THE 
Diseases and Injuries 
OF THE 
Conjunctiva, 
Especially the 
So-Called Granulated Lids. 
BY 
JOHN H. THOMPSON, M.D. 
tr / 7 
Professor of Ophthalmology and Otology, Kansas City Medical 
College, Kansas City, Mo. 
FIRST EDITION, 
(With Illustrations.) 
Kansas City, Mo. ' 
HuDSON-KIMBEEIiY PUBLISHING Go. 
1014-1016 Wyandotte Street. 
1897. Vertical section through the upper eyelid of an adult man. (Waldeyei 
Figure 1. 
Copyright, 1897, by Hudson-Kimberly Pub. Co. Kansas City, Mo. DESCRIPTION OF FIGURE 1. 
A. Skin. 
B. Loose connective tissue between the skin and the orbicularis palpe 
brarum muscle. 
C. Orbicularis palpebrarum muscle. 
I). Loose connective tissue between the orbicularis palpebrarum muscle and 
the tarsal cartilage. 
E. Insertion of the levator palpebrarum muscle onto the upper edge of the 
tarsal cartilage. 
F. The tarsal cartilage. 
G. The conjunctiva of the lid. 
H. The epithelium making the cushion at the lower internal angle of the lid. 
I. The intermarginal space between the inner edge of the lid and the opening 
of the Meibomian gland. 
K. The ciliary part of the lid from where the eyelashes project and the orifices 
of the Meibomian ducts. 
L. The region of the so-called conjunctival papillae. 
1. Epidermis. 
2. Skin. 
3. Subcutaneous connective tissue. 
4. Pigment cells of the skin. 
5. Sweat glands. 
6. Hair follicles. 
8. Nerve, cross-section. 
9. Artery, cross-section. 
10. Vein, cross-section. 
12. Modified sweat-gland opening into the dnct of a sebaceous gland. 
13. Muscle of Riolani. 
14. Opening of the duct of a Meibomian gland. 
15. The Meibomian gland. 
16. Posterior tarsal glands under the conjunctiva; evidently belong- 
ing to the lachrymal apparatus. 
17. Rows of cylinder cells at the beginning of the conjunctiva. 
IC. Dense connective tissue of the tarsal cartilage. 
19. The dense connective tissue binding the conjunctiva to the cartilage. 
The dense connective tissue on the outer surface of the cartilage. 
L Membrana propria of the conjunctiva. 
2, Fat cells. 
2 5. Loose connective tissue above the upper edge of the cartilage and between 
the conjunctiva and the levator palpebrarum muscle. 
26. Cross-section of one of the larger arteries of the lid. PREFACE. 
The purpose of this little book is to assist prac- 
titioners and students of medicine to recognize and 
treat the diseases and injuries of the conjunctiva. It 
is not intended that it shall take the place of any of 
the excellent text-books on the diseases of the eye 
written by American and English authors, for it is 
simply a collection of short essays, composed in such 
a familiar style that those who read them shall not 
mistake the writer’s meaning. 
The reason why the author has been prompted 
to publish the book is, he knows from his experience 
as a teacher and his observation as a consultant, that 
the ordinary diseases of the eye are not understood 
by the majority of physicians, since many of them 
have neglected the opportunities offered them at their 
college clinics, and others have not given the eye any 
attention until compelled to do so, for in general prac- 
tice the doctor must be prepared for every patient 
who seeks his help. 
Ordinarily, the diseases of the conjunctiva and 
cornea are not hard to understand, yet that most com- 
mon of all diseases, granulated lids, is one of the 
most difficult and important subjects in ophthal- 
mology. 
The author, believing that it is possible to simplify 
the subject “granular ophthalmia,” hazards the prom- 
ise that if the reader will study this book chapter 
by chapter, beginning at the first and missing 
none until he has finished the disease chronic blennor- 
5 6 
Preface. 
rhoea, lie will understand what the term “granulated 
lids” means, and will ever after treat the diseases 
under that title with more comfort to himself and 
advantage to his patients. 
It is to be admitted that there are some who may 
not agree with the writer in his ideas of the etiology 
and pathology of trachoma, chronic blennorrhoea, and 
follicular conjunctivitis; but, since medicine is not yet 
an exact science, friendly criticism tends to advance 
rather than retard its usefulness. 
If this little book is kindly received and proves 
itself of value, it is intended to add to it, in the near 
future, a similar work on the diseases and injuries of 
the cornea. 
J. H. Thompson, M.D. 
Deardorff Building. TABLE OF CONTENTS. 
Page 
CHAPTER I. 
Anatomy of the Conjunctiva 9 
CHAPTER II. 
General Pathology 18 
CHAPTER III. 
Examination of the Eye 23 
CHAPTER IV. 
Acute Catarrhal Conjunctivitis 29 
CHAPTER V. 
Subacute Catarrhal Conjunctivitis 37 
Simple Croupous Conjunctivitis 37 
Conjunctivitis Pustulosa 39 
Spring Catarrh 41 
Conjunctivitis of Measles 44 
CHAPTER VI. 
Chronic Catarrhal Conjunctivitis 46 
Follicular Conjunctivitis 49 
CHAPTER VII. 
Blennorrhceal Ophthalmia 56 
Gonorrhoeal Conjunctivitis 56 
CHAPTER VIII. 
Ophthalmia Neonatorum 69 
CHAPTER IX. 
Leucorrhoeal Ophthalmia 77 
CHAPTER X. 
Granulated Lids 80 
Trachoma 82 
CHAPTER XI. 
Chronic Blennorrhceal Conjunctivitis 107 
Mixed Trachoma 131 
Granulated Lids, recapitulation 132 
CHAPTER XII. 
Diphtheritic Conjunctivitis 135 
7 8 
Table of Contents. 
Page. 
CHAPTER XIII. 
Phlyctenular Conjunctivitis 141 
CHAPTER XIV. 
Xerosis 154 
CHAPTER XV. 
Conjunctivitis (Herpes, Acne, Eczema) 159 
Pemphigus 172 
CHAPTER XVI. 
Pterygium 173 
Pinguecula 173 
CHAPTER XVII. 
Tuberculosis 182 
Lupus 184 
CHAPTER XVIII. 
Syphilis of the Conjunctiva 185 
CHAPTER XIX. 
Tumors of the Conjunctiva 188 
Warts 190 
Fibroma 191 
Cysts 193 
Sarcoma 194 
Carcinoma 195 
Angioma 196 
Calculi 197 
CHAPTER XX. 
Wounds of the Conjunctiva 198 CHAPTER I. 
ANATOMY OF THE CONJUNCTIVA. 
The conjunctiva is the mucous membrane whicli 
lines the inner surface of the lids and covers the anterior 
third of the eyeball. When the lids are shut, this mem- 
brane forms a closed sac; when they are open, a part of 
it is exposed to the air. It is possible by careful dis- 
section to remove this sac entirely; then it will be seen 
that it has one large opening, corresponding to the open- 
ing of the lids, and several smaller ones, which give 
passage to the lachrymal ducts. 
That part of the membrane lining the lids is ex- 
tremely thin, is intimately adherent to the tarsal carti- 
lages; that which covers the eyeball is thin also, loosely 
attached to the underlying tissue, and is freely movable, 
excepting the corneal conjunctiva, which, being a part 
of the cornea itself, cannot be disturbed. The old 
anatomists taught that the conjunctiva did not cover 
the cornea, but it will be seen, in the description of the 
histology of this membrane, that the conjunctiva does 
not end where the transparent cornea begins. 
Between the tarsal and ocular conjunctiva is quite 
a large extent of membrane, called the retrotarsal folds, 
forming the superior and inferior cul-de-sacs. There 
the membrane is somewhat thicker. To the lids it is 
closely attached, but at the folds it is loose, held in place 
by fibrous strands from the connective tissue of the 
orbit. At the internal canthus, external to the car- Anatomy of the Conjunctiva. 
uncle, which is also a part of the conjunctiva, is found 
a distinct fold of the membrane, of sickle shape, its con- 
cave edge towards the cornea, called the plica semi- 
lunaris. This is the remnant of the nictitating mem- 
brane of birds. In man it allows the eyeball to be 
turned outwards without hindrance. 
It is important for the physician who wishes to treat 
the diseases of the eye to familiarize himself with the 
normal conjunctiva. 
On gently separating the lids, the whole ocular con- 
junctiva may be seen. If the eye is slightly cocainized, 
it is possible, with a probe, to move the membrane over 
the sclera and see how closely it is attached to the edge 
of the cornea. It does not contain many visible blood- 
vessels, but they move with the conjunctiva, which dis- 
tinguishes them from those which lie upon the sclera and 
in the subconjunctival tissues. In this way, even when 
the eye is inflamed, it is easy to tell which vessels belong 
to the conjunctiva and which vessels are a part of the 
ciliary circulation. In children the ocular conjunctiva 
is very transparent; in adults and those who live in 
wind}7, dusty places the membrane becomes somewhat 
opaque, especially that part most exposed to the air; for 
which reason we frequently see two triangular areas 
of hypertrophied tissue on both sides of the cornea; that 
towards the nose being the larger. However marked 
they may be, they never in a healthy eye encroach upon 
the cornea. Close to the nose, at the internal canthus, 
is found the caruncle, a small conglomeration of fat 
glands and hair follicles. It belongs to the conjunctiva, 
and when the membrane is inflamed, takes part in the 
process. In some eyes the caruncle is more prominent Anatomy of the Conjunctiva. 
11 
than in others; it is usually pale red, but on irritation 
becomes easily inflamed. 
The ocular conjunctiva contains many nerves, 
branches of the fifth, and is plentifully supplied with 
lymphatics; these, of course, are usually invisible, but 
sometimes in the conjunctiva of old persons the lym- 
phatic vessels are visible—tortuous, little canals filled 
with lymph fluid. In young eyes the same phenomenon 
may be observed, but it is not so common. 
When the lids are turned, the palpebral conjunctiva 
is brought into view. If the inner surface of the lower 
lid is examined, it will be observed that the mucous 
membrane is extremely thin and intimately adherent to 
the tarsal cartilage. It is so transparent that the 
Meibomian glands are seen arranged in parallel rows, 
perpendicular to the edge of the lid. Contrary to those 
of the upper lid, the retrotarsal folds of the lower lid 
are easily exposed, when it will be observed that the 
mucous membrane is thicker than on the eyeball and 
arranged in a fold at thebottom of the lid, more properly 
in the lower fornix. If it is examined with a lens, 
nothing more than blood-vessels will be seen; neither 
follicles nor glands are found in this place, in the 
healthy eye. 
The conjunctiva of the upper lid differs some- 
what from that of the lower; it also is thin and ad- 
herent to the cartilage, but along the convex edge of 
the cartilage it is thicker than at the center, varying 
according to the age of the individual and his occupa- 
tion. In children the lid is perfectly smooth. In 
especially those who live in the country, where 
the eyes are subject to irritation from the wind and Anatomy of the Conjunctiva. 
12 
dust, the upper edge of the tarsus is rough and thick- 
ened; usually it has a velvety appearance, and through 
a magnifying-glass the so-called papillae may be seen. 
It is important to know that this is a healthy condition, 
for the doctor may mistake them for granulations. The 
reason why the membrane here is rough and thick is a 
mechanical one: the cornea presses less against that 
part of the lid than at its center. 
The color of the normal lid is a delicate pink; but 
when the lid is everted, the blood-supply is partly cut off 
by compression, then the mucous membrane appears 
pale. 
It is very important to examine the superior retro- 
tarsal folds. There the conjunctiva is quite thick, and 
forms a large part of the sac. That part wdiich lies 
immediately behind the lid, between the cartilage and 
the upper edge of the orbit, is smooth. If this lid mem- 
brane is examined when the superior lid is turned and 
pulled up over a spatula, the sharp line of demarkation 
between the tarsal and lid conjunctiva will be seen. 
The superior cul-de-sac is formed of mucous mem- 
brane which covers the connective tissue of the orbit. It 
is plentifully supplied with blood-vessels and lymphatics 
and contains a large amount of adenoid tissue. At the 
upper outer edge of the fornix the ducts from the 
lachrymal gland open into the sac. It is not easy to see 
the superior retrotarsal folds, for the upper lid must be 
turned a second time or the membrane forced into view 
by turning the lid and pushing the eyeball into the 
socket, while at the same time the globe is rolled down. 
Under the outer half of the iconjunctiva of the supe- 
rior fornix and upper lid, above the tarsal cartilage, is Anatomy of the Conjunctiva. 
13 
placed the accessory lobule of the lachrymal gland. The 
secondary gland varies in size: in some it is small; in 
others it is so large that, when the lid is turned, it is 
often seen projecting down from above. This anatom- 
ical peculiarity should be remembered, for attempts have 
been made to cut away the gland, mistaking it for a 
turner. A like error has been committed regarding the 
little fold of conjunctiva under the outer canthus, which 
becomes prominent when the angle of the lids is pulled 
outwards. 
Like all mucous membranes, the conjunctiva is made 
up of three layers; the raembrana propria, the epithelial 
layer, and the submucous connective tissue. The 
framework of the membrane is composed of white 
fibrous connective tissue, with a mixture of elastic fiber. 
In the tarsal membrane there is little, if any, elastic 
fiber; in the ocular conjunctiva there is considerable; 
but at the retrotarsal folds the greatest quantity is 
found. It is this tissue which gives the conjunctiva its 
great elasticity. On the surface of the membrane is a 
distinct basement membrane on which rests the epithe- 
lium. Below the membrana propria is the submucous 
connective tissue, which binds the mucosa to the under- 
lying structures. Over the cartilages there is so little of 
that tissue that the conjunctiva is practically adherent. 
At the cul-de-sac the submucous tissue is a continua- 
tion of the cellular tissue of the orbit. 
Over the eyeball the subconjunctiva is sparing and 
very loose, but on the surface of the cornea the conjunc- Anatomy of the Conjunctiva. 
tiva is condensed to a thin, transparent, homogeneous 
membrane, called, in honor of its discoverer, Bow- 
man’s membrane.* Beween this membrane and the 
true cornea there is no submucosa, for it is impossible 
in a healthy eye to remove it without tearing away some 
of the underlying tissue. 
The memibrana propria is made up of more than 
simple white and elastic libers; it contains numerous 
connective tissue icorpuscles and capillaries. Between 
all these separate tissues there are irregular, open, and 
communicating cavities in connection with the lym- 
phatic system. Where the membrane is extremely thin 
(over the cartilages, for example), the lymph spaces and 
channels are few. In the ocular conjunctiva they are 
numerous and large. A fixed connective-tissue cor- 
puscle may contain pigment, or fat; so it is common to 
find in the mucous membrane over the sclera fat and 
pigment cells. In the two triangular areas of the con- 
junctiva, internal and external to the cornea and most 
exposed to the air, hypertrophied, hyaline-degenerated 
cells and fat predominate 
The lymph spaces contain lymph and lymphatic cor- 
puscles. Some of the spaces are filled with round 
lymph cells, which can be found throughout the entire 
conjunctiva, but in some localities the conglomeration 
of lymph cells is so great that it is called adenoid tis- 
sue. This is especially true of the conjunctiva in the 
upper and lower fornices. The little collections of cells 
*For certain reasons, which will be explained in the chapter on chronic 
blennorrhoea and trachoma, it is well to consider Bowman’s membrane a part 
of the conjunctiva. This is a debatable question, so some histologists may 
not agree with me. But if the reader will accept my opinion in this regard, 
he will easily understand why the cornea is so frequently attacked in diseases 
which are purely conjunctival. Anatomy of the Conjunctiva. 
are closely related to lymphatic glands, but nowhere in 
this mucous membrane are they surrounded by a 
capsule or dignified by a separate capillary system; 
consequently, there are no lymphatic glands in the 
conjunctiva. 
like all mucous membranes, the conjunctiva is cov- 
ered by two or more layers of epithelium, which are 
placed upon a basement membrane separating them 
from the membrana propria. The epithelial cells differ 
in size and shape according to their function and local- 
ity. When the purpose of the cell is to secrete mucus, 
it is long and narrow, and its axis perpendicular to the 
basement membrane; for which reason such cells are 
called columnar cells. When they are to protect the 
surface, they are inclined to be flat and arranged in 
layers. Beneath these cells are always found some 
young epithelial cells, which are small and round. Usu- 
ally the size and shape of an epithelial cell is modified 
by the pressure to which it is subjected. The cells of 
the conjunctiva are of one variety, but appear different 
in different parts of the membrane. Where the surface 
is subjected to pressure, as on the inner surface of the 
upper lid, the cell layers are compressed and the cells 
nearly flat. On the ocular conjunctiva there are fewer 
flat cells, but more round and columnar cells, while on 
the surface at the cul-de-sac the cells are chiefly 
columnar. 
In certain parts the membrane is indentated by folds 
and pockets, which are lined with even rows of col- 
umnar cells, so that when they are cut across for the 
preparation of microscopical sections, they resemble 
glands. These so-called glands are scattered all over Anatomy of the Conjunctiva. 
the conjunctiva. At the upper border of the tarsal 
cartilages the membrane is so cut up by grooves and 
sulci that the surface appears papillary. These papillm 
contain vessels and considerable adenoid tissue; but, in 
a histological sense, they are not papillae. There are no 
mucous glands in and no papillae on the conjunctiva. 
At the upper edge of the tarsal cartilage in the sub- 
stance of the upper lid there are a number of little race- 
mose glands, whose ducts open into the cul-de-sac. 
They are in size and shape very much like Brunner’s 
glands in the intestines. They evidently belong to the 
lachrymal system; but they are so small that they may 
be thought to be a part of the mucous membrane. 
They are under the conjunctiva and are not related 
to it. 
For an account of the nerves, tactile corpuscles, and 
the development of the so-called goblet cells of the con- 
junctiva, the reader is referred to the late works on 
microscopical anatomy. 
The conjunctiva passes over the cornea, carrying 
with it its epithelium, probably some of its lymphatics 
and nerves, but not the blood-vessels. These stop short 
at the edge of the transparent tissue. The epithelium 
is mostly columnar, mixed with round and irregular 
cells placed on a haseonent membrane and covered by 
layers of flattened cells. It is true that the cells on the 
cornea differ considerably in shape and size from those 
of the surrounding conjunctiva, but in no region of the 
body is the continuity of tissue more apparent than over 
the corneo-scleral junction. Anatomy of the Conjunctiva. 
17 
When the lids are closed, the walls of the conjunc- 
tiva are in apposition; the sac contains no air and very 
little fluid. The function of the membrane is to permit 
the lids to move over the eye and the globe to rotate in 
all directions without friction. The sensitiveness of 
the cornea is so acute that the slightest roughness is 
felt. This smoothness of the surface is maintained by 
the tears and the little mucus which is secreted. If 
from any cause the surface of the eyeball and cornea 
dries, and the sensitiveness of the nerves is not be- 
numbed, an irritation is immediately excited, and 
through it an increased flow of tears. So careful is 
Nature to keep the cornea moist, that during sleep it 
is rolled up away from the palpebral slit. Surgeons 
who have removed the lachrymal glands report that 
the patients do not suffer from dryness of the eyes, suf- 
ficient tears being secreted from the palpebral accessory 
glands to meet all ordinary purposes. But when the 
mucous function of the conjunctiva is abolished (in cer- 
tain forms of chronic blennorrhoea, for instance), the pa- 
tients complain that the lids seem to stick to the eye- 
ball, especially on waking in the morning. 
It is essential for good vision that the surface of the 
cornea be moist. This is particularly noticeable when a 
solution of the muriate of cocaine is dropped in the eye. 
The salt benumbs the nerves both of the cornea and con- 
junctiva, so that the reflex action on the lachrymal 
glands and facial nerve nucleus is cut off. The lids do 
not close every fewT seconds; then the cornea becomes a 
little dried. The effect of this on the epithelium is to 
mar its transparency and, in consequence, the acuteness 
of vision. The eye is an extremely sensitive organ; for our 
comfort it is essential that the conjunctiva be healthy. CHAPTER H. 
GENERAL PATHOLOGY. 
The majority of the diseases of the conjunctiva are 
catarrhal or blennorrhceal; so, to treat them success- 
fully, it is necessary to understand the pathology of 
catarrh and blennorrhoea. This short chapter will be 
devoted to that subject. 
A simple catarrh is nothing more than an increased 
activity of a mucous membrane, which means an abnor- 
mal secretion of mucus and serum. The mucus conies 
from the mucous glands, if the inflamed membrane 
contains them; from its epithelium, if it does not. In 
health comparatively few cyclinder cells generate or de- 
generate into goblet cells or suffer mucoid transforma- 
tion. In disease it is different; many of them become 
active. There is an active congestion of the membrana 
propria, and in consequence an over-transudation of 
blood serum, which, collecting in the membrane and 
under it, causes an oedema. The overflow passes to the 
surface,and there,mixing with the mucus,forms the dis- 
charge. As the blood serum passes through the mem- 
brane it carries along with it some of the lymph cells, a 
few leucocytes and many of the round cells from the 
deep epithelial layer. If the inflammation is intense, 
the serum may contain red blood-corpuscles which have 
escaped from the capillaries, either through ruptures or 
by diapedesis. As the process continues, the mucosa be- 
comes filled with leucocytes and newly formed cells. 
18 General Pathology. 
The epithelial covering suffering considerably; micro- 
scopic areas of cell layers are exfoliated, reestablished, 
and again thrown off. When the disease disappears, 
the inflammatory products are absorbed and the epithe- 
lium re-formed. 
In some forms of catarrhal inflammation a peculiar 
coagulum forms on the membrane. From some cause 
which is not understood, the albuminoid and fibrin- 
ogenous materials in the transudation coalgulate upon 
and between the epithelial cells, forming a croupous 
membrane. It is a yellowish, dirty white deposit of 
varying thickness and extent, containing many mucus 
cells and leucocytes imprisoned in a network of fibrin. 
A true croupous membrane is superficial; it never ex- 
tends into the membrana propria. For this reason it is 
presumptive that the exciting cause is either in or on 
the epithelium. Certain mucous membranes are prone 
to croupous inflammation, especially that in the larynx 
and trachea, also the conjunctiva. Croup may accom- 
pany acute or subacute catarrh. It is very common in 
conjunctivitis, for the little white flakes seen in the dis- 
charge are of that character. When an acute catarrh 
loses its intensity and continues indefinitely, it is 
called chronic catarrh, although there is a difference be- 
tween subacute and chronic catarrh. 
The changes found in the mucous membrane in 
chronic catarrh are dependent upon the continued hy- 
persemia. The membrana propria becomes filled with 
new cells which tend to the development of connective 
tissue, which ultimately destroys the glandular char- 
acter of the membrane, if it contains glands, and so al- 
ters the normal circulation in the tissues that the 20 
General Pathology. 
epithelial surface suffers accordingly. The membrane, 
at first hypersemic and thickened, becomes thin, atro- 
phied, and anaemic. These changes are very easily seen 
under the microscope. In a transparent membrane, 
like the conjunctiva, the atrophy is not apparent, but 
it is easy to see the fibrous changes; the membrane be- 
comes opaque, and in some places shrunken. 
Blennorrhoea is a suppurative inflammation of a 
mucous membrane, the discharge containing a large 
proportion of pus—in fact, it is a purulent catarrh. 
Like catarrh, there are two kinds of blennorrhoea, acute 
and chronic. In acute blennorrhoea the catarrhal con- 
dition is intensified; the membrana propria is greatly 
thickened because of an exudation of serum and leu- 
cocytes. In catarrh it is rare for the albumen and fibrin 
to coagulate in the tissues; in blennorrhoea it is the rule. 
So dense may be the deposit that the tissues suffer from 
pressure anaemia. The filling of the small arterioles and 
connective-tissue spaces with white blood-corpuscles 
hinders the free circulation of the blood. Thus is estab- 
lished a passive congestion—plenty of blood,'but little 
nourishment. The result of this may be coagulation 
necrosis of certain cell areas of the connective tissue. 
Other cells lose their vital tone and succumb to the 
attack of micro-organisms or their toxines. In this 
way, minute abscesses collect in the tissues and ulcers 
form on the surface. In a mucous membrane like the 
conjunctiva the swelling will be in proportion to the 
looseness of the submucosa. Over the eye the mem- 
brane may be one-eighth of an inch thick, and so dense 
that when it is cut it will not collapse; at the retro- 
tarsal folds there is nothing to prevent an enormous General Pathology. 
21 
swelling of the tissues; on the tarsal cartilage there is 
a limit. ", | ! 
In blenuorrhoea the epithelial coat suffers exten- 
sively; all the cells may be exfoliated and the base- 
ment membrane destroyed to such an extent that the 
diseased mucosa is exposed. Sometimes, from certain 
causes, the fibrin in the discharge coagulates on the 
membrane; then it is evident that the false membrane 
on the surface and the deposit in the interior are con- 
nected. This is diphtheria. Such a false membrane 
cannot be forcibly removed without tearing away some 
of the mucosa imprisoned in it. It may melt away and 
leave the tissue intact; usually, however, it suppurates 
off, leaving ulcers of greater or less extent. Thus we 
can understand that an acute blenuorrhoea can not last 
indefinitely, the inflammation will in time destroy the 
membrane. 
Blenuorrhoea is always caused by infection. The 
inflammatory process is the endeavor of Nature to 
destroy or cast off the invading host of micro-organisms. 
Some micro-organisms are very active and excite a 
dreadful combat—the gonococcus, for instance; others 
are less irritating, but sufficiently offensive to keep up 
an inflammation more or less intense; such are the 
streptococci, the staphylococci, etc. Between a gono- 
coccus and a living cell there is no compromise; one of 
the two must succumb; usually it is the gonococcus. 
For the time the battle is active, but when it is over, the 
campaign is finished. For this reason gonorrhoeal con- 
junctivitis rarely becomes chronic. 
When a less virulent microbe attacks a mucous sur- 
face, it often, in the beginning, excites an acute inflam- 22 
General Pathology. 
mation. In time, however, it either loses its virulency, 
or the tissues become accustomed to its presence. Then 
the inflammation is less acute and, in consequence, 
prolonged. 
A blennorrhoea is a purulent inflammation of a 
mucous membrane; chronic blennorrhoea is a chronic in- 
flammation of the same kind. In both the micro- 
organisms invade the membrana propria. In catarrh 
the inflammatory new products may be absorbed; in 
chronic blennorrhoea the new cells tend to the forma- 
tion of new growth. There is, in consequence, a large 
increase of adenoid and fibrous tissue. This over- 
growth of adenoid tissue may be diffused over the en- 
tire conjunctiva; but in those places where normally 
adenoid tissue predominates (in the superior and in- 
ferior cul-de-sacs, on the inner surfaces of the lids, over 
the internal margin of the tarsal cartilages) the hyper- 
plasia may be very great. It is these little lymphoid 
tumors which form the so-called granulations. If the 
diseased process is stopped, the excessive cell-develop- 
ment can be absorbed, as in catarrh and acute blen- 
norrhoea; but in tftne the cells develop into spindle cells, 
connective tissue, fibrous tissue, scar tissue! The 
mucous membrane is more or less destroyed; in conse- 
quence, its function is impaired. Such are the changes 
and such the results of chronic blennorrhoea. CHAPTER 111. 
EXAMINATION OF THE EYE. 
It is necessary, for a proper understanding of the dis- 
eases of the conjunctiva, to know how to examine the 
eye. Ignorance or indifference in this respect may lead 
to disastrous results. To turn the lids easily and in a 
moment recognize a disease of the conjunctiva is an ac- 
complishment which can only be acquired by practice. 
There is no excuse to mistake a catarrh for a foreign 
body, or to send a patient a long distance to a specialist, 
who may find a lash sticking out of the punctum 
lachrynialiura. Ordinarily, most of the conjunctival 
diseases can be recognized at a glance, but the glance 
must be a searching one. It is important that the pa- 
tient should be in a good light. One can neither feel 
nor hear a blennorrhoea; he must see it. The brighter 
the light, provided it is not direct sunlight, the better; 
daylight is better than artificial light. The yellow rays 
in gas or lamp light will mask the true color of the mem- 
brane, so much so that an experienced diagnostician 
may hesitate to give an opinion of a conjunctival dis- 
ease at night. The examiner should set the patient be- 
fore the window, if possible; then notice the expression 
of the eyes and note the position of the lids. Are they 
swollen? Do they droop? Is there spasm? Are the eye- 
lashes normal in number and position? Is there any 
moist or dried pus on them? If there is a discharge, is 
23 24 
Examination of the Eye. 
it purulent, mucoid, or principally lachrymal, and does 
it flow over the cheeks? 
He should notice, particularly, the caruncle and the 
exposed ocular conjunctiva; are they congested, in- 
flamed? Is the disease confined to one eye, or has it at- 
tacked both eyes? if so, which the first? 
The physician should learn to use a jeweler’s glass. 
It is a great help. Armed with this lens, he should next 
examine the ciliary border of the lids; there may be 
scabs at the root of the cilia, he must remove them 
and see whether they cover ulcers. The next thing is 
to notice if there are any wild hairs, and see if the 
puncta lachrymalia are normal in position and in 
working order. Of course, if the tip of a cilium projects 
out of the canaliculus and is rubbing against the eye, it 
will be seen. Before going any further, it is proper to 
press against the lachrymal sac with the tip of the fore- 
finger and see if any pus wells out from the puncta. 
If the doctor neglects to do this, he may make a mis- 
take which he will regret. 
To see the ocular conjunctiva and cornea, it is neces- 
sary to gently separate the lids, which should be done 
without pressing upon the eyeball. Sometimes, be- 
cause of spasm and photophobia, this cannot be easily 
done; a drop or two of a solution of the hydrochlorate of 
cocaine dropped into the eye will often make the exam- 
ination bearable; but it must be remembered that co- 
caine bleaches the mucous membrane. 
Following this, one should examine the cornea, look- 
ing for foreign bodies on its surface. Are there any 
ulcers present? Is the cornea clear and transparent? Examination of the Eye.' 
25 
It is essential to note any abnormality either of the 
cornea or iris. Is the pupil dilated or contracted? 
Now is the time to examine the ocular conjunctiva. 
Is it inflamed? if so, how much? Is the congestion 
over the conjunctiva or under it? One must carefully 
look for ciliary congestion; hunt for foreign bodies; 
and, if there is a tumor, note its extent and position. 
The lower lid must be turned down to examine the lower 
cul-de-sac, and to see the extent and character of any 
disease that may be there; at the same time to examine 
the inner surface of the lower lid. Now the upper lid 
is likewise to be turned to examine the surface care- 
fully. One should look particularly for foreign bodies. 
Are there any granulations on the lid? Are the Meibo- 
mian glands to be distinctly seen, and are there any 
scars in the mucous membrane, especially near the lid 
margin? 
It is indispensable to learn the difference between 
granulations of blennorrhoea and trachoma and granu- 
lations springing from the bed of a ruptured chalatzion. 
The examiner should notice the thickness of the lid, 
and determine whether the tarsal cartilage is hypertro- 
phied or atrophied. 
All this may be done quickly, after the student has 
carefully made a study of only a few diseased eyes. 
Sometimes it is not so easy to carryout the recommenda- 
tions referred to above. With children and very ner- 
vous persons the examination may be very difficult. It 
is rare, however, that one is compelled to use a general 
anaesthetic. 
The upper lid is best turned with the fingers. To 
do this properly, these directions should be followed: Examination of the Eye. 
26 
Place the palmar surface of the hand on the side of the 
head, so that the thumb rests on the upper outer edge 
of the orbit. Grasp the eyelashes between the thumb 
and forefinger of the other hand, direct the patient to 
look down, then pull the lid away from the eye, and 
with the thumb push the upper part of the lid down- 
wards and inwards; the lid will turn. The lid is not 
to be turned over the tip of the thumb: it is usually 
turned from above, not from below. If the lid cannot 
be everted in this way, turn it over a probe or a thin 
piece of wood. It is not well to use a lead pencil, for 
if one is not expert enough to turn it with the fingers, 
a lead pencil will be awkwardly thick. Older children 
will usually allow the lids to be turned if they are not 
frightened by formal preparations and instruments; 
young children nearly always object. Then it is neces- 
sary to be very careful, I usually put the child on its 
parent’s lap and drawit backwardsso that its head rests 
between my knees. By this means, I can hold the head 
steadily. I then turn the lid over the back of a hair- 
pin. If the child struggles very much and closes the 
lids spasmodically, it will be necessary to grasp the eye- 
lashes to turn the lid; otherwise the finger simply rolls 
the lid over. This method of turning the upper lid is 
recommended especially for infants. 
This may seem a trivial thing; it is not. Many eyes 
have been lost which could have been saved if pressure 
had not been applied to the eyeball in turning the lid. 
When a large child struggles and will not permit the 
eye to be opened, forcible means are required, especially 
if it is necessary to see the cornea. Children over six Examination of the Eye. 
27 
years of age require am anaesthetic. Younger children 
can be examined between the knees or held by assist- 
ants; then the lids are separated by elevators. If 
these are not to be had, one may readily make them out 
of wire; the back of a hairpin bent over makes a most 
excellent elevator. With these simple instruments the 
examination can be made without difficulty. It is not 
advisable to use a sprang speculum unless the child is 
under an anaesthetic. Usually when the lids are thus 
separated, the eyeball rolls upward. Then it is neces- 
sary to grasp it with forceps and roll it down so that the 
cornea comes in view. It is requisite in these examina- 
tions to learn the exact condition of the cornea. An 
infant may be blind when it is brought to the doctor. 
If he is careless in his first examination, he may not 
recognize the blindness; then in the end he will 
be blamed. This is especially so in ophthalmia 
neonatorum. 
It is a little difficult to see the retrotarsal folds. 
The best way to bring them in view is to turn the upper 
lid, direct the patient to look down, then through the 
lower lid push the eyeball upwards and inwards with 
the thumb of the right hand; the folds will come 
forward. Of course, if there is any disease of the eye- 
ball which makes pressure painful, or the cornea is ex- 
tensively or deeply ulcerated, it cannot be done. In the 
retrotarsal folds look for foreign bodies and granula- 
tions. If there is a discharge on the membrane, note 
whether it is mucus or pus. In the chapter on the treat- 
ment of chronic blennorrhoea it will be shown how im- 
portant it is to give this part of the conjunctiva the 28 
Examination of the Eye. 
most careful attention. An inflexible rule should be: 
Before the examination and after, wash the hands! This 
should not only be a rule, but a habit. It may prevent 
the doctor infecting his patient and may save his own 
eyes. CHAPTER IV. 
ACUTE CATARRHAL CONJUNCTIVITIS. 
Simple acute catarrhal conjunctivitis is an acute 
inflammation of the conjunctiva, characterized by a 
more or less intense congestion of that membrane and 
the exudation of mucus. There is pain, photophobia, 
and lachrymation. Usually there is oedema of the lids, 
especially the upper. The first symptom of an attack is 
an uncomfortable feeling in the eye and the sensation 
of a foreign body under the lid, which is caused by the 
enlarged blood-vessels rubbing against the cornea. The 
sandy feeling usually lasts during the course of the dis- 
ease, but when the mucus and tears flo w, it is, in a meas- 
ure, relieved. That part of the conjunctiva least ex- 
posed to the air is the first attacked; so in the beginning 
the membrane in the lower cul-de-sac will be most 
severely inflamed. In a few hours the inflammation will 
be diffused over the entire conjunctiva, then the car- 
uncle and semilunar fold will become red and swollen. 
As the ocular conjunctiva becomes involved, the blood- 
vessels enlarge and increase in number until the eye- 
ball is covered by a network of capillaries. Usually 
the white sclera shows through the meshes. On careful 
examination it will be seen that the congestion is con- 
fined principally to the conjunctiva. So long as the eye 
is open and the lidis blink every few seconds, the mucus 
and tears collect about the edge of the lids and are 
wiped off, but during sleep the mucus dries and glues 
29 30 
Acute Catarrhal Conjunctivitis. 
the lashes together, so that, on waking, the eye must be 
bathed before it can be opened. The pain may be 
moderate or severe. There is a burning, drawing sensa- 
tion, which is always worse in the afternoon. The eye 
is so irritable that dust and smoke add greatly to the 
discomfort, especially tobacco smoke. Some people 
will not complain much; others, not necessarily nervous 
persons, will find it almost impossible to stay in the 
light and will have so much pain that the physician may 
suspect grave intraocular trouble. 
The swelling of the lids varies in degree. In old 
people with relaxed skin the swelling may be so great 
that the lids are opened with difficulty and the skin 
of the lower lids and cheek looks as if it had been blis- 
tered. This (edematous form of acute conjunctivi- 
tis is very common in the aged, and since the con- 
junctiva may present but little inflammatory evidence 
of disease, it may puzzle the doctor to make a correct 
diagnosis. 
In acute catarrhal conjunctivitis we do not ordina- 
rily see the eyeball very red and covered by large tortu- 
ous vessels. Usually that condition is the result of poul- 
ticing, a favorite but dangerous domestic treatment. 
When the lids are separated, the sticky mucus will be 
diffused over the eye and under the lids, also smeared 
over the cornea, which is the only reason for the blur- 
ring of the vision. If this mucus is removed, the cornea 
will appear particularly bright and clear in contrast to 
the red surroundings; but if its surface is examined 
through a lens, it is not unusual to see that in places its 
epithelium hais been exfoliated, especially at its per- 
iphery. In old people such denuded patches on the Acute Catarrhal Conjunctivitis. 
cornea are common. They do not ordinarily go deeper 
than Bowman’s membrane, and heal rapidly. Similar 
denuded areas are scattered over the conjunctiva, but 
are not easily seen. 
When an eye with a dense pinguecula is inflamed, it 
presents a peculiar appearance. The pinguecula does 
not, like the surrounding conjunctiva, become red, so it 
shows very conspicuously, a yellow-white patch on a 
red base, at the side of the cornea towards the internal 
or external canthus. An inflamed pterygium becomes 
very prominent; an angry, red, fleshy band extending 
from the caruncle to and over the edge of the cornea. 
