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Diseases Of The Conjunctiva

Diseases Of The Conjunctiva

Congenital Anomalies of the Conjunctiva. Pigment patches, like moles, sometimes appear on the conjunctiva, accompanying moles of the face.

Dermoid tumors develop on the ocular conjunctiva (often extending on to the cornea), at the caruncle, and at the upper outer quadrant of the globe (see page 32,9). They are at times associated with coloboma of the lids. They may be pigmented. Dermoid cysts have also been observed.

Telangiectatic patches may appear on the caruncle and also on the palpebral conjunctiva. They are flat, slightly elevated, bright red in color, and often accompany telangiectatic patches on the lids and face.

Cavernoma of the conjunctiva also exists as a congenital growth. The color is dark blue, and the conjunctiva is bulged forward at the affected part. When the head is lowered or the child cries or coughs the tumor increases in size.

Small subconjunctival lipomata may accompany congenital coloboma of the lids or may exist alone.

Well developed bone tissue has been observed situated beneath the ocular conjunctiva, between the margin of the cornea and the outer commissure.

The caruncle may present an abnormal development of hair (trichosis caruncule). Congenital duplication of the caruncle has been reported by Stephenson.

Hyperemia of the Conjunctiva (Dry Catarrh). This condition usually affects the palpebral conjunctiva, and is manifested by a persistent redness with no appreciable thickening. The posterior system of conjunctival vessels is involved.

Etiology. The causes of this affection are numerous, and comprise the entrance of minute irritating particles into the conjunctival sac, exposure to strong winds, cold, beat, and glare of light. Conjunctival hyperemia may be produced by use of the eyes with poor illumination, eye strain from errors of refraction or muscular irregularities, by too continuous use of the eyes on fine work, by indigestion, alcoholic beverages, rheumatic gout, vaso motor disturbances, nasal catarrh, lachrymal disease, blepharitis marginalis, acute exanthematous fevers, etc.

Pathology. There is little change in the tissues; the blood vessels are enlarged and overfull, and there is a scanty small cell infiltration and increase in nuclei.

Symptoms. The lids feel heavy and hot; movements of the eve are painful; there are increased lachrymation and slight photophobia. Attempts to use the eyes by artificial light are accompanied by distress.

Diagnosis and Prognosis. Redness of the conjunctiva without discharge other than increased lachrymation, and without other appreciable change in the conjunctiva, suffices to establish a diagnosis. The prognosis is favorable, provided the cause can be removed.

Treatment. This should include the prevention of the entrance of foreign substances into the eve, and the correction of habits and systemic conditions that contribute to the continuation of the hyperemia. Errors of refraction and muscular defects should be corrected. Bathing the conjunctiva with a solution of boric acid, 2 or 3 per cent., three or four times a (lay, usually suffices for the local treatment. Strong astringents are not advisable.

Conjunctivitis (Ophthalmia). This term embraces a number of diseases of the conjunctiva characterized by increased altered secretion from the surface of the conjunctiva, pronounced distressing symptoms, and transient or permanent pathological changes in the membrane.

Simple Conjunctivitis (Catarrhal Ophthalmia). There is a relatively large number of forms of conjunctivitis which are mild in character and tend to spontaneous recovery, without serious complications, which may be placed in this class. They are characterized by slight swelling of the lids and conjunctiva and the presence of a muco purulent secretion. The specific disease known as acute contagious conjunctivitis, usually considered under this bead, will be described separately.

Etiology. (a) Mechanical or traumatic varieties are caused by the presence of dust or other irritating substances, as certain kinds of pollen, fishscales, foreign bodies of any description, insects and parts of insects.

(b) Associate varieties accompany the eruptive fevers (measles, scarlet fever, small pox), i influenza,. acute coryza, facial erysipelas, eczema, and blepbaritis marginalis. The pneumococcus of Friinkel (Fig. IV., Plate 2) has been described by Morax, Parinaud, and others as an infrequent, and by Gifford' as a frequent, cause of simple conjunctivitis.'

Symptoms. The development of muco purulent secretion is preceded by burning sensations, increased lachrymation, hyperemia, and slight swelling of the palpebral conjunctiva and transition fold. More or less marked swelling of the lids occurs, movements of the lids are painful, and photophobia with inability to use the eyes develops. Frequently one eye alone is affected, particularly in those cases having a mechanical origin.

Diagnosis and Prognosis. Often the history of the case is all sufficient. Examination of the conjunctiva] sac may disclose the presence of an irritating substance in addition to the muco purulent secretion. In doubtful cases a microscopical examination of the secretion will serve to decide its character. The prognosis as to duration is favorable in all cases where the cause can be discovered and removed. No serious impairment of vision occurs.

Treatment. The causes that produce the disease should be sought for and removed, when rapid recovery even without local medication often will take place. However, a cleansing wash, as a solution of boric acid, or of sublimate I : 15,000, may be used every two or three hours to advantage.

After the acute stage is passed an astringent stimulating collyrium of zinc sulphate, alum, or nitrate of silver, in the strength of one grain to the ounce, may be instilled once daily until all secretion has disappeared.

Acute Contagious Conjunctivitis (Acute or Epidemic Catarrhal Conjunctivitis; Muco purulent Conjunctivitis; "Pink Eye" (vulgarly)).This is an acute, highly contagious, muco purulent inflammation of the conjunctiva, accompanied by some swelling of the lids. A period of incubation precedes the acute stage; both eyes are usually affected. No age is exempt, except perhaps the first ten days of life. The affection is met with most frequently in the spring and fall months, often becoming epidemic. So far as is known it is prevalent throughout almost if not quite the entire world.

Etiology. This disease is due to the presence of a specific microorganism, a bacillus, in the conjunctival sac. A careful study of this microorganism was first made by the writer 1 in 1886, and his work has since been confirmed by Kartulis,' Morax 3 and others. The bacillus resembles that of mouse septicemia, measuring 0.25 micro millimeters in thickness (Figs. 11. and III., Plate 2).

Pathology and Pathological Anatomy. The posterior and anterior systems of blood vessels are congested, and there is apparently an increase in the number of capillaries and arterioles. The conjunctiva at the transition folds becomes thickened through the medium of the enlarged vessels, slight serous effusion, and the presence of leukocytes in moderate number in the conjunctival tissue. Small transfusions of blood occur in the ocular conjunctiva from the smaller vessels of the anterior vascular system.

Microscopical examination of the conjunctiva at the fornix discovers a slight infiltration of leukocytes at the base of the epithelial laver and between the epithelial cells, a moderate edematous condition of the' tissue, and the presence of a few bacilli disposed in small groups in the epithelial and very superficial conjunctival lavers. The secretion contains manv bacilli, free and aggregated, on or in the leukocytes.

Symptoms. About thirty six hours after the inception of the con the patient experiences a mild burning sensation in the lids, which are stuck together on waking in the morning; lachrymation is slightly increased. On the morning of the third day the lids are glued together with a thick layer of muco pus. They are swollen, sometimes intensely so, and the patient suffers from a sensation as of a foreign body in tile eye. Some photophobia is experienced. Use of the eyes is accompanied by pain ; vision is blurred by the presence of the secretion. The palpebral conjunctiva is deeply injected, the transition fold thickened, and the ocular conjunctiva presents a bright red appearace, a peculiarity which has given the disease the popular name of " pink eye." At the end of the third day the affection is usually at its height.

In the greater number of cases the swelling of the lids does not become intense, but in a few this symptom is pronounced, and when accompanied by pseudo membrane the disease may be mistaken for diphtheria.

