BY M. E. LAZARUS, M. D.

Under this name, Mr. Desmarres recognizes a malady sui generis, though of fourfold origin. The great importance of clear definitions to therapeutical progress, the necessity of adhering in nosology to the personal authority of specialists, who most perfectly represent the existing state of science, and the nearly absolute success of Mr. Desmarres, treatment to which I can testify, in this formidable disease, determine me to give some extension to this article.

From its fourfold origin, Purulent Ophthalmia has borrowed as many names.

1. Ophthalmia neonatorum:-of spontaneous evolution during infancy.

2. Ophthalmia blenorrhagica:-of either children or adults positively determined by the contact of leucorrheic or venerial blennorrhagic urethral pus, or by that of other eyes thus contaminated; in other cases, termed metastatic, possibly by the constitutional evolution of a disease at first localized in the urethra.

3. Ophthalmia Egyptiaca:-the ophthalmia of armies, spontaneously engendered under certain conditions of exposure and climate, (chill and wet nights alternating with burning days and glare and dust,) and afterwards transmitted and perpetuated by contagion and infection.

4. Ophthalmia granular or chronic, propagated by granulations. This latent form of the disease giving rise to the acute purulent form either in the same, or oftener, in another patient.

Purulent ophthalmia ought not to be practically confounded either in its description or its treatment with catarrhal conjunctivitis on account of the two points they have in common, to wit:-The secretion of muco-pus, and the property of being reciprocally developed by contagion from granulations, for it appears that one subject may take purulent ophthalmia by contact with the muco-pus secreted from lids granulated by catarrhal conjunctivitis, while another takes the catarrhal form by contagion of muco-pus secreted from lids granulated by purulent conjunctivitis. Whether this depends more on the peculiar condition of the granulations or on the differing susceptibilities of the subjects, is a question still open.

M. Desmarres teaches us to distinguish the purulent form by the following signs and characters.

The red line, indicated by Billard and Baron, across the upper lid from angle to angle, interrupted at first in its middle. This, however, he also observed in other ophthalmias in adults of lymphatic temperament. But if a clear citron drop be found in the great angle of the eye, this is pathognomonic as in urethral blennorrhagia. Succeeding to the first secretion of muco-pus with tears, common to the catarrhal and the purulent form; the clear yellow drop is only visible during a few hours; it is then replaced by a profuse secretion, serous, whitish and turbid, then by floods of pus reproduced as fast as it is washed away, and which becomes deeper colored, yellow or green and excoriating, as the disease gains its height, then creamy, when on the decline.

Purulent conjunctivitis becomes a true and general ophthalmia from its extreme liability to destroy the cornea. While the cornea remains intact, the deep-lying membranes are not invaded by the malady or quite exceptionally so; hence no constitutional disturbance until the mischief is already done. The accidents to the cornea often coincide with a diminution of the previous secretion, and are sometimes announced by sharp shooting pains. The prognostic is not absolutely grave from a general opacity of the cornea, since this often clears up in the course of a few months; but when the cornea becomes conical, the worst must be apprehended. The swelling of the lids is early remarkable, it is increased by the chemosis or submucous engorgement; the chemosis of the bulbar conjunctiva forms a prominent feature of the advance of the malady into its second period. Acute ectropion supervenes from this cause, especially on eversion of the lids to examine the cornea, whence the expediency of employing elevators, and best such as arc made full. The redness and true phlogosis of the mucous membrane is favorable, the pale chemosis, refusing to bleed, indicates strangulation and imminent danger to the cornea.

The cornea may slough during the first twenty-four hours, but the period of greatest danger is generally between the third and eighth days. Its infiltration is first indicated by a light cloud, its annular ulceration by a whitish marginal ring. A conical sally betokens its general softening; the touch of the little finger may test the resistance of its layers, and give the indication for external compression, equally required to maintain an ectropion reduced. It is in the second stag that granulations are developed.

The third period is characterized by the opacity and consistency of the chemosis, by the strangulation, so complete that incisions draw no blood and caustics make deep eschars which remain long adherent. The secretion is less, but thicker, deeper colored and excoriating.

Mr. Desmarres enjoins in the ordinary purulent ophthalmia, whether of children or adults, continual injections or spongings of weak astringent wash, usually alum 1/300 His first measure, purely homoeopathic or ectrotic, is the substitution of a frank or simple, for the specific and destructive inflammation, as in Ricord's mode of arresting a purulent urethrite with caustic injections.

Mr. Desmarres prefers for the eye, the solid stick nitrate of silver, which he immediately neutralizes by an injection of salt water, then before allowing the lids to close, he makes them bleed by rubbing with a linen rag. A collyrium of Nitr. Arg 1/300 every hour, may be substituted at the discretion of the surgeon in particular cases.