In acute conjunctivitis the vision is disturbed both 
by the discharge on the cornea and the distress on ac- 
commodation, which is purely reflex; reading cannot be 
continued any length of time. 
This disease is common to all ages, but more particu- 
larly in middle life; yet I do not believe that I ever saw 
a nursing infant suffering from acute catarrhal opthal- 
mia.* Men are more frequently attacked than women. 
The disease occurs sporadically and in epidemics, 
particularly in the spring and fall months. It nearly 
always attacks both eyes, one shortly after the other. 
Acute catarrhal conjunctivitis may be mistaken for 
blennorrhoea, iritis, or glaucoma. In blennorrhoea the 
discharge is purulent. In iritis there is neither mucus 
nor pus in the discharge; it is lachrymal; the conges- 
tion is under the conjunctiva and in the beginning 
around the cornea; the anterior chamber is clouded, 
the iris discolored and contracted; the eyeball tender, 
and the pain more severe at night. If there is any 
*There is a variety of ophthalmia neonatorum which can properly be 
named acute catarrhal ophthalmia, but it is a rare disease. 32 
Acute Catarrhal Conjunctivitis. 
doubt in the differential diagnosis, it can be settled by 
the application of atropia: in conjunctivitis the pupil 
will dilate fully and rapidly; in iritis it will dilate 
slowly, irregularly, or not at all. To mistake iritis 
for conjunctivitis is a fntal error. In acute inflam- 
matory glaucoma the eye is very red and painful, 
the pupil always dilated, the eyeball hard, the anterior 
chamber shallow, and the cornea dull. Glaucoma is a 
disease of the aged and cannot possibly be mistaken 
for conjunctivitis if the physician will be careful. If 
the eyeball is not hard, there is no glaucoma. If there 
is a suspicion of glaucoma, the intraocular tension 
should be tested before using atropia. In simple acute 
iritis the eyeball is apt to be soft. 
Cause.—Acute catarrhal conjunctivitis is often 
caused by a local irritant, such as dust, smoke, etc. The 
most frequent cause, especially in epidemic conjunctivi- 
tis, is a microbe; although, until the micro-organism is 
discovered, it is not unscientific to say that certain forms 
of catarrhal ophthalmia are miasmatic contagious. Ac- 
cording to our present ideas of inflammation, it may be 
correct to say that neither cold nor heat can excite 
this disease; but the evidence that local cold may cause 
it is so convincing that until it is disproved it is safe to 
consider it an etiological factor. The disease is not 
directly contagious—that is, the discharge from one eye 
will not create a like inflammation in another. Some 
authors believe that it will, and support their opinions 
with the fact that there may be several cases in a build- 
ing at the same time; so there may be two or more 
cases of malarial fever in the same house or familv, 
and it is known that that disease is not contagious. Acute Catarrhal Conjunctivitis. 
33 
The materies morhi evidently circulates in the atmos- 
phere, for an endemic will be frequently confined to a 
certain section of a city and among people who are not 
in any way brought in contact with each other. It may 
be that the inflammation is the local manifestation of a 
constitutional disorder, like the subacute conjunctivitis 
of measles, although it must be admitted that there 
are no marked constitutional symptoms. The malaise 
and restlessness are dependent upon the local inflam- 
mation. One attack of acute catarrh does not predis- 
pose an individual to another. If an eye suffers repeated 
at tacks of acute conjunctivitis, there is in all probability 
some exciting cause in or about the eye, which may be 
discovered if sought for. 
Prognosis.—The prognosis of acute catarrhal oph- 
thalmia is good, provided the disease is let alone or 
properly treated. Had treatment or poulticing may 
convert a benign trouble into a serious affair. In old 
people with a tendency to ulceration of the cornea and 
spasmodic entropion the disease may become intract- 
able, but, as a rule, it will get well. Ordinarily it lasts 
from three to ten days; it has no tendency to become 
chronic, and does not naturally leave sequelae. 
Treatment.—The best treatment is rest and the local 
applications of mild astringents. The patient must be 
removed from close, dusty quarters to better hygienic 
surroundings. Bathing the eye with hot water is par- 
ticularly agreeable and beneficial, but poulticing and 
continued hot applications are bad; indeed, they are 
dangerous, and may lead to sloughing of the cornea. 
If the oedema is not great and the inflammation is 
severe, cold applications are better; but the attendant Acute Catarrhal Conjunctivitis. 
34 
should be careful in using ice-cold compresses in old 
people and cachectic individuals. They lower the 
vitality of the tissues, and thus favor ulceration of the 
cornea. As a rule, it is well to let the patient select the 
temperature for the water which is agreeable to him, 
provided the above warnings are heeded. The sov- 
ereign remedy is the nitrate of silver. A solution of 5 
grains to the ounce of distilled water may be applied to 
the inverted lids, and immediately washed off, once a 
day. It is rare that more than three applications are 
necessary to effect a cure. Between these daily treat- 
ments the following eye-wash can be used: 
R. Boracic acid T| drachm. 
Calcined magnesia scruple. 
Water 3 ounces. 
Mix, filter, and make an eye-wash. 
The patient should lie upon a bed or sofa, face up, 
so that the pocket at the internal angle of the eye and 
nose will hold one-half teaspoonful of the fluid; then 
the lids are separated and the wash allowed to run into 
the eye. By lifting the upper lid from the eyeball and 
rolling the eye around, the entire conjunctival sac can 
be washed out. This preparation is very soothing; it is 
a slight astringent and antiseptic. It alone will cure 
simple acute catarrh. When it is not convenient to use 
the nitrate of silver, any one of the mild astringents will 
do. The acetate or sulphate of zinc, one grain to the 
ounce of water, is very good. Astringents of that 
strength may be dropped into the eye three times a day. 
It is advisable not to use the salts of lead in eye-drops, 
for there is danger, if the substance of the cornea is ex- 
posed, of an indelible white deposit of the carbonate of Acute Catarrhal Conjunctivitis. 
35 
lead. During the preparation of this article I saw an 
eye totally ruined by a dense white deposit of the car- 
bonate of lead in the cornea immediately over the pupil. 
It had been a case of corneal ulcer treated for conjunc- 
tivitis with a collyrium of the acetate of lead. Even if 
the epithelium of the cornea is exfoliated, there is dan- 
ger of such a deposit forming on Bowman’s membrane. 
This salt of lead, therefore, in a collyrium is not safe, 
unless the physician who uses it is an expert. A wash 
of the dilute subacetate of lead (without opium) is a 
very nice cooling application to the hot, inflamed eye- 
lids of acute conjunctivitis. 
It is unfortunate that the acetate of load behaves in 
this way, for all the mineral astringents it is the best 
and the least irritating. Alum is an excellent astrin- 
gent, 4 to 6 grains to an ounce of water. 
A great many physicians order distilled water for 
the menstruum of a collyrium, which is a mistake. Pure 
distilled water has an injurious effect on epithelial cells; 
consequently plain filtered water is better. Another 
mistake commonly made is the addition of the sulphate 
of morphine. Morphine tends to irritate rather than 
soothe a mucous surface. Whenever it is proposed to 
stop an eye pain with opium or its derivatives, they are 
better given by the mouth or hypodermatically, Co- 
caine will relieve pain but for a few minutes, when it 
must be again given. Unfortunately, this medicine 
paralyzes the walls of the blood-vessels. Thus it not 
only aids the congestion, but antagonizes the mild 
astringents so useful in the disease. My experience is 
that cold or hot water will relieve the pain of acute con- 
junctivitis. One of the best local remedies for pain in 36 
Acute Catarrhal Conjunctivitis. 
the eye, especially if the cornea is affected, is the sul- 
phate of atropia. Unfortunately, the drug causes 
paralysis of the accommodation, which does not dis- 
appear for some days after it is stopped. Some authori- 
ties believe that atropia is dangerous, for it tends to 
elevate the intraocular tension in old subjects. This 
may be true, but certainly, glaucoma from that cause is 
extremely rare. The spasmodic entropion—turning in 
of the ciliary border of the lower lid—in old people suf- 
fering from acute conjunctivitis can be relieved by hot 
applications or painting the skin of the lid with col- 
lodion, A simple compress below the lid would be good 
if the retention bandage did not prevent drainage. 
This condition only lasts a few days during the acute 
stage, and will usually disappear as the eye improves. 
The sticking together of the lids can be prevented by 
smearing the lashes with vaseline on retiring. Under 
no circumstances should attempts be made to reduce 
the swelling by the application of absorbants, tincture 
of iodine, etc. They will irritate and do more harm 
than good. If the oedema is so great that the lids can 
not be opened—a very extraordinary occurrence in sim- 
ple acute catarrhal ophthalmia—it can be quickly re- 
lieved by multiple puncture, a Graefe cataract knife be- 
ing the best instrument. There is no danger of this 
disease becoming chronic. When the inflammation dis- 
appears, the astringent collyria can be stopped, but it 
is well to continue for a few days the boracic acid wash. CHAPTER V. 
SUBACUTE CATARRHAL CONJUNCTIVITIS. 
Under this heading will be considered certain special 
forms of catarrhal ophthalmia, which, in an etiological 
sense, cannot be ranked with the disease, simple acute 
catarrhal conjunctivitis. They are all subacute ca- 
tarrhs, non-contagious; some are relapsing and others 
have a tendency to become chronic. Chief among these is 
a non-contagious, subacute inflammation of the con- 
junctiva, characterized by the formation on the sur- 
face of the mucosa of a croupous membrane. The 
disease is more common than is usually supposed, 
for a false membrane often forms on the inner sur- 
face of the lids in simple ophthalmia in children. 
The inflammatory symptoms are not severe. There 
may be some swelling of the lids and congestion of 
the eyeball. The discharge is not excessive, although 
it will glue the lids together at night; there is usually 
some photophobia; not much pain. The disease comes 
on suddenly and attacks both eyes. On turning down 
the lower lid, the membrane in the cul-de-sac will be 
found inflamed and swollen; on it long, narrow patches 
of yellow-white deposit. Sometimes it is seen on the 
ocular conjunctiva, but the most favorite locality is 
the mucous surface of the upper lids. This false mem- 
brane is quite adherent; it can be removed by rubbing 
SIMPLE CEOUPOUS CONJUNCTIVITIS, 38 
Subacute Catarrhal Conjunctivitis. 
with cotton and is apt to leave a bleeding spot. It is in 
all respects a croupous membrane; however often it may 
be removed, until the disease is well it will return. 
The amount of false membrane in the eye may be 
limited or excessive. Sometimes the entire con- 
junctiva is covered. It can only be mistaken for diph- 
theria. In diphtheria the inflammation is very severe, 
the lids much swollen and hard, the eye painful, and 
the discharge serous. In croup it is easy to turn the 
lids; in diphtheria it is difficult, often impossible. The 
false membrane in diphtheria is thick, on an angry, 
inflamed base; it cannot be rubbed off, and when it is 
torn away by forceps, it leaves a bleeding surface. In 
diphtheria the cornea is apt to be attacked; in croup 
never. In one there are no acute constitutional symp- 
toms, in the other the fever may be high and the pulse 
rapid. A bacterial examination will make the diagno- 
sis certain. 
Cause.—In determining the cause of this disease, 
it is essential to know whether it is a simple conjunc- 
tivitis with a false membrane, or a true croupous inflam- 
mation. At present it is not known. Sometimes it 
appears to be excited by a special germ; then again it 
has the characteristics of a local expression of a consti- 
tutional disease. At any rate, the disease is most com- 
mon among poor, ill-nourished children living in damp, 
foul, crowded tenements. Until the bacteriologist 
solves the question, it is reasonable to believe that the 
cause is both in the conjunctiva and the blood; there 
being a special tendency in some individuals to develop 
croupous deposits on all inflamed mucous surfaces. Subacute Catarrhal Conjunctivitis. 
39 
Prognosis.—Croupous conjunctivitis, unlike diph- 
theritic conjunctivitis, will get well and not injure the 
eye, excepting in some extraordinary cases like the one 
reported in Chapter XV. There is always some danger 
of symblepharon, but that is remote. Although there 
have been reported cases which lasted for weeks, usu- 
ally the disease is over in a few days. 
Treatment.—The treatment should be constitutional 
and local, good food, fresh air, etc. In some cases the 
syrup of the iodide of iron and cod-liver oil are neces- 
sary. When there is a false membrane on the conjunc- 
tiva, it is not advisable to use local astringents; they 
will do harm. All that is necessary to use in the eye is 
the boracic acid wash or a mild solution of the bi- 
chloride of mercury in salt water, 1 to 4000; 30 grains 
of salt to a pint of water makes a good menstruum 
for the bichloride. In very bad cases care must be 
taken that the conjunctival surfaces do not adhere after 
the membrane comes away. It is best not to forcibly 
remove this membrane, or to try to dissolve it by lime 
juice, papoid, etc.; as long as it is croup it will do no 
harm. This is a relapsing disease; consequently when 
the eye is well, the patient should continue for a time 
the internal treatment and should enjoy the benefits of 
hygienic surroundings. 
A subacute catarrhal conjunctivitis in which the dis- 
ease attacks principally the ocular conjunctiva, the 
mucosa of the lids being not particularly inflamed. 
The characteristic lesion is a small, shallow ulcer 
on the conjunctiva, situated from one-eighth to one- 
CONJUNCTIVITIS PUSTULOSA. Subacute Catarrhal Conjunctivitis. 
fourth of an inch from the edge of the cornea, usual- 
ly on the temporal side of the eye. The ulcer is on 
a broad, elevated base, and is, as a rule, covered by 
the eyelids when they are naturally open. When the 
diffused inflammation is severe, the ulcer is not prom- 
inent; but when the disease is confined to a limited area, 
the lesion is very noticeable. 
Conjunctivitis pustulosa is a misnomer, for at no 
time is there a pustule. The ulcer does not start from 
a ruptured bleb, but begins by the falling off of the 
epithelium from the summit of a wheal. The charac- 
teristics of the ulceration are best seen through a lens, 
when it will be found that its walls are sharp, its floor 
flat and covered by a faint light gray deposit. The 
symptoms are much like acute catarrhal conjunctivitis, 
but less severe. There is a burning pain in the eye, lo- 
cated at the place of the ulcer. The lachrymation may 
be excessive; as a rule, there is not much mucus dis- 
charged. It is rare to find more than one ulcer at a 
time, the first disappearing before a second appears. 
This is a relapsing disease; it attacks chiefly young 
persons, and lasts from five to seven days. It is not 
dangerous. It must be differentiated from pinguecula, 
phlyctenular ophthalmia, and especially episcleritis. 
In the last disease the swelling is in the episcleral tis- 
sues, usually very near the cornea, and i s never ulcerated. 
In episcleritis the disease spot is pink and the color deep 
in the tissue; in conjunctivitis pustulosa it is red, super- 
ficial. One is a chronic disease, the other (conjunc- 
tivitis pustulosa) comes end goes in a few days. Con- 
junctivitis pustulosa and phlyctenular ophthalmia are Subacute Catarrhal Conjunctivitis. 
somewhat alike. The differential diagnosis will be con- 
sidered in the description of the latter disease. 
All the circumstances connected with conjunctivitis 
pustulosa suggest a microbe origin, yet we do not know. 
The treatment is simple. The boracic acid or bi- 
chloride wash is the only local application necessary. 
Astringents are harmful. Sometimes the healing will 
be hastened if the ulcer is cauterized or stimulated by 
touching it with a mild solution of the nitrate of silver; 
dusting a little calomelinto the ulcer i s good. If the pain 
is severe, especially at night, atropia is the best seda- 
tive. It not only soothes, but quiets the reflex irritation 
in the eye itself. Of course, it is essential for comfort 
to protect the eyes by colored glasses. If the attacks 
are frequent, there is some local cause; then it is neces- 
sary to test the refraction, and, if any error, how- 
ever slight, is discovered, suitable glasses should be 
prescribed. 
SPRING CATARRH. 
The profession was first definitely informed of this 
peculiar disease by Aron Arlt, in 1846. Since then it has 
been extensively discussed by the German school of 
ophthalmology, but by the English and Americans little 
has been said of it. It is strange, for in this great Mis- 
sissippi valley it is by no means a rare disease. Every 
year I see many cases. I shall describe the disease as 
I have found it in the West. It comes under the head 
of subacute catarrh, for it is not a very acute inflamma- 
tion of the conjunctiva, nor is it a chronic affection, 
since, when the eyes get well, all traces of it disappear, 
although the patient may suffer repeated attacks for 
years. 42 
Subacute Catarrhal Conjunctivitis. 
In the early spring-time, which in this climate 
anticipates summer but a few days, some children and 
young persons will come to the physician with sore eyes; 
many of them will have simple acute catarrhal ophthal- 
mia, a few the spring catarrh. The eyes are congested, 
irritable, and watery. The lids are not swollen, but the 
lashes may be covered with dried mucus and Meibomian 
secretion. When the patient looks up, the examiner 
will see distinctly that there is an inflammation of the 
ocular conjunctiva, particularly around the cornea, for 
at that place the membrane is slightly swollen and has 
a tendency to chemosis. At the exact edge of the 
Spring catarrh, showing the irregular thickening of the conjunctiva 
around the cornea. 
Figure 2. 
cornea and all around it will be found little bead-like 
tumors, some confluent, others scattered; they are 
waxy red, and, if examined with a glass, will be seen to 
be in the limbus of the conjunctiva. The cornea im- 
mediately adjoining them is clouded, which is very 
superficial and evidently in the epithelium. The little 
tumors are caused by an infiltration in the stroma of the Subacute Catarrhal Conjunctivitis. 
43 
conjunctiva and an active hyperplasia of the superin- 
cumbent epithelium. They are not always small; some 
of them may be quite large, one-eighth of an inch or 
more across. At the edge of the cornea they are 
sharply raised, but gradually fall off to the level of the 
surrounding conjunctiva. They do not have coursing 
towards them large parallel blood-vessels as in phylc- 
tenular ophthalmia, but they are covered by a fine capil- 
lary network. The conjunctiva bulbi is distinctly 
oedematous and slightly opaque. In the lower fornix 
the membrane is not especially inflamed, but on the 
inner surface of the lids it is red, swollen, and rough, 
the so-called papillae over the edge of the cartilages be- 
ing distinct. One of the characteristic, I may say diag- 
nostic, signs, which is seen in no other disease of the eye, 
is a milky appearance of the conjunctiva, especially in 
the lower cul-de-sac and on the inner surface of the lids. 
It looks as if a red surface were washed over with a faint 
white fluid. This remarkable appearance is present 
in main 7 cases, in others it is absent. The disease always 
attacks both eyes simultaneously. The patients com- 
plain of the light, and some of them of an intolerable 
itching of the lids, it being almost impossible to avoid 
scratching them. The eyes are irritable during the day, 
especially in the sunlight, but at night or on dark days 
they are not so bad. Studying and close work are an- 
noying, but if the eyes are not taxed they are compara- 
tively comfortable, barring the itching which comes on 
in spells. The disease attacks children and young per- 
sons, not infants, and rarely adults. It comes in the 
spring, and often lasts through the summer. Some pa- 
tients will be attacked every year, but it has been no- 44 
Subacute Catarrhal Conjunctivitis. 
ticed that as the children grow older the attacks become 
less frequent and less severe. 
The cause of the disease is unknown. It is in all 
probability not constitutional, for the most healthy chil- 
dren are as liable as the poor and weak. lam in- 
clined to believe that it is the bright sunlight and the 
warm atmosphere, for unless the eyes are protected 
from the hot and bright rays of the sun, or the days are 
cloudy, the disease will not moderate. 
The best treatment is a warm boracic acid wash; 
atropia is very soothing. The usefulness of astringents 
is doubtful. The nitrate of silver solution, 0.5 per cent, 
applied to the lids, will sometimes act wonderfully, then 
again it may do harm. lam in the habit of trying one 
mild remedy, then another, until I find something that 
will do good. At bedtime the edges of the lids should 
be smeared with an ointment of the yellow oxide of 
mercury, one grain to the drachm of vaseline. Blue 
glasses should be worn on bright, hot days. By these 
means one may cure the disease or moderate its in- 
tensity. Usually, in spite of all that can be done, it 
comes and goes during the summer, to disappear of its 
own accord in the fall. 
CONJUNCTIVITIS OF MEASLES. 
All persons suffering from acute, infectious diseases, 
especially the exanthemata, are liable to inflammation 
of the eyes. The trouble may be within the eye, in the 
cornea, or on the conjunctiva. The disease which in- 
terests us particularly is the conjunctivitis of measles, 
the prototype of subacute catarrhal ophthalmia. 
This inflammation is as essential to the history of Suhacnte Catarrhal Conjunctivitis. 
45 
measles as the eruption, and is always present in a more 
or less degree. It comes with the dermatitis and is a 
part of the irritation of the entire respiratory mucous 
tract. For a long time it was thought the catarrh ex- 
tended from the nose to the eyes, but it is believed now 
that it is excited in the mucosa of the eyes by the 
matcrics morhi circulating in the blood. It is, there- 
fore, a constitutional disease. 
The inflammation in the conjunctiva is a simple 
catarrh, characterized by some swelling of the lids, con- 
gestion of the entire conjunctiva, severe lachrymation, 
and the exudation of mucus. The eyes are very irritable. 
They do not pain, as a rule, unless the patient is in the 
bright light; for which reason the sufferer should al- 
ways be confined to a moderately dark chamber. It 
comes on suddenly and tends to disappear in a few days. 
Unfortunately, however, it is liable to leave behind 
some slight conjunctivitis, which may not disappear for 
months. 
It is not often that the eyes require any special 
treatment. But should they be unusually irritable and 
painful, with spasm of the lids, the cornea must be care- 
fully examined. A slight keratitis or a tiny ulcer may 
be discovered. Then, of course, atropia is indicated. 
But under no circumstances should any astringents 
other than the boracic acid wash be used. CHAPTER VI. 
CHRONIC CATARRHAL CONJUNCTIVITIS. 
The term chronic catarrh expresses better than any 
other the diseases about to be considered. In a patho- 
logical sense, chronic inflammation means a more or less 
determined disease, characterized by the formation of a 
new connective tissue. In ophthamology this is not 
exactly true, for simple conjunctivitis may last a long 
time, then disappear, leaving the mucosa absolutely 
healthy; at other times permanent changes are estab- 
lished; but whether the mucous membrane is damaged 
or not depends upon the character of the disease and its 
cause. 
In very few organs can a simple chronic inflamma- 
tion last indefinitely without exciting or inviting some 
secondary disturbance, which in the end will over- 
shadow it in gravity; for example, chronic catarrh of 
the bladder, secondary pyelitis; endocervicitis, cancer; 
in the eye, catarrh, then blepharitis, which by interfering 
with the drainage of the tears completes a vicious circle. 
For these reasons a description of a simple chronic 
catarrhal conjunctivitis may be tedious and difficult, un- 
less one limits his remarks to the original complaint 
and ignores the secondary diseases, which he cannot 
always do. 
There is a great difference between an irritable con- 
junctiva and an inflamed one. An individual may 
awake in the morning and find a little white discharge 
46 Chrome Catarrhal Conjunctivitis. 
47 
collected in the internal canthus. Beyond the fact that 
his eyes look a little dulled, he is not conscious of any 
trouble. This condition may last a few hours and then 
disappear until he again subjects his eyes to some irri- 
tating matter, usually bad, smoky air. If, during these 
attacks, the inner surface of the lower lid and the 
mucous membrane in the inferior fornix are examined, 
they will be found slightly inflamed. There may be a 
trace of mucus in the cul-de-sac, but not enough to smear 
the cornea. It is evident that if the cause is continued, 
the result will remain, it being the simpler form of 
chronic catarrh. It is presumptive-that such a person 
has tender eyes, for dust and smoke do not affect the 
majority of people in that manner. Tobacco smoke is 
particularly irritable. Some men work on books and 
smoke at the same time. The heat and fumes from the 
cigar or cigarette irritate the eyes; a slight conjunc- 
tivitis is set up, which may be unnoticed,or it distresses, 
through sympathy, the accommodation. Very often 
the sufferer seeks relief in glasses, which, if they are un- 
suitable, add to the discomfort. 
People who work in dusty places, furnace attendants, 
farmers, and cattlemen have more or less catarrh of the 
eyes. This trouble is not annoying to them, for they do 
not read much by artificial light. The disease is very 
common on the plains, where is is rare to see native 
adults with clear, transparent conjunctive. In adults 
chronic cartarrhal conjunctivitis does not follow acute 
inflammation; with children it is different, for following 
measles it is not uncommon, and many times we are 
justly suspicious that the foundation for the disease 
was laid during an exanthematous fever. 48 
Chronic Catarrhal Conjunctivitis. 
That eye-strain can cause continued congestion of 
the conjunctiva is acknowledged. This is frequently ob- 
served among young subjects who are not suffering 
from great errors of the refraction or accommodation. 
At the present time there are so many opportunities to 
get correct glasses that few people fail to seek relief. 
If the asthenopia is at all distressing, astigmatism is the 
most frequent anomaly. It is surprising what relief can 
be got from cylinders of low degrees and how quickly 
all signs of conjunctivitis will disappear if the proper 
glasses are worn. The profession was a long time com- 
ing to this conclusion, but now that it is an acknowl- 
edged fact, there is a tendency to forget that there 
are other causes for catarrh of the conjunctiva which 
spectacles cannot remove. 
When an irritation like any of the above is continued 
a length of time, the conjunctiva becomes decidedly in- 
flamed, but the redness will be limited to that part of 
the membrane least exposed to the air—on the inner 
surfaces of the lids and on the lower fornix. It is not 
usual for the eyeball to be inflamed unless the eye is 
rubbed or the lids disturbed. The conjunctiva at the 
extreme margin of the lids is inflamed and slightly 
swollen, which gives a peculiar appearance to the eye, 
characteristic of chronic conjunctivitis—viz.,a red band 
along the mucous edge of the lid. Ordinarily there is 
little or no discharge in the sac, but when the eye is dis- 
turbed, the tears collect more freely than usual. On 
turning down the lower lid the pathological changes so 
characteristic of chronic catarrh are apparent. The 
mucous membrane is not only thickened, but may be so 
opaque that the Meibomian glands cannot be seen Chronic Catarrhal Conjunctivitis. 
49 
It is this condition of the conjunctiva which gives the 
sclera a slightly yellow amber color. As said before, 
there is always a tendency in chronic conjunctivitis for 
the papillae (?) at the edge of the upper cartilages to en- 
large, but they never become distinctly condylomatons, 
as in blennorrhoea, nor do they appear scattered over 
the conjunctiva at the center of the lids. The lids may 
look a little rough; as a rule, they are smooth. ' 
The subjective symptoms are the sandy feeling, 
burning and irritation of the eyes whenever the patient 
is in wind, bright sunlight, or artificial light. Many 
complain that on waking in the morning the eyelids feel 
dry. All find that close work, like reading, writing, 
etc., is particularly distressing. 
Chronic catarrh of the eyes in children usually takes 
the form of follicular conjunctivitis, one of the most in- 
teresting diseases, which for a long time was, and even 
now is by some, thought to be related to trachoma. 
FOLLICULAR CONJUNCTIVITIS. 
In youth there is a tendency to the development of 
lymph tissue in a mucous membrane when it is irritated. 
It makes little difference what the irritant is, the conse- 
quent congestion tends to the accumulation and growth 
of adenoid deposits. Consequently, in chronic conjunc- 
tivitis in childhood the conjunctiva is often studded 
with little sago-like bodies, scattered through the stroma 
of the membrane. The favorite place for them is the 
lower fornix, where they are arranged in rows parallel to 
the retrotarsal folds. Under the lens they look like 
little jelly deposits. They may be discrete or confluent. 
In bad cases the entire conjunctiva is covered by them, 50 
Chronic Catarrhal Conjunctivitis. 
but on the inner surface of the lids, where the conjunc- 
tiva is thin, they appear like minute blebs. They will 
be found in the superior cul-de-sac if they exist in the 
lower. The eye is usually a little congested, but when 
the lids are turned to examine them, the congestion be- 
comes marked. At other times, on simply looking at 
the eyes, not touching them, one would not suspect 
that there was anything the matter. Sometimes the 
eyes are watery and there may be a trace of mucus in 
the corners, but on waking in the morning the lids are 
stuck together. The subjective symptoms are the same 
as in the chronic catarrh: irri table eyes, which are easily 
fatigued. As said above, it makes no difference what 
the irritant is, the so-called follicles will appear; often 
it is dust, bad air, and smoke; other times it is a septic 
microbe. If there is a chronic hlennorrhoea in a chiM's 
eye, the follicles will certainly grow. This I believe to 
be of great importance, for it assists materially to a 
better undersanding of a disease not at all uncommon 
in this section of the United States—viz., trachoma. A 
very frequent cause of follicular conjunctivitis is the 
long use of atropia and eserine, especially the latter. 
After either of these medicines has been used a certain 
time, some eyes become irritable and a slight conjunc- 
tivitis arises, which is apt to be follicular. This is not 
in any way related to acute local atropia poisoning, to 
which some people are liable. 
There is a form of catarrhal conjunctivitis which it 
is convenient to call septic, for it is caused by a microbe Chrome Catarrhal Conjunctivitis. 
or its toxines. The germ or poison acts like a specific 
irritant and excites a subacute, non-purulent conjunc- 
tivitis. The disease would have been placed under 
that heading, Subacute Catarrh, if it were not chronic. 
I t is seen as one of the forms of ophthalmia neonatorum 
and in disease of the lachrymal sac. 
Whenever there is a constriction of the lachrymal 
canal the tears will accumulate in the sac. Then the mi- 
crobes and foreign matter washed off the eye collect in 
the distended sac, where they excite a catarrh or a blen- 
norrhoea. In this place they are nourished, and multi- 
ply, and become a medium of infection to the conjunc- 
tiva. A vicious circle is completed. This condition 
may last a long time, but in the end the dacryocystitis 
becomes purulent. The pus which wells up from the 
punctum when the sac is pressed upon is extremely 
poisonous, but it will not generate blenuorrhoeal con- 
junctivitis. The most damage it can do the conjunc- 
tiva is to inflame it. The poison acts more severely on 
the cornea, for if that tissue is inoculated by it, it will 
be destroyed. The majority of cases of abscess of the 
cornea are from that cause. However severely the con- 
junctiva may be inflamed, the conjunctival disease will 
disappear as soon as the sac is opened and drained. 
The purulent discharge simply irritates the mucosa. 
These remarks do not apply to those cases of conjunc- 
tivitis which are secondary to corneal abscess, they re- 
fer alone to the conjunctivitis dependent upon the 
dacryocystitis. The catarrh of the newborn will be 
considered in the chapter on ophthalmia neonatorum. 
Blepharitis ciliaris pustulosa sometimes follows 
chronic catarrh; frequently it causes it. The disease 52 
Chronic Catarrhal Conjunctivitis, 
at the edge of the lids, particularly the lower, not only 
destroys the hair bulbs, but causes contraction of the 
skin to such an extent that the internal margin of the 
lid and the punctum are turned away from the eyeball— 
ectropion; the tears then collect in the eye. These, to- 
gether with the reflected irritation from the diseased 
lids, excite a catarrh, which will continue so long as the 
original trouble lasts. That is a serious condition, for 
when the blepharitis has deformed the lid, it can only 
be relieved by surgical means, which, at best, are 
unsatisfactory. 
Ulceration of the cornea sometimes happens in 
acute conjunctivitis; it may also complicate simple sub- 
acute catarrhal ophthalmia. The lesions are apt to be 
long, shallow ulcers in the cornea, near its edge, and 
not very prominentso, if the examiner is careless, he 
may overlook them. They are very easily discovered 
if the physician uses a jeweler’s glass, when it will be 
noticed that the cornea adjoining them is clouded. 
Another kind of ulcer, common in this disease, is 
irregular in outline, but superficial. The lesion is 
started by a falling off of the corneal epithelium in per- 
sons of low vitality suffering from chronic conjunc- 
tivitis; for which reason it is unwise to use cold applica- 
tions in the treatment of eye catarrhs in the aged. 
The little superficial corneal ulcers or excoriations are 
not dangerous, provided there is no disease of the 
lachrymal sac. If they are the result of chronic conjunc- 
tivitis from that cause, the eye is in great danger, for 
through them the septic material can reach the stroma 
of the cornea and destroy it. Chrome Catarrhal Conjunctivitis. 
53 
Treatment.—Before beginning active treatment one 
should discover, if possible, the cause, which should 
be removed. The eyes must be protected from all sorts 
of irritation. It is not a bad plan to test carefully the 
refraction. Any anomaly, however slight, must be cor- 
rected. Very low degrees of astigmatism with axes 
oblique or against the rule* require correction. The 
same regarding the phorias.f The best local appli- 
cation for chronic catarrh is the nitrate of silver; a 
solution 3—5 grains to the ounce of water may be ap- 
plied to the inner surface of the lids once a day. The 
medicine should be washed off after each application 
and not permitted to touch the cornea. The boracic 
acid wash can be used once or twice between the daily 
treatments. 
Follicular conjunctivitis should be treated on the 
same principles. As the catarrh improves the follicles 
will disappear. Children must be removed from all 
deleterious environments. With them it is not neces- 
sary to be so particular regarding the refraction, for 
*Although the human eye is a wonderfully constructed organ, and for the 
purposes for which it is intended could not be improved upon, yet, in an optical 
sense, it is not perfect, for the curved surfaces of the cornea and lens are not 
accurate. Consequently, a beam of parallel rays of light cannot be exactly 
focused on the retina. The error is usually such that in the vertical meridian 
of the eye the refraction is greater than in the horizontal. Therefore, nearly 
all men are astigmatic in a more or less degree, usually from 0.25—0.5 dioptres. 
Because such astigmatism can be corrected by a minus cylinder lens axis 180° 
or a plus cylinder lens axis 90°, and because this is usually the case, oculists say 
such astigmatism is according to the rule: minus astigmatism, vertical 90° ; 
plus astigmatism, horizontal 180°. If, however, the meridian of greatest re- 
fraction is horizontal, or the meridian of least refraction is vertical, the astig- 
matism is contrary or against the rule. Astigmatism of low degree, according 
to the rule, does not usually cause asthenopia. But when it is against the 
rule, it is often very annoying, and should be corrected by glasses. 
fPhorias, a term used to designate the different varieties of insufficiency 
of the recti or oblique muscles of the eyes. See Tiffany’s "Anomalies of Refrac- 
tion and Accommodation of the Eye,” 1896, page 220. 54 
Chronic Catarrhal Conjunctivitis. 
the usefulness of mild cylinder glasses in infants is 
doubtful, and little boys and girls do not usually require 
spectacles. The mildest astringents are only applica- 
ble: 1 grain of the nitrate of silver to the ounce of 
water; 1 grain of the acetate or the sulphate of zinc to 
the ounce of water;the acetate of lead 2—4 grains to the 
ounce; tannic acid 4 grains to the ounce of water and 
glycerin mixed; boro-glycerin, made by dissolving 
boracic acid in warm glycerin. All these collyria 
may be used two or three times a day, excepting the 
silver, which can be used but once. It is advisable to 
use one remedy for a short time, then change to another; 
and it is important to remember that after the catarrh 
is cured, it will be some time before all the follicles dis- 
appear. But, if the irritating applications are con- 
tinued beyond the necessary time, they will not dis- 
appear. A few follicles will do no harm. The sul- 
phate of copper is too severe and powerful for use in 
children: some may be tempted to use the copper crystal, 
but they will find that it will do more harm than good. 
When the conjunctiva is covered with follicles and the 
cul-de-sacs are full of them, they may be removed by 
crushing them between the thumb-nails or forceps. In 
simple catarrh that operation is rarely necessary. Of 
course, if follicular conjunctivitis follows the use of 
atropia or eserine, they should be discarded. By add- 
ing 1 or 2 grains of the sulphate of zinc to the ounce of 
atropia solution, the irritating effect of the mydriatic 
may be controlled. It requires long experience for the 
doctor to know when atropia is irritating an eye and 
when it is not. Eserine, when it irritates, must be 
stopped; it is better to do an iridectomy than to con- Chronic Catarrhal Conjunctivitis. 
55 
tinue the drug under such circumstances. The only 
treatment for chronic catarrh from disease of the lach- 
rymal sac and canal is to remove the cause by dilating 
the stricture and cleansing the sac. All chronic dis- 
eases are difficult to cure even if curable; they require 
of the physician skill, and of the sufferer patience. CHAPTER VII. 
BLENNORRHCEAL OPHTHALMIA. 
GONOEEHCEAL CONJUNCTIVITIS. 
The blennorrhoeal ophthalmias comprise the most 
important diseases of the eyes, because of their‘fre- 
quency, their destructive tendencies, and the difficulty 
of curing them. The prototype of these diseases is 
gonorrhoeal conjunctivitis, which is caused by infecting 
the conjunctiva with the gonococcus. 
The inflammation begins, usually, in one eye like a 
simple acute catarrh: slight conjunctivitis, some lachry- 
rnation, and the well-known sandy feeling; there is 
some smarting and ocular distress. In a few hours the 
inflammatory symptoms increase; the lids become 
oedematous, especially the upper, which swelling enor- 
mously projects beyond the lower; the conjunctiva be- 
comes very much inflamed. It is likewise oedematous 
and swollen. At the edge of the cornea the swelling 
stops suddenly, so that the conjunctiva is sharply ele- 
vated above the level of the cornea—chemosis; the 
eyeball is very red; there is considerable muco-purulent 
discharge in the sac and very often the tears are stained 
with blood. The lids are not hard at this time, so 
they can be turned, when it will be seen that the mem- 
brane over them is fiery red. The pus now commences 
to flow and collects under the edge of the upper lid; it 
may run down over the cheek. On the lashes and at 
the angle of the lids the discharge dries, forming scabs. 