The secretion seldom loses its ropy character, due to the presence of mucin, but in some cases it becomes quite purulent, resembling the discharge of gonorrheal conjunctivitis. There is seldom any chemosis, although the ocular conjunctiva is intensely injected. Close inspection will disclose the presence of many small transfusions of blood in the ocular conjunctiva: this is such a common symptom that Nettleship has given the affection the name of ‘’hemorrhagic catarrhal conjunctivitis."

The acute stage, which is often accompanied by slight rise of temperature and frontal headache, lasts from four to ten days. The discharge gradually diminishes in quantity, becomes thicker, and collects in little yellow masses at the inner canthi. The swelling of the lids and conjunctiva and the painful symptoms gradually subside, and recovery usually occurs in from two to three weeks. In the subacute stage the conjunctiva at the transition folds presents a swollen, succulent condition, with enlargement of the papillary body and some follicular hypertrophy.

Diagnosis and Prognosis. A. history of the presence of the affection in all or a number of the members of a family, or of its epidemic character in institutions, will aid much in establishing a diagnosis. The very yellow mass of secretion at the inner canthus is quite characteristic. Acute contagious conjunctivitis may be mistaken for purulent conjunctivitis, and, when a pseudo membrane forms, as it does in about 4 per cent. of the cases, for diphtheritic conjunctivitis. The microscope may be depended on to make the diagnosis clear in doubtful cases.

In the greater number of cases recovery ensues without leaving a trace of the disease; relapses and recurrences are frequently observed. One attack does not ensure immunity. Phlyctenule may develop in the later stages or trachoma may follow, but these conditions must be regarded as secondary diseases grafted on the primary disease by added infection. The cornea is rarely affected. In adults the attack is more severe than in children. The disease is contagious as long as secretion is present.

Treatment. As the disease is very contagious, isolation should be resorted to if possible. Bathing appliances should be separate. In all cases where large numbers of individuals are aggregated quarantine should be rigidly enforced, and persevered in until all traces of secretion have disap and even for a few days after that period.

For the first three to five days of the acute stage cold applications are indicated. These may be applied as follows: Thin pads of absorbent cotton, I I inches in diameter, or pieces of linen, I I inches square and two or three layers in thickness, to the Dumber of ten or twelve, should be placed on a cake of ice over which a thin napkin is spread, and a pad transferred to and from the eye sufficiently often to keep the lids cool every two minutes. In severe cases the cold applications should be continuous; in mild cases it will suffice to keep up the. applications through the daytime.

While this is being done the eye should be cleansed every half hour if the secretion is profuse, less often if the secretion is scanty, with some bland antiseptic solution. Boric acid, 2 or 3 per cent., or the bichlorid of mercury, 1 :15,000, may be employed. When the acute stage is subsiding the cold applications should be discontinued, the bathing continued, and in addition a more energetic germicidal astringent may be employed. Nitrate of silver, in the solution of 0.5 to I per cent., is excellently adapted for this purpose. The application may be made once in twenty four hours, and may be continued with less frequency until the secretion ceases. Other topical applications are alum (gr. 1 f3j), acetate of lead (gr. 1 f3j), sulphate of zinc (gr. 1 f3j), peroxid of hydrogen, formalin (Schering's solution I :200 to I : 500).

Bandaging the eyes and the application of poultices of tea leaves, oysters, scraped potatoes, bread and milk, and other domestic concoctions should be avoided. These only serve to retard recovery, and in many cases increase the inflammation.

Purulent Conjunctivitis (Acute Blennorrhea of the Conjunctiva). The term purulent conjunctivitis properly applies to all forms of conjunctivitis in which the discharge is more or less copious and comparatively free from mucin. This condition obtains in certain cases of acute contagious conjunctivitis, in some cases of traumatic conjunctivitis, in the forms induced by the application of a poultice of tea leaves in simple conjunctivitis (tea leaf conjunctivitis), and in the later stages of diphtheritic conjunctivitis. As commonly employed, it refers to the conjunctivitis induced by the presence of the gonococcus of Neisser, and is usually considered under the terms gonorrheal conjunctivitis and conjunctivitis neonatorum.

Gonorrheal Conjunctivitis. This disease occurs in men much more frequently than in women. It is characterized by marked swelling of the lids and copious discharge of purulent secretion from the conjunctiva.

Etiology. The gonococcus of Neisser (see Fig. I., Plate 2) in secretion from a diseased mucous membrane is brought in contact with the conjunctiva. Probably the most frequent manner of its conveyance is by means of the finger from' a urethral or vaginal gonorrhea. The use of a common washing bowl, towels, etc. may serve to communicate the disease. It is not probable that the contagium can be carried through the air. The discharge in gleet, as well as in pronounced gonorrhea, may serve to set up the affection, but it is supposed to be less severe when arising from gleet.

Pathology and Pathological Anatomy. Engorgernent of the vessels of the palpebral and ocular conjunctiva rapidly develops. An infiltration of leukocytes into the superficial layers of the entire conjunctiva and edema induced by a serous and in some cases a fibrinous exudation occur early. The conjunctival epithelial layer is swollen and uneven. The pathogenic microorganism grouped in or on the leukocytes in the characteristic manner is seen in the superficial layers of the conjunctiva (Fig. 187). The secretion contains the gonococci, which are found free and on the pus cells (Fig. 188).

Symptoms. The stage of incubation, which lasts from twelve to forty eight hours, is succeeded by the acute stage. The lids swell rapidly, and sometimes enormously, taking on a dark red line. The vessels of the conjunctiva become deeply congested, the conjunctiva red and swollen. There are a gritty sensation and smarting and burning of the lids. The increased weight of the lids produces a continuous dull pain in the eyes. The acute stage reaches its height in two or three days, at which time the swelling of the lids in typical cases is intense. The upper overlap the lower lids; from beneath the margins of the upper lids the secretion, which at first is watery and flaked with pus, and later becomes thick and creamy, oozes out on to and flows down the cheek. At times the secretion is retained in the conjunctival sac, producing much pain by pressure on the globe.

The conjunctiva of the tarsus and transition fold becomes much thickened and presents a deep red, velvety appearance. The ocular conjunctiva becomes very edematous, marked chemosis develops, and extravasations of blood are observed in this part of the conjunctiva. The chemotic tissue may overlap the cornea, giving lodgement to secretion in the sulcus thus formed, which is difficult to remove, and which serves to macerate and destroy the corneal epithelium, establishing an ulcer of the cornea. The chemotic tissue may protrude between the lids.

The acute stage continues from four days to two weeks, and gradually merges into the subacute stage. The thickening of the lids is now much less; they are pale, soft, and flabby. The conjunctiva presents a velvety appearance, and is still much hypertrophied; the chemosis is less marked and the secretion less profuse.

What might be termed the atonic stage succeeds the subacute stage. The swelling of the lids has subsided, but the conjunctiva of the tarsus and transition folds is left rough, rugose, and presents many papilliform elevations. The secretion is thinner and not so profuse. Use of the eye is difficult. This stage may drift into a chronic condition if not treated properly, in which corneal ulcer, trichiasis, entropion, etc. may develop.

Of the complications that develop, corneal involvement is most dreaded. Total destruction of the cornea may occur early from interference with the nutrition of that membrane; the cornea loses its luster, becomes gray, and disappears. Loss of the crystalline lens and panophthalmitis may follow. Involvement of the cornea is most frequent in the second week of the disease, the ulcer commencing at the margin of the cornea as a grayish, uneven defect which increases in depth and area. Pseudo membrane occurs in a small percentage of the cases. It appears on the palpebral conjunctiva as a result of the deposition of fibrin on a surface from which the superficial epithelial cells have been lost. Gonorrheal rheumatism is an infrequent consequence of gonorrheal conjunctivitis.