If, when the patient is presented, the malady be already advanced to the second period, and the cornea endangered, caustic would only increase the risk. Many eyes have been thus destroyed, and Mr. D. carefully impresses on us his experience on this point. He now substitutes bold scarifications as long as they draw blood, at several points of the corneal periphery, as often as three times a day with free incisions of the chemosis, which he snips with scissors. These measures become useless if the circulation has become jugulated. If the cornea be threatened at one point with perforative ulceration, he relieves the strangulation on which this depends by making paracentesis, and evacuating the aqueous humor. The iris may make hernia a little here, but as the external superior corneal margin is the elect site of the incision, the eye is thus saved, its circulation is restored, and the pupil will only be deformed.

Mr. Desmarres has renounced the employment of the little emporte piece, similar to a shoemaker's punch, which he once had made for this purpose, and with which he anticipated perforations at points less convenient, or entire sloughs of the cornea. Without absolutely rejecting the local aid of leeches or cups to the temples, moderately employed in the earlier stages of purulent ophthalmia, or the derivation of purgatives; he does not push these measures as in simple inflammations, and seldom has recourse to them at all; regarding as unworthy of confidence or as applying to cases of catarrhal and simple, mistaken for the purulent form, the antiphlogistic and mercurial treatment so much vaunted by some surgeons. It sometimes becomes necessary to remove with curved scissors or to touch with the nitrate of silver a herniad point of the iris.

Whenever central perforation is menaced, instillations of atropine in the strength of 1/300 are combined with external compression by the adjustment of a bandage. Care must be taken, especially with infants, not to narcotize the patient as well as the eye, but subject to this restriction only, the instilations should be very frequent and so contrived with the aid of a quill or fine syringe, as not to derange the central adjustment of the corneal compress.

In the blennorrhagic ophthalmia of adults, especially if robust, Mr. Desmarres, though placing little reliance on antiphlogistic measures, yet gives in so far to the spirit of routine as to recommend every four hours during the violence of the first days, a centigramme of Calomel with one or two of Opium, or else with two or three of Belladonna in powder, every four hours during the first days, and cupping or leeching to the temples, in ratio to the intensity of the disease and the vigor of the constitution. We do not hesitate to allow the value of Belladonna or Mercury, we do not see the indication for Opium, and we have too often witnessed the efficacy of dynamised drugs, to doubt it here.

DIFFERENTIAL DIAGNOSIS.-The march or course of catarrhal conjunctivitis is regular, that of the purulent form, insidious: -for example: the pain, redness and signs which keep awake the attention of patient and surgeon subside in proportion to the strangulation of the cornea. If nervous disturbance, tremblings, vomitings, fever, diarrhea, occur; it will be after perforation, and be symptomatic of hernia of the iris. The cornea may be destroyed within twenty-four hours in the acutest forms.

After beginning with such mildness that all the symptoms seem to yield to an astringent collyrium, it may suddenly rise to its highest degree and destroy the eyes.

As in its incipient stage, it is easily confounded with the catarrhal form, every affection of the eyes in young children should be regarded with suspicion and met with measures often more vigorous than the occasion seemed to require.

Purulent ophthalmia, after passing through its different phases without destroying the cornea, may remain some time stationary, twelve or fifteen days; then suddenly return in its most dangerous form. This uncertainty is not confined to the ophthalmia neonatorum. The patient must be kept under observation so long as the least abnormal secretion exists, and if the slight catarrhal discharge of tears and mucus be replaced by the clear citrine yellow drops, a relapse becomes certain.

In the purulent form, the second eye is usually attacked from the third to the eighth, and even as late as the twentieth day, is liable to be completely destroyed, while the first eye recovers.

The most destructive purulent ophthalmias may be communicated through the contagious granulations of persons whose corneas are sound, and in whom these granulations retain the virus in a latent form.

It is in the second period of the ophthalmia neonatorum that granulations are developed, but these seldom persist many weeks after the inflammation which caused them. This spontaneous resolution, not common to other granulations, is probably the reason why Velpeau has denied them altogether.

As the catarrhal form advances, the redness of the conjunctival injection intensifies and scarifications continue to draw blood and give relief. As the purulent form advances, the conjunctival injection pales and refuses blood to the scarificator, which, of the highest utility in the second period, may become useless in the third and needs the aid of warm lotions to give it any effect. The chemosis of the catarrhal form is phlegmonous, occasioning strong pains and throbbing in the eyes, with fever. In the purulent form, it is generally indolent, leaving the nervous system in repose.

The cornea is less frequently menaced in the catarrhal form, and never in its totality, but at certain points of its periphery; while in the purulent form, it often gives way in the centre, and may slough completely within the first twenty-four or forty-eight hours, though seldom so early. The general and even the local antiphlogistic measures, which control the catarrhal form, are impotent in the purulent. Conversely, the latter is benefited by the invigorating influence of free exposure, as in the marching of regiments, &c.

I have never witnessed the diphtheritic form of purulent ophthalmia, to which Mr. Chassaignac successfully applied his favorite opthalmic remedy, the cold water eye-douche, so prolonged and in such force, as to wash away the false membranes and prevent their re-formation.