56 Gonorrhoeal Conjunctivitis. 
57 
There will be considerabe purulent matter inthe sac,so 
that when the lids are pressed upon or separated it wells 
out, one-half drachm or more. The skin of the lids 
and adjoining parts is not only swollen, but hot; it looks 
inflamed. In a few hours there is a change in the ap- 
pearance of the conjunctiva. The oedema gives way to 
plastic infiltration; all the inflamed tissue becomes 
hardened, which makes the turning of the lids difficult 
and painful. Sometimes there will be found a distinct 
croupous membrane under the lids, and if the inflamed 
conjunctiva is much disturbed, it bleeds. The cornea is 
usually clear, but if the chemosis is very great, it will 
look small and depressed, and, as a rule, there will be 
some discharge in the deep corneo-conjunctival angle. 
Even at this early stage, if the pus is washed off and 
the surface of the cornea examined, superficial semi- 
lunar ulcers may be found near its edge. It may be 
necessary to push the chemosis aside to see them, 
when, if they are examined through a lens, they will 
appear well defined. Such is a picture of ordinary 
gonorrhoeal ophthalmia. Sometimes the inflamma- 
tory symptoms are greater, sometimes less. The pa- 
tient may be restless, have some pain and, perhaps, 
fever. If the disease is allowed to run its course with- 
out treatment, the cornea will necrose. The little ulcers 
which start at its edge grow larger and expose the 
corneal stroma to microbic invasion; the entire mem- 
brane becomes infiltrated, abscesses form, the eye rup- 
tures, and the cornea sloughs away, allowing the iris 
and lens to fall forward into the wound. This dread- 
ful accident may happen at any time after the third 
day. At first the discharge is muco-purulent, then Gonorrhoeal Conjunctivitis. 
58 
Figure 3. 
Cross-section of the lids and eyeball in gonorrhoeal ophthalmia, to show 
the swelling of the conjunctiva, the chemosis, the corneal ulcer, and the ac- 
cumulation of pus. 
sanguino purulent, finally pure pus. About the sixth 
day the inflammation commences to recede, the swell- 
ing of the lids grows less, but the discharge continues 
freely from ten to fourteen days, when it gradually 
ceases. The disease lasts about four weeks, and, with 
rare exceptions, leaves the conjunctiva healthy. So far 
as the conjunctivitis is concerned, there is nothing more 
to say; but the lesions to which the cornea is liable 
deserve further consideration. The cornea may be 
destroyed by ulceration, abscess, or necrosis. The 
ulcers usually start at the edge of the cornea under the 
overhanging conjunctiva; they may begin at any part 
of the surface. Marginal ulcers are the most frequent; Gonorrhoeal Conjunctivitis. 
indeed, it is doubtful if any case of gonorrhoeal conjunc- 
tivitis escapes them. If the overhanging fold of the 
chemosed tissue is not pushed aside in the examina- 
tion, the physician may not see them, and will be as- 
tonished some morning to find the cornea almost sur- 
rounded by a ring ulcer. Such ulcers, if not kept clean, 
tend to extend towards the center of the cornea and eat 
into the anterior chamber. The nutrition of the cornea 
is cut off by the constriction of its marginal blood- 
vessels under the dense chemosis. The resulting 
anaemia destroys the vital energy of the corneal tissue, 
.and renders it liable to succumb to the destructive ac- 
tion of the discharges. The first symptom of necrosis 
Section of the cornea in acute purulent ophthalmia. 1. Marginal ulcer, 
never reaches the edge of the sclera. 2. The glacial ulcer. 4. Shows Descemet’s 
membrane being pushed through the thinned cornea. 3. Infected ulcer and 
abscess of the cornea. 
Figure 4. Gonorrhoeal Conjunctivitis. 
is a deep clouding of the cornea; it becomes white and 
in a few hours sloughs away. Abscess of the cornea is 
very common, the purulent process starts at the edge of 
an ulcer, rapidly extends throughout the surrounding 
tissue; and thus the cornea is transformed into a layer 
of pus and rotten stroma. It gives to the intraocular 
tension and breaks away. 
Ulcers which appear during the decline of the dis- 
ease are very peculiar. They are remarkable in being 
non-inflammatory, are transparent, shallow, have slop- 
ing walls, and look as if parts of the clear cornea had 
melted away. They have little tendency to perforate, 
but extend peripherally so that the superficial layers 
of the cornea may be extensively destroyed. On ac- 
count of their transparency, they are difficult to see. 
When they heal, they leave dense cicatrices; but, fortu- 
nately, as they are rarely situated in front of the pupil, 
their opacities do not interfere much with the vision. 
I have called these apparent ulcers “glacial ulcers,” for 
they look exactly like depressions melted into the sur- 
face of a piece of clear ice. 
Cause.—The cause of gonorrhoeal ophthalmia is di- 
rect infection by the gonococcus. It makes little differ- 
ence where the microbe comes from or how it reaches 
the conjunctiva, the result is the same. As a rule, the 
infecting material is carried directly from the genitals 
to the eye by the fingers, sometimes by towels and wash- 
ing materials. The urine from gonorrhoeal patients can 
excite the ophthalmia, which is proof that moderate 
dilution of the pus does not always destroy its infecting 
properties. About half the eyes are infected by the 
discharge from a gonorrhoeal eye; such pus is as dan- Gonorrhoeal Conjunctivitis. 
gerous as that which comes directly from the urethra. 
It is presumptive that pus from very acute clap will 
cause the most intense ophthalmia and vice versa. The 
gonococcus seems to lose its virulence wThen it comes 
from a subacute blennorrhoea. Although the discharge 
from a chronic urethritis or vaginitis will cause an 
ophthalmia, which is apt to be less acute, yet a simple 
vaginitis may give the most severe conjunctivitis. Is 
there a gonorrhoeal antitoxin? Probably; for the 
ophthalmia in an individual who is free of clap is apt 
to be more severe than in one suffering from acute 
urethritis. Physicians and nurses, when they contract 
gonorrhoeal ophthalmia, suffer dreadfully. One of the 
most astonishing things connected with the cause of 
the disease is the few who suffer from it in comparison 
to the thousands who have gonorrhoea. 
Prognosis.—The prognosis is bad; there is great 
danger that the eye will be destroyed. The most expert 
physicians will lose some cases, the poor or indifferent 
ones will lose nearly all. Again, the prognosis depends 
very much upon the severity of the inflammation, the age 
of the patient, and the treatment. I have never seen a 
case of gonorrhoeal ophthalmia in which the cornea was 
not more or less ulcerated. Young patients stand the 
disease better than old ones. The greater the chemosis 
the more the danger of destruction of the cornea. The 
marginal ulcers are not so malignant as the central les- 
ions, which, if they appear early in the disease, will sure- 
ly ruin the eye. A clouded cornea is very dangerous, a 
milky cornea will slough. Abscess of the cornea makes 
the prognosis grave. If the whole or the major part of 
the cornea turns yellow, the eye is lost. The glacial ul- 62 
Gonorrhoeal Conjunctivitis. 
cer is the least dangerous of thecorneal lesions. If it ap- 
pears at the end of the first week, it may destroy much of 
the corneal surface and is apt to penetrate; that is, it 
weakens the cornea so that the aqueous fluid breaks 
through, pushing Descemet’s membrane before it. The 
glacial ulcer rarely destroys the eye, for when the cor- 
nea collapses the melting process stops, and there is 
hope that sufficient clear cornea will remain to justify an 
operation for an artificial pupil. The longer the lids re- 
main hard the greater the danger. When there is an ery- 
sipelatous blush on the skin of the lids and cheeks, it 
shows that the conjunctivitis is particularly severe. 
Sudden pain in the course of the disease means either 
perforation of the cornea or iritis. Ulcers, abscesses, 
and necrosis of the cornea., in gonnorrhoeal ophthalmia, 
progress without much pain. 
Treatment.—To treat a case of gonorrhoeal ophthal- 
mia with any hope of success requires absolute cleanli- 
ness; consequently, if possible, a trained nurse should 
be with the patient day and night until he is well. So 
much depends upon washing the eye and other little 
things which only an expert can do, that, if convenient, 
the patient should be sent to the hospital. Home is no 
place for these cases. The bed should be small, so the 
attendant can reach the patient from both sides. It 
should be in a light, airy, cool room, the surroundings 
clean, and vessels and materials at hand for the im- 
mediate destruction of every rag and piece of cotton 
that comes in contact with the disease. The nursing 
is really more important than the specific treatment; 
therefore considerable space will be given to that 
subject. , - . (hmon'horal Conjunctivitis. 
63 
As a rule, the physician is not called to a case of 
gonorrhoeal ophthalmia until the disease has reached 
the stage of acute inflammation; consequently, when he 
sees the case, there is no doubt of the diagnosis. Some- 
times he will find both eyes inflamed, often one, which is 
fortunate, for the second eye will surely be infected, by 
the first unless immediate precautions are taken. The 
well eye must be hermetically sealed or covered by a 
watch-glass. When called to a case of ophthalmia in 
one eye, see if the second is inflamed; if not, proceed as 
follows: 
1. Take a piece of absorbent cotton and wipe the 
pus off the lids. 
2. Clean your own hands carefully with soap and 
water. 
3. Cover the sound eye with a clean rag rolled up 
and packed carefully under the brow and at the side 
of the nose. 
4. Wipe off thoroughly with moist cotton the face 
and forehead around the bad eye, starting at the sides 
and cleaning towards the eye, but don’t touch it; now 
go over the cleansed area with a solution of the bi- 
chloride of mercury 1; 2000, but be careful that the 
fluid does not wet the rag on the good eye. 
5. Cover the diseased eye with a big bunch of anti- 
septic gauze; then wash your hands again, and clean 
the other side of the face, working from the eye out- 
wards, but be careful not to touch the lids, although 
the angle at the nose must be carefully cleaned; go 
over with the bichloride 1:2000, and dry thoroughly. 
The eye is now prepared for sealing. Over the 
closed lids put a thin layer of absorbent cotton, then Gono'i'rJioeal Conjunctivitis. 
fill up the depression with little pieces of iodoform 
gauze.* Cover the whole with a piece of oiled silk and 
fix the edge to the skin with silk plaster. Cover this 
with collodion, and be especially careful that the cover- 
ing sticks tightly to the bridge of the nose. Such a 
packing will prevent any fluids from the opposite side 
reaching the eye. The dressing should be removed 
every third day. If there is no pus on it, it is not neces- 
sary to open the eye; so long as it is not diseased, keep 
the lids shut. Some prefer to shield the eye with a 
watch-glass. It has an advantage over the pack, since 
the eye can be seen, is well ventilated, and the patient 
is not blinded. Wash as advised in the first instance. 
Take a clean wash-glass and fix it to the brow and 
nose with silk plaster; cover the plaster and skin with 
collodion. Whenever the plaster comes loose, remove 
the glass, clean it, and re-apply it. If this is done in 
time, disease of the second eye will be prevented. The 
patient must keep his hands away from his face and be 
warned of danger. i 
A great many specialists doubt the usefulness of 
constitutional treatment for this disease. They may 
be correct, but it does seem rational to combat the in- 
flammation by such internal remedies in use to control 
acute diseases elsewhere. We have no specific to rely 
on, but we have certain drugs which tend to modify the 
intensity of acute inflammation. 5—6 grains of calomel 
at night, followed in the morning by a glass of Hunyadi 
Janos water, will not only clean out the bowels, but 
act as a derivative. Veratrum viride to soften the 
pulse or aconite to relax the skin, are useful. If the 
*Do not put iodoform gauze next to the skin of the face in a permanent 
dressing, unless you know that it will not irritate. Gonorrhoeal Conjunctivitis. 
65 
inflammation is very severe, small nauseating doses 
of tartar emetic continued for 24 hours are advisable. 
In fact, all constitutional antiphlogistic means at our 
command should be made to assist the local treatment. 
The risk is too great to play with fancy drugs; give the good 
and reliable ones freely. 
The object of local treatment is to keep the inflam- 
mation under control and save the cornea. It is ques- 
tionable if any application can stop the progress of the 
disease if it gets a good start, although we can cetainly 
modify its intensity if we see the eye before the acute 
stage is reached. If one knows that infecting material 
has reached the conjunctiva, which sometimes happens 
to attendants in washing a diseased eye or urethra, he 
must immediately proceed to remove or destroy the 
germs. Place the individual on his back and wash out 
the conjunctival sac with warm salt water, according 
to the method advised in using the boracic acid wash. 
Be sure the fluid reaches the upper cul-de-sac;then wash 
out with a solution of the bichloride of mercury 1:2000. 
Don’t use us it in drops, apply it copiously and thor- 
oroughly; then apply ice-cold compresses for an hour; 
go over the same process again in about two hours. 
Instead of the bichloride, the nitrate of silver, 8 grains 
to the ounce of water, may be dropped into the sac. 
Use 4or 5 drops and let them run over the eyeball, fol- 
low with cold applications to relieve the smarting. 
When about to use silver, wash with plain water, not 
salt water; the salt destroys the silver, but adds to the 
efficacy of the mercury. This solution of silver will 
cause considerable reaction, which must not bemistaken 
for the disease. The artificial conjunctivitis should dis- 66 
Gonorrhoeal Conjunctivitis. 
appear in a few hours. If a large quantity of pus or 
purulent water reaches the eye, there is little hope 
that the disease can be aborted. 
When the lids are very much swollen, apparently 
pressing upon the eyeball, and there is great chemosis, 
to avoid sloughing of the cornea, relieve the tension. 
Give an anaesthetic; then with a pair of strong scissors 
cut the external canthus out to the bone; put the fore- 
finger under the upper lid and raise it from the eyeball; 
the so-called external tarsal tendon will be distinctly 
felt holding the lid to the bone; with a pair of sharp- 
pointed scissors nick the tense tendon until it gives 
way, but be careful not to cut the skin. One blade of 
the scissors should go into the sac, the other between 
the tendon and the skin. This will immediately take 
all pressure off the eye. Permit the wound to bleed 
freely. While the patient is under the anaesthetic, test 
the chemosis with the finger;if it is hard, scarify it; the 
cuts should radiate from the cornea. Clean out the 
sac with a solution of the bichloride of mercury I—3ooo,1—3000, 
and keep on the lids continually ice-cold applications. 
The eye must be washed with the mercurial solution at 
least every two hours, often enough to keep it clean of 
pus. In washing the eye use an eye-dropper, which 
can be pushed up under the lid; syringes are bad and 
dangerous. So long as the acute process lasts, nothing 
more can be done to protect the cornea. Some surgeons 
advise hot applications in preference to cold, claiming 
the swelling goes down quicker and that the heat has a 
good influence on the disease. This may be true. I 
know that cold is good, for it is the bridge over which I 
have many times successfully crossed. As soon as the Gonorrhoeal Conjunctivitis. 
67 
lids can be easily turned, but not before, begin tbe 
nitrate of silver treatment. Ten grains of the nitrate of 
silver to the ounce of water should be the strength of 
the solution; apply it with a came Ps-hair brush to the 
inner surface of the lids, then wash off with plain 
water, not salt water. The object is to allow a diluted 
silver solution to reach the eyeball. The silver acts not 
only as an astringent, but as an antiseptic. All other 
astringents, fancy compounds, and iodoform are use- 
less. He who sticks to the silver will save the most 
eyes. These applications should be made twice a day 
until the discharge ceases, but as the eye improves the 
strength of the solution may be reduced. The wound 
at the angle of the lids will heal without any attention. 
If there are deep ulcers on the cornea, great care should 
be exercised in turning the lid, for there is danger of 
perforation if any pressure is applied to the eyeball. 
We can do nothing for abscess of the cornea, but hope 
that when the disease disappears sufficient transparent 
cornea will be left for an iridectomy. Ido not know 
the cause of the glacial ulcer and know no way to stop 
its progress, unless it be paracentesis. This may be 
tried, but it is dangerous. The chief object of all treat- 
ment is to keep the cornea as clean as possible and pre- 
vent pressure on the eyeball. It is a question if the 
nitrate of silver will shorten the disease many days, A 
gentleman wearing an artificial eye contracted gon- 
orrhoeal conjunctivitis on the blind side. I saw him 
before the inflammation reached the very acute stage. 
He was put to bed in a private hospital, given a special 
nurse, and the good eye covered with a watch-glass, 
every care being taken to prevent secondary infection. 
Twice a day I separated the lids with a spring specu- 68 
Gonorrhoeal Conjunctivitis. 
lum and cleaned out the orbit thoroughly. I then 
swabbed it with a 10-grain solution of the nitrate of 
silver. The orbit was, moreover, cleaned out with a 
solution of the bichloride of mercury 1:3000 every two 
hours day and night. The discharge was not so plenti- 
ful as is usual in gonorrhoeal ophthalmia, but the dis- 
ease lasted one month. This was a case to test the 
abortive effect of the nitrate of silver. My experience 
is, that treatment simply controls the inflammation; the 
disease must run its course. CHAPTER VIII. 
OPHTHALMIA NEONATORUM. 
By common consent, all kinds of conjunctivitis, 
whether purulent or not, which attack children from 
three to six days old, are called ophthalmia neona- 
torum. If the term “ophthalmia” means in this sense 
a purulent disease, it is a misnomer, for diseases of the 
conjunctiva in the newborn are not always suppurative, 
Simple catarrhal conjunctivitis can arise in the early 
days of life. 
The usual ophthalmia is an acute purulent conjunc- 
tivitis, and has nearly all the characteristics of gon- 
orrhoeal conjunctivitis. The inflammation may be as 
severe as gonorrhoeal, but usually it is much milder. 
Between 24 and 36 hours after the child is born a 
slight swelling and congestion of the edges of the lids 
is observed; there will be a little muco-purulent dis- 
charge, which collects at the angle of the lids and on 
the lashes. Very soon afterwards the inflammation 
will be established. If it is to be a severe case, the 
swelling nmy equal that of acute ophthalmia; com- 
monly it is decided, but not excessive. Then the mat- 
ter begins to flow freely; it may run down over the 
cheek, and, because the bridge of the baby’s nose is 
flat, it easily reaches the other eye. Usually both eyes 
are diseased. If the eye is now examined, the conjunc- 
tiva will be seen very much inflamed, but the mem- 
brane covering the eyeball will not be so oedematous as 
69 Ophthalmia Neonatorum. 
in purulent disease in the adult, nor will the chemosis 
be as prominent. At first there will be some difficulty 
in turning the upper lid, but in a few hours it can be 
easily done, because of the swelling of the tissues of the 
superior retrotarsal folds. Often this swelling re- 
sembles granulations, and when the upper lid is turned 
Figure 5. 
Ophthalmia neonatorum, showing the granulations which sometimes project 
from the upper cul-de-sac when the lids are turned. 
they spring into view, a red, granular, suppurating 
mass. This condition may prevent the lid closing down 
on the eye. At other times the swelling is so great 
that when the child cries the upper lid turns out of itself. 
The inner surface of the lid is very red, often covered by 
patches of croupous membrane, and, if it is roughly 
handled, will bleed. 
The cornea is apt to ulcerate, the ulcers starting at 
any place and very rapidly progressing. The cornea 
may slough away entirely, which, unfortunately, is a 
very frequent occurrence; the corneal lesions be- 
ing exactly like those found in gonorrhoeal ophthal- 
mia. Such an inflammation will run from 3 to 6 
weeks. In some cases there is not so much swelling of 
the tissues. The discharge, instead of being thick, yel- 
low pus, is creamy white and profuse. When the lids 
are turned, the retrotarsal granulations do not come in 
view; such a condition one would expect in subacute Ophthalmia Neonatorum. 
ophthalmia. In the first ease the lids are usually 
closed; in the latter they may be open from time to 
time. Even in the modified disease, the cornea is in 
danger. There is another variety of ophthalmia, in 
which the inflammation is very slight, some irritation, 
congestion and slight discharge of pus, enough to glue 
the lids together during sleep and collect about the 
lashes; the child keeps its eyes open, they are irritable, 
and there is evidently some photophobia. 
The catarrhal ophthalmia begins about the fourth 
day; the lids are not red nor swollen, but the eyes are 
slightly inflamed, the conjunctivitis being principally 
behind the lids; there is some mucous discharge and 
excessive lachrymation; the eyes look as if the tear- 
ducts were closed. There is evidently some photo- 
phobia, for the child avoids the light. Thus it is seen 
that ophthalmia neonatorum may be of all grades, from 
the simple catarrh to the most profound blennorrhoea. 
Cause.—Ophthalmia neonatorum is nearly always 
caused by the conjunctiva being infected by tbe dis- 
charge from the maternal vagina during the passage of 
the head. There is no reason why the disease cannot be 
contracted from dirty clothes and fingers. One thing is 
certain, the 7nateries morbi comes from some genital 
mucous surface. Bright light, dirt, smoke, and soap 
do not cause it, so the popular opinion that careless 
nurses are responsible is a cruel mistake. The origin 
of the disease is often gonorrhoea. This statement is 
at present in dispute. Because a child’s father had 
gonorrhoea months, or perhaps years, before is no 
proof that his trouble had any thing to do with his 
offspring’s misfortune. There is strong evidence to the Ophthalmia Neonatorum. 
contrary, for I have seen the disease in children of par- 
ents who never had gonorrhoea. When gonorrhoea is 
the immediate cause, there are no doubts, because the 
inflammation is dreadfully severe and the gonococcus 
can be found in the discharge. That simple leucor- 
rhoeal pus can cause ophthalmia is undoubtedly true; in 
fact, there is reason to believe that a purulent dis- 
charge from the genitals, whatever be its character, is 
poisonous to the eye. 
Prognosis.—If a case of suppurative ophthalmia 
runs its course without treatment, the prognosis is very 
bad; eighty times in a hundred the eyes will be 
destroyed. Some may have damaged eyes and some 
may recover from the disease with good vision. When 
an infant receives proper treatment and care, the 
prognosis is good. There is little excuse for a physi- 
cian to lose an eye if he sees the case early and attends 
to it carefully until it is well. If the eyes are infected 
by gonorrhoeal pus, the progress is doubtful, but not so 
bad as the same disease in the adult. Under the best 
care the cornea may slough. Slight ulceration does 
not endanger the eye very much, for few cases of severe 
ophthalmia recover without some corneal lesion. A 
rapid clouding of the cornea precedes sloughing but a 
few hours, but that is not apt to happen unless the eye 
is neglected. If one eye is diseased, the second rarely 
escapes. The configuration of a baby’s face and nose 
makes bandaging impossible, and certainly no one 
would attempt to fit a watch-glass. Mild cases re- 
quire as much attention as severe ones, for it is sur- 
prising to see how rapidly the cornea may slough, even 
though the lids are not swollen. So long as there is Ophthalmia Neonatorum. 
73 
any pus secreted, there is danger. The disease lasts 
from three to five weeks. 
Simple catarrhal ophthalmia neonatorum is not at 
all dangerous. It is tedious and annoying to physi- 
cians; it lasts for days, even wreeks. 
Prophylaxis.—Within recent years it has been found 
that it is possible to save children from an attack of 
ophthalmia, even though the mother has suffered from 
leucorrhoea up to her lying-in. In all large maternity 
hospitals the prophylactic method of Crede is a routine 
practice. It has enormously reduced the percentage of 
infantile ophthalmia. For this purpose he suggests a 
most powerful, yet harmless, antiseptic. It is a 2 per 
cent solution of the nitrate of silver—9—10 grains of the 
salt to an ounce of distilled water. It should be freshly 
prepared before use. When the baby is born, wipe its 
face with a clean, damp cloth, then dry the skin about 
the eyes. It is well to start the cleaning at the eyes, as 
suggested in the chapter on gonorrhoeal ophthalmia. 
The eyes are by no means always infected, although 
poisonous matter may be on the face; so if the physician 
carelessly washes the face, he may infect the eyes him- 
self. As soon as the child is washed and dressed, sep- 
arate the lids and drop in two drops of the silver solu- 
tion, allow it to remain a second or two, then close the 
lids and wipe off the escaped fluid. One application is 
sufficient; the eyes recover from the treatment in a few 
hours. The disease will be prevented in 95 per cent of 
cases, even if the conjunctiva is infected. If a quantity 
of gonorrhoeal pus has entered the eye, Credd’s method 
may prevent ophthalmia, but I doubt it. 74 
Ophthalmia Neonatorum. 
Treatment.—There is no disease of the eye which 
will respond so certainly to correct treatment as this. 
But it must be remembered that the eyes require the 
most careful attention until all traces of the inflamma- 
tion are gone. It is dangerous to turn over an improv- 
ing case to the care of the nurse or mother. A very 
competent oculist was treating a case of ordinary 
ophthalmia neonatorum: he used the nitrate of silver 
and had almost cured the child; he then prescribed a 
wash, and left the city for a fewT days; when he returned 
he found the inflammation as bad as at first and both 
corneas sloughed away. We often hear physicians 
speak of the virtues of alum water, sulphate of zinc, 
pyoktanin, etc. They may be good and may cure 
some cases, but there are others they will not cure. 
The risk is too great to rely on anything but the nitrate 
of silver. It is true that keeping the eyes clean by 
washing them every hour or so is good treatment, but 
no one should depend on that alone. Whatever be the 
character or degree of the inflammation, the treatment 
should be the same. 
The best treatment is the local applications of a 
solution of the nitrate of silver 3—20 grains to the 
ounce of water. Sometimes it is necessary to make it 
stronger, and when the granulations are excessive, the 
mitigated stick* may be used. The condition of the 
cornea should not modify this treatment whatever. 
When a physician is called to a case of infantile 
*Aegbnti Niteas Dilutes, U. S'.—Diluted Niteate of Silvee. Argen- 
tum nitricum fusum mitigatum, Lapis inf emails nitratus. 
Preparation— Nitrate of silver 1 part; nitrate of potassium 1, 2, or 3 
parts. Melt the salts together in a porcelain crucible at as low a temperature 
as possible, stirring the melted mass well until it flows smoothly. Then cast 
it in suitable moulds. Keep the product in dark amber-colored vials, pro- 
tected from light.— U. .S'. Ophthalmia Neonatorum. 
75 
ophthalmia, he must be sure to examine the cornea, 
for the prognosis should be made at the first visit. If 
the cornea is badly ulcerated or necrosed, the relatives 
must be informed; for if the child loses its eyes, they 
will blame the physician, while they praise the one who 
stops the inflammation, even if they know the eyes 
are The eyes must be kept scrupulously 
clean; the matter removed from the lids as soon as it 
accumulates. The eye is best washed with an ordinary 
dropper, the lids being separated, and the fluid applied 
drop by drop. Water will do, but the bichloride solu- 
tion 1:3000 is better; of course, care must be taken 
that the fluid does not enter the mouth or run down 
the nose, for this preparation of mercury is a little 
strong. It is doubtful if weaker solutions have any 
antiseptic virtues. If, on turning the lids, a mass of 
granulations springs forward from behind the upper 
lid, they should be carefully cauterized by the mitigated 
stick or a 20-grain solution, but the silver must be im- 
mediately neutralized by salt water. The cauterization 
may be made once a day. It is surprising to see how 
rapidly such bad cases improve. If there are no granu- 
lations, apply to the inverted lids a 10-grain solution of 
the nitrate of silver, wash off with plain water; all the 
silver must not be neutralized, a little should reach 
the eyeball. This application should be made morning 
and evening; sometimes it is necessary to use a stronger 
solution. The pyorrhoea should moderate immediately. 
When the excessive flow stops, the intervals between 
the treatments may be lengthened, but it is not advis- 
able to use less than a 1 per cent solution until the dis- 
charge stops entirely. Even then the case must be 76 
Ophthalmia Neonatorum. 
watched a few days, for there is danger of a relapse. 
It is not necessary to examine the cornea at every visit. 
As soon as the discharge commences to diminish, the 
cornea will improve, and all ulcerative processes stop. 
The most encouraging sign is to find that the child 
opens its eyes, which shows that the swelling is going 
down, and that the case is on the way to recovery. 
True gonorrhoeal ophthalmia in an infant requires the 
same treatment as the disease in the adult. Canthot- 
omy may be necessary to relieve the tension, but one 
must not wait until the acute stage moderates before 
commencing the silver applications. A bleeding con- 
junctiva is not a contra-indication to this treatment. 
It is surprising how rebellious and annoying the 
simple catarral ophthalmia may be. The best treat- 
ment is the nitrate of sliver, 5 grains to the ounce, 
applied once a day. During the treatment of opthal- 
mia neonatorum the child must be kept in a clean, well- 
ventilated, cool room. So keep the infant away from 
the stove, and do not let it get heated under a pile of 
bed-clothes and shawls. This is one of the most 
difficult regulations to introduce, for parents and 
nurses have an idea that the baby must be kept hot 
or half-smothered. CHAPTER IX. 
LEUCORRHCEAL OPHTHALMIA. 
As before stated, there is a strong suspicion that 
any purulent discharge from the urethra or vagina will 
excite ophthalmia if it reaches the conjunctiva. Oph- 
thalmia neonatorum is caused in this way, although the 
contagium may not be related to gonorrhoea. Those 
who practice in large dispensaries meet cases of con- 
junctivitis which it is convenient to call leucorrhoeal 
ophthalmia. The conjunctiva is very much inflamed 
and the eyeball very red; there is some swelling of the 
lids so that the upper lid droops—partial ptosis. There 
is no chemosis; the cornea is clear and remains so until 
about the second week, when superficial keratitis and 
the deAmlopment of blood-vessels occur. There is 
always a muco purulent discharge and the eye is ex- 
tremely irritable. The disease usually attacks one eye 
first, but the second may be infected by the discharge 
from the first. There is no characteristic symptom, but 
in every case the tarsal conjunctiva will be found quite 
rough, deeply congested, and velvety. The disease 
tends to become chronic. 
I have no proof that it is caused by leucorrhoeal 
matter, but every case I have seen was evidently of 
that character. A little girl four years old was at- 
tacked by a severe purulent ophthalmia. She was the 
child of well-to-do people. She had not been out of the 
house for several days before the eye inflamed. On 
77 78 
Leucorrhoeal Ophthalmia. 
inquiring into the cause of the ophthalmia, I found that 
the mother was suffering from a profuse chronic, non- 
gonorrhoeal leucorrhcea. The father was healthy. 
A young woman consulted me for an attack of sub- 
acute purulent conjunctivitis; she, too, was suffering 
from a non-specific leucorrhcea. I have seen many 
other cases of like character, when it was not prudent 
to inquire too strictly for the cause. The disease differs 
from the initial stage of chronic blennorrhoea or granu- 
lar ophthalmia is one important respect. It is not 
difficult to cure, and, if properly treated, it will not be- 
come chronic; yet, if neglected, it may run into a condi- 
tion which cannot be differentiated from granular 
ophthalmia. 
The best treatment is the nitrate of silver, a 2 per 
cent solution applied to the tarsal conjunctiva once a 
day. This medicine will smart considerably, so it is 
well to bathe th‘e eyes afterwards with cold water. The 
mild astringents will do no good, and it is not safe to 
rely upon simple antiseptic collyria. In using the 
silver be careful not to let it come in contact with the 
cornea. That tissue does not ordinarily ulcerate, but, 
if it is irritated, it will inflame. Hot eye-baths are 
sometimes beneficial, but warm applications and poul- 
tices are dangerous. It is advisable to keep the eye 
under the influence of atropia. It should be protected 
by smoked glasses, and the patient must avoid a smoky, 
dusty atmosphere. If the silver is used in the morning, 
is not a bad plan to wash out the eye at night with the 
bichloride 1:2000. Should this solution smart severely, 
it may be diluted to 1:3000. It is important to keep up 
the treatment until the eye is perfectly well. As the in- Leucorrhoeal Ophthalmia. 
79 
flammation improves the strength of the silver so- 
lution can he diminished, then the boracic acid wash 
substituted. 
Inflammation of the cornea does not contra-indicate 
this plan of treatment, but it should be irritated as little 
as possible. CHAPTER X. 
GRANULATED LIDS—TRACHOMA—CHRONIC 
BLENNORRHCEA. 
It is doubtful if there is any subject in ophthalmol- 
ogy more important or interesting than granulated lids, 
vel trachoma, vel chronic blennorrhoea. This statement 
is based on the fact that in this Western country there 
are more people suffering from chronic sore eyes than 
any other single disease. It is true more die from 
consumption than lose their sight from chronic blen- 
norrhoea; but there is not a town of 2,000 inhabitants 
in Missouri and the adjoining States in which there are 
not from 20 to 30 persons with some disease of the con- 
junctiva. In our large cities the percentage is even 
greater, and one need only visit the dispensaries to find 
how much more prevalent it is than all other ophthal- 
mic cases. Although chronic disease of the conjunc- 
tiva does not add many to the blind list, it makes an 
enormous number of persons utterly miserable and 
causes the loss of thousands of dollars by rendering so 
many incompetent to work. It is the oculist’s bate noire, 
ever present in his office, ready to rob him of his com- 
fort, his reputation, his conceit, and his time. 
Any one of ordinary experience with the disease 
must have some idea concerning its cause and treat- 
ment. Hundreds have written of granular ophthal- 
mia, yet it is by no means certain that any one has 
mastered the subject. Instructed by one of the best 
80 Granulated Lids. 
81 
authorities on the diseases of the conjunctiva (Von 
Arlt), and closely studying every case it has been my 
fortune or misfortune to treat, I have also reached 
some conclusions, which I present for what they are 
worth, and hope that they may assist some to a better 
understanding of the subject and materially aid to the 
relief of many who suffer now and will in the future. 
One peculiarity which makes the study of this dis- 
ease so difficult is the fact that it differs greatly in dif- 
ferent parts of the world. A German or an Austrian 
writer may be an authority in his own land and his book 
be of little assistance to a practitioner in the Mississippi 
valley. Few men in London know anything of Egyptian 
ophthalmia, and it is doubtful if a New Yorker could 
formulate a plan of treatment to be carried out with 
any great hope of success in Kansas City. I take it 
this is one of the reasons why the profession does not 
agree. Schweiger, in his text-book on the-diseases of 
the eye, says, “The sovereign remedy for acute granu- 
lar ophthalmia is the sulphate of copper.” Evidently 
this is true in Berlin, but here I find that copper is 
often very unsatisfactory, and will not cure 10 per cent 
of the cases. In Vienna I have seen many cases which 
I shall call simple, pure trachoma; in this Western 
country I have seen comparatively few. At the Ameri- 
can Medical Association I have heard my Eastern con- 
freres discuss the subject, when I have been forced to 
the conclusion that in the United States there is a vari- 
ation in type of the disease called trachoma. There- 
fore I believe it would be a waste of time and a confus- 
ing task to quote the many authorities both in this coun- 
try and abroad. In the pages devoted to this subject 82 
Trachoma. 
I shall give my own ideas, with the understanding that 
what I write refers to the disease called granulated lids 
in this great, western, central valley. 
Under the title “Granulated Lids” are three separate 
and distinct diseases: 1, Trachoma; 2, Chronic Blen- 
norrhoea; 3, Follicular Conjunctivitis. An individual 
may suffer from any one of them and have what the 
doctors call granular lids. He may have at the same 
time any two of them—trachoma and chronic blen- 
norrhoea; chronic blennorrhoea and follicular conjunc- 
tivitis; tradhoma and follicular conjunctivitis; indeed, 
the three may be combined in the same person. It is 
this tendency to mix the diseases which makes the sub- 
ject so difficult. For convenience, it is best to describe 
them separately. Follicular conjunctivitis has already 
been considered; consequently I shall begin the (subject 
“Granulated Lads” with a description of the disease 
called trachoma. 
TRACHOMA. 
An infectious disease of the conjunctiva, charac- 
terized by the growth in the stroma of the membrane 
of a number of little round sago-like bodies called 
trachoma follicles. The nodules are about the size of 
the head of an ordinary pin; they are colorless, very 
much like the follicles in common, follicular conjunc- 
tivitis, but differ from them in that they are smaller and 
harder. They may be scattered over the entire con- 
junctiva, but in those places where the mucous mem- 
brane is thick, succulent, and filled with adenoid tissue, 
they are most numerous. So it is not unusual to find 
the retrotarsal folds, especially the upper, so thickly Trachoma. 
83 
covered by them that when the lids are turned they 
spring into view like a mass of frog’s spawn. 
In the lower cul-de-sac there are never so many, but 
in all cases the trachoma bodies will be found deep 
under the inferior lid, if the examiner will use a magni- 
fying-glass. A very favorite locality for them is the 
convex edge of the upper tarsal cartilage, where they 
are usually quite large and distinct. They may be scat- 
tered more or less abundantly over the inner surface of 
the upper lid, but there they differ in appearance accord- 
ing to their depth. On the surface of the membrane, 
they are distinct, round tumors, so when the finger is 
passed over the lid there is a decided roughness; but, 
in the cartilage the neoplasms are small and diffused 
and appear like little, round, white specks about one- 
twenty-fifth of an inch in diameter. Such an eruption 
may be in an eye very little, if any, inflamed; indeed, 
the conjunctiva can be anmmic. This is what is called 
simple non-inflammatory trachoma, a disease rarely seen 
in this part of our country, but common in Europe. In 
nearly all cases there is a slight conjunctivitis; the eyes 
are irritable, and there is a little muco purulent dis- 
charge, enough to slightly glue the lids together at 
night. The trouble may thus insidiously progress for 
months, when suddenly there is a sharp attack of acute 
inflammation, and in an hour the entire character of the 
disease changes. 
Acute inflammatory trachoma is simple trachoma 
plus acute conjunctivitis. Sometimes there is an in- 
flammatory oedema of the conjunctiva and lids, con- 
siderable photophobia, especially if the cornea is at- 
tacked; the lids are tightly closed, and when they are 84 
Trachoma. 
forcibly opened, a quantity of tears, mixed witli mucus, 
flows out. The entire conjunctiva is inflamed, that 
covering the eyeball is very red. Because of the swell- 
ing of the membrane, the trachoma nodules are not so 
prominent as in simple trachoma, but they can be easily 
seen. It appears that the tarsal cartilages are also in- 
flamed, for they are much enlarged, both in length, 
breadth, and thickness. The condition of the lid will 
depend upon the stage of the disease. Trachoma may 
attack the eye as an acute inflammation, when, of course, 
all that will be seen is an eruption of small nodules on 
an acutely inflamed conjunctiva. Usually, however, the 
inflammation attacks an already diseased mucosa, then 
the neoplasms will be found confluent, deep, in places 
cicatrized. It is in such cases that the upper tarsal 
cartilage is hypertrophied, because of the oedema, the 
trachomatous infiltration, and the thickening of the 
mucous membrane. 