Diagnosis. Gonorrbeal conjunctivitis presents manv degrees of severity. It may be so mild that it readily passes for simple conjunctivitis; or so severe that diphtheria is suspected. The history of the case will assist in making a diagnosis, and microscopical examination will absolutely establish it. The conjunctivitis occurring in young girls with leukorrhea, which is observed from time to time, is often gonorrheal, but, according to some authors, may have other causes.

Prognosis. In spite of all treatment, a large percentage of cases result in impairment of vision, to a greater or less degree, from corneal complications. If an ulcer appears at the margin of the cornea, and the cornea at this point becomes vascular, recovery without perforation may be looked for. Partial ulceration of the cornea, with or without perforation, may be followed by partial staphyloma after the ulcer has healed. Adherent leukoma follows perforating ulcer of the cornea, and in rare cases the lens may become adherent to the sear. Panophthalmitis, as already stated, may be the result.

Treatment. Prophylaxis as regards other individuals and in regard to the fellow eye must be first considered. The disease, through the secretion is extremely contagious; hence immediate isolation should be secured, and' should be persisted in until all secretion has disappeared. All dressings and appliances with which the secretion comes in contact should be destroyed or thoroughly sterilized. To protect the fellow eye a Buller's shield, which consists of a watch crystal held over the eye by means of strips of rubber plaster, should be applied.

Local Treatment. In the acute stage cold applications should be em day and night, after the method described on page 277, and the conjunctiva freed from secretion as often as is necessary every thirty to sixty minutes, with a bland aseptic solution boric acid 3 per cent. or bichlorid of mercury (1 :15,000). For the carrying out of this treatment two nurses, a day and a night nurse, are required. If' the lids become sore and erosion of the epithelium is threatened, some borated vaselin may be applied after each bathing.

There are many ways of cleansing the eye. The lids may be held gently apart and the warm solution be permitted to run into the conjunctival sac from a piece of absorbent cotton. A pipette may be used to force a stream beneath the lids after they have been gently opened. A speculum with perforated blades has been devised (Andrews) for cleansing the conjunctival sacs, and a lid retractor which permits the solution to flow through the handle and into the blade, escaping at openings at the margin of the blade, has been made for the same purpose. Except in very skilful hands the instruments devised for cleansing the eyes are dangerous, as they are apt to injure the cornea and induce corneal ulceration.

Applications of cold, which are generally made inadequately, may be made too assiduously and the vitality of the cornea threatened. When' too much cold is applied the cornea takes on a steamy appearance and breaks down more easily. If corneal luster fails without evidence of loss of substance, the applications of cold should be intermittent.

Hot applications in the acute stage are contraindicated; they serve to increase exudation and the growth of the gonococcus. In the subacute and atonic stages they may be resorted to with benefit.

As soon as the discharge takes on a purulent character and the lids are less rigid, local applications to the conjunctiva may be made. For this purpose a solution of the nitrate of silver, 1 or 2 per cent., is probably the best. The lids are carefully everted, the secretion removed, and, by means of a piece of absorbent cotton wound around the end of a small applicator the solution is applied to the entire surface of the conjunctiva. This should be followed by applications of cold for one or two hours. The treatment outlined above will suffice to effect a cure in the greater number of cases.

Finely pulverized iodoform is sometimes employed by dusting it into the conjunctival surface two or three times daily. Peroxid of hydrogen has been advocated by Landoll; it is of value as ad cleansing and germicidal agent. Sublimate solution, I: 500, has been employed recently by applying it to the conjunctiva sufficiently often to hold the secretion in check. Aqua chlorine, formalin (1 :3000), permanganate of potassium in copious irrigations (1 : 500 or 1 : 1000), are used to irrigate the eve. Dr. Wilson of Bridgeport advocates filling the conjunctival sac with a boric acid ointment (boric acid gr. x1viij, vaselin 3j) every one to two hours after cleansing, continuing this treatment until the acute stage has passed: lie claims excellent results. In some severe cases Noyes has resorted to scarifying the conjunctiva and brushing in a solution of corrosive sublimate, I: 560, repeating the operation in two or three days if the discharge returns.

If corneal ulcer develops, atropin (gr. ij to 3j) should be instilled two or three times daily. Ehrenthaler 1 recommends eserin (gr. ij to 3j) in those cases of corneal ulcer where congestion of the iris is not present, alternating with atropin in other cases unless perforation is imminent. He avers that the circulation is improved and recovery more certain.

When the lids are greatly swollen and tense a free cantholomy may be done. This relieves the pressure on the cornea, unloads the blood vessels, and prevents spasmodic contraction of the orbicularis palpebrarum muscle. In the last stage hot water bathing, the sulphate of copper or alum crystal, and tannin may be employed.

Systemic Treatment. The bowels should be kept free by use of calomel and a saline. Rich food and alcoholic beverages should be forbidden. Opium may be administered if there is much pain.

Conjunctivitis Neonatortim (Ophthalmia Neonatorum). This is a purulent affection of the conjunctiva, accompanied by great swelling of the lids and thick purulent secretion, occurring within a few days after the birth of the child.

Etiology. That form of the affection which develops within three days after the birth of the child is undoubtedly produced by gonorrheal infection from the vaginal secretions of the mother at the time of birth. In cases that have developed ten days to three weeks after birth other causes are found : the small bacillus of acute contagious conjunctivitis, the pneumo bacillus, and the Klebs Loffler bacillus have been observed. The use of soiled towels or napkins about the infant or the unclean hands of mother or attendant may serve as a means of carrying infectious material to the infant's eye. Exceptionally, inoculation in utero may occur (ante partum conjunctivitis).

Pathology. The pathology of ophthalmia neonatorum resembles that of purulent conjunctivitis in the adult, so far as the tissue changes are concerned.

Symptoms. Slight puffiness of the lids and a tendency to stick together will be noticed twenty four or thirty six hours after birth, and on inspec¬tion the palpebral conjunctiva will be found to be congested. As a rule, the change in the lids and the presence of secretion are not sufficient to attract attention until the third day, when the secretion has become distinctly purulent and the lids somewhat swollen. At the end of the fourth or fifth day the lids are greatly thickened and of a dusky red color; the secretion is purulent and quite copious. It either flows out on to the cheek or is retained in greater part by the lids and bursts forth on attempts to separate the lids.

The swelling of the conjunctiva is so intense in some cases that ectropion of the upper lid is produced. Chemosis is not so marked as in purulent conjunctivitis occurring in adults, and involvement of the cornea occurs in a smaller proportion of cases. What has been stated in regard to tile symptoms in gonorrheal conjunctivitis of the adult, except as indicated above, applies to conjunctivitis neonatorum.

Diagnosis. The history of the case and the age of the child will suffice to establish a diagnosis.

Prognosis. If not properly treated the prognosis is grave, but not to such a degree as in the adult. Properly treated, the prognosis is good. Careful observation of many cases has taught the writer that if the patient is seen while the cornea is still clear impairment of vision need not occur, except in the cases in which the affection is very severe and the patient's vitality much impaired. Since the retention of vision depends so much on careful and proper treatment, it is of the greatest importance that the infant should be seen by a competent physician as early as possible. Neglected cases have contributed 20 per cent. to the number of the blind.

Prophylaxis. The great work done by Crede in Leipzig in reducing the number of cases of conjunctivitis neonatorum from 10.8 to 0.2 per cent. in the infants born at the Lying in Asylum under his charge shows what may be accomplished by prophylaxis. Crede's method was to drop two drops of a 2 per cent. solution of nitrate of silver into the conjunctival sac of the infant's eyes very shortly after its birth, having first wiped the lids clean. The reaction is quite severe in some cases.