Mr. Desmarres inclines to ascribe the purulent ophthalmia of adults, in general, to direct contagion, but without maintaining this opinion as exclusive. Avoiding Beer's classification by diatheses, and rallying closely to anatomical character; he has logically advanced in this direction, opened in Paris by Velpeau in his celebrated critique on Sichel and the German School, published in the Annales d'Oculistique. Among other points, Desmarres has, in continuing the seriation by tissues, distinguished the blepharitis proper, from the conjunctivites, which in their catarrhal and purulent, as well as in their traumatic and simple forms, interest the conjunctiva of the globe as well as that of the lids.

As to the ophthalmia called by the school of Beer, and still known in London as Rheumatic; he distinguishes, on the one side the true SCLEROTITIS, a perfectly localized and chronic malady, often confounded, and even by Velpeau, with a pustule on the other side, the choroido iritis with perikeratic injection, which either may or may not coincide with that form styled by Ricord opthalmie blennorrhagique catarrho rhumatismale, and which presents none of the characters of true purulent ophthalmia, though sometimes confounded with it, because coincident with urethral blennorrhagia. This coincidence, Mr. Desmarres inclines to regard in some cases as fortuitous, in others as one of the developments of the same constitutional influence which determines in the urethra, a blennorrhagy, in the joints an arthropathy; and which has been termed metastasis. He believes with Vidal, that purulent ophthalmia may sometimes occur in the same filiation, and without direct contagion or inoculation: of the latter he avails himself as the basis of the cure of pannus, by inoculation of blennorrhagic pus from the urethra. Desruelles cites also purulent otitis, stomatitis and coryza from contact of the blennorrhagic virus.

Certainly, we must all recognize the atmospheric contact of virulent principles, as well as their fluid contact. The principle of infections and contagions is often identical, and has this point of filiation with epidemics and endemics, that the causal miasm may exist in a more concentrated form in the bodies of those who are already its subjects.

On the other hand, there are facts more difficult of explanation, such as that cited by Desmarres from the experience of Mr. McKenzie, surgeon of the 62d regiment of the British Army, whose eyes were unaffected by the prolonged contact of the pus of purulent ophthalmia in Egypt. Was this exception personal? Was it the character of that particular epidemic? Was the pus truly brought into contact with the mucous surface? Was its virulence exhausted by the chronicity of the disease in the eyes whence it was taken? So many questions which can be answered only by numerous and varied experiments.

Another series of questions arises in connection with ophthalmia in its filiation with arthropathy and urethral blennorrhagy: Do they arise from a mere coincidence of a local irritation from coitus, with the access of arthritis, or from the evolution of the arthritic diathesis?

Are they to be ascribed to the permeation of the organism by a venerial poison, analogous to the syphilitic, but different from it? (an opinion which Teste expresses in his article on Sepia). Is the urethra, and in an especial manner its prostatic portion, an organic centre, whose irritations are especially expressed in rheumatic or arthritic symptoms, and this without implying the presence of any venerial virus whatever? I have observed arthritic symptoms developed so immediately upon traumatisms of the urethra in cases of stricture and diseases of the neck of the bladder, as to incline me towards this last view. Candmont regards the neck of the bladder as the point most susceptible to the rheumatic diathesis and as frequently the first seat of its evolution.

While digressing on the chapter of differential diagnosis, I will mention the apoplectic ophthalmia cited by Quadri of Naples, with which purulent ophthalmia may be sometimes confounded:

1. The Palpebral puriform flux of Scarpa. This slowly develops itself and continues for weeks, months and even years, without any amelioration by local remedies. Astringents are ill borne, and even when they seem to act well upon the external membranes, graver alterations occur in the retina and deeper organs.

The frequent exacerbations are attended by photophobia, palpebral engorgements, sensation of foreign bodies and presence of varicose vessels towards the muscles of the globe.

After many exacerbations, ectropion senile occurs.

2. Another form, of what Quadri calls apoplectic, is also characterized by purulence and much photophobia with the same intolerance of astringents, and is intermittent.

Here the cornea ulcerates and inflames, with abscesses, and pannus almost fatally ensues from the varicose state of the vessels and the frequent exacerbations. The choroid and retina are rarely invaded, perhaps because a mortal attack of apoplexy anticipates them. The least excess may prove fatal.

Quadri recommends the red sulphuret of Mercury, combined with some grains of Aloes, and locally the citrine ointment of the Edinburgh pharmacopeia.

NOTE.-The reader will observe that in the preceding very valuable article, but little is said of the course of treatment properly pursued under the Homoeopathic Law. The very careful description of the disease which forms the subject of the paper, is of course, and very evidently its principal object. This being the case, we shall not consider ourselves as interfering with the design of our learned contributor, when making the casual remark, that Arsenic is homoeopathic to the condition of purulent ophthalmia as above described, and that in several very severe cases it has proved rapidly curative within the experience of our best practitioners.

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