It is very rare that the only trouble in the mucous 
membrane is the trachoma. On the inner surface of the 
lids, especially the upper, the conjunctiva is often hyper- 
trophied; at least, there is an increase in the normal 
adenoid-tissue and connective-tissue cells, and in conse- 
quence the so-called papillm are enlarged. Where 
they are free to grow—at the convex border of the carti- 
lage, for example—they resemble little warts, or con- 
dylomata; but on the surface of the lid, where they are 
subjected to pressure from the cornea, they are flat- 
tened, and, being crowded against each other, form a 
number of irregular sulci. Such granulations are also 
found in chronic blennorrhoea. It is very important to 
recognize the difference betwen these simple granula- Trachoma. 
85 
tions and trachoma bodies. In the great majority of 
cases, during such an acute attack, the cornea becomes 
inflamed—acute pannus. The trachoma keratitis will be 
fully described hereafter. It is sufficient to say now 
that the pain, photophobia, and eye distress are chiefly 
dependent upon the secondary keratitis. 
An eye suffering from trachoma is always liable to 
attacks of acute inflammation. Very often the acute 
conjunctivitis is caused by a fresh eruption of trachoma 
follicles; at other times it is excited by those causes 
which occasion simple conjunctivitis—viz., dirt, smoke, 
bad air, eye-strain, etc. The acute exacerbation may 
last several days, even weeks, and, if not properly 
treated, may lead to the most disastrous ulceration of 
the cornea. When the cornea is not involved, the 
attack, although it may pass off in a few days, always 
leaves the eye a little more irritable than before, and 
more liable to a relapse. Thus the disease goes on in- 
termittently from bad to worse, until finally there is 
not enough conjunctiva left to support an acute inflam- 
mation. The disease disappears, because there is no 
more healthy mucous membrane for it to involve. 
The atrophy ends the malady, but, unfortunately, 
there are sequelm, which are even more annoying than 
the original trouble—viz., entropion, pannus, and punc- 
tiform keratitis. It will be remembered that, in the 
chapter on follicular conjunctivitis, it was stated that 
the so-called follicles were always caused by some local 
irritant, which may be dust, smoke, bad air, or trachoma 
bodies. Consequently, in young eyes and many old 
ones a trachomatous conjunctiva may be plentifully 
covered with simple, non-specific follicles, so that it 86 
Trachorna. 
may be impossible for the non-expert to tell which are 
trachoma nodules and which are not. Such cases 
we call mixed—trachoma and follicular conjunctivitis. 
Of course, if these cases are treated for follicular con- 
junctivitis, they will not recover. The trachoma finally 
becomes apparent through the development of scar 
tissue, or by a most certain sign—pannus. I take it, 
this is the reason why some writers deny the existence 
of the disease follicular conjunctivitis, and unhesitat- 
ingly rank all such cases as trachoma. It is true that 
both diseases are very much alike in their early stages, 
They are both essentially chronic, but trachoma may be 
cured with the sulphate of copper, which will invaria- 
bly make follicular ophthalmia worse. The profession 
has disputed, and perhaps always will dispute, the dual- 
ity of the diseases. 
My experience is, it is best to consider them separate 
diseases, for certainly a treatment based on this conclu- 
sion is the best so far discovered. 
Pathology.—A trachoma body is a collection of new 
connective-tissue cells in the stroma of the mucous mem- 
brane, and in the substance of the cartilageimmediately 
under the conjunctiva. It is very closely related to 
the infecting granulomata, but differs from them in 
one important respect: the cells composing the tumors 
do not, as in tubercle, actinomycosis, and syphilis, 
undergo fatty degeneration or cheesy metamorphosis 
but develop into connective tissue. A trachoma nod- 
ule, unless it is absorbed, which very frequently hap- 
pens, necessarily destroys the tissue it involves, by im- 
planting in it an island of scar tissue. A few such 
isolated scars would not interfere very much with the Trachoma. 
87 
function of the mucous membrane, but when the 
trachoma is confluent and large areas of the conjunc- 
tiva are destroyed, serious consequences must result. 
Like all cicatrizing tissue, the trachoma scar contracts; 
thus it is evident that if the inner surface of the tarsal 
Figure 6. 
Cross-section of the lids and cornea in an old case of trachoma, showing atrophy 
of the conjunctiva, atrophy of the tarsal cartilages, and pannus. 
cartilage is badly diseased, the conjunctiva covering it 
will not only become atrophic, but the cartilage will be 
greatly reduced in size, and, because of the contraction 
on its ocular surface, it will be curved inwards. A very 
familiar picture in old cases of trachoma is the de- 
formed lid, which, when it is turned, shows a narrow 
band of fleshy tissue divided longitudinally by a white 
stripe. It is this apparently insignificant band of scar 88 
Trachoma. 
tissue which plays such an important part in the 
changes which take place at the edge of the lid. The 
examiner will notice that in the normal eye the inter- 
nal angle of the lid is a right angle, quite sharp, and 
Section of the conjunctiva of the upper lid in mixed trachoma. A, Tra- 
choma bodies. B, Lymph follicle. C, Enlarged and hypertrophied so-called 
papillae. 
Figuee 7. 
that the edge of the lid fits closely to the eyeball as it 
moves up and down. This angle is formed by a cushion* 
of mucous membrane at the extreme margin of the lid. 
When the conjunctiva lining the lid is destroyed, 
* See Frontispiece. Trachoma. 
89 
the little angular cushion disappears also, so the mucous 
edge of the lid, instead of being square, becomes round. 
The mucous membrane at this place is absorbed be- 
cause the scar, which runs parallel to the edge of the 
lid, cuts off its blood-supply. The deformity not only 
brings the base of the lashes nearer the eye, but it 
allows the curving of the upper lid to turn them down- 
wards—entropion. The same deformity is often seen 
in the lower lid, when the lashes are turned upwards. 
The interference of the lashes of both lids in blinking 
when there is any degree of entropion, together with 
the disturbed circulation and the disease in the carti- 
lage, excite such changes in the hair follicles that the 
cilia not only become diseased, but distorted, and grow 
out irregularly along the cutaneous edge of the lids: 
trichiasis, distichiasis. It is in this way that the lashes 
rub against the cornea. 
Etiology.—The cause of trachoma is evidently a mi- 
crobe, whose size, character, and history are still un- 
known. Some think they have found it, others deny it; 
at any rate, bacteriology has made it more than prob- 
able that a micro-organism is at the root of the evil. 
Excepting chronic blennorrhoea, trachoma is one of the 
most contagious diseases. Evidently the discharge 
contains the materies morhi, and it is only necessary 
for it to reach a conjunctival surface, prepared for its 
reception, to start the disease. 
For a number of years I have thought that tracho- 
ma belonged to the infecting granulomata and should 
be classed with tubercle, actinomycosis, syphilis, etc. 
The trachoma body is the result of a massing of cells to 
destroy or isolate a foreign, irritating substance. Un- Trachoma. 
like tubercle, the cells do not perish, but are trans- 
formed into cicatricial tissue. .Consequently, if I am 
correct, the disease should be most contagious in its 
early and acute stages. This is found to be true, for it 
is not unusual to see an entire family attacked about 
the same time, yet one member of a family may be a 
subject of trachomatous degeneration and none of the 
others be affected. But it is a dangerous disease to 
come among people in any stage. It is important to in- 
quire, Is it necesssary for infection that the virus be 
carried to the eyes by the hand, towels, or some object? 
Perhaps not, for I cannot force myself to the belief that 
drying the pus or secretions destroys the germs or 
spores they contain. It may be true that the gonococcus 
loses in part its virulency when it dries up in the secre- 
tions, for no one ever heard of gonorrhoeal ophthalmia 
contracted in any other way than by direct contact. 
We do not take the gonorrhoea from the air, but we do 
tuberculosis. We know that fresh gonorrhoeal pus 
is extremely infectious; yet, it is not surprising that 
among the millions who suffer from gonorrhoea but a 
very small per cent get ophthalmia? A very dirty, 
careless fellow with acute clap may live for days in 
a close cabin with a dozen or more individuals as care- 
less and dirty as himself and not one contract ophthal- 
mia; but let a case of trachoma or chronic blennorrhoea 
come among them, and in two weeks more than half will 
be diseased. The evidence is strongly in support of 
the belief that the contagium can reach the eyes 
through the air, and that the dried secretions are much 
more dangerous than the moist. It may be said, if this 
were true, none could escape, for a single individual Trachoma. 
91 
would infect an entire community. A few children 
in a family will escape scarlatina, although we know 
that no contagium is as persistent or certain. The prob- 
abilities are that all are not equally susceptible. It is 
presumptive that a healthy conjunctiva is not espe- 
cially liable to contract trachoma; a diseased one is. 
As with children, those who have irritable, flabby 
throats, subject to tonsillitis, are prone to diphtheria; 
so in the eye: a man with chronic conjunctivitis is 
ready to contract either trachoma or blennorrhoea, if 
he has a chance; the diseased mucosa being an inviting 
and suitable culture-field. Ido not believe trachoma 
runs through schools, barracks, and construction- 
camps because the trachoma virus is particularly viru- 
lent, but because those living in close, dirty, smoky, and 
foul quarters are nearly all subjects of chronic 
catarrhal ophthalmia. 
TRACHOMATOUS KERATITIS—PANNUS. 
The behavior of the cornea during the course of this 
disease is so varied and important that it is best at this 
time to consider the causes which lead to that form of 
keratitis we call pannus. It must be remembered that 
pannus is not alone peculiar to trachoma; it is seen in 
chronic blennorrhoea in its most aggravated form, and 
we will find that it is not at all uncommon in scrofulous 
ophthalmia. Pannus is a form of chronic superficial cor- 
neitis, characterized by a clouding of the transparent tis- 
sue and the development of blood-vessels on or near the 
surface of the membrane. The opacity of the cornea is 
caused by the deposit of inflammatory products, some- 
times cells, sometimes cicatricial tissue. In describing 
the anatomy of the conjunctiva, I said one of the 92 
Trachoma. 
proofs that that membrane covered the cornea was 
the tendency of all chronic diseases of the conjunctiva 
to encroach upon the cornea. In trachoma it is not 
at all rare to find the trachoma bodies on the eyeball; 
they also invade the cornea, beginning at its edge. 
When this disease attacks the cornea, it does not form 
nodules, but infiltrates very similar to the little white 
deposits found in the deep layers of the membrane cov- 
ering the cartilage. Such a cellular deposit may be 
above Bowman’s membrane or below it. In the first 
instance the neighboring epithelial layers are ranch 
disturbed and thickened; in the latter the surrounding 
cornea is inflamed. This localized keratitis leads to 
the formation of new blood-vessels, which approach the 
diseased spot from the nearest conjunctival edge. Since 
the disease nearly always invades the cornea from 
above, the clouding and capillary development begin at 
its upper border. The trachoma infiltrate may be ab- 
sorbed, frequently it generates into scar tissue, often it 
breaks down into an ulcer. If this happens before 
the cornea becomes vascular, the ulcers may become 
necrotic and greatly injure the eye; usually, on account 
of the plentiful supply of blood from the vessels of the 
pannus, they heal rapidly, but always leave indelible 
scars. This kind of pannus will form irrespective of 
the condition of the lids. When the upper lid is ex- 
tensively covered by trachoma bodies and hypertro- 
phied papillae, so that it feels rough to the finger, it is 
evident the cornea must suffer. There results a trau- 
matic, superficial keratitis and great hypertrophy of the 
epithelial layer; consequently, the blood-vessels de- 
velop as in all forms of keratitis. This may be called Trachoma. 
93 
friction pannus. These two forms of keratitis may 
arise in simple trachoma and from the two causes be 
combined. They are very slow in forming, but when the 
eye is suddenly inflamed from some extraneous cause, 
the corneal disease becomes aggravated. Then is the 
eye tender, the lids closed and swollen, and the photo- 
phobia intolerable. Every attack of this kind mars so 
much more the transparency of the cornea. 
There is a peculiarity about the circulation in pan- 
nus which explains how it is that a cornea almost clear 
and anaemic can within a few hours become covered 
with capillaries. A blood-vessel once formed in the 
/substance of the cornea will remain a long time. 
When the cause which provoked the growth of the 
vessel disappears, the blood ceases to circulate in it, the 
current stopping at the edge of the cornea. Usually 
one cannot see the vessel wall, so when it is empty, it is 
invisible. The moment the eye becomes inflamed and 
an irritation starts afresh in the cornea, the circulation 
is reestablished. This is the only explanation I can 
offer for the phenomenon, for it is not possible that 
new capillaries can grow in so short a time. It must 
be noted that even in a clear cornea of one who has had 
a pannus a few vessels may be discerned through a 
magnifying-glass. In simple superficial pannus the 
blood-vessels come from the conjunctiva, in pannus of 
deep keratitis the vessels come from the episcleral 
plexus. It is doubtful if many cases of trachoma con- 
tinue long without some pannus, but some escape 
severe disease of the cornea, so there may be a very 
badly scarred conjunctiva and yet a clear eye. 
A very peculiar form of inflammation of the cornea 94 
Trachoma. 
common in the degenerative stage of trachoma is the 
punctiform keratitis, which commences, a little white 
speck on the cornea, apparently in the epithelium; it 
is not confined to any region of that membrane, but 
may appear at any place. It comes suddenly, and, for 
a little affair, causes an immense amount of distress. 
An eye which before has been comfortable suddenly 
becomes injected and lachrymosed. There is always a 
great degree of photophobia. The eye smarts; it is 
painful. When the cornea is examined, a little phlyc- 
tenule will be found. The infiltrate always breaks down 
into an ulcer, which usually penetrates Bowman’s mem- 
brane. It heals readily, if not irritated, but is apt to 
be followed by others. Then the attack may last for 
weeks, and during that time the patient can scarcely 
approach the light. Sometimes these ulcers become 
infected, when they grow larger and are surrounded by 
a ring of inflamed cornea. What they are and the 
cause Ido not know. They are liable to attack the eye 
at any time; any irritant may start them, especially 
strong astringent collyria. 
Whenever the cornea becomes badly inflamed in 
trachoma, there is danger of iritis. 
Treatment.—To treat trachoma successfully re- 
quires of the practitioner an exact understanding of the 
disease, backed by experience. When properly handled, 
very much can be done for an eye, but if a mistake is 
made either in the diagnosis or the treatment, irrepar- 
able injury will be the result. Trachoma is essentially 
a chronic disease and requires the most careful man- 
agement. Although very much can be done for it, some 
cases can only be relieved., and some cannot be con- Trachoma. 
95 
trolled at all. In the most hopeful cases the treatment 
will last from six months to a year. A doctor may con- 
sider himself fortunate if he can certainly cure the dis- 
ease in two years. It is the tendency to relapse which 
not only annoys the attendant, but destroys the confi- 
dence of the patients. For this reason they go from one 
surgeon to another. So it is unusual that one has an op- 
portunity to handle the disease from its beginning to its 
end. It is a poor man’s disease, rich men have it also; to 
cure it brings the doctor little more than satisfaction, to 
fail injures his reputation. He secures the confidence of 
a community by a brilliant piece of work, which is 
undermined by the first batch of trachoma cases his 
name has attracted. 
The principle in the treatment is: Reduce the dis- 
ease to its simplest form, then treat it with the sulphate 
of copper. When this can be done, it can be surely 
cured, but, unfortunately, it is often extremely difficult. 
Some believe that the sulphate of copper is a specific 
for the disease. It is possible it has no advantage over 
the nitrate of silver other than it can be used longer 
without straining the conjunctiva. It may be that 
copper destroys the etiological organism. This can be 
neither proved nor disproved. A trachoma follicle 
which is slightly irritated from time to time and al- 
lowed in the intervals to remain quiescent will be ab- 
sorbed. If the irritation is kept up continually, the 
neoplasm will grow larger and undergo cicatricial de- 
generation. There is no medicine which can in any 
way equal the crystal of the sulphate of copper for the 
purpose of intermittent irritation. If a smooth crystal 
of the salt be passed over the inverted lids, it will cause 96 
Trachoma. 
an intense congestion of the conjunctiva; it will burn 
severely and the tears will How. The irritation will last 
an hour or so, when the eye returns to its former condi- 
tion. If the copper is rubbed on the lid, the irritation 
will last longer, if it is rubbed on extensively, it may 
cause sloughing of the mucous membrane; then, of 
course, the reaction will be violent and continued. So, 
it must be remembered that the sulphate of copper is 
not only an astringent, but an escharotic. The sloughs 
it makes are isuperficial; those made by the nitrate of 
silver may be deep. Copper is an antiseptic, but in 
this regard it cannot be compared to the silver salts. 
It is strange that the trachomatous conjunctiva, when 
irritated by the copper, does not usually react violently, 
yet it will not tolerate the irritation from particles of 
foreign matter. It may be said that a copper conjunc- 
tivitis is a specific inflammation which is very acute, 
but is soon over. As before stated, we rarely see 
simple trachoma in the country; it is usually mixed 
with other diseases, blennorrhoea and follicular con- 
junctivitis. These will not tolerate copper; consequently 
they must he cured before the trachoma is attacked. The 
treatment of chronic blennorrhoea cannot be cousid 
ered here. 
Given a case of simple trachoma in its early stages, 
wherein the mucous membrane and the retrotarsal 
folds are covered with soft trachoma follicles, the first 
thing to do is to remove as many of them as possible 
by surgical means, provided in doing so the conjunctiva 
is not extensively lacerated. The turned lid may be 
caught between the thumb-nails and the contents of the 
follicles squeezed out. We may use Knapp’s roller Trachoma. 
97 
Figure 8. 
Knapp’s Forceps. 
forceps and press them out. Prince’s forceps are very 
good and serviceable, for with them we can reach the 
entire conjunctiva. With these instruments as many 
Figure 9. 
Prince’s Forceps. 
of the follicles as possible must be removed, but under 
no circumstances should force be used. If the disease 
is in young, delicate, or nervous persons, an anaesthetic 
is advisable, for the operation is paiitful, I prefer 
beforehand to scarify very carefully the diseased sur- 
face, so that the contents of the follicles can easily es- 
cape through the cuts. 
When the operation is completed, it is well to rub 
over the raw surface a piece of cotton, wrapped around 
a match, wet with a solution of the bichloride of 
mercury 1:2000; and get as much of the antiseptic into 
the tissues as possible. The lids should be covered by 
a cold compress an hour or so, then the eyes let alone 
for twenty-four hours, when the bichloride rubbings 
should be renewed. This operation will cut short the 
treatment at least four months. 
The profession can never pay Doctor Hotz the debt 
it owes him for the introduction of this procedure. 
Disease of the cornea does not contra-indicate the opera- 98 
Trachoma. 
tion. Indeed, it is astonishing to see how quickly the 
eye will get better. Some authors rather condemn it, 
claiming that the lacerations leave scars. That is 
true, but the trachoma itself will do the same and be a 
longer time about it. When the lids no longer bleed 
during the antiseptic rubbings, it is a good plan, if the 
inflammation does not subside, to use a mild solution 
of the nitrate of silver, 1 or 2 grains to the ounce, as in 
the treatment of simple conjunctivitis. The eyes 
should be protected from the light by blue glasses, 
and under no circumstances should the patient go 
about a barn or stable, or be in a place where the air is 
dusty or smoky. When the congestion and irritation are 
gone and there is no keratitis, then is the time to begin 
the copper treatment. Procure a good, large crystal 
of the sulphate of copper, file it into a convenient shape, 
being careful that the axis of the crayon is parallel to 
the axis of crystallization; then rub it on a damp 
towel, so that it becomes perfectly smooth; be careful 
that there are no sharp flaws on it. Turn the upper 
lid and pass the crystal over it once, then wash off the 
lid with a camel’s-hair brush dipped in water ; re-turn 
the lid, and let the patient bathe the eyes in cold water. 
The next day let the edge of the crayon go a little 
underneath the inverted lid. Every day make the ap- 
plication a little more thorough, until finally the entire 
diseased surface is reached. During this time watch 
the cornea. If it shows the slightest sign of inflamma- 
tion, if it ulcerates, or a phlyctenule appears, stop the 
treatment immediately, for, if it is then pushed, there is 
danger that the cornea will become badly diseased. 
In such instances observe the rule, reduce the disease Trachoma. 
99 
again to its simplest form, and start the copper treatment 
anew. After repeated trials, the eye may be taught to 
stand the treatment; then it is on the rapid road to re- 
covery. If the eye reacts badly, either the copper cannot 
be used at all, or the applications are too severe. 
When the eye stands this treatment, the trachoma dis- 
appears, the pannus clears up, but the cornea will never 
again be perfectly transparent. In some old cases of 
trachoma with dense pannus, even if there be no 
trachoma bodies on the lids, although the conjunctiva is 
covered with scars, the copper treatment is useful; the 
cornea will clear up very much, and it is possible to get 
fair vision. What should be done in an attack of acute 
inflammatory trachoma? My experience is, it is best 
to institute no active treatment, but use such gentle, 
soothing remedies that Nature may be assisted to hurry 
through the acute stage. 
For the keratitis nothing can equal atropia. Use 
a strong solution, 4 grains to the ounce; see that it is 
neutral and that when it is dropped into the eye it 
reaches the cornea. Tio relieve the spasm of the lids, hot 
eye-baths are efficacious; sometimes cold are better. If 
the oedema of the lidis is excessive, multiple punctures 
with a Grade cataract-knife are advisable. Oounter- 
irritation over the forehead will allay the irritability of 
the eye. For this purpose use an ointment of the white 
precipitate of mercury in belladonna ointment, suffi- 
ciently strong to irritate the skin. The application 
should be made to the skin over the eyebrows and cov- 
ered with oiled silk, then a bandage. For the lids, noth- 
ing equals a mild solution of the nitrate of silver 1 to 2 
grains to the ounce. It is well to make the applica- Trachoma 
tion personally twice a day; but before the silver is 
brushed on, the surface of the inverted lid should be 
dried with a piece of clean blotting-paper. For some 
peculiar reason, in nearly all acute, painful diseases 
of the conjunctiva with photophobia very mild solu- 
tions of the nitrate of silver are soothing. 
Trachoma can be cured without copper; the nitrate 
of silver will do very well. Begin this treatment by 
scarifying and compression, but be sure not to apply a 
strong solution of silver (10—15 grains to the ounce) un- 
til the cuts are well. If the mucous membrane bleeds 
when the lids are turned, silver is contra-indicated. 
There is but one possible condition which will justify the 
use of silver as a cautery or an astringent on a bleeding 
conjunctiva—that is, ophthalmia neonatomm. 
The majority of cases of trachoma in this country 
are treated by silver, because they are nearly all compli- 
cated by blennorrhoea. Many physicians will ask, 
“What can be done for the enlarged papillae? Is it well 
to cut them off?” As a rule, all operations on the mu- 
cous membrane are detrimental, excepting those al- 
ready suggested. The French advise, when the supe- 
rior retrotarsal folds are badly diseased,to remove them 
by cutting them away with curved scissors. I have 
done so several times, but I could not see that the opera- 
tion did any good. ( 
I see no objection to cutting off large cock’s-comb 
papillae, but to take a pair of scissors and trim off the 
hypertrophied mucosa is bad treatment. All follicular 
nodules and swollen papillae left after the compression 
process are best let alone; they will disappear as the 
eye improves. Trachoma. 
Very often during tlie treatment of trachoma the 
cornea ulcerates, which is caused either by simple tra- 
chomatous ulcers becoming infected or from the use of 
caustic applications. These ulcers are always angry and 
are apt to perforate. The infected ulcers behave like all 
such ulcers of the cornea; they are surrounded by a zone 
of inflamed and necrosed tissue, and may, if not prop- 
erly treated, destroy the eye. The subjective symptoms 
are very severe, the photophobia so intense that the 
eyes cannot be properly examined without a local or 
general anaesthetic. The first thing to be done under 
such circumstances is to stop all active treatment of 
the conjunctiva. If using copper or a strong solution 
of silver, discontinue them. Either apply a 0.25 pcr cent 
solution of the nitrate of silver, or, what is better and 
safer, the bichloride of mercury 1:3000. Treat the 
cornea with atropia. If the ulcer is large, ragged, and 
ugly, one of two things may be done: either puncture 
the anterior chamber, or destroy the ulcer with the 
actual cautery. The simple operation of paracentesis 
will often give immediate relief. Thoroughly destroy- 
ing the infected tissues about the ulcer with a heated 
platinum wire, so as to change it to a simple ulcer, is ex- 
cellent treatment, but the patient must be warned of 
the resulting scar. The treatment of the so-called punc- 
tiform keratitis is simple. Usually we find in these 
cases the tarsal cartilages very much atrophied and the 
cornea quite clear; then the eye will not stand strong col- 
lyria. Turn the lid and either rub on it a 1:2000 solution 
of mercury, or make an applicatiou of a very mild solu- 
tion of the nitrate of silver for its sedative effect; atro- 
pinize the eye and keep it so; protect with blue glasses, 102 
Trachoma. 
and see that all kinds of irritation are removed. If an 
eyelash is touching the cornea, operate on it. By this 
I don’t mean, pluck it out, unless it is necessary. Either 
destroy it with electricity or transplant it. Double 
thread a very tine curved needle with a delicate strand 
of waxed silk. Enter the needle in the edge of the lid 
exactly where the lash comes out, curve the point up- 
wards and outwards so that it comes out as near the 
normal line of the cilia as possible, pull the thread 
through, and engage the offending hair in the loop. 
That lash will not again disturb the eye. 
Sometimes neither the sulphate of copper, the nitrate 
of silver, nor the bichloride of mercury will cure the dis- 
ease; they seem to lose their effect; then it is well to 
try some other remedy. One of the best is the yellow 
oxide of mercury, especially if there is much non- 
inflammatory pannus. This drug is used in an oint- 
ment, I—21—2 grains of the yellow oxide rubbed up 
in a drachm of simple cerate or vaseline. A piece of 
this about the size of No. 5 shot is put under the 
upper lid, then the lid is rubbed over the eyeball until 
the ointment escapes—a milky-white emulsion. This 
should be done once a day. If the reaction is too 
great, either the ointment is too strong or has been care- 
lessly prepared; it may contain lumps of the oxide, 
which get entangled in the mucous membrane and burn 
very severely. Anything which interferes either with 
the movement of the lids or the drainage of the tears 
embarrasses the treatment. Not infrequently the tra- 
choma attacks the mucous membrane of the lachrymal 
sac and canal. Then there arises a very serious compli- 
cation. The epiphora keeps up an irritation of the Trachoma. 
103 
conjunctiva, and since one of the cardinal rules during 
the treatment is to eliminate all sources of irritation, 
the patency of the lachrymal passages must he estab- 
lished. Slit the upper canaliculus and keep the pas- 
sage to the nose open by probing. Such operations 
and the surgical means for the relief of entropion and 
other deformities of the lids cannot be considered in 
this book; they are well described in our modern text- 
books. 
Some fifteen years ago Dr.De Wecker,of Paris, popu- 
larized the use of a Brazilian drug called jequirity, the 
seed of the Arhus precatorius—wild liquorice. If a 
cold infusion of this bean is applied to the conjunc- 
tiva, it will excite in a few hours an intense muco- 
purulent inflammation, characterized by great swelling 
of the lids and the formation of a croupous membrane 
on the conjunctiva. The intensity of the inflammation 
will depend upon the strength of the infusion and the 
susceptibility of the patient. The disease lasts from 
four to seven days. In some respects this is a very 
reliable drug, but, if not carefully and properly used, it 
may do great damage. The blennorrhoea which it 
excites has the same tendency to destroy the cornea as 
ordinary severe blennorrhoeal ophthalmia, so in using 
this drug the physician should be careful that there is 
sufficient circulation in the cornea to protect it—that is, 
there must be some pannus. An acute blennorrhoea 
will not cure acute trachoma. But in all cases of 
trachoma where the lids are scarred and there are a 
few trachomatous nodules scattered over the conjunc- 
tiva the jequirity will destroy them. The cornea will 
clear up remarkably, but neither jequirity nor any- 104 
Trachoma. 
thing else will remove the scars left after corneal ulcers. 
To clear the cornea and destroy the remnants of tracho- 
ma, jequirity has no advantage over copper or the yel- 
low oxide of mercury, other than that it does so quicker. 
A slight jequirity ophthalmia excited in an eye suffering- 
trachomatous degeneration, when there are repeated 
attacks of punctiform keratitis, will have the happiest 
effect. It should be used in the intervals between the 
attacks. People who have suffered for months will be 
greatly benefited; indeed, I have known numbers of 
persons to be absolutely cured. Sometimes a case of 
trachoma will be rebellious to ordinary treatment. If 
it is then subjected to a course of jequirity, the nitrate 
of silver and the sulphate of copper may be again 
efficacious. But it must be remembered that under no 
circumstances should jequirity be put into an eye if 
there is a trace of blenorrhoea. It then acts badly, and it 
is possible that the inflammation excited by the physi- 
cian will get beyond his control. For this reason the 
drug has fallen into disrepute. Of course, when it was 
introduced and first tried in the United States it was 
warmly—indeed, extravagantly—recommended. Like 
all good things, it has been abused; but it has virtues 
which rank it among the most valuable remedies we 
have. Use a 2 per cent infusion—that is, about 10 grains 
of the crushed bean to the ounce of water. Make a cold 
infusion and allow it to stand 12 hours, filter through 
cotton, and keep in a cool place. It should be used 
when fresh. When the eye is properly prepared, turn 
the upper lid and wipe it over once with a piece of 
cotton wet with the medicine; wait 12 hours and see 
what the effect is. If the reaction is very severe, wait Trachoma. 
105 
another 12 hours; if it is not, make another applica- 
tion, but cover more of the mucous surface. By this 
time the physician should learn how much drugging 
is necessary to excite quite a severe ophthalmia. The 
proper degree of inflammation is, swollen lids, painful 
eye, muco purulent discharge, and a croupous mem- 
brane in the lower cul-de-sac and over the upper carti- 
lage. When this stage is reached, about the end of 48 
hours, stop the applications and leave the eye alone. 
The acute stage will last about 24 hours, then quickly 
subside. In one week it should be over. If this has 
not cleared the cornea enough, do not try it again in- 
side of a month. For what I may call its catalytic 
effect, so valuable in trachomatous degeneration with 
punctiform keratitis, a slight inflammation only is 
necessary. In these cases the cornea is irritable and 
there is danger of sloughing if severe ophthalmia is ex- 
cited. If, from any cause, the physician becomes 
alarmed, he may treat the artificial disease as suggested 
in the chapter on croupous conjunctivitis. 
Since the introduction of the jequirity bean, there 
is no occasion to excite acute purulent ophthalmia to 
clear the cornea of blinding pannus, unless it is impos- 
sible to procure the drug. For a long time it has been 
recommended to subject such an eye to a course of severe 
blennorrhoea by inoculating the conjunctiva with pus 
from a diseased urethra or from a case of ophthalmia 
neonatorum. By doing so, gonorrhoeal conjunctivitis 
or a disease very much like it is excited. Desperate 
diseases often require heroic treatment, but the physi- 
cian should think twice before doing such a thing. He 
never knows, when he starts this disease, when or how Trachoma. 
it will end; but if the eye comes through the ordeal 
successfully, very much is gained so far as the vision 
is concerned. It should not be proposed unless the pan- 
nus is thick and vascular, for there is danger that the 
clear cornea will slough. The pus to be used must be 
taken from an infant’s eye in ophthalmia neonatorum; 
never from acute gonorrhoea. The mere suggestion is 
disgusting and it is dangerous, for one cannot elimi- 
nate a possible syphilitic virus nor is he sure to save 
the patient the constitutional sequelae of gonorrhoea. 
Such an ophthalmia is dangerous to everybody brought 
near it; therefore, if the disease must be excited, it is 
advisable to use the pus from a baby’s eye. The in- 
tentionally acquired disease must be treated as shown 
in the chapter on gonorrhoeal ophthalmia. CHAPTER XI. 
CHRONIC BLENNORRHGEAL CONJUNCTIVITIS. 
The most common and important variety of granular 
lids is chronic blennorrhoea, which is nothing more than 
a chronic suppurative catarrh of the conjunctiva. 
This disease is often seen in its pure form; very fre- 
quently it is found mixed with trachoma, and, for 
the reasons already suggested, there will, in young 
people, be at the same time more or less of follicular 
development. 
Chronic blennorrhoea usually begins as a subacute 
purulent conjunctivitis. At other times it is chronic 
from the start. In the subacute variety the eye becomes 
suddenly inflamed, the entire conjunctiva being in- 
volved. The 1 ids are somewhat swollen, the eyeball 
very red, and there%may be a slight chemosis. From 
the start the discharge is purulent. It will collect 
about the edge of the lids at night and may accumulate 
in the internal can thus, but never flows over the cheeks. 
When the lower lid is depressed, the pus can be dis- 
tinctly seen in the lower cul-de-sac. It will be difficult 
to spring the retrotarsal folds in view because of the 
swelling of the lids. The mucous membrane over the 
superior tarsal cartilage has a velvety appearance, and 
it will be noticed that the cartilage is enlarged. One of 
the characteristic symptoms is the color of the conjunc- 
tiva. It is not bright red, as in ordinary acute catarrh, 
but carmine—that is,thereis a bine shade in it. The eye 
107 Chronic Blermorrhoeal Conjunctivitis. 
is painful, feels very sandy, and is suffused with tears. 
This condition may last several days or weeks, when 
the acute symptoms pass off, and the eye enters a stage 
of chronic inflammation. It is in this way the disease 
often begins. Sometimes an individual believes he has 
caught a slight cold in the eyes and the physician may 
take it for a simple catarrh. But if he will note the 
color of the inflamed area, or will turn the lid and force 
the retrotarsal folds in view, there should be no doubt of 
the diagnosis. Some subacute blennorrhoeas do not at- 
tack the ocular conjunctiva, but involve the membrane 
covering the lids and retrotarsal folds. But in all 
cases, however slight, if the upper cul-de-sac is explored, 
there will be found a purulent discharge. Thus is the 
disease ushered in; either as a subacute inflamma- 
tion, or like a simple catarrh. In the subacute stage 
the inflammation is never so intense as gonorrhoeal oph- 
thalmia. It is exactly like the disease I have called 
leucorrhoeal conjunctivitis. In the mildest forms the 
disease may come on so insidiously that the patient 
does not know that there is anything the matter, when 
suddenly from some particular cause the eyes become 
acutely inflamed. From the above it is evident that the 
disease not only differs in form, but perhaps in kind. 
Now, it must be distinctly remembered that chronic 
blennorrhoea and trachoma are often combined in the 
same eye, so there may be not only the objective and 
subjective symptoms of trachoma, but also those of 
blennorrhoea. In the simple disease the trachoma 
bodies are not found, but the palpebral conjunctiva 
will always be covered with little papules, which give Chronic Blevmorrhoeal Conjunctivitis. 
109 
it a velvety look, and nowhere can be seen in the mem- 
brane about the middle of the lid the little white de- 
posits so common in trachoma. In this variety of blen- 
norrhoea the retrotarsal folds are not much swollen, but 
when the lower lid is turned down, the membrane in 
the lower cul-de-sac will be elevated in several parallel 
ridges. If the patient is a child, there will be seen on 
the summits of these folds a few or many lymphatic 
follicles, which must not be mistaken for trachoma 
nodules; they are the result of the irritation of the blen- 
norrhoeal disease. In these cases the discharge is 
muco-purulent, the eyes are irritable. The patients 
complain that in the morning the lids are dry and seem 
to stick to the eyeball; that when they are rubbed and 
the tears flow freely, they get relief. In other cases the 
characteristic peculiarity is the apparent enlargement 
of the superior tarsal cartilages and the enormous papil- 
lary development. The mucous membrane covering 
the lids is greatly hypertrophied and the papillae so 
large and numerous that one can understand the mean- 
ing of the term “granular ophthalmia.” If in these cases 
the superior retrotarsal folds are forced forward, they 
become very prominent; are succulent, granulated, and 
purulent. Often there will be found a number of fol- 
licles along the convex edge of the cartilage, which 
may be simple follicles; the probabilities are that they 
are trachoma nodules. 
There is another form of chronic blennorrhoea in 
which the inflammation is principally confined to the 
upper cul-de-sac. The eyes do not look inflamed, the 
lids may droop a little, and from time to time some 
muco-purulent discharge will smear the cornea and col- Chronic B lennorrhoeal Gonjunctivitis. 
lect at tlie edge of the lids. But the subjective symp 
toms are annoying; the eyes tire easily, they are par- 
ticularly sensitive to dust, smoke, and artificial light. 
When they are examined, a little discharge may he 
found behind the lower lid. The upper lid, when first 
turned, is normal in appearance, but almost immedi- 
ately colors up—it blushes. When the retrotarsal folds 
are exposed, the disease is apparent. There the tissues 
are decidedly inflamed and swollen, and always covered 
by a quantity of purulent discharge. So far as I 
know, these different forms are of one and the same 
disease. With few exceptions, they begin as a sub- 
acute inflammation, then pass into chronic. 
A very familiar form of sore eyes is common in this 
part of the country and supposed to be contracted dur- 
ing harvest-time. A young man with apparently 
healthy eyes starts out to make and stack hay; the 
weather at the time is hot; he accidentally gets a 
lot of hay-dust in his eyes, which usually happens when 
he is stacking or loading. In a few hours his eyes 
begin to inflame, and in a couple of days he is laid up 
with an acute ophthalmia. The inflammation may be 
quite severe. When the lids are examined, they are 
decidedly granular and present the familiar picture of 
subacute blennorrhoea. Sometimes the disease will 
get well; very often it becomes chronic. If the patient 
is asked the cause of his trouble, he will almost invari- 
ably say that he got hay-dust in his eyes. Many times 
there is no doubt that he is correct, but often the 
patient before the accident had a chronic blennorrhoea, 
and the irritation of the sharp particles of hay-fiber 
excited an acute exacerbation. Chi 'onic B lemi o i rhocal Gonjunctiv it is. 