It has been found that equally good results may be obtained with a I per cent. solution of nitrate of silver, also with a solution of bichlorid of mercury (I : 4000) dropped into the eye in the same manner. Normal saline solution, used a little more freely, is excellent, but not quite as efficacious as either the silver or sublimate solution. Aqua chlorini and carbonic acid (I : 100) have been advocated.

Those in charge of a case of conjunctivitis neonatorum should be cautioned regarding its contagious nature, and should be instructed to destroy or to disinfect all appliances that come in contact with the secretion. The infant should be removed from the presence of all persons except those in immediate attendance. A protective shield for the unaffected eye is not easily made efficient; more reliance may be placed in the ability of the nurse to keep the fellow eye disinfected. Almost always, however, the affection is bilateral.

Treatment. If the lids are at all swollen, cold applications, made as, described on page 277, and continued until the swelling of the lids partly subsides, are valuable. Three hours of the applications and one hour of intermission is an excellent way of applying cold. After the swelling has markedly diminished applications of cold for one hour, three times daily, may be kept up until little swelling remains.

The pus should be gently removed by lavage with a 2 or 3 per cent., solution of boric acid every half hour or every hour, as long as the secretion is abundant. After the first two or three days applications of a 1 per cent., solution of nitrate of silver may be mad e by the surgeon to the palpebral conjunctiva, either employing a bit of absorbent cotton on a small applicator or a camel's hair brush, once in twenty four hours. As the secretion and swelling diminish the silver solution may be weaker and may be applied less frequently. Should the integument of the lids lose some of its epithelium or become roughened, some borated vaselin may be applied after each cleansing of the eyes.

When ulcer of the cornea occurs, atropin in weak solution (gr. ij to 3j) should be instilled twice daily if the ulcer is central ; if marginal, eserin (gr. j to 3j) may be alternated with the atropin. The treatment may be varied as indicated when considering the treatment of gonorrheal conjunctivitis of adults (page 280).

Croupous Conjunctivitis (Membranous Conjunctivitis). There is a class of cases characterized by a slight swelling of the lids, by a flaky serous discharge, and by the deposit of a fibrinous pseudo membrane on the surface of the palpebral conjunctiva, extending in some cases on to the ocular conjunctiva, which from a bacteriological or clinical standpoint cannot be included with any other form of conjunctivitis. Graefe I terms the disease pseudo membranous or croupous, in contradistinction to the diphtheritic form. The cases are comparatively rare.

Etiology. No exact cause is known. The affection is regarded as a mild diphtheria by some authors.

Pathology and Pathological Anatomy. The conjunctiva is thickened, and shows on section the presence of leukocytes and an increase in nuclei. The epithelial layer is reduced in thickness; blood vessels are numerous and are enlarged. The pseudo membrane consists of fibrin, which includes in its meshwork epithelial cells from the conjunctiva, leukocytes, red bloodcorpuscles, and various forms of micro organisms. The pseudo membranes found in epidemic conjunctivitis, gonorrheal conjunctivitis, diphtheritic conjunctivitis, and those that cover the surface of the conjunctiva after burns with acids, steam, or after scarifying the conjunctiva, differ from each other microscopically only in their bacterial contents and the products of the bacterial growth. Thus membranous conjunctivitis has been ascribed to staphylococci, streptococci, Loffler bacilli, and diplococci.'

Symptoms. The symptoms are not severe. The patient complains of obscuration of vision, slight itching, and some burning pain. There is some photophobia. The lids are slightly swollen and somewhat hyperemic. Oil everting the lids a grayish pseudo membrane is found. It can be separated from the conjunctiva with comparative ease, but leaves a slightly bleeding surface. The fibrin filaments do not appear to be so munerous or to penetrate so far into the conjunctiva as is the case in diphtheritic conjunctivitis. Removal is followed by rapid regeneration of the membrane, and this tendency may continue for from ten days to many months or even longer.

Diagnosis. The diagnosis is arrived at largely by exclusion. The subacute nature of the disease, the absence of any known specific micro organism, and the persistence of the affection serve to establish a diagnosis.

Prognosis. The prognosis is good in perhaps 50 per cent. of the cases. Although the disease persists for a long time, appropriate treatment will often produce a gradual diminution in the tendency to reproduce the membrane and the patient will recover. The cornea remains clear for a long time ten days or perhaps as manv weeks. it may finally become the seat of ulcerative processes and be partly or totally destroyed.

Treatment. Unfortunately, treatment appears to be of little avail in some cases ; in others a tardy response is secured. It appears to be almost useless to remove the membrane. Frequent and prolonged bathing with some mild antiseptic solution, as carbolized water, corrosive sublimate (I : 10,000), chlorin water, or a 4 per cent. solution of boric acid, is indicated.

Some writers believe that it is best to remove the membrane and to treat the surface with the mitigated stick of nitrate of silver; but this measure is of doubtful value. A solution of chlorate of potassium has been suggested, as have also applications of iodoform and quinine.

Diphtheritic Conjunctivitis (Membranous Conjunctivitis). This is a severe, acute affection of the conjunctiva, characterized by intense swelling of the lids, which become thick, hard, and smooth, and by tile presence of a pseudo membrane on the surface of the ocular and palpebral conjunctive. It attacks individuals of all ages except the new born (Von Graefe), but is most frequent in children. Both eyes are generally involved.

Etiology. The direct cause is without doubt a specific micro organism known as the diphtheritic or Klebs Loffter- bacillus (Fig. 190), which developson the conjunctiva only when that membrane is in a suitable condition to receive it. A depreciation of the resisting power of the conjunctiva to the inroads of bacteria, tile result of malnutrition or an acute illness, as scarlet fever or measles, will favor an attack. The affection is more frequent during the climatic changes of fall and spring and when epidemics of diphtheria of the air passages occur. Many cases accompany and are secondary to faucial and nasal diphtheria, but the disease may occur primarily in the eye. To pro¬duce the disease direct infection of the conjunctiva with secretion containing the bacilli is necessary. Von Graefe 1 states that simple conjunctivitis renders the conjunctiva susceptible to the diphtheritic poison.

Pathology and Pathological Anatorny. A congestion of the bloodvessels of the conjunctiva and lids first occurs, which is soon followed by the transudation of leukocytes and plastic material into the tissue of the lids and on to the surface of the conjunctiva. A partial destruction of the epithelial layer of a portion of' the conjunctiva is probably necessary before the plastic exudation can find its way to the surface of the conjunctiva. The circulation is greatly impeded by the presence of the exudation. The pseudo membrane is composed of layers of fibrin which enclose leukocytes, degenerating epithelial cells, red blood corptiscles, and va forms of bacteria, prominent among which are the diphtheritic bacilli. At the base of the pseudomembrane fibrille of fibrin embrace the superficial epithelial cells membrane to adhere closely during and extend between them, causing the the time of its formation.

Diagnosis. In some cases it is difficult to discriminate between mem conjunctivitis due to diphtheria and that due to other forms of inflammation. Caustic applications in mild forms of conjunctivitis in infants and children may produce a pseudo membrane and an intense plastic infiltration of the lid that may be mistaken for diphtheria. Severe cases of gonorrheal and of epidemic conjunctivitis may assume a diphtheritic aspect.

The history will aid in eliminating error, but the most conclusive method is that of bacteriological examination. Should the examination of a cover glass specimen fail to afford positive results, cultivation experiments may be tried.

