being, utterly disorganised. Then, again, its continued existence or recurrence is beginning to be recognised as an unfailing proof of bad management. In this way the reputation of a public school may be seriously endangered or even altogether destroyed.

In parochial schools enormous sums of money have been spent in the endeavour to get rid of the disease. At Hanwell, for instance, upwards of £30,000 was expended in the erection of a suitable building for isolation, and at least £13,000 has been disbursed in bringing the main school into something like touch with modern sanitary requirements. The direct and indirect expenses of recent outbreaks at Norwood, at Forest Gate, at Sutton, at Edmonton, at Leavesden, at Leytonstone, and at Brentwood, must have been proportionately heavy. It is plain, therefore, that the question of the treatment of ophthalmia involves wide economic interests.

Then, there is the further important fact that a number of children leave our parochial schools carrying with them the germs of disease in a still active condition. These infected individuals constitute a standing menace to all around them. Sooner or later, they come as patients to the ophthalmic hospitals, when they are not infrequently found to have sustained damage to sight. In this way their wageearning value is reduced, and their chances of a relapse into pauperism are infinitely multiplied. Looking at these things we may say, without hesitation, that guardians who permit ophthalmia to exist in parochial schools are simply manufacturing ratepayers' burdens out of children who, under proper conditions, should become self-supporting and productive members of the community. To put the matter in another way, the money that should have been spent in preventing ophthalmia is paid many times over in supporting the victims of an evaded responsibility.

On the whole, strange though it may seem, ophthalmia has been the indirect cause of numerous improvements in pauper schools. Thus, its prevalence has drawn attention to faults of construction, of organisation, and of administration, many of which have been remedied. It has led to a system of probation, and also to the provision of field playgrounds, and of systematic indoor and outdoor recreation.

In the course of the following pages, an account will be given (a) of the various affections grouped under the common name "epidemic ophthalmia," and how to distinguish between them; (b) of the ways. in which those affections are spread; (c) of the measures that have been found most successful in dealing with those several conditions.

When brought face to face with an epidemic eye malady, the surgeon's first duty will be to distinguish clearly between the different affections that may be met with. In extensive outbreaks, it is true, he will not infrequently find a mixture of mild and severe cases, along with others of a more or less anomalous character. With a little care, however, he will be able to classify them into one or other of the following acute diseases, all of which are included under the title "epidemic ophthalmia":

I Muco-purulent or Catarrhal Ophthalmia.

2. Purulent Ophthalmia.

3. Diphtheritic Ophthalmia.

4. Acute Trachoma.

In high-class schools, epidemic ophthalmia nearly always belongs to the muco-purulent or catarrhal type of disease. In those of a lower social standing (e.g., the parochial), acute trachoma is more common, although the milder catarrhal affection is by no means rare. At the present time, epidemics of purulent ophthalmia are somewhat infrequent in this country. The complaint, however, may be introduced into a school from without, and may then spread like wildfire among the pupils. Although outbreaks of diphtheritic conjunctivitis have not, so far as I am aware, been observed in England, yet Graefe,1 Jacobson, Magnus,90 Lewinski,3 and Adler,82 have described them in Germany. As the malady may make its appearance at some future time in our large schools, its chief features will receive passing mention.

Let us next glance in succession at the salient points of these different affections.

MUCO-PURULENT or CATARRHAL OPHTHALMIA is the commonest of all the conjunctival inflammations. It is most frequent in spring and autumn, and appears to result, at any rate in sporadic cases, from atmospheric influences, the exact nature of which is still

unknown.

When once started, however, it spreads by contagion— that is to say, by the transfer of specific secretion from diseased to healthy eyes. It is, indeed, the most infectious eye malady with which we are acquainted.

In the majority of instances catarrhal ophthalmia is by no means a serious affection, and gets well in a period varying from three days to as many weeks. Its symptoms are as follows. The patient may complain of some lacrymation and photophobia and of a sensation which he likens to sand in the eye, although, as a rule, subjective sensations are not well marked. The upper lid is sometimes slightly glossy and oedematous at its free edge; the eye is bloodshot. The palpebral conjunctiva is reddened and more or less swollen, but its surface generally remains smooth. The bulbar conjunctiva, which is traversed by few or many enlarged vessels, often shows small plum-coloured spots or patches, due to hæmorrhage, and at times may be somewhat swollen and oedematous. The character of the secretion varies according to the stage of the ailment. At first, it is watery and contains flakes of mucus, while later it becomes muco-purulent. In a case of ordinary severity, a yellowish-white discharge cakes about the lashes and collects at the inner canthus, or lies free in the sinuses of the conjunctiva. If the secretion be profuse, the skin of the eyelids may get excoriated, so that eczema may be brought about, a result more common in children than in adults.

There can be no doubt that the term "catarrhal ophthalmia" includes a number of different affections which possess certain common features. Be that as it may, three particular clinical forins may be recognised without difficulty.

The first occurs in children or in young subjects, and is characterised by an enlargement of the follicles normally present in the