Because of the relation of the surface of the cornea 
to the conjunctiva, and because in all blennorriiceal 
diseases the epithelial surface suffers the most, this dis- 
ease is particularly prone to attack the cornea. We see 
exfoliation of the epithelium, superficial or deep ulcers, 
keratitis, and acute inflammatory pannus. But these 
lesions are not so common in the early stages as later, 
when the conjunctiva has suffered permanent damage. 
The cornea will not inflame in the initial attack unless 
the disease is neglected or badly handled. It is during 
the acute exacerbations which come from time to time 
A drawing to show the appearance of the eyeball in the acute keratitis of 
chronic blennorrhoea—acute pannus—ulcer of the cornea. 
Figure 10. 
in the course of the disease when arises the annoy- 
ing and dangerous keratitis. Every doctor is famil- Chronic Blenmorrhoeal Conjunctivitis. 
iar with the appearance of the cornea in the bad attacks 
of acute inflammation occurring during harvest-time. 
Unlike the pannus in trachoma, the blood vessels do 
not come particularly from the upper part of the eye, 
but from the entire circumference of the cornea. In 
this disease, as in trachoma, very much of the clouding 
in the cornea is caused by scars left from ulcers, but it 
must be remembered that during the acute attack the 
clouding and vascularization of the cornea is not pan- 
nus, but keratitis, which will, to a certain extent, mar 
its transparency. It is not as dangerous as it looks, 
but, unfortunately, if the keratitis is very severe, there 
is danger of iritis. The great danger arises from the 
inflammatory softening of the cornea, when it gives to 
the intraocular tension and bulges out—keratoglobus. 
One of the dangers of acute keratitis in chronic blen- 
norrhoea is extensive ulceration. One would believe 
that the unnatural circulation in the cornea would 
protect it, but it does not. The cornea may be almost de- 
stroyed by ulcers. My experience is, even after the dis- 
ease is cured, it may be a long time before the ulcers 
heal. In a few cases of chronic bleninorrhoea the skin at 
the edge of the lids becomes inflamed and excoriated be- 
cause of the irritating discharge; then it will be seen 
that the follicles at the roots of the cilia are also dis- 
eased. There is a suppurative blepharociliaris. As the 
disease progresses the lashes fall out and the cutaneous 
edge of the lid becomes pitted with ulcers—chronic 
suppurating eczema. If the conjunctiva over the 
lower lid and in the inferior cul-de-sac is swollen 
enough to push the edge of the lid away from the eye 
and displace the lower punctual, the tears will not run Chronic Blennorrhoeal Conjunctivitis. 
113 
into the nose, but will bathe the already diseased lid, 
which, of course, makes the blepharitis worse. In 
time the eczematous area contracts and turns the lid 
out. The ectropion thus started completes a vicious 
circle. So it happens that in some old cases of blen- 
norrhoea the lids are rolled out and covered by a red, 
inflamed, granulating mucosa. 
In nearly all cases of chronic blennorrhoea the ex- 
ternal canthus is more or less deformed. If the physi- 
cian will examine the normal ejre, he will see that at the 
external canthus the junction of the lids is an acute an- 
gle, sharp and well defined, which is true both of the 
skin edge and the mucous edge. When a discharge con- 
tinually moistens the skin at the canthus, a small 
excoriation or ulcer forms, which ultimately becomes 
a true fissure. It is quite painful and prevents the 
lids being opened fully, and in young persons causes 
blepharo spasm. After the fissure has lasted sometime, 
it heals by second intention, when, of course, the skin is 
drawn over the canthus—a vertical band pulling both 
on the skin of the upper and lower lids. In the great 
majority of cases this little deformity is harmless, bni 
since it has a tendency to prevent the lids being prop- 
erly opened, and sometimes assists in rolling under the 
lids in entropion, it may become a matter of importance. 
Although the pathology of chronic blennorrhoea is 
simple (Chapter III.), there are some clinical peculiari- 
ties which are noteworthy. In some cases of chronic 
blennorrhoea of the conjunctiva the mucous membrane 
rapidly atrophies, and there is an early formation of 
cicatricial tissue. In other cases, exactly of the same 
kind, the membrane may be inflamed a long time before Chronic Blennorrhoeal Conjunctivitis. 
it becomes permanently damaged. Then the inner 
surfaces of the lids are covered by scar tissue; never 
so great, however, as in trachoma. It is doubtful if 
pure chronic blennorrhoea leads to sufficient cicatricial 
changes to deform the lids by contraction. All it will 
do in the worst cases is to destroy the mucous function 
of the conjunctiva. 
Before considering the cause of this disease, it is 
well to examine the character of blennorrhoeas in gen- 
eral, since bacteriology has completely negatived all 
that has been written concerningthemup to a few yeai s 
ago. A mucous membrane may suppurate from one of 
two causes: 1. It may be invaded by micro-organism*, 
which live and grow on and in it. These cause an exu- 
dation of pus. Such an organism is the gonococcus, 
which may be considered the king coccus of all true 
blennorrhoeas. Let it be remembered that the mucous 
membrane of the eye, vagina, urethra, and rectum are 
suitable nourishing media for this organism. When 
it attacks them, it will multiply indefinitely unless the 
culture is destroyed by a drug, ptomain, antitoxin, or 
phagocytes. It is not stretching the imagination to 
reason that the gonococcus is the result of a long period 
of evolution; that its ancestor was a micro-organism, 
which found the genital mucosa a fitting medium for 
its propagation; and is it at all improbable if we say 
that the virulent character of that organism is lessened 
when it is in the process of degeneration? Thus it is, 
I believe, that the micro-organisms which cause all 
forms of true blennorrhoeal ophthalmia have either a 
gonorrhoeal ancestry or are nearly related to it in the 
process of evolution. iSuch micro-organisms cause Chronic Blmnorrhoeal Conjunctivitis. 
115 
true blennorrlioea. 2. All other forms of blennorrhcea 
I shall call false. They are the results of a secondary 
infection by the ordinary surgical pus microbes, the 
streptococci, staphylococci, etc. These micro-organisms 
do not flourish on or under mucous epithelium; their 
presence will inflame a mucous membrane, but such an 
inflammation is catarrhal; the leucocytes are killed 
after they reach the surface, not before, as in true 
blennorrhcea. 
A very good example of this disease is found in 
the conjunctivitis accompanying chronic suppurative 
dacryocystitis. In these instances the fluid in the 
lachrymal sac is a culture of the pyogenic cocci which 
reach it from the eye. This fluid contains myriads of 
micro-organisms, and is, of course, a concentrated solu- 
tion of toxines. The discharge is especially irritating 
to the conjunctiva and causes the conjunctivitis. If it 
reaches the connective-tissue stroma, it immediately 
causes a diffuse cellulitis. Abscess in the soft parts 
about the lacrymal sac and abscess of the cornea are 
often excited in this manner. Now, however severely 
the conjunctiva may be inflamed, as soon as the dis- 
eased sac is cleaned and drained the ophthalmia dis- 
appears. Exactly in this way is an otorrhoea started 
and continued. The discharge from the ear is a false 
blennorrhcea and the result of secondary infection, for, 
however severe the otorrhoea may be, it will stop as soon 
as the middle ear is drained and cleaned. Ordinary 
pus, therefore, will not excite blennorrhoeal conjunc- 
tivitis. There is one exception: pus from the urethra 
or vagina will. 
In giving the causes of ophthalmia neonatorum I 116 
Chronic B levmorrllocal Conjunctivitis. 
called attention to the fact that although gonorrhoea 
was often responsible, still there were times when there 
could not possibly be found any connection between the 
two diseases. The same was said regarding leucor- 
rhoeal ophthalmia. If the discharges from simple 
leucorrhoea can cause acute and subacute blennorrhceal 
conjunctivitis, they may also cause chronic;so it is very 
probable that from this source we get the contagium 
which is responsible for one variety of granular lids. 
My experience leads me to suspect that there is some- 
thing in hay-dust which will excite acute granular 
conjunctivitis. It may be that it is a microbe, or it is 
the sharp particles of dried fiber, which excite the 
irritation. That such dust will inflame an eye is cer- 
tainly true, for I have seen many cases of conjunctivitis 
directly caused by it—at least, I think so. It must not 
be presumed that every case of granular lids with such 
a history is caused by that irritant. Many farmers 
have a chronic blennorrhceal conjunctivitis and do not 
know it. If such eyes are severely irritated in the 
harvest-field, the acute inflammation is but an exacer- 
bation of the chronic disease. 
The discharge from a chronic blennorrhceal eye is 
remarkably contagious. There are but few people 
imrauned. Whether the contagium reaches the eye 
dried or moist, the result is the same, although it is pos- 
sible that fresh pus is more virulent than stale. But 
the proofs are so conclusive that it may be safely 
affirmed that most cases are contracted through the 
air, for it is impossible to believe that half the men in 
a railroad construction-camp car will be infected by a 
single individual and from one another by immediate Chronic Blermorrhoeal Conjunctivitis. 
117 
contact. Usually it is the dried discharge disseminated 
through the atmosphere which is responsible for the 
outbreaks of chronic blennorrhoea we so often see in 
barracks, camps, prisons, and schools. 
Persons suffering from chronic blennorrhoeal con- 
junctivitis have decidedly weak eyes. They complain 
that using the eyes for any purpose hurts them. They 
smart, are sandy and very uncomfortable. On waking 
in the morning the eyes feel particularly dry, which is 
not relieved until the lids are rubbed and the tears 
flow. The lids are usually glued together during sleep, 
or there will form a collection of dried discharge at the 
base of the lashes. From time to time during the day 
the discharge smears the cornea, the vision is blurred, 
which only lasts a moment, for the patient instinctively 
rubs the eye and clears the cornea. Their eyes are eas- 
ily irritated; the act of the accommodation in reading 
congests the eyeball, and such slight irritations, which 
would not disturb a healthy eye, quickly inflame them. 
If the cornea is not diseased, they do not suffer much 
pain; but if there is the slightest keratitis, the photo- 
phobia may be very distressing. Usually the subject- 
ive symptoms are not more severe than in ordinary 
subacute catarrh. 
The Prognosis of ordinary simple chronic blen- 
norrhoea is reasonably good—that is, if the patient 
gets the right treatment; otherwise it is bad, for very 
few cases get well unassisted. Some eyes cannot be 
cured; fair-skinned, red-headed people make very bad 
subjects. The prognosis again depends very much 
upon the patient’s business, surroundings, and the 
ability to remain under treatment. Farmers suffer Chronic Jilenmorrhoeal Conjunctivitis. 
when they have blennorrhoeal ophthalmia because they 
are continually exposed to the bright sun, changeable 
air, and barn-dust. I believe it impossible to cure any 
one who continues to work about a stable. It takes 
time, often a long time, to cure this disease; so many 
who practice in large cities do not often succeed, be- 
cause so few patients from the country have the means 
to remain until they are well. Our most hopeful 
patients are of the wealthy class, who have the time 
and conveniences to assist the oculist. The behavior 
of the cornea influences the prognosis very much. Ex- 
tensive keratitis is a grave complication; ulcers very 
readily become infected, and may eat into the anterior 
chamber. Simple pannus, even if the cornea be cov- 
ered with blood-vessels, is not as bad as it looks. It 
will clear up very rapidly as the disease in the conjunc- 
tiva improves, but it must not be forgotten that if the 
patient is blind, the cornea will never again be per- 
fectly transparent; the sight may improve very much, 
but it is rare that the vision will be good enough for 
reading. 
Iritis secondary to perforation of the cornea, or 
severe keratitis, nearly always occludes the pupil, but 
if the physician recognizes this complication in time 
and starts immediately to dilate the pupil with a 
strong mydriatic, the eye may be saved. As before 
stated, the prognosis depends a great deal upon the 
proficiency of the oculist and the docility of the pa- 
tient. These cases, if treated badly, will invariably 
get worse. 
Treatment.—If it will be remembered that the major- 
ity of people suffering from disease of the eye in this 
part of our country have chronic blennorrhoeal con- Chronic Blermorrhoeat Conjunctivitis. 
junctivitis, it is evident that the chapter on the treat- 
ment of this disease is the most important in the book. 
The proper management of these cases is extremely 
difficult, for the doctor will find that no particular line 
of treatment' will cure all. A drug that will benefit 
one eye may destroy another, and until one has had 
much experience he canot tell, until he tries, what will 
be good and what will be bad. Again, the patient him- 
self is often responsible for the failure in his case, for 
he cannot understand that a chronic disease is hard 
to control; so he usually goes from one oculist to an- 
other and gives none an opportunity to effect a cure. 
This disease is caused by a microbe, which lives and 
multiplies in the mucous membrane. To cure it, one 
must remove the cause, either by deslroying it or 
assisting Nature to do so. The treatment, therefore, is 
essentially anti-bacterial. Now, it is not difficult to de- 
stroy a culture of micro-organisms if it can be reached, 
but, unfortunately, the antiseptic which kills the germs 
often destroys the tissue they inhabit. When a small 
area is involved, as in infected ulcer of the cornea, the 
actual cautery is very effective, for the doctor can afford 
to destroy a part of the cornea to save the whole. But 
there is no time in chronic blennorrhcea when the 
disease is limtied to a small area of the conjunc- 
tiva; it is usually diffused over the entire mem- 
brane. It is evident, therefore, that an antiseptic, 
even if very powerful, must be brought in contact with 
the whole diseased surface. Powerful antiseptics are 
not applicable, for two reasons: they destroy the con- 
junctiva, and they disease the cornea. If it were not 
so, one could fill the conjunctival sac with an antiseptic Chronic Btennorrhoeal Conjunctivitis. 
120 
powder or ointment and cure the case in a very few 
days. If the bacterial colony were on the surface of 
the membrane, continued mild antiseptic washes would 
be effective; but the microbes are under the epithelium. 
A wash that could reach and destroy them would be 
stronger than the eye would bear. If we could cure a 
blennorrhoea at the risk of injuring to a certain extent 
the conjunctiva, there are times when we would not hes- 
itate to do so, but we cannot then avoid endangering 
the integrity of the cornea. In cases of chronic blen- 
norrhoea when the cornea is covered by a vascular 
pannus, which to a certain extent protects it, it is found 
that the applications of a strong antiseptic act quickly, 
certainly, and harmlessly. It iis fortunate that a mild 
antiseptic which will not destroy a multitude of mi- 
crobes will retard their growth. If a culture in the sub- 
stance of the mucous membrane can be thus held in 
check, the phagocytes will soon remove them and Na- 
ture effect a cure. That can be done without irritating 
the cornea. It is on this principle that the modern 
treatment is based. Our endeavors should be to de- 
stroy and remove all the germs possible, and at the 
same time paralyze those deep in the tissue so that they 
cannot resist the attack of the white corpuscles. 
Let me say here, there is no specific for chronic 
blennorrhoea. What peculiar power the sulphate of 
copper has beyond its irritating effect on trachoma 
I do not know; for that disease it is a specific, but 
for chronic blennorrhoea it is useless—indeed, often 
harmful. 
The choice of antiseptic methods to employ in the 
disease depends upon the peculiarities and character Chronic Btennorrhoeal Conjunctivitis. 
121 
of the case. As I have endeavored to show, chronic 
btennorrhoeal conjunctivitis behaves differently in dif- 
ferent people. In some cases there is found more of 
the trouble at the superior cul-de-sac, in others the 
tarsal part of the mucosa is chiefly involved, then again 
the entire conjunctiva may be affected. The treatment, 
therefore, will depend very much upon the character of 
the case. 
The two antiseptics chiefly employed are the nitrate 
of silver and the bichloride of mercury. The silver 
salt has the advantage that it is not only a powerful 
antiseptic, but it is also an astringent. It is used 
in strengths ranging from 1 to -30 grains to the ounce of 
water. A mild solution dropped into the eye three 
times a day will keep the conjunctival sac aseptic, 
but it has no penetrating power. A strong solution can- 
not be applied to the entire conjunctiva as a collyrium, 
it must be penciled on the inner surface of the lids, 
and then neutralized. 
When a strong solution of the nitrate of silver is 
applied to a bleunorrhoeal mucous surface, it immedi- 
ately penetrates the membrane. The silver salt first 
coagulates the albumen on the surface and between 
the epithelial cells; it also destroys the protoplasm of 
the cells—it Mils them. Thus is formed a coagulum 
of the albuminate of silver which has imprisoned in 
it a quantity of dead epithelium and myriads of micro- 
organisms that are killed by the antiseptic. In form- 
ing the coagulum some of the nitrate of silver is used 
up, and consequently the strength of the solution 
is reduced; the salt still penetrates, the coagulation 122 
Chronic B Icnnorrhocal Conjunctivitis. 
and the destruction of the soft tissues go on, but 
finally stop when the solution is no longer strong- 
enough to precipitate the intercellular fluids. But, 
there is a little silver left, which acts as a mild but 
sure antiseptic. In this way it is possible to reach the 
deep parts of the membrana propria, and destroy or 
paralyze in situ the septic organisms. In a few hours 
the superficial coagulum melts away or is thrown off 
because of the reaction of the underlying tissues and 
the exudation of serum. In the meantime the phago 
cytes have destroyed or carried away the dead or torpid 
germs; the surface covers over again with new epithe- 
lium, when it can be said that part of the membrane is 
less septic than before! A solution of from 10 to 20 
grains to the ounce will act in this manner. Stronger 
solutions penetrate too deeply and destroy too much of 
the mucous connective tissue; they make a false mem- 
brane very much like diphtheria, which must slough off 
and is apt to leave an ulcer. There are two reasons why 
the nitrate of silver cannot always be used in this way; 
1. It is impossible to make such an application to the 
entire conjunctiva. That part which has not been 
cauterized will soon reinfect that which has, for a sec- 
ond application cannot be made until the effects of the 
first are gone. 2. Such treatments are very irritating, 
and the inflammation excited in the conjunctiva will 
react on the cornea. Those who have used strong solu- 
tions of silver have noticed how often the cornea ulcer- 
ates. But, for all that, the nitrate of silver is ex- 
tremely valuable. 
The antiseptic properties of the bichloride of mer- 
cury make it a very useful drug in blennorrhoea, since Chronic Blermorrhoeal Conjunctivitis. 
123 
more can be done with it than any other single rem- 
edy. For that particular form of the disease for 
which silver as useful it is not so good, but there art1 
many oases it will cure which cannot be treated by sil- 
ver. It has one advantage over the nitrate of silver— 
it can be used longer, and it does not stain the conjunc- 
tiva. The yellow oxide of mercury is another very val- 
uable antiseptic. It is particularly useful because it can 
be used in an ointment and thus retained longer in the 
conjunctival sac than solutions. I have no faith in sul- 
phate of copper solutions or simple astringents. Tannic 
acid, boro-glycerin mixtures, compounds of the zinc and 
copper salts containing some vegetable extract are, in 
my opinion, useless. If they do good at all, they do so by 
keeping the eye clean. Although they are useless, yet 
they are dangerous, for they all irritate and inflame the 
cornea. The reader should not forget that for the 
successful treatment of this disease the conjunctival 
sac must be kept clean and the eye protected from 
all kinds of irritation. Even the irritation from the 
medicinal applications is bad. That must happen, so 
he should do all in his power to relieve, by soothing 
means, that which he has excited by remedies; nor 
should the physician forget that while he is an oculist 
he is a doctor. Internal drugging will sometimes help 
very much; a weak anaemic man wants tonics, cod-liver 
oil, fresh air. Such patients should be out of doors 
as much as possible; nothing can be more detrimental 
than close, foul air. Clean clothes and a clean skin 
help to clean an eye. Cheerful surroundings and hope 
stimulate the tissue cells to do their part quickly and 124 
Chronic Ble'imorrhoeal Conjunctivitis. 
well. If the patients are sick, they must be relieved. 
It would be impossible to cure a chronic blennorrhoeal 
conjunctivitis in an individual suffering from diabetes 
with excessive glycosuria without internal medication. 
No surgeon would attempt to operate on such an one 
until, by diet and medicines, he had reduced the loss of 
the sugar and elevated the body tone. It is well, in 
adults, to look to the kidneys. The confinement and 
forced indolence which many of these patients suffer be- 
fore they reach the oculist often excite lithiemia. The 
urine is then highly colored, scanty, and charged with 
the products of imperfect assimilation, urates and uric 
acid. Then will a little dilute nitro-muriatic acid, and 
less nitrogenous food, together with exercise, do won- 
ders. True, the disease is purely local; but, as I said 
before, one can only assist the body to throw it off, to 
do which he must act both on the surface and through 
the blood. 
When the disease is limited to the mucous mem- 
brane forming the superior retrotarsal folds, and there 
is no thickening of the tarsal conjunctiva, the best 
treatment is the local application of the nitrate of sil- 
ver, the stronger the solution the better. It may 
be from 20 to 30 grains to the ounce. The object is 
to destroy the redundant tissues and kill by such a 
powerful antiseptic the septic germs which are im- 
prisoned in the depressions and pockets of the inflamed 
membrane. To make the application requires the help 
of an assistant. The upper lid is turned and held by 
the thumb of the left hand, the patient is directed to 
look down; then, through the lower lid, the eyeball is 
pushed inward and upwards by the thumb of the right Chronic Blennorrhoeal Conjunctivitis. 
125 
hand. If there is any swelling of the tissues above 
the upper lid, they will immediately spring into view. 
While the surgeon holds the lids, an assistant rapidly 
dries the prolapsed folds of membrane with a piece of 
clean blotting-paper. Then, with a camel’s-hair brush, 
he (the assistant) should carefully apply the silver to 
the diseased surface. After waiting until the parts 
turn white and the solution penetrates, he must neutral- 
ize the caustic with salt water. If the application is 
properly made, there is no danger of any of the solution 
touching the eyeball. The treatment will cause some 
smarting, but not enough to distress the patient. 
Such an application should be made every day or 
every other day until the diseased mucosa is cured. 
It is surprising to see how quickly the eye will improve; 
patients who have suffered for months may be well in 
a few days. It is not necessary to do anything more 
for the eye, but the boracic wash, used two or three 
times a day, will be particularly soothing. In these 
cases the eye is irritated by the toxines and dis- 
charges which continually come from above. The 
silver salt destroys the nests of septic germs in the 
superior cul-de-sac. Sometimes it happens that the 
physician cannot expose the folds, or he has no assist- 
ant; then the patient can push his eye upwards and in- 
wards with his forefinger. The success of the treat- 
ment will depend upon the ability of the surgeon to 
reach the entire suppurating surface. In young peo- 
ple, when the folds are exposed, they may be found 
covered by soft lymphatic follicles. Then it is best to 
remove them by compression or with Knapp’s or 
Prince’s forceps. 126 
Chronic Blermorrhoeal Conjunctivitis. 
In diffused chronic blennorrhoeal conjunctivitis 
when the entire conjunctiva takes part in the suppu- 
rating process, in those cases where the upper lids 
and cartilages are enlarged and the mucous membrane 
covering them is thick, succulent, and papillary, the 
nitrate of silver is sometimes efficacious, but it should 
be used in a mild solution, 5 to 10 grains to the ounce, 
and should be applied to the conjunctiva lining the 
lids and the superior and inferior folds. My experience 
is, for the majority of such cases, the silver is useless. 
The best treatment is local bleeding (scarification) and 
the application of the bichloride of mercury. Scarify- 
ing the conjunctiva is almost a lost art. Let it be 
revived, for there is nothing more beneficial than local 
bleeding in these cases. 
The object in bleeding is to keep the inflamed tissues 
bathed in fresh arterial blood. When a mucous mem- 
brane becomes invaded by millions of septic organisms, 
i t begins the battle by bringing to the parts all the blood 
it can hold. At first the circulation is free, but as in- 
flammatory changes take place, it becomes embar- 
rassed because of the pressure on (he venous radicles 
which leads to passive congestion. 
If the white blood-corpuscles act as phagocytes, if is 
evident that when they are exhausted or hold within 
themselves captured organisms, they must leave the 
field of action and give way to fresh corpuscles or they 
will succumb. At this time the lymph channels and 
veins are choked with stagnant fluids, hindering their 
absorption. If the blood serum is an active agent in the 
contest, the same reasoning holds good, for it is evident, 
the greater the amount of fresh blood in the tissues the Chronic Bleunorrhoeal Conjunctivitis. 
127 
quicker the contest will be decided. To a culture of 
micro-organisms fresh blood serum is destructive; to 
the same host stale serum is nutritious. The connect- 
ive-tissue cells probably take no active part in the con- 
test; they simply react to the irritation, multiply, and 
as neutrals embarrass the field of action, although in 
some forms of inflammation they serve to imprison 
the offending irritants, as in some of the infecting 
granulomata—trachoma, for instance. If the used-up 
blood cannot be forced back into the circulation, it 
can be removed, and a fresh supply permitted to take 
its place; scarification will do this. 
It is probable a mild solution of corrosive subli- 
mate has an inhibitory influence on the growth of micro- 
organisms ;it is certain that in livingtissues only strong 
solutions will kill them. To use the bichloride of 
mercury to destroy them on the surface of Ihe con- 
junctiva is impracticable, for it would not only kill 
the cocci, but necrose the tissues; consequently it is not 
safe to use solutions stronger than 1 to 2000. Even 
then, it is necessary to be guarded, for such solutions 
may be very irritating. This medicine, in appropriate 
strength, must be brought in contact with the entire dis- 
eased surface, and it should be forced in between the 
epithelial cells. When the surface of the diseased 
membrane is attacked by this agent and the deep parts 
continually bathed in fresh arterial blood, the septic 
germs will have a poor chance to thrive. They will 
ultimately disappear. 
To scarify the conjunctiva seems a simple matter, 
but to do it properly is a delicate surgical operation. It 
is not necessary to cut deep into the mucous mem- 128 
Chronic Blennorrhoeal Conjunctivitis. 
brane; only the most superficial incisions should be 
practiced, and they should be made with the point of a 
sharp knife. The cuts should not be more than one- 
eighth of an inch long, and not deeper than necessary 
to reach the blood. They should be mere scratches, 
yet incisions. It is not essential nor practical to scarify 
the lower lids, nor should the ocular conjunctiva be 
wounded. Attack alone the upper lid, and let the field 
of operation extend as far towards the upper cul-de-sac 
as possible. Use a Graefe cataract-knife with a sharp, 
A, The appearance of the inverted upper lid when correctly scarified. B, The 
same carelessly, badly done. 
Figure 11, 
narrow point, and, holding the instrument like a pen, 
start the scarification at the lower edge of the inverted 
lid, so that as the blood flows it does not hide the field 
of operation. In this way the entire surface of the lid 
should be gone over; but as the free edge is approached 
the cuts should be smaller and scattered, for at that 
part of the lid the conjunctiva, even when inflamed, is 
very thin. A plentiful flow of blood should be en- 
couraged. Unfortunately, the operation is painful, but 
may be made bearable by cocaine. 
When the bleeding stops, apply to the conjunc- 
tiva of both lids a solution of the bichloride, in salt 
water, Ito 2000. It should be gently rubbed on the Chronic B Icrmoi 11local Conjunctivitis. 
129 
membrane by a cotton applicator; a piece of absorb- 
ent cotton wrapped around the end of a match or tooth- 
pick will do very well. These applications should be 
made once a day, and roughly enough to make the 
wounded membrane bleed afresh. TwTenty-four hours 
after the operation a false membrane will be formed 
on the upper lid, which should be rubbed off by the ap- 
plicator moistened with the antiseptic. In a few days 
the membrane will not bleed when rubbed. Then the 
lids will be much thinner. The discharge will grad- 
ually cease. If there is any swelling, scarify again. 
It is rarely necessary to do so more than three times. 
Between the daily treatments it is well to wash out the 
eye with a solution of the bichloride 1 to 5000 or the 
boracic acid wash. It is astonishing to see how rapidly 
the eye will recover; not infrequently the disease will 
be cured in two or three weeks. When the scarifica- 
tions have been properly done, the lids will heal with- 
out scars. It is not necessary to interfere with the 
cornea; as the eye improves that membrane will im- 
prove also. If it is very opaque from keratitis, it will 
not clear up completely, although, after the disease is 
cured, a course of jequirity ophthalmia may materially 
aid vision. 
Of course, it is to be understood that atropia is 
indicated in all cases where there are any signs of 
keratitis. Sometimes during the treatment, the bichlo- 
ride seems to lose its effect; then I would advise several 
applications of a 1 per cent solution of the nitrate 
of silver, which must be carefully washed off; but under 
no circumstances should the silver be used if the con- 
junctiva shows any tendency to bleed. Chronic Blennorrhocal Conjunctivitis. 
130 
The third form of chronic blennorrhoea, character- 
ized by a mild inflammation of the entire conjunctiva, 
where there is not much hypertrophy of the membrane, 
the cartilages not markedly swollen and the lids 
smooth; those cases in which, when the lower lid is 
depressed, the conjunctiva from the inferior cul-de-sac 
comes forward in parallel folds between which is seen 
some pus, are very difficult to cure. My experience is, 
the nitrate of silver has no effect whatever. The best 
treatment is the bichloride rubbings; scarifying is un- 
necessary, but the application should be quite roughly 
made, and for that purpose nothing is better than pre- 
pared cotton-wool* wrapped around the end of a match. 
The treatment may last for weeks before the eye shows 
improvement. 
However greatly one may be experienced in the 
management of granular lids, there are times when he 
will be compelled to use empirical means, for it can- 
not be denied that some cases of blennorrhoea cannot be 
cured by the treatment above suggested. Then it is 
advisable to try the astringents. For a number of 
years there was used quite a favorite prescription. 
It was a solution of the sulphate of zinc, sulphate of 
copper, and alum in glycerin and water. It was a 
dreadful mixture to put in the eye, but it had the 
reputation of curing many cases, though there were 
thousands it did not cure. In the chapter on mixed tra- 
choma it will be seen that there are conditions where 
such a mixture is advisable. It may cure simple chronic 
"Cotton-wool is finely prepared wool used by surgeons in porous dressings. 
It has more body to it than cotton, and cannot be compressed into a hard 
wad. When it is wrapped around the end of a match, it makes a most excel- 
lent applicator, if slight roughness is desired. Chronic Blennorrhoeal Conjunctivitis. 
blennorrhoea. When all other rational treatment fails, 
the mixture of the compound astringents may be tried; 
but 1 would advise the doctor to watch carefully the cor- 
nea and stop it as soon as any keratitis arises, which 
will happen in the majority of cases. Sometimes an oint- 
ment of tannic acid acts well and rapidly. There is no 
danger of injuring the eye with this medicine, so the 
ointment may be made any strength. I have found 
that the yellow oxide of mercury ointment will do good 
sometimes, not often. Tannic acid mixed with the sugar 
of milk dusted into the eye with a camel’s-hair brush 
has been used with effect. I have, on suggestion, 
rubbed the surface of the inverted lids with powdered 
boracic acid, but I could not see that it did any good. 
Wells, our Belgian authority, advised rubbing the 
lid with the acetate of lead, and claimed that it did 
wonders. The treatment is almost forgotten; it is 
presumptive that it, too, has gone the way nf others 
once extravagantly extolled, tried, then abandoned; so 
with hundreds of others, among which were iodoform, 
antipyrdn, etc. 
MIXED TRACHOMA. 
One of the reasons why ordinary granulated lids is 
so difficult to cure is, it is usually a mixture of trachoma 
and blennorrhoea. From what has been said above, 
it should not be difficult for the reader to under- 
stand the pathology of this disease and picture to him- 
self the appearance of the lids and conjunctiva. It is 
one of two things, either blennorrhoea has attacked 
a trachomatous eye or trachoma a blennorrhoeal eye. 
Usually the latter, for if the infections were mixed, the 132 
Chronic Blennorrhoeal Conjunctivitis. 
suppurative inflammation would be the first estab- 
lished. Be that as it may, the two are associated, and 
if the practitioner does not recognize it, his treatment 
will be ineffectual. In these cases the blennorrhoea 
must be cured first, then the trachoma. Again, the 
fundamental principle is emphasized: Reduce the 
trachoma to its simplest form, then treat with the sulphate 
of copper. The first step is, remove all the soft tra- 
choma nodules and enlarged follicules by surgical 
means, keep the eye clean until the inflammatory re- 
action is gone,usinga wash of the bichloride of mercury. 
1:4000, Then examine and see if the blennorrhoea is 
confined to the upper cul-de-sac; if so, attack it with a 
strong solution of the nitrate of silver. If the disease 
involves extensively the lids, scarification is in order, 
followed by the bichloride treatment. When by these 
means the blennorrhoea is stopped, try an application 
of the crystal of copper. If the eye stands it and the 
blennorrhoea does not return, continue the copper 
treatment. 
It will require from six months’ to three years’ care- 
ful attention to cure such cases. Even then, some will 
resist all our endeavors, for there are patients who 
cannot be cured. 
GRANULATED LIDS. 
Recapitulation.—The term “granulated lids” can 
mean either of the three diseases: trachoma, chronic 
blennorrhoea, or follicular conjunctivitis. Trachoma, 
imcoiitaminated by blennorrhoea or follicular catarrh, 
is called simple trachoma. It is rarely seen in this 
western country. The best remedies for it are the Chronic Blennorrhoeal Conjunctivitis. 
sulphate of copper, the nitrate of silver, or the bichlo- 
ride of mercury. Trachoma is nearly always found 
in this country mixed with blennorrhoeal conjunctivitis 
or follicular catarrh, or both. Then it is necessary to 
cure the conjunctivitis or catarrh and reduce the dis- 
ease to its simplest form. When that is done, the best 
final treatment is the sulphate of copper. 
Chronic Blennorrhoea is a purulent conjunctivitis. 
The inflammation may involve the entire conjunctiva, 
or it can be limited to the fold of the mucous membrane 
in the upper cul-de-sac. Of diffused purulent conjunc- 
tivitis, there are two varieties. In one the conjunctiva 
lining the lids and making the retrotarsal folds is in- 
flamed, but not particularly thickened; it is carmine- 
colored, and slightly velvety. In the other, the entire 
mucous membrane is thick, succulent, and the papillae 
on the cartilages very numerous and large. In the 
first the ocular conjunctiva is not apt to be inflamed 
and the cornea is usually clear. In the second the eye- 
ball is always red and the cornea liable to become dis- 
eased. When the inflammation is limited to the supe- 
rior retrotarsal folds, the eyes are not injected and the 
conjunctiva lining the lids looks healthy, but as soon as 
the upper lids are turned, they become congested—that 
is, they blush. If the superior cul-de-sacs are explored, 
it will be found that the swollen and infiltrated mucosa 
is covered by a purulent discharge. Such eyes are 
irritable and easily inflamed; there is apt to be slight 
ptosis. Blennorrhoea of all kinds must be treated anti- 
septically. The best remedies are the nitrate of silver 
and the bichloride of mercury. The sulphate of copper 
will make the disease ivorse, and will almost surely inflame Chronic JBlennorrhoeal Conjunctivitis. 
the cornea. Consequently the student will appreciate 
the advisability of attacking the blennorrhoea first in 
cases of mixed trachoma. 
Follicular Conjunctivitis is a catarrhal disease caused 
by some local irritant. It may be dust, smoke, bad air, 
strain of the accommodative apparatus, blennorrhoea, 
or trachoma. The treatment is to remove the cause if 
possible, and to empty the follicles by compression. 
For simple follicular conjunctivitis, when there are 
but few follicles and an operation is unnecessary or 
impossible, I think the best local remedy ds a collyrium 
of the acetate of lead—that is, provided the cornea is 
healthy. CHAPTER XII. 
DIPHTHERITIC CONJUNCTIVITIS. 
One of the most dreadful diseases which can attack 
the eye is diphtheria. This disease of the conjunctiva 
is, fortunately, very rare in this country, for, in my 
experience dn Missouri, I have only seen a few eases. 
There are many practitioners who have never seen any, 
and there are thousands of medical men who would be 
puzzled to make the diagnosis if they did see it. This 
is not to be wondered at, for, until Yon Graefe de- 
scribed the disease in the fifties, it was without a 
name. 
The inflammation starts like an acute conjunctivitis 
—congestion of the eye, the sandy feeling, and pain. 
Within a few hours the lids, the upper especially, 
grow oedematous; they swell enormously, get hot, and 
very hard. The pain is so great that it is impossible to 
move them without causing much suffering. Even 
under an ansesthetic the doctor will have difficulty in 
turning them. Of course, the upper lid hangs over the 
lower as in gonorrhoeal ophthalmia. From the eye 
flows a little serous discharge, which may contain 
flakes of yellowish-white material as in croupous 
ophthalmia. 
If the examiner can gently raise the lid a little by 
grasping the lashes, he may get a view of a part of the 
conjunctiva, and may see a little of the under surface 
of the upper lid, where he is apt to find a false mem- 
brane. In some cases the lids are so swollen and in- 136 
Diphtheritic Conjunctivitis. 
durated that, without an anaesthetic, it is impossible to 
see the cornea; at other times, when the amount of 
diphtheritic deposit is limited, it is possible to see 
the eye. When the eye can be examined and the false 
membrane seen, there should be no difficulty in making 
the diagnosis, for there is a dirty-white membrane inti- 
mately adherent to a thick, dense, inflamed mucosa. 
The conjunctiva around the diphtheritic spot is so 
anaemic from plastic infiltrations that it has a waxy 
look, but that part of the membrane distant from it is 
red and engorged, and may bleed a little. If the false 
membrane is on the ocular conjunctiva, there will be 
considerable chemosis,as in acute purulent ophthalmia, 
and it wrill be noticed that near or adjoining the false 
membrane the cornea is hazy. The discharge will con- 
tain very little, if any, pus. Such is the usual condition 
of the eye on the second or third day. The constitu- 
tional symptoms depend upon the condition of the pa- 
tient and the severity of the inflammation. If the dis- 
ease attacks a patient suffering from fauceal diphthe- 
ria, the symptoms will be exaggerated; if it attacks the 
eye of one free of diphtheria, the symptoms may be 
marked, but not necessarily severe. In all cases there 
will be the systemic disturbances of diphtheria—viz., 
fever, rapid pulse, depression, and, because of the pain 
and the anxiety necessarily associated with such a fear- 
ful ophthalmic disease, restlessness. 
When the disease has reached its acme, which lasts 
from two to three days, the objective symptoms change. 
The lids become softer, the local fever leaves them, 
and the discharge changes to a flow of pus. At this 
time it simulates exactly acute purulent ophthalmia. Diphtheritic Conjunctivitis. 
137 
As soon as the lids soften and can be turned, the dam- 
age that has been done can be appreciated. Every 
bit of the conjunctiva involved in the false membrane 
will be destroyed. Here and there will be seen the rem- 
nants of the deposit which has not entirely sloughed 
off. In other places the mucous membrane presents 
ragged, flat ulcers, which are bathed in pus and 
bleed if disturbed. The cornea may be totally de- 
stroyed. Usually it will be deeply ulcerated, some- 
where between its center and its periphery. As 
a rule, the ulcer reaches the edge of the conjunctiva. 
This, the decline of the disease, lasts from one to two 
weeks. The suppuration gradually ceases; the ulcers 
heal by granulation; what is left of the cornea will 
clear up, and the eye get well. If the patient has any 
sight left, he is fortunate. Invariably the conjunctiva 
will be dragged into the cicatrices which the wounds 
leave. 
Cause.—There is but one cause for diphtheritic con- 
junctivitis-direct infection by the Klebs-Loeffler 
bacillus. 
The microbe must come in contact with the con- 
junctiva to excite the disease. The fact that diphtheria 
is so extremely common and the ophthalmia so rare 
is presumptive evidence that the conjunctiva is not at 
all susceptible. Many a physician has died of diph- 
theria contracted during the examination of a child’s 
throat, the patient having coughed directly into the 
doctor’s face. We know medical men do not, with their 
mouths open, examine diphtheritic patients, and very 
few protect their eyes with glasses. Yet, I can find but 
one recorded case of diphtheritic conjunctivitis con- 138 
Diphtheritic Ophthalmia. 
tracted in that way. It would seem that in some per- 
sons—very few—there is an idiosyncrasy favorable to 
diphtheritic ophthalmia. What influence evil sur- 
roundings have over the susceptibility of the conjunc- 
tiva I am unable to say. Probably none, for the dis- 
ease is no more frequent among the poor and neglected 
than amongthe rich. The cases I have seen were adults, 
living in well-ventilated houses on the open prairie. 
They had no disease in the throat nor had they been 
near diphtheria. It is unnecessary to again consider 
the pathology of diphtheritic conjunctivitis; that has 
been done in Chapter 111. 
Diagnosis.—The diagnosis is easy, although it may 
be confounded with gonorrhoeal ophthalmia, acute or- 
bital cellulitis, phlegmon of the lids, and panophthal- 
mitis. The similarity of croup and diphtheria in the 
throat and larynx is not apparent in the eye. 
Croupous and diphtheritic conjunctivitis are so 
dissimilar that it is hardly necessary to differentiate 
their characteristics. The appearance of the lids in 
gonorrhoeal ophthalmia and diphtheritic conjunctivitis 
is much alike. In both the lids may be enormously 
swollen. In gonorrhoea they are comparatively soft, in 
diphtheria they are very hard. Disturbing the lids in 
the first disease does not cause much pain; with care 
they may be turned; in diphtheria the upper lid cannot 
be everted without great suffering. 
The discharge in gonorrhoeal ophthalmia soon be- 
comes purulent; in diphtheria the pus does not flow 
until the disease has entered the second stage; then 
there may be some excuse in mistaking them. Some 
cases of orbital cellulitis, especially if the phlegmonous Diphtheritic Conjunctivitis. 
139 
inflammation has attacked the cellular tissue of the 
upper lid, may simulate diphtheria. But then there is 
always a certain amount of exophthalmos and there 
is no discharge of any moment. Both in that disease 
(orbital cellulitis) and diffused purulent choroiditis the 
oedema of the conjunctiva is so great that thickened 
folds of the mucous membrane project out between the 
lids. In diphtheria that never happens, unless by 
chance a perforating ulcer has opened the eye to 
septic infection. 
Treatment.—In the acute stage of the disease it is 
impossible to make any treatment directly to the diph- 
theritic patch. All that can be done is to keep the eye 
as clean as possible; for which purpose nothing is bet- 
ter than hot injections of the bichloride of mercury 
1:3000. It is best done by attaching a flattened hard- 
rubber tube to a fountain syringe. The object of mak- 
ing the tube flat is to allow it to slip easily under the 
lid, A glass tube heated in a flame until red, then com- 
pressed, will do equally as well. With such an instru- 
ment it is possible to reach the superior cul-de-sac and 
thoroughly disinfect the eye without hurting the patient 
too much. The object in the treatment is to prevent 
an extension of the false membrane and hasten the 
breaking down of that already formed. At the present 
time we are compelled to believe that injections of the 
diphtheria antitoxin are indicated. I have had no ex- 
perience in that treatment of diphtheritic ophthalmia, 
but I think it will save the eye more certainly than any 
other. The lids should be covered with hot compresses, 
to hasten the advent of the purulent stage. From Diphtheritic Conjunctivitis. 
140 
experience that has been found to be the quickest way 
to do it. But I think if the physician should see the 
case at the very beginning, ice-cold applications would 
be indicated. They would be good for the disease in 
all its stages if it were not that cold tends to inhibit the 
vital forces of the corneal tissues. There must be 
as much life there as possible to prevent the extension 
of ulcerative necrosis. Gold and hot applications, 
antiseptic washings, and the antitoxin injections are 
all any one can do. When the acute stage is passed and 
the blennorrhoea begins, the methods and means to 
control purulent ophthalmia are indicated. 
The object is to save as much of the cornea as pos- 
sible, with the hope that an artificial pupil may restore 
vision. The conjunctiva will be badly scarred, nothing 
can prevent it, nor can anything be done to remedy it 
until all signs of the inflammation are gone. 
A doctor who saves an eye suffering from diph- 
theritic ophthalmia can congratulate himself on his 
good fortune and his ability. CHAPTER XIII. 
CONJUNCTIVITIS SCROFULOSA—PHLYCTENULAR 
CONJUNCTIVITIS. 
A disease of the eye peculiar to children, charac- 
terized by a catarrhal inflammation of the conjunctiva, 
the development of one or more nodular infiltrates on 
the surface of the cornea or conjunctiva (phlyctenulae), 
lachrymation, and intense photophobia. Strictly 
speaking, this affection may not properly belong to the 
conjunctival diseases, as it is more a corneal trouble. 
But since the authorities have always spoken of it as a 
form of conjunctivitis, it is not out of place in this book. 
If we believe that Bowman’s membrane and the super- 
imposed epithelium are a continuation of the conjunc- 
tiva over the cornea, we have reasons to think that in 
reality phlyctenular keratitis is a conjunctival disease, 
especially since we know that the eruption is not always 
limited to the cornea. At any rate, this classification 
is open to serious and interesting debate, which is out 
of place here. 
The attack usually comes on at night. A child will 
awaken in the morning and complain that the light 
hurts its eyes. Little children will violently rub the 
eyes, cry, and bury the face in the pillow. Older chil- 
dren will say that there is something in the eye; they 
also avoid the bright light. When the mother tries to 
see what is the matter, she will find the child cannot 
open its lids, that there is a little swelling of the skin 142 
Phlyctenular Conjunctivitis. 
over the eye, and that there is an unusual flow of tears. 
The moment she takes the child up, it will hide its face 
on her shoulder. That alone is a characteristic symp- 
tom. A child with a foreign body under the lid will 
make a great fuss, but it will not seek the dark. If the 
nurse is an observing person, she may have noticed 
that for a day or so before the attack the child was a 
little restless, had not played around as usual, and that 
it had fingered its eyes. Such premonitory symptoms 
are not usually observed before, but remembered after- 
wards. From the beginning the symptoms increase in 
severity, the light becomes intolerable, the lids swell a 
little at the edges, and, if disturbed, are spasmodically 
shut. The excessive lachrymation scalds the skin of the 
cheeks, and the continual flow of the tears into the nose 
excites an inflammation of the skin around the nostril 
and of the upper lip. From that cause the child may 
have a lateral coryza. The patient refuses to eat and 
play, it sits in a dark corner of the room, with closed 
eyes, and bowed head, or it will remain constantly on 
its mother’s shoulder. As soon as the sun goes down, 
it brightens up, will open the lids a little, and take 
food. 
If nothing is done for the child, it will do one of two 
things; either get well or get worse. It may lie around 
a few days, then open the eyes, and commence to play, 
and seem itself again. But the eyes do not look well 
and bright, there will remain a slight drooping of the 
lids. So it will go on for an indefinite time, when sud- 
denly it will have another attack as bad if not worse 
than the first. When it does not by itself improve, the 
lids swell considerably, the irritation increases, and the Phlyctemi lar • C onjunctivitis. 
eczema about the noise, lips, and cheeks gets very bad. 
Because of the lack of exercise and nourishment, the 
child rapidly runs down. It will require so much con- 
tinual attention that the entire household becomes ex- 
hausted and the patient a pitiable invalid. 
What is it that has caused such a disturbance? 
Probably nothing more than a little infiltrate on the 
surface of the cornea, not larger than the head of a pin. 
If the eye is now examined, which, by the bye, is very 
difficult to do, it will be found that there is more or less 
catarrh of the conjunctiva, and that the acute inflam- 
mation is limited to the anterior surface of the eye- 
ball. At one particular zone of the cornea the con- 
junctiva will be very red and the blood-vessels enlarged. 
Usually there is ciliary congestion all around the cor- 
nea, but about the inflamed spot the congestion is more 
intense. Near or at the limbus of the cornea, to- 
wards the inflamed area, a little white spot may be 
seen, prominent, well defined. This spot is at first an 
infiltrate under the epithelial layer, but it soon breaks 
down into an ulcer, which will have running towards it 
a few parallel capillaries from the nearest edge of the 
conjunctiva. The phlyctenule may be large and cres- 
centic, its concave edge towards the corneal limbus. 
Then there will always be found external to the infil- 
trate an ulcer connected to the conjunctiva by a band 
of blood-vessels. It may be that two or more such 
phlyctenules have coalesced, then the lesion is larger 
and the vascular band broad and prominent. If the 
conjunctiva is carefully examined, it is possible to find 
similar infiltrates in it, and it is not unusual to see on 
the inner surface of the lid, near its edge, a well-defined 144 
Phlycteumlar Conjunctivitis. 
ulcer. Such are the usual appearances of an ordi- 
nary case. 
The pathology of the disease is interesting. Imme- 
diately under the epithelium of the cornea or conjunc- 
tiva collect a number of round cells which evidently are 
derived from the epithelium itself. The massing of the 
cells elevates the epithelial layer and thus forms a 
nodule—a phlyctenule. The lesion may appear at any 
part of the cornea, usually, however, about one or two 
millimeters from the limbus. The cells may be ab- 
sorbed. As a rule, the bleb ruptures, leaving a super- 
ficial ulcer, which may heal without a scar, but usually 
the ulcer penetrates Bowman’s membrane, and because 
the corneal stroma is then exposed, the ulcer becomes 
infected. About this time a few blood-vessels shoot 
out from the nearest edge of the conjunctiva and reach 
the bed of the ulcer; soon the cells of the phlyctenule 
nearest the capillaries are absorbed, but the cells above 
the edge of the ulcer, remote from them—towards the 
center of the cornea—increase in number; the wall of 
the ulcer under them breaks down, and the capillaries 
follow along. In this way a little wave of ephithelial 
exudation passes over the surface of the cornea, leaving in 
its wake a narrow linear excavation filled in at the bottom 
with new Mood-vessels. 
When such an ulcer heals it leaves a scar, which in 
young children may apparently disappear, but for a 
long time it can be seen by focal illumination. The 
width of such an ulcer will correspond to the long 
diameter of the phlyctenule, but the ulcer through 
secondary infection may become inflammatory and 
spread laterally, then there is danger that it will pene- Phlyctenular Conjunctivitis. 
145 
trate the cornea. If it does, the moment the cornea 
ruptures the iris falls into the wound and heals there. 
That is a very unfortunate accident, for when the eye 
recovers, the entangled iris drags on the ciliary body, 
which in children often causes secondary glaucoma. 
There may be two or more phlyctenules on the cornea; 
some may coalesce, some will ulcerate, others will not; 
so it sometimes happens that the major part of the sur- 
face of the cornea—indeed, the whole—is covered by 
discrete and confluent patches of exudation and such a 
quantity of blood-vessels that there is a dense pannus, 
cutting off all view of the anterior chamber and iris. 
If the physician is not careful, he may make a mistake 
and believe that the keratitis is secondary to blen- 
norrhoeal conjunctivitis, especially since in these cases 
the catarrh will be so severe that the tarsal conjunctiva 
grows velvety. The history, the photophobia, and the 
lack of blennorrhoea should make a differential diagno- 
sis easy. Not infrequently the disease attacks a 
trachomatous eye; then the diagnosis is very difficult. 
It is hardly necessary to remind the reader that con- 
junctivitis pustulosa and phlyctenular ophthalmia, 
although somewhat alike, are different diseases, and 
there should be no difficulty in recognizing them. 
Cause.—For many years this disease has been called 
scrofulous ophthalmia. Perhaps this is a misnomer, 
for the bacteriologists have nearly convinced us that 
scrofula is a myth and tuberculosis a fact. It is true 
that the microscope and artificial cultivations do ap- 
proach nearer exactness than any other of our methods 
of investigation. It is equally as true that there are 146 
Phlyctenular Conjunctivitis. 
things we learn from clinical experience that cannot be 
negatived by laboratory experiment. The microscope 
may tell ns a cell is dead, or dying, but it cannot say 
whether it is sick or well. 
Until my faith was somewhat shattered by Koch’s 
investigations, I thought there was a condition of the 
body, either inherited or acquired, wherein the cells of 
the blood or connective tissue lost to some extent their 
vital powers. Such subjects would necessarily re- 
act badly to pernicious influences. They suffered from 
colds, catarrhs, diarrhoeas, emaciation, and lymphatic 
excitability. Many of them were the offspring of 
tuberculous parents. They were light-haired, fair per 
sons; often had bad teeth; rarely dull, usually pre- 
cocious. Such children we called scrofulous. Some 
thought they discovered a syphilitic ancestry, but now 
it is proper to say “tuberculous.” It is not probable 
that this condition is a constitutional stigmata of 
degeneration? 
Those who still believe in the scrofulous diathesis 
may say that, often, phlyctenular conjunctivitis is a lo- 
cal reaction to an irritation in a scrofulous patient. I 
can assure them that this is a good foundation upon 
which to base the treatment. But it must not be forgot- 
ten that many children suffer from this disease who are 
not scrofulous. A very frequent cause is indigestion. 
Nineteen times in twenty we will find that the children 
of the well-to-do who suffer are those who are allowed 
to eat everything and anything; candies, sweetmeats, 
hot bread two or three times a day, apples and cakes in 
the interim. Babies fed on tea and coffee and enter- 
tained by green bananas are the ones liable to this com- Phlyctenular Conjunctivitis. 
147 
plaint. Sncli pernicious dietary predisposes little chil- 
dren to attacks of ophthalmia, as it does to attacks of 
dermatitis. Such are the constitutional causes. The 
local causes are not known. It looks very much as if 
a special microbe had something to do with it, for it is 
significant that only local antiseptics will cure it. If 
the illustration published by Fuchs in his text-book on 
Figueb 12. 
The construction of a phlyctenule on the surface of the cornea, showing its 
relation to a corneal nerve. (After Iwanoff.) 
the diseases of the eye, taken from Iwanoff, is anatom- 
ically correct, it is possible that the nervous system has 
something to do with it. In the drawing is shown, 
where the phlyctenule rests on Bowman’s membrane, 
a corneal nerve penetrates the basement membrane 
and is lost in the collection of new cells. This is signifi- 
cant, for it is possible that the phlyctenule is the result 
of a nervous influence, as is the pustule in herpes 
zoster. Some authorities teach that the eye-disease 
is secondary to nasal disease; that the materies morhi 
reaches the conjunctiva by way of the lachrymal duct. 
Debilitated, scrofulous children nearly always have 
some rhinitis, but there is no evidence that the ophthal- 
mia is secondary, while there is proof that the trouble 
in the nose comes directly from the irritation in the eye, 148 
Phlyctenular Conjunctivitis. 
probably because of the constant flow of the tears into 
the nose, perhaps through the reflexis. 
Diagnosis.—There should be no difficulty in recog- 
nizing this disease. The intense photophobia and lach- 
rymation are suggestive, especially in little children. 
The white exudation on the cornea and the band of 
blood-vessels uniting it to the neighboring inflamed 
conjunctiva are characteristic. The little phlyctenules 
which suddenly come on the cornea in old cases of 
trachoma are somewhat similar to the phlyctenules in 
scrofulous ophthalmia, but anatomically there is no 
resemblance. Trachoma phlyctenules never appear in 
children; they rarely form in persons under twenty 
years of age, and then there are always marked evi- 
dences of degenerative trachoma—atrophy of the con- 
junctiva, scarred lids, etc. A foreign body may light 
upon and be rubbed into the cornea. If it is not re- 
moved, it will ulcerate off. Then there is some diffi- 
culty in determining the cause and character of the ul- 
cer. Such ulcers may be quite large and yet there be no 
particular photophobia. The fear of light in scrofulous 
ophthalmia is not dependent upon the size or seat of 
the ulcer, but upon its peculiar character. Often on 
the upper limbus or edge of the cornea during the pro- 
gressive stage of chronic blennorrhoeal ophthalmia 
there will suddenly appear an irritable, ugly ulcer. 
If there is no pannus at the time, the blood-vessels 
will quickly shoot out towards it. These ulcers are 
very painful, the photophobia intense, and the lach- 
rymation excessive. The beginner may mistake 
them for broken-down scrofulous phlyctenules. But 
in such cases there is always a history of chronic Phlyctenular Conjunctivitis. 
149 
eye-disease and there are marked evidences of tracho- 
ma or blennorrhoea. 
Phlyctenular conjunctivitis is sometimes seen in 
children about puberty and in young adults; it is 
then somewhat different in character from the dis- 
ease in infants. There is not nearly so much photo- 
phobia, and very rarely, if ever, does the inflamma- 
tion lead to the well-marked scrofulous pannus. Usu- 
ally it is a simple comeal ulcer near the limbus, which 
has a tendency to inflame and break down. Such ulcers 
should not be mistaken for trachoma or blennorrhoeal 
ulcers, nor the catarrhal ulcer in older people. 
Colored people are often attacked by a peculiar form 
of conjunctivitis. The disease appears as a simple con- 
junctivitis, which is evidently secondary, for the charac- 
teristic lesions attack the conjunctiva of the eyeball. 
There is always ciliary congestion, which in black sub- 
jects, because of the pigmentation of the sclera, is dif- 
ficult to see. At the extreme edge of the conjunctiva, 
on the corneal limbus, little round bead-like nodules 
appear. There may be a number of them, usually three; 
some are small, others large. The cornea is not often 
inflamed, but sometimes a little inflammatory ulcer 
will develop in the cornea adjoining the conjunctival 
growth. There is some photophobia, excessive lachry- 
mation, no particular pain, but discomfort. Colored 
people of all grades and conditions are subject to it. 
But I have noticed that it is more common among the 
pure negroes. The disease is scrofulous ophthalmia. 
Treatment.—The treatment is both constitutional 
and local, which must be combined in all cases. Both 
are extremely simple and satisfactory, for of all the Phlyctmular Conjunctivitis. 
150 
severe inflammations of the conjunctiva and cornea this 
is the easiest to cure. The first thing to do is to regu- 
late the diet. Hot bread, pancakes, tea and coffee, 
and all other forms of indigestible food should be for- 
bidden. Let milk and water be the only drink. Meat 
once a day, chicken well cooked, and beef a little rare. 
Pork, ham, and salted meats must be avoided. The 
ordinary vegetables will do no harm excepting, perhaps, 
carrots and cabbage. A little sugar is harmless, but 
candy must be prohibited. Cakes and sweetmeats 
are bad. It is better to let the child eat little and 
often than to satisfy it at one meal. Fresh air is as 
necessary as good food. The child must not be confined 
to a hot, dark, ill-ventilated room. If the photophobia 
is so severe that it cannot go out, it is well to wrap a 
handkerchief around its eyes and have it carried out. 
It is imperative to give it the best possible hygienic 
surroundings and by the improved dietary remove all 
possible causes for reflex disturbances from the di- 
gestive canal. It is proper to prescribe a good emul- 
sion of cod-liver oil, alone or compounded with the 
hypo-phosphites. They all demand some preparation 
of iron. From experience, I find that the syrup of the 
iodide of iron is the best; twenty to thirty drops three 
times a day, after meals, given in a little sugar or syrup. 
The change of diet should correct any form of indiges- 
tion; if not, pepsin may help the stomach and small 
doses of calomel regulate the bowels. Such is the con- 
stitutional treatment. It is rarely necessary to give 
anodynes or opiates. The local treatment is even more 
simple, but it is essential that the physician should 
know exactly the condition of the eye. Sometimes Phlyctenular Conjunctivitis. 
151 
that is very difficult to find out, for the examination of 
the eyes of these little patients is not easy. Because 
of the photophobia and the fear of the doctor, there is 
such violent spasm of the lids that they cannot be 
opened with the fingers wide enough to expose the cor- 
nea; lid-elevators are then necessary. I usually put 
a drop of cocaine between the lids. When ready, 
the child is held fast and steady by assistants. Then I 
open the lids with a spring speculum. If it is properly 
done, there is no danger of injuring the child. As soon 
as the lids open and the eye rolls up, I firmly grasp the 
conjunctiva below the cornea with a pair of forceps and 
pull the eye down. In this way one can see the char- 
acter and extent of the disease. The spring speculum 
is not a good instrument to use if one feels he is not an 
expert; the ordinary lid-elevator will do, or one made by 
bending over the back of a hairpin. This operation 
should last but a moment. It is better to take a little 
time and see everything than to do it quickly and see 
nothing. Of course, the child will do a great deal of 
kicking and screaming; so if such disturbances are too 
much for the doctor and the parents, an anaesthetic is 
advisable. 
Atropla is indicated in all cases, one grain to the 
ounce of water. One or two drops of this solution 
should be put into the eye three times a day. Nothing 
added to the atropia solution will add to its efficacy, 
unless it be a little cocaine. Morphine and astringents 
will do harm. All the preparations of mercury 
applied locally are specifics because they are powerful 
antiseptics. The ones usually selected are calomel and 
the yellow oxide. With a camel's-hair brush, a little 152 
Phlycten/ular Conjunctivitis. 
dry calomel should be dusted on the conjunctiva of the 
lower lid once a day. Very little should be used, 
enough to be distinctly visible, as a powder on the 
mucous membrane. If a larger quantity is used or if 
it is lumpy, it will collect between the folds of the mem- 
brane and excoriate. The calomel is evidently changed 
by the fluids into the bichloride of mercury, and since it 
is not all acted on at once, but by degrees, it is evident 
that the eye is influenced for a longer time than it 
would be if a solution of corrosive sublimate were 
dropped in. The yellow oxide of mercury ointment, 
carefully prepared, 1 grain to the drachm of vaseline, 
is a popular remedy. Of this (golden ointment) a 
little piece is put under the upper lid once a day. 
When the photophobia is very severe and the child is 
suffering from spasm of the lids, I have found that the 
best remedy is an application of a mild solution of the 
nitrate of silver, 2 grains to the ounce. The inverted 
upper lid may be painted with this once a day, the 
excess washed off. This application will often act 
wonderfully; over and over again, I have seen children 
open their eyes twelve hours after it is used. 
It is not well to try to relieve the blepharospasm by 
internal antispasmodics. They will do no good, but will 
irritate the stomach and counteract the improvements 
inaugurated by the new diet. Under this treatment 
the eye in mild cases should commence to improve in 
about four days. The local treatment must be con- 
tinued until the child is well, the constitutional treat- 
ment longer. Some may be tempted to destroy the 
phlyctenule by the actual cautery. If one is proficient 
in handling that instrument, it may be tried, but it is Phlyctenular Conjunctivitis. 
rarely necessary; then again, it can do more harm than 
good. Whatever may be the condition of the cornea, 
atropia, calomel, or the yellow oxide are the best local 
remedies. 
This is essentially a relapsing disease. Children 
rarely have but one attack; consequently it is advisable 
for the doctor to inform the parents of this fact and 
that there is danger of a relapse, especially if indis- 
cretions in eating are permitted. As the child grows 
older the relapses become less frequent; finally cease. 
It is to be regretted that scrofulous ophthalmia 
destroys many eyes, either through destruction of the 
cornea by ulceration, or because of secondary glau- 
coma caused by a bulging staphyloma holding in its 
cicatricial grasp ihe iris. CHAPTER XIV. 
XEROSIS, 
The word “xerosis” is derived from the Greek ad- 
jective xeros, dry. Xerophthalmia is a condition of 
the conjunctiva and cornea characterized by extreme 
dryness. It is dependent upon one of two causes: 
either the mucous membrane is like an oiled surface 
and cannot be wetted, or there are no tears to moisten 
it. In the chapter on the anatomy of the conjunctiva it 
was mentioned that the tears did not come alone from 
the lachrymal gland proper, but in part from the lach- 
rymal glands under the upper lid and the minute 
racemose glands above the convex border of the upper 
tarsal cartilage. From these two latter sources 
enough fluid can be secreted to keep the eye comfort- 
aide, for when the lachrymal gland is removed from the 
orbit, no bad effect is noticed other than that the indi- 
vidual cannot cry. The tears are not only a solution of 
certain salts in water, but they contain some mucus and 
exfoliated epithelium. The amount of the chloride of 
sodium in them is so great that they taste decidedly 
salty. The object of the salt is to prevent the water 
swelling the epithelial cells, for when the epithelium 
covering the cornea is swollen or distorted, the acuity 
of vision falls. Ordinarily the lachrymal flow is just 
sufficient to keep the -surface of the conjunctiva and 
cornea moist. The tears do not run over the eye, but 
are diffused over it by the action of the upper lid. 
154 Xerosis. 
155 
When the lid falls, it spreads over the eyeball the tears 
that have accumulated above it; when it rises, it 
spreads over the cornea and ocular conjunctiva an ex- 
tremely thin layer of fluid from below, enough to soak 
in between the superficial epithelial cells and by 
osmosis replenish the water of the epithelial proto- 
plasm lost by evaporation. If there are no tears or the 
epithelium will not absorb them, the mucous mem- 
brane dries. 
There are two kinds of xerosis, true and false. 
False xerosis often occurs in exhaustive diseases 
accompanied by coma—viz., typhoid and typhus fever, 
chronic septicaemia, cholera, dysentery, and hysteria. 
It is simply a drying of the conjunctiva, because there 
are no tears and the patients lie for a long time with 
the eyes open. The exposed epithelium of the cornea 
and the conjunctiva becomes covered by a layer of 
sticky mucus, which dries on the eyeball and along 
the edge of the lids. The membrane immediately reacts 
to the mechanical irritation; it becomes inflamed, so 
t here may be considerable redness and SAvelling, The 
cornea clouds up, and, if not protected, may ulcerate. 
Clinically this is a very serious condition, for the 
majority of the patients die; yet the most marked case 
I ever saw was a girl in hysterical coma. Her eye- 
lids had not been closed for hours, so one can imagine 
her condition. When she recovered, she had quite an 
attack of conjunctivitis, but the cornea did not ulcerate. 
The only treatment necessary in such cases is to keep 
the eye moistened with salt water or glycerin and wa- 
ter and hold the lids shut by adhesive plaster. If is not 
advisable to use a bandage for this purpose, for the 156 
Xerosis. 
lids may open under compress and the cotton come in 
contact with the exposed cornea. This trouble never 
happens if there are any tears secreted; so long as the 
lachrymal glands functionate, the lids may remain 
opened indefinitely and the eye be kept moist, as is fre- 
quently observed in those with facial paralysis or de- 
formity of the lids from burns. 
Of xerosis proper there are two varieties; perenchy- 
matous and epithelial. The first is quite common, the 
second very rare. One is dependent upon profound 
atrophic degeneration of the entire mucous membrane, 
the other upon disease of the epithelium. It is easy 
to understand how the conjunctiva can be totally 
destroyed by trachoma, chronic blennorrhoea, and 
ulcerative diseases. When a mucous membrane be- 
comes transformed to a layer of dense cicatricial tissue, 
its function is abolished, and if it has any epithelium on 
it at all, it is deformed and useless. Such a condition 
of the mucous membrane is seen in pharyngitis sicca, 
atrophic rhinitis, and in old cases of granulated lids. 
In some the conjunctiva will be so shrunken that the 
cul-de-sacs are closed and the atrophied lids joined 
to the eyeball above and below the cornea like hinges. 
If the sensibility of the cornea is not benumbed by a 
pannus, there is no danger of xerosis, for the reflex 
action on the lachrymal gland is retained, and the 
tears will flow, although the ducts leading from the 
accessory glands are obliterated. In anaesthesia of the 
cornea the entire lachrymal apparatus may atrophy; 
then, of course, the dryness will be extreme and the 
mucous membrane changes to a layer of tissue resern- Xer'osis. 
bling skin. If the student will notice the blind beggars 
on the streets, he will find some cases like these. 
I do not know that anything can be done for ad- 
vanced parenchymatous xerosis. If the case is seen 
in time, every energy should be exerted to retain the 
sensibility of the cornea and dissolve the pannus. For 
that purpose nothing can equal the sulphate of copper. 
A crayon should be slightly rubbed over the inner 
surface of the upper lid once a day. Massage with 
the yellow oxide of mercury ointment is good. When 
these do not arrest the progress, the case is hopeless. 
The most remarkable of the different forms of 
xerosis is the epithelial. From some unknown cause 
the epithelium covering the ocular conjunctiva, espe- 
cially that part most exposed to the air between the 
circumference of the cornea and the canthi, is altered 
in such a way that it will not absorb the water of the 
tears. Then, of course, the most superficial layers 
of the cells die. The patch has an opaque, frosty ap- 
pearance, which makes it very prominent by compar- 
ison to the life-like surroundings. We do not know the 
changes that take place in the epithelial cells, but a 
particular bacillus has been discovered in the xerotic 
area, so, some believe it is dependent upon a local cul- 
ture of micro-organisms. The probabilities are it is not 
a local disease, since nearly all the patients present 
other evidences of constitutional trouble; prominent 
among these is hemeralopia (night blindness); a defect 
of vision always a symptom of some intraocular disease, 
or the result of depressed nerve tone. 
Xerosis epithelialis is seen in epidemics and among 
the poor and ill nourished. But people in the best of 
health may suffer from it, and it is not always accom- 158 
Xerosis. 
parried bj any visual disturbance. The epithelial cells 
evidently die and as foreign bodies excite a certain 
amount of inflammation. They are cast off or the patch 
sloughs away. In the first case new epithelium takes 
their place to live or die; in the second an ulcer is left 
to heal by granulation. Sometimes the disease attacks 
the cornea; then, if it leaves an ulcer, there is danger 
of the resulting leucoma interfering with vision. Usu- 
ally little damage is done, for the disease disappears, 
either because it has run its course or the cause is 
removed. 
The treatment should be constitutional and pro- 
tective. Good food, cod-liver oil, and fresh air are 
requisite, and smoked glasses to protect the eyes from 
the glare of light, the dust, and the wind. CHAPTER XV. 
CONJUNCTIVITIS (HERPES, ACNE, ECZEMA). 
In all diseases of the skin of the face there is a 
tendency to inflammation of the conjunctiva and cor- 
nea. The most common are herpes, acne, and eczema. 
Sometimes the inflammation passes from the integu- 
ment to the mucous membrane of the eye; usually the 
disease attacks the conjunctiva directly, but at the 
time of the dermatitis. None of them (unless it be 
eczema) are dependent upon local irritation; they are 
constitutional eruptions. The ophthalmic surgeon is 
interested in three forms of herpes: herpes simplex, as 
it appears in herpes labialis, herpes zoster, and herpes 
iris. On very rare occasions a herpetic eruption ap- 
pears on the conjunctiva of the eyeball and on the 
cornea. It comes suddenly and from the same causes 
that occasion its outbreak on the lips. This disease, 
when it attacks the eye, very closely resembles phlyc- 
tenular ophthalmia, but it is not apt to trouble chil- 
dren or young persons. The disease suddenly appears 
on the cornea as one or more minute blebs, which 
almost immediately rupture and leave small ulcers. 
The ulcers may be inflammatory—-that is, infiltrated, or 
they can be so transparent that there is difficulty in see- 
ing them, even under focal illumination. The accom- 
panying conjunctivitis is always severe. There is a 
burning pain in the eye, great photophobia, and lachry- 
mation. While some of the ulcers are healing, new ves- 
159 Conjunctivitis, Herpes. 
ides may break out, but usually the first eruption is the 
acme of the attack and passes away in a few days. The 
ulcers are very superficial and leave but faint traces. 
Very few doctors will be on the look-out for this dis- 
ease, so it is rarely diagnosticated correctly, unless the 
ophthalmia and dermatitis come simultaneously. The 
causes are the same that excite an outbreak of herpes 
around the mouth—viz., fever, indigestion, pneumonia, 
and menstrual disorders. The cases I have seen were 
women suffering from functional disorders of the re- 
productive organs; they all had such a history, and the 
monthly intervals between the attacks were suggest- 
ive. The treatment is very simple: solutions of atropia 
or eserine for the eye and proper medication for the 
body. The conjunctiva and the cornea will not stand 
anything but the most soothing applications. Astrin- 
gents are contra-indicated, cocaine may moderate the 
pain some; atropia, a snug bandage, and warm appli- 
cations are all that are necessary unless some compli- 
cation arises. 1 
In this place I shall call attention to a form of herpes 
which attacks the margin of the lids. In the inter- 
marginal space, usually of the upper lid, where the 
ducts from the Meibomian glands open, one or more 
little blebs suddenly appear; they are transpar- 
ent, being filled with an amber-colored fluid. The 
surrounding skin is not inflamed. On examination they 
look as if the ducts had become occluded and the blebs 
were the result. They are not connected with the ducts, 
for I have seen them between the mouths of the ducts 
and the lashes. The symptoms are simply annoying. 
The diseaised spots may burn a little, but when the lids Conjunctivitis, Herpes. 
come together in winking, they interfere, and worry the 
eye like foreign bodies. They last from six to twelve 
hours, rupture, then disappear. This is a very simple 
affair, and all that is necessary to give immediate relief 
is to puncture them with a needle. If the attacks are 
frequent, it may be advisable to test the refraction and 
prescribe appropriate glasses if they are indicated. 
HERPES ZOSTER OPHTHALMICA. 
This is one of the most painful diseases that can at- 
tack the eye. The cases are never mild, they are al- 
ways severe. The trouble begins, like herpes zoster 
in other regions of the body, with intense neuralgia and 
hyperaesthesia of the skin; often it is over the distribu- 
tion of the supraorbital nerve and the nasal branch of 
the fifth; sometimes the pain is below the orbit in the 
area supplied by the infraorbital nerve. The eye symp- 
toms arise soon after the beginning of the neuralgia, 
sometimes before the eruption on the skin. I can best 
describe the disease by reporting the following case: 
A gentleman twenty-five years old was suddenly 
attacked by a most severe supraorbital neuralgia over 
the right eye. The pain involved the same side of the 
nose as far as the nostril. His doctor thought it was a 
malarial attack and gave him large quantities of qui- 
nine. The next day the eye was so congested that the 
patient was turned over to me as an ophthalmic case. 
On my first examination I could not tell what was 
the matter, nor did I know for two days, when an erup- 
tion broke out over the brow and along the side of 
the nose. The herpetic blebs reached the exact mid- 
dle line of the face, and did not cross over to the other 162 
Conjunctivitis, II crpcs. 
side. Seventy-two hours after the beginning of the 
pain a bleb appeared on the cornea, and with it came 
the photophobia and lachrymation. The lesions on 
the skin suppurated, and, when they healed, left deep 
pits. The bleb on the cornea broke down into an ni- 
cer, which disappeared in a few days, leaving a scar. 
The subsequent effects were remarkable. Soon after 
the eruption, tin1 cornea became anesthetized, which 
lasted several days. There was marked paresis of the 
internal and superior recti muscles, which did not en- 
tirely disappear for months. The iris, too, was par- 
alyzed; the mydriasis remained half a year. There 
was also developed an astigmatism, which still exists. 
For a long time I thought the astigmatism was lenticu- 
lar, but now I am inclined to believe it is corneal, de- 
pendent upon the scar left by the lesion. The par- 
ticularly interesting clinical point in this case was the 
appearance of the conjunctivitis hours before the out- 
break of the eruption either on the skin or the cornea. 
Herpes zoster is a form of neuritis. The skin over 
the area of distribution of the diseased nerve may be 
so low in vital tone that the ulcers left after the ex- 
foliation of the scabs may become necrotic. The same 
danger threatens the eye. The corneal ulcers can en- 
large and perforate the anterior chmber. Such an acci- 
dent I saw in an old man. The cornea was almost 
destroyed by a secondary abscess. The anaesthesia was 
so great that I had unusual difficulty in healing the 
wound after the abscess was incised and cleaned. 
Diagnosis.—Until the eruption appears on the skin, 
it is not possible for the physician to make a correct 
diagnosis. If the patient is subject to attacks of Conjunctivitis, Hcrpcs. 
163 
shingles, a sudden supraorbital neuralgia together 
with congestion of the eye may suggest herpes zoster. 