Symptoms. In a typical case the onset is sudden. Slight discomfort in the lids, increased lachrymation, and congestion of the conjunctiva precede the severer symptoms by a few hours. Swelling of the lids takes place rapidly : at the end of twenty four hours the upper lid may have attained four or five times its normal thickness. The folds of the skin of the lid are obliterated; it becomes shiny and assumes a dusky red hue. The lid is hard to the touch, slightly elastic, closes the eye completely, and cannot be easily raised or everted. A little flaky serous secretion, sometimes tinged with blood, oozes from between the lids at this stage. Attempts to open the eye on the part of the patient are futile, and the surgeon will only partly succeed. A sensation of weight and tension on the globe is experienced, but aside from this there is little pain.

On raising the lid from the globe the palpebral and often the ocular conjunctival surface will be found to be covered with a gray membrane, which, in the average case, is about one millimeter in thickness. On attempts to remove this membrane shortly after it has formed, it will be found to be closely adherent : forcible removal leaves a raw, bleeding surface, which is soon covered again by new formed membrane.

The acute stage, which may last three to seven days, is accom n ed by slight rise of bodily temperature, and sometimes by cephalalgia. Gradually the lids become less rigid, the secretion more puriform ; the pseudo membrane comes away in large or small plaques, and finally disappears. Corneal complications in the form of ulcers and extensive sloughing frequently develop, Dot only when the membranous deposit is extensive, but also when it is moderate in amount. There is great variation in the degree of severity, rapid destruction of the eye occurring in some cases, while others are so mild that the nature of the disease is not recognized.

Prognosis. Diphtheritic conjunctivitis is probably the most destructive disease that effects the conjunctiva. The nutrition of the cornea is often interfered with at an early stage, and the membrane sloughs. Of 40 cases reported by von Graefe occurring in children, 9 eyes were destroyed, in 3 there were adherent leukomata, in 7 simple leukomata, and in 21 the cornea remained unaffected. Of 8 cases in adults, 5 sustained perforation of the cornea, and 3 presented marked simple leukomata after the disease bad passed. Symblepbaron of varying degrees may result from adhesion of opposing raw surfaces. Tendinous cicatricial bands may form in the conjunctiva. Great changes in the lid may ensue as a result of the formation of cicatricial tissue.

Treatment. The indications are to prevent the communication of the disease to the fellow eye and to the eyes of other individuals, to limit the infiltration of the lids, to prevent destruction of the cornea by pressure or by infection, and to check the extension of the diphtheritic process to other mucous membranes. Aseptic or antiseptic solutions may be employed to cleanse the unaffected eye at stated intervals, or, better still, Buller's shield may be applied to the sound eye. The patient should be isolated, dressings and secretions from the eye destroyed, and towels, linen, etc disinfected after use. Cold applications should be made as advised on page 277, until the lids are less tense. A free canthotomy will cause desired depletion and relieve the pressure on the eyeball exerted by the tense lids. The conjunctival sac should be carefully cleansed at frequent intervals with a solution of boric acid, bichlorid of mercury (1 : 5000 or 10,000), or chlorin water (one half the U. S. P. strength. To prevent extension to the mucous membrane of the air passages mercury to saturation has been advised. The usual constitutional treatment of diphtheria is indicated.

Recently, serum therapy has been resorted to with results which, if uni as brilliant as in the cases reported, will rob the disease of its terrors.' As soon as the diagnosis is made, 10 cgm. of Bebring's diphtheria antitoxin is injected into the abdominal wall, and the injection is repeated after fortyeight hours if there is not a marked recession of the disease. In many cases improvement is noted before the end of the first twenty four hours, and the membrane disappears before the expiration of forty eight hours. Antitoxin is said to modify favorably the necrotic process in the cornea.

Phlyctenular Conjunctivitis (Lymphatic Conjunctivitis (Fuchs); Scrofulous Ophthalmia; Eczema of the Conjunctiva). This disease is characterized by the appearance of one or more small translucent elevations at the limbus or at some point on the ocular conjunctiva, accompanied by an increased local vascularization (Fig. 191). If a single nodule appears, it is situated at the apex of a triangular patch of injected vessels, the base of the triangle being directed toward the equator of the globe. The affection is common in children, never affects the new born, and is rarely seen in adults.

Etiology. A depraved condition of the system induced by inherited taints, malnutrition, filth, and bad hygienic surroundings predisposes to this affection. Although most frequently met with among the children of the poor, the children of the rich are not exempt. Experiments that have been conducted with cultivations made from the contents of the vesicles permit of but little doubt that the immediate cause is the presence of the staphylococcus pyogenes aureus or albus beneath the epithelium of the affected portion of the conjunctiva (see Fig. 192). This affection is frequently associated with moist eczema of the lids, face, scalp, ears, or other parts. The nodules of eczema closely resemble those of phlyctenular conjunctivitis, from which the same micro organism may be cultivated. It is undoubtedly from the eczematous process that the infectious principle is derived in many cases. Pustular blepbaritis marginalis supplies the necessary bacterium in some cases. Phlyctenular conjunctivitis frequently follows the exanthemata, as measles and scarlet fever. Simple and epidemic catarrh of the conjunctiva encourage to the development of phlyetenuloe, which appear six or seven days after the onset of the acute conjunctivitis due to a secondary infection. Naso disease always accompanies the affection.

Pathology. Apparently as a result of the depreciation of the resisting powers of the tissues of the body, the surface cells do not prevent the entrance and development of the pathogenic micro organisms. The contents of the nodule in the early stage are a thickened fluid containing many leukocytes and some granules; later the contents resemble pus. A section of a nodule shows it to be formed by the elevation of the epithelial layer from the underlying basement membrane; the vessels in the vicinity are congested, and there is an increased number of leukocytes in the adjacent tissue.

Symptoms. The palpebral conjunctiva is congested; this is also the condition of the ocular conjunctiva in the affected portion. There are slight stinging pain, lachrymation, photophobia, and annoyance on use of the eyes. The photophobia in phlyctenular conjunctivitis is slight compared with that accompanying phlyctenular keratitis (see page 305). In almost all cases the preauricular glands are enlarged. Frequently there is marked coryza, the upper lip becoming thickened by the flow of irritating secretions over it.

Diagnosis. Herpes conjunctive vernal catarrh, and trachoma affecting the ocular conjunctiva may be mistaken for phlyctenular conjunctivitis. In herpes the vesicles which spring from the injected conjunctiva are transparent and appear in clusters. They do not select the limbus, and are much more transient. In vernal catarrh the elevations are larger and do not ulcerate. Trachoma of the ocular conjunctiva is associated with trachoma of the palpebral conjunctiva, and seldom affects the limbus conjunctiva.

Prognosis. W lien the conjunctiva only is affected the. prognosis is favorable, as recovery occurs without leaving a trace of the disease. The duration is variable, from a few days to a number of months, successive phlyetenula appearing. Recurrences are frequently observed.

Treatment. This should be local and constitutional. The local treatment consists in keeping the eyes clean by the use of some antiseptic lotion. Bathing with a saturated solution of boric acid in water three or four times a day gives good results. An ointment of the yellow oxid of mercury (1 1.5 per cent.), introduced into the conjunctival sac twice daily after the phlyctenule has broken down, is of much value. Calomel may be dusted on the conjunctiva once daily if the patient is not taking iodin. A mild alterative in the shape of small doses of calomel may be continued for some weeks with benefit. Nourishing food and general tonic treatment iron, quinin, cod liver oil, and perhaps strychnin may be given. The naso pharynx should receive appropriate treatment. (Consult also Phlyetenular Kerato page 307.)

Herpes Conjunctiva. This occurs at times in connection with herpes febrilis or herpes zoster affecting the lids and face. It is seldom that the complete vesicles are found, as they rupture early, and their site is marked by shreds of epithelium which remain attached to the conjunctiva at the margins of the preceding vesicles.

The condition is accompanied by irritation and increased lachrymation. Herpes of the cornea may accompany herpes conjunctiva. The affection is extremely rare. It calls for no treatment other than that given for the affection which it accompanies (see also page 309).

Vernal Conjunctivitis or Catarrh (Fruehjahr's Catarrh (Saemisech); Spring Catarrh; Phlyctena Pallida (Hirschberg)). This is a chronic form of conjunctivitis which presents peculiar features. The tarsal conjunctiva is covered by small, closely placed, flattened, papilliform excrescences, which appear to be covered by a delicate grayish film. At the margin of the cornea the conjunctiva is thickened and unequally raised, forming pale, translucent, or waxy nodules, which are largest opposite the palpebral fissure, encroach a little on the cornea, but extend to a greater distance outward into the ocular conjunctiva.

Etiology. Nothing definite is known of the cause of the affection. Some writers believe it to be a form of trachoma, and so classify it. Fuchs is of the opinion that it is a specific disease, and that, although no specific microorganism has been discovered, it is produced by such a micro organism. Both eyes are affected. The male sex suffers most, the attacks being experienced between the ages of one and thirty five years.

Pathology. Little is known regarding the development of the papilla of the tarsal conjunctiva. The elevations about the cornea are preceded by local injection of the vessels; the thickening develops slowly. The papilla , of the tarsal conjunctiva are composed of a central cylinder or cone, made up of connective tissue and a few small blood vessels, which is covered by a thickened layer of epithelium. Over the nodules, at the limbus, the epithelial layer is uneven, and is thicker than normal.

Symptoms. The ropy nature of the secretion produces a sensation as of a foreign body in the eye. There are photophobia, burning of the lids, and burning of vision, principally due to the presence of secretion on the cornea. Use of the eyes by artificial light increases the irritation and lachry¬mation; the redness of the ocular conjunctiva about the cornea and the nodules at the limbus are apparent on inspection. On everting the lid the fine fissures of the tarsal conjunctiva due to separation of the papillae are recognized. The disease gives but little annoyance during winter months, but is very trouble¬ some during the summer months, at which time there is more or less stringy discharge and the eyes are painful. When cold weather comes on the elevations at the margin of the cornea become much smaller, some disappearing entirely ; the tarsal conjunctiva is less thickened, but the papilliform elevations still remain. Burnett states that in the colored race the bases of the nodules are pigmented.

Diagnosis. The history of the case is of great value in making a diagnosis. No other form of conjunctivitis recurs and persists to the same extent during the warm weather. The conjunctivitis that accompanies hay fever has none of the anatomical and few of the symptomatic characteristics of this disease.

Vernal catarrh may be confounded with trachoma and with phlyetenular conjunctivitis. The elevations on the tarsal conjunctiva do not have the appearance of the follicles of trachoma, nor do they have the same anatomical structure. The pericorneal elevations differ from those of phlyetenular conjunctivitis in that they are not so transient and do Dot break down and form ulcers.

Prognosis. The disease recurs for a number of years, and may then disappear entirely. In the greater number of cases no injury is done to the central area of the cornea; however, the nodules may advance for a considerable distance, and in rare cases may cover the cornea, abolishing useful vision.

Treatment. A complete cure by means of treatment must not be expected, but much can be done to relieve distressing symptoms, and the advance of the nodules on to the cornea may be checked. Bathing the eyes with a warm solution of boric acid three times daily will serve to keep them fairly clear of secretion. This, with the application of a smooth ointment of the yellow oxide of mercury (I,' per cent.) to the conjunctival sac twice daily, will produce very favorable results. Calomel and solutions of bichlorid of mercury are useful. If the nodules are large, they may be reduced and their advance checked by destroying them with the cautery; electrolysis has been recommended. Randolph advises salicylic acid applied to the conjunctiva in the form of an ointment (gr. iij 3iv) and as a collyrium (gr. v f 3J).

Follicular Conjunctivitis (Conjunctivitis Follicularis Simplex). This inflammation of the conjunctiva is characterized by the occurrence of small, oval, pale or light red elevations in the transition folds of the conjunctiva.

A few follicles the size of a pinhead are often observed in the tarsal conjunctiva
Etiology. Follicular conjunctivitis occurs among persons inhabiting crowded quarters and among those whose habits and surroundings are not cleanly. Soelberg Wells states that lie thinks that there can be no doubt that the disease is contagious. It is often met with in the young, and is of frenuent occur nee in inmates of residential schools.

Pathology. The follicles are due, according to Krause and Schmidt, to an abnormal enlargement of the lymphatic follicles of Krause, which are not visible to the unaided eve in the normal state but which are situated imme¬diately beneath the epithelium of the conjunctiva. They are supposed to be neoplastic growths. The follicles are composed of a mass of lymphoid cells contained in a delicate network of connective tissue having an incomplete capsule in which a few small vessels ramify.

Symptoms. These are few and not pronounced; indeed, follicular conjunctivitis may exist for months without the knowledge of the individual affected. On inspection the lower lid appears to be slightly thickened; there may be increased lachrymation, some mucoid secretion, and the ocular conjunctiva may be injected. On everting the lower lid the transition fold is found to be reddened, and may be swollen to such an extent that the follicles will not be visible ; however, in the greater number of cases the follicles appear as small, oval, translucent nodules, arranged in rows, lying in the transition fold. They may be few or numerous. Although ordinarily confined to the lower, they may be found in large numbers in the upper, transition fold
Diagnosis and Prognosis. If the conjunctiva is not greatly swollen, the diagnosis is easy. Follicular conjunctivitis differs from typical trachoma in that it is more transient, is more amenable to treatment, and is not followed by cicatricial changes. The prognosis is favorable for a return to the nor condition of health in a number of months if medicinal measures are adopted, and in two or three weeks if surgical measures are employed. There is no tendency to involve ent of the cornea.

Treatment. The patient should not be allowed to use the same bathing appliances with others, and should be isolated when practicable. The hygienic conditions should be made as good as possible, and cleanliness should be insisted upon. Constitutional treatment in the form of tonics, iron, strychnin, or quinin should be employed. Locally, a mild astringent collyrium of zinc* sulphate (gr. j to 3J), alum (gr. j to 3J), tannic acid, and glycerin (gr. 30 60 to 3J) may be employed. The sulphate of copper or alum crystal may be lightly applied to the follicles every forty eight hours.

For the surgical treatment of this affection see Surgical Treatment for Trachoma, page 563. 1 Expression of the follicles with suitable forceps is the most efficient measure to destroy them.

Granular Conjunctivitis (Trachoma; Granular Ophthalmia; Military Ophthatinia). This disease of the conjunctiva presents as its distinctive feature in its early or first stages numerous discrete, oval bodies in the tarsal conjunctiva and transition fold (trachoma bodies). When the conjunctiva is .not hypertrophied these granules are prominent, translucent, and resemble frog spawn, to which they have been compared. Granular conjunctivitis is most common in youth; however, individuals at all ages are affected, except perhaps those in the first year of life.

Description. In describing the clinical features of granular conjunctivitis it is convenient to divide it into three stages.

The first stage is that in which the granulations are discrete, in which the cicatricial contraction has not occurred, and may be termed the stage of hypertrophy. It manifests itself in a number of distinct phases which we will consider separately.

1. Cases appear sporadically in which, with little or no previous indication, no secretion, but with perhaps a little thickening of the lids, the granules develop, and the physician is surprised on everting the lid to find the palpebral conjuctiva completely studded with well formed granulations (Fig. 193). There is scarcely any injection of the conjunctiva and no marked discomfort to the individual. Only one member of a family may be affected or only one or two pupils in a school may, show this condition. If this form of granular conjunctivitis is at all contagious, it is only very slightly so, probably because of the very scanty secretion.

2. The clinical picture presented by this phase of the disease is the most common. The onset is not very acute, but there is redness of the conjunctiva and of the margins of the lids, accompanied by increased lachrymation, scanty mucoid secretion, and a sensation of burning and itching. In the morning the lids are stuck together, but can be opened without much difficulty. At tile end of a week the conjunctiva at the transition folds is thickened, injected, and presents a few shreds of mucoid secretion in its folds. Tile pain and irritation have increased. There may be some photophobia. The irritation is aggravated by use of the eyes.

At the end of two weeks, if the hypertrophy of the conjunctiva is not too great, numerous slight elevations which have much the color of the conjunctiva, can be made out, situated in the transition folds and frequently in the tarsal conjunctiva. The conjunctiva is much hypertrophied, and in a small percentage of the cases the granules are so hidden that they are seen only when the hypertrophy subsides. In from three to six weeks the hypertrophied condition of the conjunctiva lessens; a hyperemic condition prevails and becomes chronic. The cases are contagious from the time that the secretion appears until it disappears. The disease often appears in epidemic form. Corneal complications may occur during the second stage, and are not uncommon.

3. The third form of onset is, so far as the writer knows, confined to adults, and begins much the same as an acute conjunctivitis of not a very severe type. The eyelids are considerably swollen; the secretion, which is muco purulent, is accompanied by much lachrymation; the hypertrophy of the conjunctiva is excessive, causing it to lie in large folds in the upper and lower cul de sacs. The ocular conjunctiva is injected, but not much hypertrophied; the caruncle and semilunar fold frequently take part in the general thickening. None of the ordinary forms of treatment have much effect in reducing the hypertrophy, and at the end of two to four weeks it becomes evident that the large rigid folds represent one mass of lymphoid or trachomatous tissue.

Corneal irritation is experienced relatively soon in this form of the disease, and quite marked pannus may also occur early. This variety is eminently contagious, the type produced corresponding with this or with the second described.

The first stage of granular conjunctivitis, as described in the three types of onset, merges gradually into the second stage, which is one of commencing atrophy with the persistence of granulation tissue.

The hypertrophy of the conjunctival tissue has passed away, and bands of cicatricial tissue begin to appear (Fig. 194). The individual follicles have lost their character and have coalesced, forming larger or smaller masses; not infrequently the upper tarsus of the tipper lid is one continuous plaque of lymphoid tissue. The area of the conjunctiva is considerably lessened by cicatricial contraction. The tarsus IS not so wide, and is more sharply curved from above downward. The margins of the lids are thickened, the palpebral fissure narrowed (partial ptosis) and shortened. Lymphoid tissue may appear on the ocular conjunctiva or even ()it the cornea.

From irritation by the rubbing of the roughened lids the corneal epithelium is disturbed, and in the effort on the part of nature to protect this membrane vascular pannus appears over the parts most seriously menaced (Fig. 194). When the corneal epithelium is disturbed and superficial ulcers are establisbed, the irritation to the eye when exposed to light is intense, and marked photophobia is experienced. This brings on contraction of the orbicularis palpebrarum muscle and clonic or tonic spasms, with a forward bending Of the head.

With a cicatricial contraction of the inner or posterior surface of the tarsus, which increases the curvature and thickens its lower half, and the for down of the marginal fibers of the orbicularis palpebrarum muscle, the eyelashes are made to impinge upon the cornea and entropion is established. Slight mucoid secretion and profuse lachrymation accompany this stage; frequently the tears and secretion flow on to the checks, causing more or less erosion of the epithelium of the lower lid and face.

The third stage is essentially one of atrophy. All lympboid tissue has disappeared, the cicatricial contraction has partly or wholly abolished the retrotarsal folds, and the conjunctival sacs are rendered very shallow. There may remain some islets of fairly good conjunctiva and sufficient moisture to lubricate the lids. The cornea is partly or wholly opaque. In some cases the eye becomes opaque and dry (xerosis). Vision is greatly impaired or wholly abolished.

Although granular conjunctivitis in not a few cases pursues the course outlined above, it may also assume a much more benign type.

Duration. There is great variation in the duration of all the stages of granular conjunctivitis. The first stage may give way to the second stage in the course of three or four months; it may last six months or a year. The second stage is much more prolonged; it may never pass into the third stage. Seldom fewer than ten years are required to bring the patient to the stage of atrophy, and in most cases the individual has reached middle age before complete atrophy is established.

Etiology. Bad air, overcrowding, poor and scanty food, and filth contribute largely to the development of granular conjunctivitis. It is very probable that a contagium must be added to produce the disease. It becomes epidemic in residential schools, barracks, almshouses, prisons, etc.

A micro organisms supposed to be specific has been described by Sattler and Michel. It is a small double coccus, and may be cultivated from the contents of a trachoma follicle (see Fig. 195). No satisfactory results have been reached by inoculation experiments. Mutermilch' has described a fungus which he terms microsporon trachomatosum, with pure cultures of which he claims to have produced trachoma in calves and rabbits. Other microFIG. 195 ' Trachoma organisms have been mentioned as probable causative faccoccus (Michel). tors. Although it is thought by all who have studied the disease that it is microphytic in origin, sufficient evidence is not as yet at hand to make the belief indisputable. Parasitic protozoa have been described (Pfeiffer, Ridley).

So far as is known, there is no constitutional condition that predisposes to the development of granular lids. Individuals of a lymphatic condition are said to be especially prone to trachoma, but there is no good evidence upon which to base this assertion. Among certain peoples, as the Jews, Italians, Egyptians, and other inhabitants of the East, trachoma is prevalent. According to Burnett, the negro of pure blood is immune to trachoma; but his observations have apparently been confined to the negroes of our Southern States. The geographical Distribution of granular lids has attracted much attention. In certain regions of the inhabited portions of the earth the disease is of extremely rare occurrence. This is true of the Scandinavian peninsula and of the southern part of California.

Pathology and Pathological Anatorny. In the inflammatory cases the blood vessels become enlarged, and apparently increase in number, accompanied by an increase in the nuclei and in the cellular elements of the con The papillary body becomes enlarged, the lymphoid tissue is greatly increased, and numerous small lymphoid follicles develop in the palpebral conjunctiva.

An attempt has been made to separate folliculosis from trachoma on histological grounds, the claim being made that in follictilosis there is an enlargement of the lymph follicles of Krause, which normally reside in the conjunctiva. It is affirmed that the follicles in granular conjunctivitis are neoplasms, and, although anatomically identical with the follicles in follictilosis, have no connection with it. In careful studies made by the writer no such distinction has appeared to be possible. The follicle consists of aggregations of lymph corpuscles situated immediately beneath the epithelium, having a more or less marked fibro vascular capsule and traversed by very fine trabecule of connective tissue fibers ; some capillaries may be 'traced into them. The epithelium over the follicle is irregular and slightly thick¬in some parts. After the granules have coalesced the mass resembles a flattened lymphoma (Fig. 196).

The cicatricial tissue is made up of fine connective tissue fibrille closely associated, which contract as they mature. Small cysts develop in the conjunctiva in the second stage in some cases of granular conjunctivitis.

Diagnosis. Granular conjunctivitis may be confounded with the papilliform swellings of the transition fold which occur in acute muco purulent and in purulent conjunctivitis, with vernal catarrh, and with the cases of fibroid or fungoid excrescences of the conjunctiva.

In the first a further observation of the case will serve to decide its nature. Vernal catarrh affords by its history, by the fact that the transition folds are relatively free, and by the peculiar character and arrallgenient of the elevations about the cornea sufficient data to relegate it to another class. Fibrous or horny granulations may require careful study mieroscopically perhaps to enable one who has not observed other cases to determine their nature. The masses are not lymphomata, but are fibromata with a muchthickened epithelial layer.

Prognosis. This is favorable if the case is seen before much permanent impairment of vision has resulted. If seen in the first stage, a cure may be effected with but little damage to any of the tissue involved. Some cicatricial tissue will develop in the conjunctiva at the site of tile follicles, but the function of the eve will be but little interfered with.

In the second stage much can be done to improve the condition if treatment is instituted. If the disease is permitted to take its course, spontaneous recovery will occur in some cases, but in many corneal ulcer, pannus, trichiasis, and entropion will develop.

When the third stage is reached little can be done to improve the condition of the eye.
Treatment. This is prophylactic, medicinal, and surgical.
Isolation should be practised, if possible, so long as discharge persists. Cleanliness by irrigating the eye with some bland, antiseptic, or mild germicidal solution is first to be observed, care being taken that bathing appliances used by the patient shall not be used by others. A. solution of boric acid or a solution of bichlorid of mercury (I : 10,000 or 1 :15,000) or formalin 0 : 3000) may be employed three or four times daily, bathing ten or twenty minutes each time. A solution of bichlorid of mercury (I : 5000 or 1 :8006) which contains a few grains of sodium chlorid, or chlorin water, 50 per cent., officinal, may be dropped freely into the eye after each bathing. Applications of nitrate of silver (gr. iij to 3j) once daily will be of much value if there is secretion.

When the acute symptoms have subsided stimulating astringent application may be made. Alum crystal, sulphate of copper crystal, or the mitigated stick of nitrate of silver may be employed to lightly touch the granula once every second day. Sulphate of copper is most generally used and gives greatest satisfaction. Not all conjunctivae will tolerate these applications; trial will enable one to decide in which cases to employ them. In the intervals between the applications the patient should continue with the bathing and drops, using them at least three times daily. Corneal complications usually require atropin, but nothing additional. With an improvement in the lids the corneal ulcers will disappear.

Surgical treatment is of the greatest value in the early stage, and is described on page 563.
Chronic Conjunctivitis (Chronic Ophthalmia). A thickened, congested, irritable condition of the palpebral conjunctiva sometimes persists for months after an acute conjunctivitis, accompanied by redness of the margins of the lids. A similar condition may accompany blepharitis margin concretions in the lachrymal canals, atrophic or hypertrophic rhinitis, and eye strain from errors of refraction or muscular abnormalities. The affection is more than a simple congestion, being accompanied by a scanty muco purulent secretion.

In old people a flabby, slightly congested condition of the conjunctiva sometimes exists, also accompanied by a scanty discharge. Swelling or hypertrophy of the caruncle is found in almost all cases of chronic conjunc¬

Treatment. The lachrymal, and nasal passages should be carefully examined and any abnormal condition properly treated. Errors of refraction should be corrected, and the condition of the margins of the lids made favorable by proper treatment. The conjunctivitis may subside spontaneously after the successful treatment of the source of irritation, but in many cases stimulating and astringent measures must be resorted to. Applications may be made with a solution of nitrate of silver (I per cent.) once in forty eight hours until the secretion ceases, or with glycerol of tannin (3ss to 3ij) sprayed on the conjunctiva once daily. Extremely light applications of sulphate of copper or alum crystal may be made every second day. These measures, with careful cleansing two or three times daily with a solution of boric acid (3 per cent.), will in many cases effect a cure.

Egyptian and Military Ophthalinia. These terms are used without discrimination to indicate acute or subacute inflammations of the conjunctiva which appear in Egypt or may affect an army. They comprise at least three distinct forms namely, epidemic acute contagious conjunctivitis, gonorrheal conjunctivitis,' and acute trachoma. The consideration of these diseases is found tinder their appropriate headings.

Lachrymal conjunctivitis is an inflammation of the conjunctiva accompanying dacryocystitis, and due to the presence of the irritating purulent secretion from the lachrymal sac, which contains streptococci (Fig. 197). The inner third of the palpebral and ocular conjunctiva is most congested, but the whole lower cul de sac is frequently involved. The eye is often suffused with tears and muco purulent secretions, which, failing to escape by the tear passages, flow over on to the cheek.

The presence of a dacryocystitis determines the diagnosis. It is easy however, to overlook this cause, and it is therefore advisable to examine the condition of the lachrymal sac in all cases of conjunctivitis.

The prognosis is favorable if the dacryocystitis can be corrected. In some cases an ulcer of the cornea forms, becomes infected, and perforation follows, with greater or less impairment of vision.

An early correction of the da is advisable in all cases.

Lithiasis conjunctiva is characterized by the formation of white calcareous concretions in the acini of the Meibomian glands. These concretions penetrate the epithelial laver and produce great irritation by friction on the cornea and conjunctiva. They usually accompany a gouty diathesis, and are apparently of the nature of tophi.

On everting the lids the white concretions are readily seen and F,G. 197. Streptococei pyogenes (Fraenkel and Pfeiffer). recognized. The prognosis is good; however, new formations of similar deposits must be expected. The treatment consists of liberation of the concretions by incision.

Toxic conjunctivitis is a term employed to designate those forms of conjunctivitis that are due to the chemical action of certain substances. The following substances may be mentioned as acting in this manner: Atropin and other mydriatics, the myotics, chrysarobin, calomel, the dust from anilin dyes, fumes from menthol and formalin, and virus introduced by the bites of insects.

The conjunctivae of some individuals do not tolerate atropin even in very weak solutions. When a few drops of a solution of atropin are introduced into the conjunctival sac of such individuals, a smarting and pricking sensation is soon experienced; the conjunctiva and lids become slightly swollen and congested. The congestion of the lid is confined to the palpebral portion, imparting a peculiar and quite characteristic appearance. More or less dryness of the throat and irritation of the nasal mucous membrane may accompany the conjunctivitis. If no more atropin is instilled, the smarting and swelling subside in twenty four to forty eight hours, and recovery ensues. A similar condition may follow the use of hyoscyamin, duboisin, cocaine and homatropin, but is much less apt to occur. Eserin sometimes produces congestion of the conjunctiva. If a non sterile solution of atropin be used daily for some time, a follicular conjunctivitis, in which the follicles are largely confined to the lower cul de sac, may be produced. The condition responds readily to treatment after the atropin is discontinued.

Chrysarobin, when used in the form of an ointment, may produce a violent non suppurative conjunctivitis which gradually subsides on the discontinuance of the drug.

Calomel when dusted into the eye, as in the treatment of corneal affections in one who is taking iodin in any form, undergoes a rapid change into an iodid through the action of the lachrymal fluid, and may produce marked inflammation of the conjunctiva with superficial ulcers (calomel conjunctivities). If the calomel treatment is withdrawn and the conjunctival sac thoroughly cleansed, recovery will rapidly occur.

The irritation occasioned by the dust formalin dyes and the fumes from menthol and formalin will subside when the cause is removed.

sting of the fly produces intense edematous swelling of the conjunctiva and lids, accompanied with but little secretion. