been infected, and thought that the condition might be due to the sweating caused by the glass; secondly, the fear that I might infect the eye myself by manipulation; third, I was employing an unusual method of treatment, which, if it failed in the end, would have been employed on two eyes instead of one; fourth; the reflection that in case of failure I would have the condemnation of my colleagues, if not of my own conscience. Fifth, I felt that I had the matter completely in hand, and I wished for the right eye to be profoundly infected before I attacked the disease, in order that I might establish my views on this subject firmly and unequivocally.

I saw the patient again at half past one on the same day. The left eye continued to improve, the secretion becoming scantier, only an occasional thread being found in the lower cul de sac, though the lashes were matted together from the former secretion; no chemosis, no swelling of the lid, no pain, except the natural discomfort of an acute conjunctivitis; no corneal complication. The right eye had in the inner corner a ball of moist yellow pus; the eyeball had commenced to be red; the patient complained of great discomfort on that side, was himself convinced that the right eye was infected, and importuned me again to apply the nitrate of silver to that eye. I refused, and determined to wait until six

the same manoeuvre as with the first. The upper lid was turned and the eye was thoroughly cleaned of all pus by 1-3000 bichloride, and the same solution of nitrate of silver was applied in exactly the same manner, with the head in the same position as before and allowed to remain about fifteen seconds. It was then washed off with normal salt solution. Ice applications were ordered, together with the same instructions as had been given for the left eye. Two separate basins and blocks of ice, and two separate sets of pads, however, were used; one for the left and the other for the right side. The nurse was instructed to be careful not to transfer any infection from the right to the left eye.

The following morning at nine o'clock the upper lid of the right eye was slightly swollen, and the same bluish oedema appeared as had been seen in the left. The secretion had become less and the right eye was behaving in all respects exactly as the left had done, except it was running on a schedule twenty-four hours behind. the other.

I now felt that I had the situation completely in hand, and had no fears whatever for the ultimate result. The left eye had by this time ceased to run pus, and from that time on until the case was dismissed there was no untoward symptom of any kind. The treatment was kept up persistently day and night, and the right eye continued twenty-four hours behind the left one in all respects.

To cut the matter short, the patient could have returned home on the fifth day with his eyes simply red. By that time the discharge had entirely ceased in both eyes. Ice applications were stopped on that date, the eyes were simply kept clean, and boracic acid solution was instilled into the lower cul de sac.

On the Friday which completed one week of treatment, the patient returned to his home with his eyes slightly red, but without any swelling of the lid, without any discomfort, and without their being stuck together in the morning, although no salve of any kind was used at night.

when the damage has been accomplished. and the mucous membrane has again become soft. I have not had a case of this disease in the adult to treat since argyrol and protargol have been introduced to the profession. I have used them however in infected keratitis and conjunctival affections characterized by the presence of discharge and I have always obtained good results.

At this writing, ten days from the date. of his infection, the eye is almost perfectly white, and the patient is thoroughly comfortable. This is the history of the

case.

Gonorrhoeal conjunctivitis of the adult and the new born while they have the same etiology are two very different diseases from a clinical standpoint. The prognosis in the new born except in unusually severe cases that have progressed for a considerable time before being seen, is as a rule good, whereas the prognosis of gonorrhoeal conjunctivitis in the adult, is almost always bad and invariably grave.

I, for my part, approach the treatment of the disease in the adult with the profound conviction that the eye will either be entirely lost or irreparably damaged. Added to this is the necessity of continuing the treatment unceasingly day and night for weeks.

The majority of cases of gonorrhoeal conjunctivitis in the adult are seen when the process has gotten well under way when the pus is running in great abundance and when the upper lids have become intensely swollen and the brawny stage is present.

Nitrate of silver has always been my mainstay in the treatment of gonorrhoeal conjunctivitis of the new born at all stages except that in which brawn has appeared, but I have always avoided its use in the gonorrhoeal conjunctivitis of the adult except in the late stages

It is certain, however, that these two latter day agents are not comparable in germicidal qualities to nitrate of silver even in a weak solution. Moreover both argyrol and protargol are nasty and tenacious and it is not so easy to cleanse the eye when they are used as when nitrate of silver is. For these two reasons I do not employ it as often as I do nitrate of silver. On the other hand the latter is painful in strong solution and will leave a permanent stain on organic textures.

The main object, however, in the treatment of our cases should be to get the best result in the quickest way and I have always found that nitrate of silver has given. me that result.

I purposely avoided using argyrol or protargol in order to forestall the statement that might be made by the advocates of these two agents that their use had been instrumental in the success obtained.

When I first saw this case, after diagnosis had been established by the microscope, I recognized a good opportunity to establish the period of incubation of gonorrhoeal conjunctivitis, but my hopes along this line were dashed to the ground by the statement of the patient that he had not only had no gonorrhoea himself but had had no sexual connection within a month, and had come in contact with no suspicious persons during that time. The infection

must have been accidental through the hands of some one whom he met.

So far as I am aware no one has absolutely established the period of incubation of gonorrhoeal conjunctivitis at least in the adult. We know that children are sometimes born with infected eyes, but that ordinarily they become inflamed from 24 to 52 hours after birth, so that the period of incubation of gonorrhoea in the newborn is probably from 24 hours to three days.

This gentleman first stated that he had gone to bed with his eyes completely well, and had risen in the morning with a small amount of pus in the left eye; but a later questioning revealed the fact that he had read in bed up to 3 o'clock, when his eyes felt uncomfortable. The following morning his left eye was affected as has been described. It is fairly safe to say, however, that when I saw the case for the first time, infection had been present anywhere between 12 to 24 hours. At the most, I believe, I saw the case 48 hours after its infection. This will serve, therefore, in a measure, as a rule by which we may apply nitrate of silver in infections of the adult.

It will be recalled that I saw him first at four o'clock and that treatment started at half past six. He noticed his first symptom on arising at 8 o'clock, so that my treatment started within 10 or 12 hours. It will also be remembered that I allowed at least 10 to 12 hours to elapse in the right eye after pus was noticed, before I commenced the treatment, in order that I might have definite data for future guidance. When we consider the dramatic and fearful course which this disease is ac

the

customed to pursue and reflect upon rapid and successful cure which was made of it in this case, the result is gratifying and striking.

For my part, in the future, if I should have a case of gonorrhoeal conjunctivitis in which the lids were still more swollen, and in which chemosis even had already started, I would most certainly attempt to abort it by the same method. My own experience has taught me that nothing can be more fearful than this disease when allowed to run its natural course under palliative treatment, and any attempt to abort it even with severe measures cannot be fraught with much worse consequences than would naturally follow without them.

The result bears perhaps as much upon the prophylaxis in those who treat gonorrhoeal conjunctivitis as upon those who are afflicted with the disease. As soon as I realized that I had the disease well in

my grasp my nervousness in regard to my own eyes and that of my nurses ceased entirely.

We cannot fail to recognize the value of the discovery of the gonococcus by Neisser, and the suggestion of Credé, by the combination of whose efforts this result has been made possible. As soon as pus of a suspicious nature is seen in the eye, bacteriological examination should be made, and if gonococci are present, this method of treatment should be at once employed in detail supplemented by the regulation treatment with which we are all familiar. In this way 8 to 10 hours may be gained upon the ravages of the microbe and success assured even more certainly than in the case described. II E. 48th St.. N. Y.

THE SOCIAL AND CLINICAL AS

PECTS OF TRACHOMA.

BY

AARON BRAV, M. D.,

Medical Director to the Trachoma Institute and Ophthalmologist to the Lebanon Hospital,

Philadelphia.

Clinically we may divide trachoma into four distinct stages, i. e., (a) the formative stage, (b) the acute inflammatory stage, (c) the stage of decline or cicatrization, and (d) the post-trachomatous stage. Every ophthalmologist who had the opportunity to observe a number of trachoma cases will recall the disease in one of these stages. There is no doubt an incubating period which clinically speaking however cannot be recognized, and consequently cannot be taken into consideration in a paper that treats on the subject purely from the clinical point of view. Trachoma in this country runs a milder course than it does in European countries where the disease is more prevalent. In fact a case of blindness as a result of trachoma in this country must be considered a rarity indeed, excepting among the Indians where the disease is much neglected. This must be explained on the rational ground that the general hygienic rules are more readily observed here. Our dwelling places are better, cleaner and more aerated. We give more attention to personal cleanliness; daily or semiweekly bathing is more practiced here than it is in the so-called trachoma districts of Europe and Africa; and above all the people of this country are better educated to the necessity of consulting a physician. in minor ailments in the early stages of the disease. Even the newly arrived immigrant quickly adapts himself to mode of living.

Our

Trachoma is a contagious disease the infectious nature of which is caused by a micro-organism that has as yet not been isolated. In the formative stage of the disease there is no discharge from the conjunctiva and indeed the patient may not be aware of any existing abnormal condition in his eyes. The disease develops slowly and insidiously and advances to the formation of little granules without giving the slightest warning. Occasionally the patient may feel a sense of dryness or roughness on closing the lids. With the formation of little follicles or granules the patient often feels a sensation as if small particles of sand were in the eyes. On examination at this time by everting the upper lids we find that the tarsal conjunctiva is studded with small papillae which is the result of some proliferation of lymphoid tissue. The same is noticeable in the utrotarsal fold probably to a more marked degree. This formative and quiescent stage may last for a considerable length of time. Slight photophobia may also be present at this stage. During this stage the disease is not contagious, there being no discharge from the conjunctiva. Sooner or later however acute inflammatory symptoms set in and it is during this stage of acute inflammation that the disease is most contagious. In the formative stage the disease is absolutely curable and judicious treatment applied will cure the condition leaving no untoward sequelae behind. When however this stage is permitted to pass and the acute stage sets in the disease becomes more serious and less amenable to treatment. Acute trachoma, that is trachoma with a sudden onset without the formative stage, I believe is not seen in this country and I doubt that it exists in any other

country. We must not rely on the patients' statement that they did not have the disease prior to the onset of the acute inflammatory symptoms. Trachoma is essentially a chronic disease that has periodic acute exacerbations. These exacerbations may be the result of a superadded conjunctivitis non-trachomatous in origin. Even in cases of so-called acute trachoma where the patients claim that they always had good eyes a close examination will reveal the fact that for a considerable time prior to the onset of the acute inflammatory symptoms they felt some irritation, some sense of dust particles lodging in the conjunctiva to which they paid no attention. During the acute stage of the inflammation the patient suffers from marked photophobia so much so that the patient has difficulty to keep the eyes well opened. A mucous or mucopurulent discharge is present not only in the morning but may be constant. The conjunctiva is markedly thickened, the follicles and granules as the case may be are much enlarged and the lids as a result of this thickening may droop somewhat. This stage is the most infective stage and great care must be taken to avoid contact with the discharge. It is however well to recall the fact that in many families where one member is affected with this disease during the acute stage, and although no special care is enjoined still other members of the family are not necessarily affected. I have repeatedly found this to be true in the families that I have examined. This would tend to the belief that the infectious nature of this disease has been greatly overrated.

Treatment applied at this stage while effective will require a very long time to effect a cure. One to two years' treat

ment under these circumstances will be necessary. Operative treatment however in suitable cases will shorten the course decidedly. From this stage the disease goes over into the third stage, that of cicatrization. The inflammatory symptoms gradually decline. The photophobia diminishes, the muco purulent discharge ceases, the pain stops, the conjunctiva becomes thinner, the follicles and granules slowly disappear. The conjunctiva is no longer rough but assumes a smooth character and the previous lymphoid cells are converted into fibroblasts, epithelial cells disappear and are replaced by smooth fibrous tissue of the nature of a cicatrix. In favorable cases the contour of the lid is preserved, the integrity and the function of the lid is maintained and the eyes retain an approximately normal appearance. In many cases however the disease passes into the fourth stage, the so-called para or post trachomatous stage. During the third stage of the disease the condition is less. infectious; as a matter of fact the disease has run its course, only the consequent changes in the tissues resulting from the conjunctival inflammation can be observed. The fourth stage may be seen in a quiescent state as well as in an inflammatory state. This may also be observed in the third state. But this inflammation is not caused by the primary causal element of trachoma but is rather of a mechanical nature. Usually the cicatricial fibres in opening and closing the lids and in the movement of the ocular muscles cause traction upon the conjunctiva of the eyeball and thus mechanically causes quite often a recurrent inflammation with slight mucoid discharge which discharge however is no longer infectious. Recurrent ulcerations are very