But that is unlikely, for few people have the disease 
a second time. The diseases of the eye somewhat like 
it in the beginning are iritis and glaucoma. There 
should be no difficulty in the differential diagnosis. In 
iritis the pupil is contracted and dilates slowly or 
irregularly under atropia, and there is always well- 
marked ciliary congestion. In acute inflammatory 
glaucoma the pupil is dilated, the cornea blurred and 
the eyeball very hard. 
The cause of herpes zoster is not known. Most 
writers believe that it is of nervous origin; others think 
the inflammation is dependent upon disturbances of the 
circulation in the affected skin area. The bacteriolo- 
gists see evidences of microbial invasion. I believe it 
is a neurosis. 
The treatment is palliative; no internal or external 
medication will prevent the disease running its normal 
course. For the eruption simple drying powders are 
better than ointments or washes; for the eye atropia 
and a compress bandage are indicated. Since the cor- 
neal ulcer involves a tissue of low vitality, the physician 
should be careful not to further depress it, which will 
certainly happen if ice-cold applications are ordered, 
therefore, it is necessary to keep the eye warm. Noth- 
ing wall surely relieve the pain but morphine. Cocaine 
is contra-indicated. If the coal tar preparations are 
used as analgesics, the physician must be careful, for 
only dangerous doses will be effective. The disease 
lasts from six to fourteen days. Conjunctivitis, Ho pes. 
164 
This is an extremely rare disease of the eye; very 
few cases have been seen or reported. The skin lesion 
is not more interesting to the dermatologist than the 
ophthalmia is to the oculist. The conjunctivitis is 
purely a croupous inflammation. The following trans- 
lation of the report of a case by Von Arlt is an excellent 
description of the disease, although it is not as typical 
as the one I shall mention: 
HERPES IRIS OPHTHALMICA. 
“A man fifty-seven years old was admitted to the 
clinic, suffering from inflammation of the eye, which 
was thought to be a conjunctivitis, for there was a gray 
deposit over the inner surface of the under lid. The 
conjunctiva of the retrotarsal folds was somewhat 
swollen, that covering the eyeball was not inflamed. 
It was the fifth day of the disease; evidently it was not 
diphtheria nor acute blennorrhoea. He had a herpetic 
eruption on the upper lip towards the angle of the 
mouth on the right side. It was very noticeable, but 
not carefully examined. After his admission on the 
eighth day, it was determined that it was not syphilis. 
At that time the inner surfaces of the upper and under 
lids were covered by a thin gray false membrane, 
which was quite adherent. Besides, he had an erup- 
tion over the palm of his right hand, which was recog- 
nized as herpes iris. The skin of the lids was some- 
what red, but not swollen. The palpebral conjunctiva 
not covered by the membrane was thickly injected. 
The deposit extended from the folds to the edge of the 
lids, and was 0.5 m. thick; with forceps it could be torn 
away in shreds, would leave a bleeding spot, and soon 
re-form. The mouth became sore two days after the Conjunctivitis, Herpes. 
165 
eye. A mottled gray-white membrane covered the 
greater part of the mucous membrane of the mouth. 
The upper and lower lips were covered by dried scabs. 
The inside of the cheeks, gums, hard palate, and sides 
of the tongue were covered by single and confluent 
patches of false membrane. Because of the pain in 
masticating and swallowing, the patient had eaten very 
little; in consequence, he was very much run down. 
The breath had the smell of fresh pus. During twenty- 
four hours the flow of saliva was 300—400 grams. It. 
contained nothing abnormal. He had no disease in 
the throat, nose, or larynx. The disease of the skin 
appeared seven days after the disease of the eye; it be- 
gan by an itching in the hand at night; the next morn- 
ing there was a well-marked eruption over the palm. 
The young efflorescence was a hypersemic spot about the 
size of a split pea, scarcely raised above the level of the 
skin, in its center was a dark red spot (a small hem- 
orrhage). Shortly afterwards there appeared a red 
cedematous ring around the original patch, then an- 
other ring formed around it. When the efflorescence 
was completely developed, there were four concentric 
rings (two white and two red) around a central 
hemorrhage. The case progressed without fever. In 
two days, the membrane over the tarsal cartilage of the 
upper lid broke away, leaving exposed the reddened 
mucosa devoid of its epithelium. Nine days after he 
entered the hospital, the eye was free of false mem- 
brane. It left the conjunctiva slightly hyperaemic 
with some prominence of the papillae. The eruption 
which appeared on the left palm, May 2d, showed the 
next day on the back of the right hand, then on the 166 
Conjunctivitis, Herpes. 
extensor sides of the elbows, finally on the soles of 
the feet and on the fingers of both hands; there, some 
were abortive, while others developed into large blis- 
ters filled with opaque serum. On the 27th of May the 
patient was discharged. 
The following case I have reported once before. 
It is appropriate in this place, and, because it is so 
similar to the above, it is of particular interest. 
In the spring of 1884, a lady, the mother of three 
children, the wife of a well-to-do farmer, was brought 
to me for treatment of her eyes. She was suffering 
from what appeared to be a complication of diseases. 
She was totally blind and had been so for one week. 
Two week before I saw her, she was taken ill with 
what was supposed to be an attack of indigestion. Her 
eyes inflamed a little, the lids closed and could not be 
opened; then an eruption appeared over the body and 
fever blisters on her lips. When I saw her, the con- 
dition was as follows: Over the legs and arms 
were scattered a number of round, well-defined, flat, 
hypersemic patches. In the center of each was a dark 
red spot; some of the lesions were larger than others. 
A number of them had evidently disappeared, for they 
left dark blotches on the skin, which did pot disappear 
on pressure. The palmar surfaces of her hands and 
the soles of her feet were covered by immense blisters, 
which were filled with serum. Her mouth was in a 
dreadful condition; both lips were covered by black 
hemorrhagic scabs, which extended up to the nose and 
down to the chin. Inside of the lips and cheeks was a 
dirty false membrane, tightly adherent. The mucous 
membrane of the fauces, tongue, and palate was not Gonjunctivitis, TTerpes. 
diseased. It looked like a very aggravated case of 
herpes labialis. The eyelids were closed; they were 
not swollen, and until they were separated no one would 
suspect that there was anything the matter with the 
eyes. When an attempt was made to part the lids, it 
was seen that they were closely adherent to a false 
membrane, which covered the eyeball. With care it was 
possible to peel the upper lid off the deposit. It left 
the mucous membrane raw, for it bled considerably. 
Nothing could be seen of the eye, for the croupous de- 
posit evidently filled the entire conjunctival sac. 
With two pairs of forceps 1 gently tore a way through 
the membrane towards the cornea. When I had gone 
about one-eighth of an inch, I reached a space filled 
with clear fluid, which was in front of the cornea and 
showed that the deposit was not adherent to its epi- 
thelium. As soon as the opening admitted the light, 
the patient could see. There was no disease.either of 
the cornea or deeper tissues. She did not suffer any 
pain about her eyes, she only complained that she could 
not open the lids. The treatment for the eyes was con- 
tinued warm applications; nothing else was done. In 
a few hours the opening I made closed and the lids ad- 
hered again. There was no discharge. Gradually the 
membrane melted away. It got thinner and thinner 
and finally disappeared. When it was gone, I found 
it had completely stripped the epithelium off the con- 
junctiva and left it red, but not inflamed. The great 
difficulty, then, was to prevent the lids adhering to the 
eyeball. Every morning I was compelled to free them. 
The operations were painful and bloody. Oil and vasel- 
ine would not prevent the sticking together of the mu- Conjunctivitis, Acne. 
cous surfaces. The eyes got well, but the superior cul- 
de-sacs were completely occluded. The skin disease 
disappeared, the lips cleaned off, and the patient left 
the hospital in six weeks. 
ACNE CONJUNCTIVITIS. 
If acne is an inflammation of the follicles and 
glands of the skin dependent upon a local cause, it is 
difficult to understand how the disease can attack the 
conjunctiva and cornea, for it is very exceptional for 
a dermatitis to encroach upon the mucous mem- 
brane lining the lids. People who have acne of the 
face sometimes suffer from acute inflammation of 
the eyes, and since it is more than a coincidence, the 
authorities have described an acne ophthalmia. The 
cause of the two diseases is evidently the same; there- 
fore it is presumptive that certain forms of acne are 
constitutional. The variety which interests the ocul- 
ist is, acne rosea. That disease of the skin of the face 
apd nose is a familiar picture. The red skin, the swol- 
len aim of the nose, and the arborescent capillaries 
shooting out from the naso labial folds are character- 
istic. Scattered over the congested area are often 
found little pimples, some tapped by a small pustule. 
Such an affection we have always recognized as the 
sign of high living, the mark of deranged digestion. It 
is difficult to explain the relationship between the dis- 
ease in the eye and that on the skin, for in this form of 
conjunctivitis the skin lesion is not always prominent. 
The worst cases are often in those who have no marked 
acne of the face, but who suffer periodic attacks of 
pimples. i i Conjunctivitis, Acne. 
169 
Acne of the conjunctiva is very much like phlyc- 
tenular ophthalmia, inasmuch as there is a corneal 
lesion—an ulcer—a certain amount of conjunctivitis 
and the most intense photophobia. It differs from 
scrofulous ophthalmia in two particulars: it does not 
attack children and there are no capillary bands. The 
ulcer is small, angry-looking, and persistent. It may 
heal in a few days; as a rule, it will last for weeks. It is 
essentially a relapsing disease; the second lesion 
comes as the first goes. Although this disease is not at 
all dangerous, so far as the eye is concerned, yet it is 
very annoying. The photophobia may be so severe 
that the patient must remain in a darkened room. 
The best treatment is atropia, counter-irritation 
over the forehead (the white precipitate ointment), and 
tempered light. Brushing the inverted lids with a 
mild solution of the nitrate of silver will sometimes 
allay very much the fear of light and the blepharo- 
spasm. Eserine has disappointed me in this, as it has 
in other diseases of the cornea for which it has been ex- 
travagantly recommended. My experience is, that 
destroying the ulcer with the actual cautery is the 
best method devised to cut short the disease. Un- 
fortunately, the ulcers are apt to come immediately in 
front of the pupil; then the cautery is contra-indicated, 
for the resulting scar will blur the vision. 
The following case is a very good example of this 
disease: 
A lady forty years old was led into my office suffer- 
ing with pain in the right eye and the most intense 
photophobia. The eye could not be examined without 
the aid of cocaine. When, by that means, the eyeball Conjunctivitis, Acne. 
was exposed, a small angry ulcer was seen at the upper 
edge of the cornea. There was considerable diffused 
conjunctivitis. It was the first time she had had any- 
thing the matter with her eyes. In hunting for the cause 
of the ulcer, I found a few acne pimples scattered over 
the cheeks and forehead. These she had not noticed, for 
they evidently came out on the skin at the time the 
eye was attacked. Her general condition was good, 
but she suffered considerably during her monthly pe- 
riods. I destroyed the corneal ulcer with the electric 
cautery, put the eye under the influence of atropia, and 
applied a compress bandage. The relief was imme- 
diate, and in a few days the eye was well. About three 
months afterwards she had another attack in the same 
eye, also an acne eruption on the face. At that time 
the ulcer was immediately in front of the pupil. Fear- 
ing the use of the cautery, I tried to heal the lesion by 
atropia and bandaging. They failed; eserine was sub- 
stituted. She then suffered dreadfully and could only 
get relief from large doses of morphine. 1 tried dubois- 
ine, hom,atropine, and cocaine; was then compelled to 
resort to the cautery; again she had immediate relief. 
Six months after, she had another attack, with it the 
acne. But, as the eruption on the face was so decided, 
I sent her to a dermatologist, who signally failed to cure 
it. The corneal ulcer was extremelypainful and in front 
of the pupil. . Knowing that if the cautery were used, 
she would never again have a useful eye, I declined to 
operate. She then went under the care of another 
oculist. If lam to judge from the length of time she 
wore a bandage, he had an experience similar to if not 
worse than mine. Conjunctivitis, Eczema. 
171 
ECZEMA CONJUNCTIVITIS. 
On rare occasions the irritative effects of eczema of 
the face extend to the eye, particularly so in eczema pus- 
tulosa and eczema capitis in children. It is doubtful 
if ever the characteristic eruption comes on the con- 
junctiva. Some cases have been reported in which, 
during the course of the skin inflammation, ulcers 
appeared on the cornea and the symptoms were 
very much like scrofulous ophthalmia. But it must 
be remembered that that is no proof the disease on the 
eye was like that on the skin, for it is not surprising for 
children with eczema about the head to have at the 
same time phlyctenular conjunctivitis. In adults it is 
different. When they, during the course of severe der- 
matitis of the face, suffer from subacute conjunctivitis 
together with circumscribed keratitis, it is presumptive 
that the same cause is inflaming the eye. In eczema of 
the face, with swelling of the eyelids, it is a rule to find a 
certain amount of conjunctivitis, but I do not know 
that I ever saw the cornea inflamed. It must be remem- 
bered that very often, when there is great photophobia 
and lachrymation, the eczema on the lips and cheeks 
is secondary, dependent entirely upon the tears moist- 
ening the skin. This is often seen in scrofulous 
ophthalmia. 
Case.—A man was admitted into the Missouri Pa- 
cific Railway Hospital under the care of Dr.C. W. Davis, 
of this city, suffering from suppurative eczema of the 
face. There was considerable swelling of the skin; the 
eyelids were puffy and the conjunctiva very red. He 
complained that his eyes smarted and that the light 172 
Conjunctivitis, Eczema. 
hurt them. The conjunctiva was very much inflamed, 
but the cornea was clear. The conjunctivitis lasted 
until the face was well. It was not dependent upon 
a neighboring irritation, but had a constitutional cause. 
A very rare lesion of the conjunctiva associated 
with the disease of the skin is the pemphigus bleb. 
But few examples have been recorded. The majority 
of ophthalmic surgeons have never seen a case. It 
appears that the blister on the conjunctiva is exactly 
like that on the skin, but differs from it in one important 
respect: in the eye the lesion entirely destroys the mu- 
cous membrane under it; in the skin it does not. Conse- 
quently the results are exactly like those after diph- 
theria and burns: great shrinking of the conjunctiva 
and symblepharon. 
PEMPHIGUS. CHAPTER XVI. 
PTERYGIUM. 
PINGUECULA. 
To understand in part the etiology and nature of the 
pterygium, it is necessary to know something of an ap- 
parently harmless little growth in the conjunctiva next 
to the cornea, called the pinguecula. This can scarcely 
be called a disease, for the majority of adults in this sec- 
tion of the country have it. It is invariably seen on that 
part of the conjunctiva of the eyeball always exposed 
when the lids are open. Consequently, it may be on 
both sides of the cornea; usually it is only on the nasal 
side. To the reader it may be surprising to learn that 
nearly all men over thirty have pingueculte. The reason 
why they are not generally noticeable is, they are often 
small and transparent. 
The pinguecula is a little triangular growth in the 
conjunctiva on the nasal or temporal side of the cornea; 
its base on the circumference of the cornea, its apex 
toward the canthus. It appears to be a simple thick- 
ening of the membrane and does not encroach upon 
the transparent cornea unless it is subjected to con- 
tinued irritation, when it is apt to grow towards the 
pupil and make the pterygium. The reason why 
so many people who live upon the Western plains 
have the pinguecula is, the eye is almost continual- 
ly subjected to bright light, wind, and dust. Under 
these circumstances the people ride and go about with 
173 174 
Pinguecula. 
the eyelids almost closed to protect them; then the 
triangular area of the conjunctiva, which must be ex- 
posed that they may see, is alone irritated. When 
a mucous membrane is irritated, it does not, like the 
skin, protect itself by covering its surface with thick 
layers of epithelium; it simply hypertrophies. That 
is, there is an increase in the connective-tissue ele- 
ments. So, in ping u ecu la the elastic fibers binding 
the conjunctiva to the sclera are greatly multiplied. 
Therefore the denser the tissue becomes the more 
amende it must be; so one can easily understand why 
in acute conjunctivitis the eyeball is deep red and the 
pinguecula pink. Most pingueculae are white; many of 
them are amber color, because there is deposited in and 
between the connective tissue bundles of the tumor 
hyaline matter. 
The growth is harmless and requires no treatment 
unless it crosses the edge of the cornea. Then it 
should be removed, which is best done by cocain- 
izing the eye and dissecting off the tumor with a sharp, 
thin knife-blade; but care must be taken that all par- 
ticles adhering to the sclera are scraped away. A 
stitch to bring the cut edges of the conjunctiva together 
is not always necessary. 
A comet-like growth on the eyeball, its head on 
and adherent to the cornea, its tail radiating over 
the conjunctiva. It is very common in this country, 
especially among cattle-men. We see it and have 
an opportunity to study it nearly every day; yet of 
all the diseases of the conjunctiva this is under- 
THE PTERYGIUM. Pterygium. 
175 
stood the least. It is nearly always on the nasal side 
of the eye; rarely it is seen on the temporal side; then 
there are two, an external and an internal, double 
pterygia. Simply glancing at it, the pterygium looks 
like a fleshy growth on the eye extending from the car- 
uncle over into the transparent cornea. It is in the me- 
dian line and on that part of the conjunctiva most ex- 
posed to the air. Sometimes it is fiery red and promi- 
nent; then it is very deforming. Unless inflamed, it is 
rather transparent and not very noticeable, for the 
majority of them are small. When the pterygium is 
carefully examined, it will be observed, that if it is 
large, most of the growth is below the exact horizontal 
meridian of the eye, and that part on the cornea is a 
distinct tumor, closely adherent and sharply defined 
towards the pupil, to which a fold of the conjunctiva 
is attached. It looks as if a growth started on the 
white part of the eye, and, moving over the cornea, 
dragged the mucous membrane with it. The neck, 
that part which crosses the corneo-scleral line, is gen- 
erally thick, and it is possible with a probe to find that 
it is not flatly adherent to the eyeball, for there is usu- 
ally a folding under of the conjunctiva above and below 
it. It is distinctly striated and contains many parallel 
blood-vessels. Starting at the neck, the tail gradually 
spreads out towards the nose; it becomes very thin, and 
may fade away entirely ;it is fan-shaped. Because the 
vessels and folds of the conjunctiva radiate towards 
the neck, it looks somewhat like the wing of a fly, and 
for that reason it is called pterygium. There are two 
kinds of pterygia, true and false. A false pterygium 
is nothing more than a duplication of the conjunctiva 176 
Pterygium. 
adhering to the cornea. It results from ulcerative 
keratitis and shows that the cornea has been partly 
destroyed. When, in acute blennorrhoea, there is 
extreme chemosis and the surface of the conjunctiva is 
pushed into the bed of a corneal ulcer, it is possible for 
them to grow together; then, when the inflammation and 
swelling subside, the displaced fold of the conjunctiva 
remains attached. Such an accident can happen at 
any part of the circumference of the cornea; conse- 
quently such pterygia may be above or below the pupil 
and covered by the lids, which is never the case in the 
true variety. If the ulcer is exactly on the edge of the 
cornea, the resulting cicatrix may pull the conjunctiva 
over the scleral border; and, if a section of the cornea 
and conjunctiva are destroyed together, as in burns and 
diphtheria, the scar will always be a false pterygium. 
One of the most interesting subjects in ophthalmic 
surgery is the nature and growth of the true pterygium. 
There are only two theories concerning it worthy of 
consideration, the Yon Arlt and the Fuchs. Until the 
latter explained its development from the pinguecula, 
the accepted explanation was as follows: From some 
cause (usually an injury, often a disease), a small ulcer 
appears at the nasal or temporal side of the cornea ex- 
actly on the median line. The inflammation excited by 
the ulcer extends to the neighboring conjunctiva and 
causes a swelling of it. Because the chemosis is being 
continually compressed between the edges of the clos- 
ing lids, its epithelial surface is forced against the bed 
of the ulcer and becomes fixed by inflammatory exuda- 
tion, exactly as was described the formation of false 
pterygium. Of course, the fold of the mucous membrane Pterygium 
177 
will be considerably elevated above the surface of the 
cornea, and, at the edge of the ulcer, towards the pupil, 
will be sharp and steep. In the healing process the cor- 
neal and the conjunctival epithelium do not fill in the 
angle, and because that little linear pocket is irritated 
by foreign substances, catarrhal secretion, wind, etc., 
the ulcer remains. The irritation being continued, the 
inflamed head of the pterygium follows the ulcer as it 
moves towards the center of the cornea. During this 
time, inflammatory products are added to the tissues 
making the head of the growth. As the new con- 
nective tissue grows, the old cicatrizes, and will either 
tear the tumor off the cornea or pull the conjunctiva 
to it. The latter usually happens, for the mucous mem- 
brane is loose and elastic, whilst the attachment to the 
cornea is strong. In this way the tumor advances 
towards the pupil. So long as the ulcer is present and 
the head inflamed, the pterygium is progressive. 
If the ulcer heals, the growing process stops, the 
inflammation subsides, and the head atrophies, but the 
nodular cicatrix remains. Now comes the ingenious 
reasoning why the pterygium does not go beyond the 
center of the cornea, for it is evident that, if the ulcer 
does not heal, the growth will cross to the opposite side. 
Yon Arlt is silent on this point, but Fuchs well ex- 
plains it. The cornea receives its nourishment from the 
vessels of the conjunctiva and episcleral tissues sur- 
rounding it, whose capillaries terminate just inside of 
the transparent membrane. The nutrient fluids are 
thrown off from this circular band and flow towards the 
center of the cornea. When the pterygium crosses the 178 
Pterygium. 
scleral line and becomes fixed to the underlying tis- 
sues by inflammatory exudate, it constricts or oblit- 
erates the blood-vessels under it; consequently, that 
segment of the cornea receives less nourishment than 
its surroundings, but it is well supplied from the 
lymphatic channels at its sides. Now it is evident 
that the circulation of the lymph is greater near the 
edge of the cornea than at its center, so as the head ad- 
vances towards the pupil it gets into the region of least 
vitality, when the amount of inflammatory material 
thrown off becomes less and less, until there is not 
enough to drag the steep wall of the conjunctiva down 
to the level of the ulcer. The head of the pterygium 
ceases to be irritated; the inflammation subsides and 
the ulcer has a chance to heal. Again, the further the 
head is from the edge of the cornea the greater the 
tension of the tail; so when the pull of the conjunctiva 
equalizes the drag of the cicatrix at the head, the 
growth can advance no further. For that reason, a 
pterygium with a narrow head will not go very far; a 
broad one may reach the center of the cornea. This ex- 
planation accounts for the development of the pteryg- 
ium, but a serious objection to it is, there is not always 
a progressive ulcer piloting the head. This is easily 
overcome. It takes from five to fifteen years for a 
pterygium to advance over the cornea one-fourth of an 
inch. It is certain that an irritable ulcer would reach 
the pupil in a few weeks. If the theory is correct, it is 
evident that at the head of the pterygium there is very 
seldom an ulcer; so one rarely has an opportunity to see 
it. In fact, the growth advances a little at a time and 
at very long intervals; consequently it may be said they Pterygium. 
179 
are all progressive, but for months and mouths station- 
ary. It is not necessary that the ulcer should extend 
below Bowman’s membrane. At the angle there may 
be simply an epithelial defect which allows the two 
basement membranes to come together and adhere, as 
we have seen they will do in the chapter on croupous 
ophthalmia. Pterygia of this kind are loosely attached 
to the cornea and easily pulled off. 
Very often the pterygium develops from the pinguec- 
ula, as Fuchs has very well explained (Graefe’s “Ar- 
chives,” 1892, Part 3). In these instances the tumor ad- 
vances from its seat on the sclera over into the cornea 
and pulls the conjunctiva with it. The head is not led 
by an ulcer, for the growth does not always move over 
the surface of the cornea, but under it. The pinguecula 
is a connective-tissue tumor, and enlarges at its per- 
iphery. Why it should grow towards the center of the 
cornea is not known. Possibly it is, that that part of 
the cornea immediately in front of the tumor is the 
place of least physiological resistance because of the 
embarrassed circulation. The advancing edge of the 
growth pushes along under Bowman’s membrane be- 
tween the superficial layers of the cornea, and it has in 
front of it a zone of keratitis, which can be distinctly 
seen through a lens. These pterygia are always pro- 
gressive; it is only a question of time when they will 
reach the pupil. 
Since the neck and tail are made up of folds of the 
conjunctiva, they sometimes develop cysts, because two 
adjoining surfaces unite and close in a pocket of the 
mucous membrane. Such a cyst I have removed as 
large as a pea. Pterygium. 
I believe there are two kinds of true pterygia; that 
Yon Arlt was correct, Fuchs also. 
Beyond the disfiguration, pterygia are harmless, un- 
less they encroach upon the area of the pupil. Then 
they interfere with vision. Not alone will the head cut 
off the rays of light, but it will disturb the refraction 
and curvature of the cornea a considerable distance 
beyond it; so we may find with a small tumor annoying 
disturbances of vision. They are easily inflamed, then 
they become very red and irritable, and their presence 
atone may excite chronic conjunctivitis. Very large 
pterygia hinder the free outward rotation of the eye, 
which is often distressing. 
Treatment.—There is but one thing to do—remove 
the tumor. Anything else is not even palliative. The 
nitrate of silver, calomel, tincture of opium, etc., will 
do no good. The pterygium must be cut away, and the 
sooner it is done the better. There are many ways to 
do it; the best is to cut the head off from the surface of 
the cornea, which permits the tumor to shrink towards 
the canthuis. If it does no do so sufficiently, help it by 
snipping the conjunctiva with scissors. Then with a 
sharp knife scrape the shreds and remnants off the 
sclera and cornea. With one or two stitches bring the 
conjunctiva from above and below and cover as much 
of the wound ais possible. This is the ideal operation, 
and all other plastic methods are modifications of it. If 
it is successfully done, the true pterygium will not re- 
turn, but the wound may, and very often does, suppu- 
rate; then, since it must heal by granulation, there is a 
scar left, which makes the false pterygium. This is a Pterygium. 
Figure 13. 
Operation for pterygium, completed. 
deforming as the time, but it will not advance. It is for 
this reason the operation is often, apparently, unsuc- 
cessful. Now, the smaller the wound the greater the 
hope that it will heal by first intention; consequently 
the smallest pterygium should be removed, and if a 
pinguecula crosses the edge of the cornea, it calls for an 
operation. When the head of a pterygium encroaches 
upon the pupil, very little is to be gained, so far as the 
vision is concerned, from the operation. If the patient 
is quite blind, it is best to leave the tumor alone, but 
make an iridectomy upwards. CHAPTER XVII. 
TUBERCULOSIS OF THE CONJUNCTIVA. 
When we consider the universal distribution of 
tuberculosis and the prevalence in the atmosphere of 
Koch’s bacillus, it is astonishing that tubercular con- 
junctivitis is so rare. 1 have never seen a case which 
was proved to be tubercular by bacterial investigation, 
although I have seen some, in my own practice, which 
I thought were tubercular. The probabilities were that 
I was mistaken. Anyone who is familiar with the dis- 
ease in the pharynx and understands the pathological 
anatomy of tubercular growths can picture the disease 
as it affects the conjunctiva. 
From physical and histological causes, primary 
tuberculosis of the conjunctiva selects two parts of 
the membrane in preference to any other—the superior 
retrotarsal folds and the conjunctiva of the upper lid a 
little internal to its edge, where foreign bodies are most 
frequently found. This is evident, for in these two 
localities the tubercle bacillus has a chance to re- 
main long enough to implant itself. In some respects 
the disease resembles trachoma, for the membrane is 
covered with granulations, which may project in masses 
down from above. The lids are thick and heavy, the 
entire mucous membrane swollen. If any of the tuber- 
cular surface is ulcerated, there will be a purulent dis- 
charge very much like that in blennorrhoea. In an eye 
in this condition one would expect the cornea to be- 
182 Tuberculosis. 
183 
come involved; consequently there is either irritative 
or ulcerative pannus, for it is only a matter of time 
when the disease attacks the conjunctiva on the eye- 
ball. Then, as in trachoma, the infiltrate rapidly 
breaks down. An ulcer, once started at the edge of the 
cornea, will soon reach the anterior chamber and open 
the interior of the eye to tubercular invasion. In the 
majority of cases the lymphatic glands connected with 
the diseased eye are infected, and it will be observed 
that the lachrymal sac is often filled with granulations, 
but this is not peculiar to tubercular conjunctivitis, for 
It is seen in trachoma. 
We know that the conjunctiva is very rarely 
attacked by the tubercle bacillus; consequently the 
disease is in the nature of an accident; so for the two 
eyes to become infected at the same time is an improb- 
able coincidence, but it is not impossible. The only 
disease it can be mistaken for is trachoma, but if the 
reader will compare the histories and pictures of the 
two, and remember that trachoma of such severity 
would never be confined to one eye, the differential 
diagnosis should be easy. Should the physician see a 
case which he thinks is tubercular, unless the bacillus 
is found in the discharge, it is better for all concerned 
to believe himself mistaken, and to make the diagnosis 
by exclusion, for the granulations coming from an old 
chalazion, and the granulations which collect about a 
foreign body buried in the tissues of the upper cul-de- 
sac may deceive him. An ulcerating gumma or an 
epithelioma of the conjunctiva can worry the diagnos- 
tician not a little. 
In both these there may be adenitis of the pre- 184 
Tuberculosis. 
auricular ganglion. Indeed, the lymphatics can be swol- 
len in all suppurative diseases of the conjunctiva, espe- 
cially if there are ulcers admitting to the deep tissues 
the septic microbes. Tubercular conjunctivitis is a 
malignant disease. The focus must be removed, even if 
it is necessary to destroy the eye. When the diagnosis 
is confirmed by the microscope or tuberculin injec- 
tions, the sharp curette should be used and the wound 
dressed in iodoform. 
It is well determined now that lupus is a form of 
tuberculosis, for the Koch bacillus is found in the in- 
durated tissues about the ulcer. Lupus of the con- 
junctiva is usually an extension of the disease from 
the skin of the lids, although cases of primary lupus 
conjunctivitis have been reported. In these Western 
States lupus of any kind is comparatively rare. In 
those countries where the disease is common lupus of 
the conjunctiva is seldom seen. The disease may be 
mistaken for epithelioma, and, unless one has had con- 
siderable experience in skin diseases, the differential 
diagnosis cannot be made without the aid of the micro- 
scope. The treatment is the same as in tubercular 
conjunctivitis, but it is not necessary to be so heroic. 
The disease is essentially chronic, and there is no danger 
of systemic infection. 
LUPUS. CHAPTER XVIII. 
SYPHILIS OF THE CONJUNCTIVA. 
When the close relationship between the mucous 
membrane of the eye and the skin is considered, it is 
not surprising to learn that syphilitic diseases of the 
conjunctiva are not uncommon. The reason why they 
are not oftener seen is, they are not looked for, unless 
there is a deformity or the patient directs the attention 
to the eye. If the physician will examine through a 
glass the conjunctivas of all persons suffering from 
secondary syphilis, he may be surprised to find that 
often the eruption is nearly as distinct there as on the 
body, especially if the dermatitis is of the erythema- 
tous variety. For that reason the text-book authorities 
write of the intractable conjunctivitis of syphilis. 
There is always a cause for conjunctivitis. As in 
some of the exanthematous fevers (measles, for ex- 
ample) the conjunctiva and the skin react to the same 
poison, so in syphilis. 
The conjunctiva is subject to chancre, macular 
and papular eruptions, gumma, mucous patches, and 
ulcers. Hunterian chancre of the conjunctiva is com- 
paratively a rare lesion; few cases are reported; but it 
is much more common than is generally supposed. The 
spot of inoculation appears on the inner surface of the 
lids near the edge or at the cul-de-sac. Chancre in these 
places behaves exactly as it does on the penis. There is 
great swelling, painless induration, and enlargement of 
185 Syphilis. 
the lymphatic glands of the head and neck, especially 
the preauricular gland. However severe the lesion 
may be, there is li ttle danger that it will leave a deform- 
ing cicatrix, unless it is badly treated or it is placed 
on the eyeball. Such a case was reported by Mackenzie. 
The inoculation usually happens by infecting the eye 
from the month—kissing the eyelids. The disgusting 
habit common among some people of cleaning the eye 
of foreign bodies by the tongue has been responsible 
for many of these cases. The diagnosis is easy; there 
is nothing I know of like it. Epithelioma can be ex- 
cluded by the history and the course. Certainly no 
careful doctor ought to mistake a chancre for a chala- 
zion; yet I know that has happened. The treatment 
is scrupulous local cleanliness, mercurial inunctions, 
and dusting the chancre with a little dry calomel once 
a day. 
Mucous patches on the conjunctiva are rare lesions. 
They look like mucous patches elsewhere; they appear 
most frequently on the extreme inner edge of the lids 
and on the outer half of the lower cul-de-sac, but they 
have been seen near the nose. They heal readily on 
internal and local treatment, but they may ulcerate and 
act badly, which is undoubtedly the reason why the 
older authorities wrote so freely of syphilitic ulceration 
of the conjunctiva and lids. 
I have seen two cases of gumma of the conjunc- 
tiva, more correctly gumma under the conjunctiva, but 
involving the membrane. In both the mucosa of the 
eyeball was affected. In one, the tumor was very 
much like an aggravated episcleritis; at the same time Syphilis. 
187 
there was a gumma in the iris. They improved rapidly 
on mixed treatment. These tumors may break down 
and ulcerate, when it will be a hard task to differ- 
entiate between them and certain malignant diseases; 
epithelioma, for example. But if the reader will not 
forget that all suspicious tumors about the eye, es- 
pecially in young persons, demand a course of the 
iodide of potash preliminary to operative interference, 
there will be little danger of a mistake. Either be- 
cause we are gradually becoming immuned or our 
treatment is greatly improved over that of Mackenzie’s 
time (1854), destructive syphilitic disease of the con- 
junctiva and lids is almost unknown. Certainly no 
modern author could report such a list as that writer 
did in his text-book of the diseases of the eye. CHAPTER XIX. 
TUMORS OF THE CONJUNCTIVA. 
It is not intended to consider in this chapter benign 
or malignant diseases of the conjunctiva, which have 
encroached upon it from the surrounding tissues. I 
shall only mention those diseases which can and do 
primarily attack the mucous membrane, and from that 
focus extend indefinitely. Many of these tumors are 
very uncommon, but the subject is so important and 
interesting that it demands more than a passing notice. 
Tumors of the conjunctiva are benign and ma- 
lignant; some of them are connective-tissue growths, 
others epithelial; some start from blood-vessels, others 
from the lymphatics. No part of the conjunctiva is 
exempt, but where the membrane crosses the edge of 
the sclera to cover the cornea is the favored seat tor 
their development, especially if they are malignant. 
Many tumors of the conjunctiva are congenital; the 
majority are acquired. 
Simple granulation tumors (proud flesh) start from 
a granulating wound or from the edge of a fistulous 
opening. They frequently follow operations for squint. 
A chalazion which has ruptured through the mucous 
side of the lid will always have granulations around 
the opening, and because from the pressure of the eye- 
ball the granulations are flattened out over an in- 
durated area in the lid, they may look malignant. A 
probe and sharp curette will quickly clear up the diag- 
188 Tumors. 
189 
nosis. A mass of exuberant granulations projecting 
down from tire upper cul-de-sac behind the lid is a 
certain sign that there is a foreign body buried some- 
where in the tissues or a pus cavity is in communica- 
tion with the conjunctival sac. 
I was talking one afternoon with Prof. R. Berlin 
(Stuttgart), when a young girl came into his office with 
a monocular biennorrhoea. When he turned the upper 
lid, a quantity of granulations sprang forward fr:m 
above. Without asking a question, he reached for a pair 
of forceps, and, pushing through the mass of proud 
flesh, caught and pulled from the orbit a splinter of 
wood an inch and a half long. We were all astonished 
but him. Experience had taught him that that condi- 
tion was usually caused by a foreign body. 
Granulating tumors may be excited to grow by con- 
tinued irritation. A tight, ill-fitting, rough artificial 
eye will do it, especially if the individual sleep with the 
eye in. When an eye is removed and the wound 
allowed to heal under a clot, the edges of the conjunc- 
tiva and the tissues around the head of the nerve come 
together and a little granulating tumor will grow. At 
first it is quite broad, but when the healing tissues con- 
strict its base, it is transformed to a polypus. Until 
the tumor is removed, the stump will suppurate. It can 
be cut away with a pair of scissors sharply curved on 
the flat. The best way to remove a quantity of granu- 
lations is to scrape them off with a sharp spoon. If 
the surgeon attempts to remove them with scissors 
and does not cut them all off with one snip, the bleed- 
ing will embarrass him and he may injure the eye. 
Unless the cause is removed, they will return, Chal- 190 
Papilloma. 
azions must be cleaned out and foreign bodies taken 
away. It would be quite an extensive and painful 
operation to scrape off a large quantity of proud flesh 
caused by an artificial eye. It is better to cut away as 
many as possible with scissors and reduce the rest by 
applications of the nitrate of silver, 10 to 20 grains to 
the ounce. In doing this great care must be taken that 
the caustic does not come in contact with the healthy 
membrane, or cicatrices may be formed which will pre- 
vent the wearing again of the false eye. 
The common warts found on the skin sometimes 
grow on the conjunctiva, where they may be seen 
scattered over the lower cul-de-sac and grouped about 
the caruncle. They are never very large; sometimes 
they look like little condylomata; usually they are papil- 
lary. These growths are soft, but do not bleed when 
disturbed. They do not directly cause any irrita- 
tion, nor can it be asserted that they are produced by it. 
Sometimes they will interfere with the fitting of the 
lower lid to the eyeball; consequently the eyes may 
be suffusM with tears. I have never seen them in 
adults; my patients were always young. In my cases 
both eyes were affected. I could not discover the 
cause, but I am inclined to the opinion that warts, 
both on the skin and mucous membrane, result from 
a local irritant, perhaps mechanical or chemical, prob- 
ably microbic. I once saw a papilloma spring from 
the mucous edge of the lower lid below the caruncle. 
When the lids were closed,it projected forward and was 
exposed at the internal canthus. The patient was a 
WARTS (PAPILLOMA). Fibroma. 
191 
young boy, 14 years old. The tumor was removed 
three times. I finally stopped its return by touching its 
base with the actual cautery. 
It is a difficult thing to remove warts from the 
skin; it is harder to cure them when they attack the 
conjunctiva. We cannot destroy them by touching 
them with caustics or dusting them with calomel; they 
must be removed, and if they are grouped about the 
semilunar fold and caruncle, it is much easier said than 
done. The cases I have had were cured after months 
and months of careful attention. Each individual 
wart was cut off the conjunctiva and its base immedi- 
ately cauterized with a red-hot platinum point. If 
the reader ever has a case—the patient, a nervous child 
—he will have cause to appreciate the difficulties I 
have mentioned. When operative interference is im- 
possible, it is advisable to treat them on antiseptic prin- 
ciples. One or two drops of a solution of the bichloride 
of mercury 1 to 2000 should be put in the eye in the 
morning, and a mild astringent collyrium used at night. 
The sulphate or acetate of zinc or the acetate of lead in 
solutions of appropriate strength are serviceable. 
FIBROMA. 
The basement substance of conjunctival warts 
and papillary growths is composed of fibroid tis- 
sue, which is limited in quantity. If, however, it 
should be more diffused, making what is generally 
called a tumor, the growth is a fibroma. Excepting 
pinguecuhe and pterygia, fibroid tumors of the con- 
junctiva are very rare; then they are either congenital 192 
Fibroma. 
or reach the mucous membrane from the deeper 
tissues. 
The following case is interesting on clinical 
grounds, for it was probably diffused myxofibroma of 
the conjunctiva. lam not certain, however, for I did 
not have an opportunity to examine it microscopically. 
A young lady, 22 years old, consulted me for dis- 
ease of her eyes. Some years before she noticed that 
yellow spots appeared on her eyeballs; that they grad- 
ually grew larger, and, coalescing, covered the white of 
both eyes. She had no pain; could see very well, but 
the deformity distressed her. The eyeballs up to and 
all around the cornea were covered by a semitrans- 
parent yellowish membrane. It looked exactly as if a 
pinguecula had grown and involved the entire ocular 
conjunctiva. It was composed of a number of flat 
tumors. Around the cornea they were hard and quite 
thick, 1.5 millimeters or more, but towards the equator 
they became smaller, thinner, and gradually faded 
away. The tissue was too opaque to see the under- 
lying vessels, nor was it itself well supplied with 
blood. That part of the conjunctiva involved was 
adherent to the episcleral tissues; consequently it 
could not be moved over the sclera. The thickened 
tissues were not very hard; they could be easily in- 
den tated by a probe. The cornese were clear; there 
was no discharge or evidences of inflammation. Both 
eyes were exactly alike. I could not remove the 
growths, but, believing that if small areas of the 
tumors were violently inflamed, they might be ab- 
sorbed, I caught parts of the tumor between the blades 
of forceps and crushed them. In that way much of the Cysts. 
deformity was removed. My diagnosis was, myxofibro- 
matous disease of the conjunctiva. 
Fibroid tumors involving the conjunctiva from 
within the orbit are very deceiving, for they are much 
larger than they appear. The physician may start to 
cut away what he thinks to be a little tumor, and find 
before he is through that the supposed little affair ex- 
tends into the depths of the orbit. 
Lipoma (fatty fibroma) are more common, but it 
must be remembered that in the cases reported the dis- 
ease started either in the subconjunctival tissue or in 
the orbital cellular tissue. They are congenital, and 
are found principally on the upper outer part of the 
eye, between the superior and external recti muscles. 
CYSTS. 
Small retention cysts are quite common; they 
often grow from the neck of a pterygium, starting 
from a pocket of mucous membrane caught between 
the folds of the conjunctiva. Some may develop into 
tumors as large as a pea. Most of them are small. 
Dermoid cysts are, of course, congenital. Such 
cysts of the conjunctiva are on the eyeball near the 
cornea, and may contain growing hairs. We should 
not forget that a transplanted cildum from a trauma of 
the lids may develop a cyst under the conjunctiva. I 
have seen several dermoid cysts of the conjunctiva 
and cornea. They were in children, and could not be re- 
moved without endangering the eye; consequently they 
were let alone, especially since they were in babes and 
did not seem to be growing. It is doubtful if cysti- 
cercus cysts ever develop in the conjunctiva; usually 194 
Sarcoma. 
under it. Then, again, they are so extraordinarily rare 
that the subject needs no further Comment, 
SARCOMA. 
Not an infrequent tumor of the conjuctiva is 
the sarcoma, which may be white or melanotic. 
The favorite seat for them is over the corneo scleral 
junction and the caruncle, although these growths 
can appear at any part of the* mucous membrane. 
They look like small fleshy tumors, round, flat, lob- 
ulated, or papillary. Some bleed, others do not. As 
a rule, these tumors spring from the episcleral tis- 
sue; many of them are pigmented and start from con- 
genital moles of the conjunctiva. They are usually ma- 
lignant, but not so much so as we have been taught to 
believe. There is a vast difference between the malig- 
nancy of an intraocular melanosarcoma and a pigment 
tumor of the conjunctiva: so much so that some are 
inclined to the opinion that many melanotic tumors of 
the conjunctiva may be benign. This opinion is not 
based on the text-books, but on the fact that so 
many of these tumors have been removed without a re- 
turn, which is not the history of black sarcomas else- 
where. I once removed an inky-black tumor from the 
orbit of a woman who had had her eye enucleated some 
years before for disease. The growth was about the 
size of a large marble, and was surrounded by a dense 
white capsule. It did not, to my knowledge, return, 
for she is still living. I attendedheraboutten years ago. 
Dr. Sattler, of Cincinnati, has had considerable experi- 
ence in conjunctival and subconjunctival melanomas; 
he, too, believes in the benign character of some of Carcinoma. 
195 
these growths. Sarcoma of the conjunctiva attacks 
principally adults. In making a diagnosis of these 
tumors the physician should distinguish between a pri- 
mary and a secondary tumor, for not infrequently a 
sarcoma of the choroid perforates the sclera and ap- 
pears as a black swelling under the conjunctiva, pro- 
jecting up from the depths of the orbit and from the 
interior of the eye. Such eyes, of course, are blind. 
Then the prognosis is very bad; all the soft structures 
in the orbit must be removed, even the periosteum. 
Sarcomas of the conjunctiva must be completely re- 
moved. Many of them simply cover the cornea, and 
can be cut away without destroying the eye. Diffused 
melanoma of the palpebral conjunctiva is a very diffi- 
cult disease to deal with. It should be removed and the 
defect covered by a skin- or mucus-graft. We always 
hear of these operations when they are successful, but, 
unfortunately, the failures are lost to ophthalmic 
literature. • 
True cancers of the conjunctiva are rare; most 
of them start at the edge of the lids, at the inter- 
nal canthus and involve the mucous membrane sec- 
ondarily. Carcinoma may appear at the caruncle, 
when it is especially dangerous and difficult to cure. 
Epithelioma of the conjunctiva proper nearly always 
comes on the eyeball and springs from the corneal edge 
of the membrane. I have a very beautiful specimen of 
a carcinoma I removed from the conjunctiva midway be- 
tween the cornea and the external canthus, about over 
the insertion of the external rectus muscle. It was in 
the conjunctiva, and was removed without any diflS- 
CARCINOMA. 196 
Angioma. 
culty. It did not return. The tumor was about the 
vsize and shape of a split pea, white, and as hard as carti- 
lage. Under the microscope it proved to be an epithe- 
lioma. The further a cancer is away from the internal 
canthus the better the prognosis. In all cases it 
should be removed, even if the eye is sacrificed. Cancer 
of the caruncle is very bad, for however heroically it 
may be cut away, there is danger of a fatal return. 
The great trouble is, until a cancer about the eye 
ulcerates, there is no certainty in the diagnosis. It is 
very well to be wise when we have a nicely stained sec- 
tion of a tumor under the microscope, but we must 
remember that we cannot slice off a piece from a man’s 
eye as easily as from his turbinated bones; consequently 
there is always danger that the neoplasm will get a 
good start before we are prepared to operate. Sus- 
picious growths on and about the eyes should be first 
subjected to anti-syphilitic treatment for a time; then, 
if necessary, removed. It is better to lose an eye, even 
both, than die of cancer of the face. 
ANGIOMA. 
Angioma of the conjunctiva are rare tumors. I 
have seen them under the mucous membrane, but never 
in it. Wine-marks of the skin of the face and eyelids 
do not, as a rule, encroach upon the conjunctiva; such a 
case would be an interesting curiosity. There is noth- 
ing to be done for them. Wine-marks on the skin may 
be removed and the defect covered by a skin-graft; that 
could not be done on the eye. Calcali. 
197 
Not infrequently in old people little calcareous de- 
posits form in the Meibomian glands. They seen irri- 
tate the eye as foreign bodies. They can be removed 
by a flat needle. CHAPTER XX. 
WOUNDS AND INJURIES OF THE CONJUNCTIVA. 
FOREIGN BODIES. 
The most common accident is the reception into the 
conjunctival sac of a foreign body. Very few writers 
give the subject more than a passing notice; yet, of all 
the injuries to which the eye is liable, these are the 
most important, because of their frequency and the dis- 
tress and annoyance they often give the patient. For- 
eign bodies are of all sizes, shapes, and grades—coal- 
cinders, sand, vegetable matter, pieces of stick, eye- 
lashes, bugs, insects, etc. I have removed worms from 
the conjunctival sac, and I have known a bug to set up 
such a dreadful inflammation with sloughing of the 
conjunctiva that it was almost impossible to tell 
whether the trouble was a trauma or a disease. 
Again, I have seen the eye badly mutilated in an at- 
tempt to remove what was thought to be a cinder on 
the cornea, but what was in reality a pigment speck on 
the iris. 
The majority of small pieces of stone and cinder 
which alight upon the conjunctiva and cornea are 
wiped off by the lids or washed away by the tears; they 
pass along the border of the lower lid, reach the inter- 
nal canthus, and leave the eye at the nose. But it 
depends largely upon the force with which the foreign 
body strikes the eye whether it can be thus removed; 
198 Wounds and Injuries. 
199 
then again, the isdze of the object is material. A large 
hot cinder may strike the cornea with great force, as 
often happens when one thrusts his head out of a car 
window and looks toward the engine. The cinder 
glances or rebounds off the eyeball, or is caught be- 
tween the closing lids. If the body is small, it may 
stick to the epithelium, and when the lid comes down, 
pass under it. Ninety-nine times in a hundred the 
individual immediately rubs his eye; this forces it 
deeper into the cornea or into the conjunctiva of the 
upper lid. Then the tears flow, and may wash it 
away. Sometimes they fail to do so, when it must be 
removed or work its way off. A small body on the 
conjunctiva or cornea may let the lid pass over it and 
be caught in the little depression behind the epithelial 
cushion at the mucous edge of the lid as the lid rises 
again. That is the reason why so many little cinders 
are found adhering to the bottom of the upper lid. 
Often a foreign body buries itself deep in the mem- 
brane or cornea, which happens in blasting accidents or 
premature powder explosions. In the first the flying 
stones usually destroy the eye. When it is spared, the 
conjunctiva is badly lacerated. In gunpowder injuries 
the conjunctiva is generally dotted over with half-burnt 
powder-grains, which usually enter in and under the 
membrana propria. If the face is very near the ex- 
plosion, the cornea and conjunctiva may be badly 
burnt. The condition of the lashes and eyebrows is a 
good indication of the nearness of the fire. 
In large manufacturing towns injury of the eye 
from emery-dust is very frequent. It happens in Wounds and Injuries. 
200 
sharpening edged tools. The small particles of stone 
or steel fly with great rapidity, and, when they strike 
the eye, bury themselves. They have no deleterious in- 
fluence on the conjunctiva, but they are extremely irri- 
tating to the cornea. When small splinters of wood, 
straw, twigs—indeed, anything long and narrow—get 
well up under the upper lid, they are apt to lodge in 
tlie upper cul-de-sac, where they remain and set up con- 
siderable irritation. Then there iis usually a purulent 
discharge. If the foreign body wounds the conjunctiva 
and is half-buried under that membrane, it will cer- 
tainly start the growth of granulations (proud flesh). 
Most insects contain formic acid. When they strike 
the eye and get caught under the lid, they are generally 
mashed during the first rubbing; the acid reaches the 
eye and causes an intense burning, which usually lasts 
a minute or so. Although bugs have legs, sharp-pointed 
wings, etc., they do not often remain in the eye, for they 
soon become covered with mucus and slip out. It is sur- 
prising to see how rapidly the mucus collects around 
such objects; in a few minutes a little fly will be all 
gummed up. Has not the reader noticed, when a single 
eyelash is removed from behind the lower lid, how it is 
buried in sticky mucus? That the larvae of certain 
insects can reach the conjunctiva is shown by the fol- 
lowing case: 
A negro from the Indian Territory was admitted 
to the City Hospital suffering from severe inflammation 
of the nose, eyes, and head. The man was in a dread- 
ful condition. The pain had almost worn him out. 
There was great swelling of the face and almost com- Wounds and Injuries. 
201 
plete closure of the nose from oedema of the mucous 
membrane. I found that all the sinuses in his head 
were filled with the larvae of the Texas fly. In examin- 
ing his eyes, I discovered a large maggot free on the 
conjunctiva and another working its way out of the 
lachrymal sac. They were removed. The man was 
cured by filling his nose with the vapor of chloroform, 
then syringing it out with dilute creolin. It was sev- 
eral weeks before all traces of the larvae disappeared. 
The annoyance and pain excited by a foreign body 
will depend largely upon its position, size, and charac- 
ter. They all irritate more or less, but a piece of straw 
or wood may remain for a long time imprisoned in the 
folds of the upper cul-de-sac and be unnoticed. 
Small cinders adhering to the lid do not worry the 
individual unless they come in contact with the cornea; 
then the pain may be very severe, and if the offending 
particle is not removed, an inflammation may be ex- 
cited very much like acute catarrh. Little pieces of 
stone, steel, metal of any kind, or grains of powder 
sticking on or in the cornea will always cause trouble 
if they remain over a few hours. Because, in these 
instances, the irritation is confined alone to the cornea, 
the congestion affects principally the ciliary vessels, as 
in iritis or keratitis. Then there is a rose-colored zone 
around the circumference of the cornea; the pupil will 
be contracted, also photophobia and lachrymation. 
In these cases the severity of the symptoms is nearly 
always dependent upon the size of the object. Large 
cinders buried in the cornea excite a great deal of 
inflammation; small ones, on or under the surface, 
irritate from time to time. The individual will con- 202 
Wounds and Injuries. 
gratulate 'himself often during the day that it is out, to 
be disappointed at night, when he attempts to read. 
Minute particles of emery or steel on the cornea 
invariably excite great irritation in the eye. So much 
so, that, if the doctor is not careful, he may overlook 
the cause and treat for iritis. The same with poder- 
grains. The little sharp hairs from certain plants 
♦ 
and off some caterpillars excite great disturbance in 
the eye if they reach the conjunctiva. The cause is 
mechanical and chemical, so one can picture the condi- 
tion that can be excited by them. 
The only danger to be feared from foreign bodies is 
acute keratitis, but that is remote, for the patient will 
use every possible means to have the offending material 
removed. Again let me assure the reader that if there 
is a chronic purulent inflammation of the lachrymal sac, 
the simplest wound of the cornea which opens into the 
lymphatic spaces may lead to destruction of the eye, 
from septic infection. 
Diagnosis.—Although, as a rule, the diagnosis—a 
foreign body, is easy when the foreign body can be seen, 
still it is sometimes very difficult, for one cannot always 
readily And it. An expert will in the majority of cases 
make a correct diagnosis from the general appearance 
of the eye, but a doctor who has not had much experi- 
ence in such cases may be puzzled to know what is the 
matter. 
If a patient complains of something in the eye and 
it is not found on the upper lid when it is turned, the 
probabilities are it is on the cornea and will be seen if 
the eye is examined through a watchmaker’s glass. 
Even then it is sometimes necessary to use focal illu- Wounds and Injuries. 
203 
ruination, especially if the injury is received at the 
emery-wheel. If an eye is badly inflamed 24 hours 
after a gunpowder accident and it is not burnt, the 
trouble is in the cornea. Powder wounds of the con- 
junctiva do not pain much. In cases of monocular 
blennorrhoea without disease of the lachrymal sac ex- 
amine carefully for a foreign body. Turn the upper lid 
and, by the method already given, spring the retro- 
tarsal folds in view; search carefully the cul-de-sac. 
If there are granulations (proud flesh), the great prob- 
ability is there is an irritating substance buried in the 
tissues. The probe and forceps should soon settle the 
question. The practitioner should never neglect the 
retrotarsal folds in such cases. Children may require 
an anaesthetic. 
Treatment.—There is but one treatment : Remove 
the foreign body if it can be done. Powder-grains in 
and under the conjunctiva cannot be removed. Many 
of them will break down and be partly absorbed; the 
rest will remain for life. A very large powder-grain 
distinctly elevating the membrane may be grasped 
with a pair of forceps and cut away, together with a 
piece of the conjunctiva. If the wound gaps very much, 
a single stitch may be advisable; otherwise it will 
heal promptly without a perceptible scar. A foreign 
body sticking to the cornea is best removed by passing 
over it a piece of absorbent cotton wrapped around the 
end of a probe. It will usually be caught in the meshes 
of the cotton and pulled off. If that is not successful, 
it is best to benumb the cornea with cocaine and then 
pick it off with an appropriate instrument. A body 204 
Wounds and Injuries. 
buried in the superficial layers of the cornea is best 
picked out with a cataract-needle. But the operation 
should be done under a glass, for often more of the 
cornea is picked to pieces than is necessary. It is diffi- 
cult to remove pieces of emery, especially if they are 
minute. When a piece of iron or steel sticks on the 
cornea and remains a day or so, it oxidizes and deeply 
stains the tissues immediately around. After the body 
is removed from its bed, it will be found that a little 
dark ring is left. This deposit is as irritating as the 
body itself, and should be removed. It is best done by 
paring it off with a sharp needle. The ease with which 
a foreign body is removed will depend very much upon 
the tension of the eye. Cocaine, if used for any length 
of time, will make the eye very soft, when it may be 
impossible to use a needle successfully; so it is advis- 
able, if the object is not removed before the eye grows 
soft, to wait a few hours and try again. The after- 
treatment is simple. When the cornea is injured after 
removing a foreign body, the eye should be washed with 
a mild antiseptic (boracic acid solution), then bandaged 
for a few hours. If there is pain, a drop of a 0.5 per 
cent solution of homatropdne will be soothing. Atro- 
pia relieves instantly, but its after-effect prohibits its 
use, unless the reactive inflammation is so severe that 
its employment is imperative. Often the patient will 
return and complain that the foreign body is not out; 
sometimes it is not, but usually the sandy feeling, in 
such instances, is dependent upon the same cause as it 
is in catarrhal ophthalmia. Wounds and Injuries. 
BURNS. 
205 
The conjunctiva can be burnt by flame, hot bodies, 
steam, chemical substance, and the rays from the 
arc-electric light. Like on the skin, these burns 
are graded from simple irritation to complete destruc- 
tion of the mucous membrane. The simplest burn is 
the common sun burn, which never happens from the 
direct rays, but from the reflected ones. It is mostly 
seen in amateur fishermen. It will be noticed that 
those who suffer from severe sun dermatitis of the face 
often have red, congested eyes. The same is seen in 
mountain-climbers and adventurers of the North, the 
sun’s rays being reflected from the snow. Burns of this 
kind are excited by the rays coming from the arc 
electric light. In these cases the symptoms are very 
severe; there is not only severe dermatitis and swelling 
of the face and lids, but also oedema and inflammation of 
the conjunctiva very much like acute catarrh. The 
eye-pain and the photophobia are distressing. Work- 
men about electric furnaces and welding machinery are 
subject to it. Steam burns of the conjunctiva are not 
uncommon. Of course, the severity of the burn will 
depend upon the heat of the steam and its tension. 
Such accidents usually occur about boiler explosions 
and in railroad wrecks. If the steam escapes from a 
ruptured boiler or pipe, it will burn the conjunctiva be- 
fore the lids can be closed. Such burns of the con- 
junctiva are not apt to be very severe; usually there 
is congestion of the eye and exfoliation of the corneal 
epithelium. 
Those caught in Illuminating gas explosions are 
always burnt about the eyes. The flame, which is very 206 
Burns. 
hot, reaches the conjunctiva before the lids close, be- 
cause the reflex action from the retina to the orbicularis 
muscles is too slow to protect the eye. All burns of 
that kind I have seen were subjectively severe, but 
the eyes were not permanently damaged. If in gun- 
powder accidents the eyes are destroyed, the flame is 
rarely responsible, for it does not remain long enough 
in contact with the conjunctiva to sphacelate it. The 
damage is usually done by the force of the explosion or 
the foreign bodies driven against the eye. Lighted 
cigars and cigarettes burn the eye dreadfully when 
they touch it. Parlor-match burns are very severe, be- 
cause the fire does not go out immediately. Glowing 
cinders and molten metal always destroy the area of 
the conjunctiva they touch. Such burns are usually 
on the under half of the eye or in the lower cul-de-sac. 
The most common chemical burns are from lime, 
ammonia, and acids. Lime burns are of two kinds: 
those made by slacked and unslacked lime. Really 
they are the same burns, but differ in degree. It is not 
often that a person gets sufficient pure lime in the eyes 
to damage them; but should such an accident occur, the 
conjunctiva would be certainly destroyed and the cor- 
nea rendered permanently opaque. Lime burns usu- 
ally occur when a quantity of fresh mortar strikes 
the eye, which often happens to workmen looking up 
from the basement of a building. The mortar then 
hits the open eye with considerable force, and, as a 
rule, fills the conjunctival sac with sand and partly 
slacked lime. That generally injures the mucous mem- 
brane, but the greatest damage is done the cornea. Al- Burns 
207 
most immediately the alkali penetrates to the super- 
ficial layers, and either destroys them or renders them 
opaque. The corneal epithelium always turns white. 
The pain from the sand and chemical is very severe; so 
much so that the physician may have great difficulty in 
cleaning the eye. 
Since the introduction of ice-making machines in the 
cities and nearly all large towns, ammonia burns are 
becoming quite common. They are usually severe and 
excite considerable inflammation, but I have never seen 
the eye destroyed by that means. It can happen, for 
liquid anhydrous ammonia is used, and that will imme- 
diately kill living tissues. 
Pure sulphuric and nitric acids destroy immediately 
all the mucous surfaces they reach. They, too, turn the 
cornea white. The subjective symptoms are severe. 
These accidents rarely happen to the eye alone. The 
skin of the lids is usually cauterized. Indeed, the 
greatest danger is to be feared from the consequent 
deformity of the lids. Dilute acids usually fly into the 
eye in explosions of chemical apparatus. The parts 
may be severely burned, but it is not the rule that the 
eye is damaged so much from the chemical as from the 
flying pieces of the retort. 
Treatment.—In simple burns of the conjunctiva, 
when there is hypersemia and loss of the corneal epithe- 
lium, it is well to anoint theinside of the lids with vas- 
eline, instill atropia, and apply cold compresses. Unfor- 
tunately, little more can be done for severe burns. We 
must wait until the sloughs come away, then try and 
hasten the healing. If two opposing conjunctival ul- 
cers meet at the cul-de-sac, nothing will prevent the lid 208 
Burns. 
and eye-ball growing together. The doctor may try by 
separating them, and congratulate himself that he has 
succeeded, but in the end he will be disappointed. The 
lid will adhere to the eyeball over the burnt area. 
Therefore it is best to let Nature take her course, hop- 
ing that a plastic operation may remedy the deformity. 
The best treatment for severe, deep burns of the cornea 
is atropia and a compress bandage. When the con- 
junctiva is burnt by molten metal, the great difficulty 
will be to remove the foreign bodies, because often the 
metal will be adhering tightly to the mucosa. 
Lime burns are annoying to treat. In the first 
place, the physician must give a prognosis, and it may 
be several days before he can determine how much of 
the conjunctiva is destroyed. If the cornea is not dry 
and the iris can be, even faintly, seen, the probabilities 
are that the white cloud will disappear. If, on the 
other hand, the opacity is so dense that nothing back 
of the cornea is visible, the chances are that the eye 
is ruined. There is no certainty, however, unless the 
cornea is dead; otherwise it is advisable to be guarded 
in the prognosis. iSome of the most desperately burnt 
eyes will recover in a way that is surprising. 
It is not often the physician has an opportunity to 
see a case immediately after chemical burns of the eye. 
Acids are very rapidly neutralized by the copious flow 
of tears they excite, and liquid alkalies are soon washed 
out. If, however, the doctor is present at the accident, 
the best he can do is to wash out the conjunctival sac 
thoroughly with plain water. It takes time to prepare 
chemical antidotes; water is always handy and effect- Burns. 
209 
ive. When a piece of solid but melting chemical is 
caught under the lids, such as a crystal of the nitrate 
of silver or a lump of un slacked lime, lie should not 
attempt to wash it out, but turn the lids and remove 
it. Water will invariably make the bad worse. If 
the burn is severe, the eye is to be filled with pure vas- 
eline or olive oil and cold compresses applied. That 
is all that can be done for the time being. The after- 
effects must be treated on general surgical principles. 
Should a child get some freshly slacked lime in its eyes, 
the conjunctival sac may be washed out with olive or 
sweet oil, which is the best mechanical and chemical 
antidote. 
When an eye is filled with mortar, the lids must be 
turned, and the eye cleaned with a piece of cotton 
cloth; then it should be cocainized, and every piece of 
sand removed, which will surely be found sticking to 
the lids and eyeball; finally, the conjunctival sac must 
be filled with dilute sugar syrup (Yon Arlt), then a cold 
compress applied. In these cases the doctor should be 
careful in making a positive prognosis, for it may be 
several hours before the full effect of the injury can be 
appreciated. 
Simple wounds of the conjunctiva are usually trivial 
affairs, for it is very seldom the mucous membrane is 
so badly torn that stitching is necessary. Then, usu- 
ally, the eye itself is damaged. Small wounds heal very 
rapidly without a scar. Even a few hours after a for- 
eign body has penetrated the sclera, it is often hard to 
find where it pierced the conjunctiva. Extensive 
wounds may close up rapidly. For example, a man was 
brought into the hospital, comatose. A day or so before Burns. 
210 
he had fallen on a pick; at thait time his eye bled some. 
When I saw him, it was evident that he had some cere- 
bral lesion, although it was impossible to find where it 
was. At first I could not see that the eye was injured, 
nor could I by probing the cul-de-sacs find any hole such 
as a pick would make. Finally I found that the point 
of the pick had glanced off the cornea, penetrated the"1 
conjunctiva at the corneal edge, and, passing between it 
and the eyeball, punctured the roof of the orbit. The 
eye was enucleated, the orbit cleaned out, and a large 
quantity of broken-down brain matter and bone re- 
moved. The man recovered. This case was under the 
care of Dr. King at the Missouri Pacific Hospital in 
this city. It is cited to show that a very extensive 
wound of the conjunctiva may escape the scrutiny of 
trained observers. Usually, conjunctival wounds are 
best let alone; when, however, they gape, it is well io 
bring the edges together with a stitch to avoid healing 
by second intention and the growth of granulations. 
HEMORRHAGE. 
A very common accident is hemorrhage under the 
conjunctiva. Sometimes this is a matter of no moment; 
at other times it is a very serious symptom, especially if 
it follows a head injury. 
Often a blood- vessel will break behind the conjunc- 
tiva, and in a few minutes the eyeball will become 
blood-red. Usually the hemorrhage is diffused over a 
large part of the eye, rarely over all. When the blood 
reaches the cornea, it stops advancing, but in a few 
hours the coloring matter will enter the eyeball and Hemorrhage. 
stain the iris. Because of gravity, the mass of blood 
sinks to the lower cul-de-sac, and may reach the con- 
junctiva of the lids. It is not often there is enough 
blood to make a distinct bleb; usually it is only a deep 
stain. 
This condition is always very alarming to the pa- 
tient, for, as a rule, his attention is first called to it by 
his friends. The looking-glass is consulted, and imme- 
diately afterwards the doctor. Now, although this is 
often a trivial affair, still it demands of the doctor the 
most careful study. From no apparent reasan, a blood- 
vessel has given way. The same could happen in the 
brain and be of serious moment. Consequently he 
should hunt for the cause. It may be a slight trauma, 
or straining at stool. Never turn these cases away with 
the promise that all will be well, without first examin- 
ing the urine. Be sure there is not Bright’s disease or 
diabetes. In fracture of the skull, either of the vault 
or base, subconjunctival hemorrhage is diagnostic, 
especially in wounds of the side of the head with rup- 
ture of the middle meningeal artery; but simple blows 
on the temple, like fist-blows on the eye, are often fol- 
lowed by ecchymosis of the eyeball, irrespective of fract- 
ure or dangerous injury. The best treatment is to leave 
the parts alone. If the eye is seen at the beginning of 
the bleeding, a compress bandage may stop it. In 
severe hemorrhage with bulging of the conjunctiva an 
incision to let out the superfluous blood is advisable, 
but the wound must be treated antiseptically. 
Ordinarily the blood will be absorbed in from two 
to six weeks, and it may leave a faint stain on the sclera 
for months. INDEX. 
Page. 
ABSCESS OF THE CORNEA— 
in disease of the lachrymal sac 51 
in gonorrhoeal ophthalmia 61 
ACCOMMODATION— 
errors of a cause of chronic conjunctivitis 53 
ACETATE OF LEAD— 
dangers of in corneal disease 35 
use of in conjunctivitis 35 
ACETATE OF ZINC— 
use of in conjunctivitis 35 
ACTUAL CAUTERY— 
in acne conjunctivitis 169 
in phlyctenular conjunctivitis 152 
in ulcer of the cornea 101 
in warts of the conjunctiva 191 
ANAESTHESIA OF THE CORNEA— 
in herpes zoster ophthalmica 161 
in xerophthalmia 156 
x\NATOMY OF THE CONJUNCTIVA 9 
ANGIOMA OF THE CONJUNCTIVA 196 
ANTERIOR CHAMBER IN GLAUCOMA 32 
ANTISEPTICS 121 
ARTIFICIAL EYE— 
* cause of granulations 189 
ASTHENOPIA IN CONJUNCTIVITIS 48 
ASTIGMATISM IN CONJUNCTIVITIS 53 
with the rule • '. 53 
against the rule 53 
ATROPHY OF THE CONJUNCTIVA— 
in chronic hlennorrhoea . .113 
in trachoma 87 
a cause of xerophthalmia 155 
ATROPIA, USE OF— 
in hlennorrhoea 129 
in injuries of the cornea 204 
in trachoma .. 99 
in phlyctenular conjunctivitis 151 
in ulcer of the cornea 101 
BLENNORRHCEA— 
acute 56 
chronic 108 
subacute 77 Page. 
BLEPHARITIS MARGINALTS 51, 112 
BLEPHAROSPASM— 
in phlyctenular ophthalmia •.. .. 142 
BURNS OF THE CONJUNCTIVA 205 
from caustics 206 
from matches 206 
from metals 206 
CALCAREOUS DEPOSITS— 
under the conjunctiva 197 
CANALICULUS, SLITTING OF— 
in trachoma 103 
CANTHOTOMY— 
in gonorrhoeal ophthalmia 66 
CANTHUS, EXTERNAL 113 
CARUNCLE 14 
CELLULlTlS— 
differential diagnosis in diphtheritic ophthalmia.. ..139 
CICATRICES— 
from burns 208 
from trachoma (see Trachoma). 
from wounds 203 
ClLlA— 
operation on 102 
COCAINE, USE OF— 
in phlyctenular conjunctivitis 151 
in wounds and injuries - 204 
danger of in herpes zoster ophthalmica 163 
COCCl— 
cause of inflammation 21 
CONJUNCTIVA— 
anatomy of 9 
angioma of 196 
blood-vessels of 11 
calculi in 197 
cysts of 193 
dermoid growths of 193 
epithelioma of 195 
excision of in trachoma 100 
fibroid tumors of „ 191 
foreign bodies on 198 
function of 
glands of 
lacei’ations of 210 
lupus of 
nerves of lg 
ocular 
Index. 214 
Index 
Page. 
physiology of . 17 
pigmentation of 14 
sarcoma of 194 
syphilitic diseases of 185 
tarsal.. 11 
tubercular diseases of.. .. .. 182 
xerosis of 154 
CONJUNCTIVITIS— 
Blennorrhceal— 
acute.. .. 56 
subacute 77 
chronic . .. .108 
Catarrhal— 
acute 29 
subacute 37 
chronic 46 
Croupous 37 
Diphtheritic 135 
CORNEA, INFLAMMATION OF— 
in blennorrhoea.. 58, 111 
in catarrh 31, 33, 45 
in diphtheria 137 
in phlyctenular ophthalmia 143 
in wounds, diagnosis 198 
COUNTER-IRRITATION— 
in trachoma 99 
CYSTS OF THE CONJUNCTIVA 193 
CYSTS OF THE PTERYGIUM 179 
DERMOID GROWTHS IN THE CONJUNCTIVA 193 
DIPHTHERIA OF THE CONJUNCTIVA 135 
DISTICHIASIS 89 
ECCHYMOSIS— 
of the subconjunctiva 210 
ECTROPION '.. ..112 
ECZEMA— 
of the conjunctiva 171 
of the face 142 
of the lids ' 142 
of the lips 142 
ELECTROLYSIS 102 
ENTROPION 85 
spasmodic 36 
EPITHELIOMA OF THE CONJUNCTIVA 195 
EPISCLERITIS 40 
EXAMINATION OF THE EYE 23 
EXCISION OF THE CONJUNCTIVA— 
in chronic blennorrhoea 100 Index. 
215 
Page. 
EXOPHTHALMOS— 
in orbital cellulitis 139 
EYELASHES, DISEASES OF 112 
FATTY TUMORS OF THE CONJUNCTIVA 193 
FIBROID TUMORS OF THE CONJUNCTIVA 191 
FOREIGN BODIES ON THE CONJUNCTIVA 202 
GONORRHtEAL OPHTHALMIA 56 
GLACIAL ULCER OF THE CORNEA 60 
GRANULATION OF THE CONJUNCTIVA 187 
HEMERALOPIA ASSOCIATED WITH XEROSIS 157 
HEMORRHAGE UNDER THE CONJUNCTIVA 210 
HERPES— 
simplex ophthalmica 158 
iris ophthalmica 161 
zoster ophthalmica 161 
INJURIES OF THE CONJUNCTIVA.. 198 
INOCULATION IN TRACHOMA 105 
INSECTS IN THE CONJUNCTIVAL SAC 200 
lODOFORM, USE OF 64, 67 
IRITIS IN ACUTE BLENNORRHCEA 62 
JEQUIRITY IN TRACHOMA.. 104 
KERATITIS— 
in blennorrhoea 112 
in trachoma 91 
phlyctenular ophthalmia 145 
LACERATIONS OP THE CONJUNCTIVA * ..209 
LACHRY'MAL APPARATUS— 
atrophy of in xerosis igg 
LACHRYMAL SAC— 
trachoma of 102 
disease of 
LIMBUS CORNEA (see Anatomy). 
LUPUS OF THE CONJUNCTIVA 184 
LYMPHATIC GLANDS OF THE CONJUNCTIVA 15 
LYMPHATIC VESSELS OF THE CONJUNCTIVA 15 
MEASLES— 
conjunctivitis of 44 
OPACITY OF THE CORNEA FOLLOWlNG— 
blennorrhoea 60 
trachoma ’ ’’ ’’ 92 
phlyctenular conjunctivitis.. 141 
OPHTHALMIA NEONATORUM 69 
PANNUS— 
in chronic blennorrhoea H2 
in trachoma '' \ \ 91 
in phlyctenular conjunctivitis.. 146 
PARACENTESIS OF THE CORNEA. . 67 
PEMPHIGUS OP THE CONJUNCTIVA.. ... ” ‘ ‘ ”172 216 
Page. 
PHLYCTENULAR CONJUNCTIVITIS 141 
PIGMENT CELLS OF THE CONJUNCTIVA (sea Anatomy). 
PINGUECULA 17? 
PLICA SEMILUNARIS (see Anatomy). 
POULTICES— 
dangers of 33 
POWDER BURNS 206 
PTERYGIUM 173 
REFRACTION— 
eri’or of in chronic conjunctivitis 53 
SARCOMA OF THE CONJUNCTIVA 194 
SCARIFICATION IN CHRONIC BLENNORRH(EA 128 
SCROFULOUS KERATITIS 144 
SECONDARY GLAUCOMA.. 145 
SEPTIC INFECTION OP THE CORNEA 59 
SPRING CATARRH 41 
SULPHATE OP COPPER, USE OF— 
in trachoma 95 
in chronic blennorrhooa 130 
SYPHILITIC DISEASES OF THE CONJUNCTIVA 185 
chancre 186 
mucous patches 186 
TENSION OF THE EYEBALL— 
in glaucoma 32 
in iritis 32 
TRACHOMA— 
mixed 131 
simple 82 
TRICHIASIS 89 
TUBERCLE OF THE CONJUNCTIVA 182 
TUMORS OF THE CONJUNCTIVA 188 
ULCERATION OF THE CORNEA— 
in acne conjunctivitis 169 
in blennorrhoea.. 58, 111 
in catarrh 31, 33, 45, 52 
in herpes.. .. .. 159 
in trachoma 85, 92, 101 
in wounds and injuries 204 
in xerosis 158 
WARTS ON THE CONJUNCTIVA 190 
WOUNDS OF THE CONJUNCTIVA 198 
XEROSIS OP THE CONJUNCTIVA 154 
Index.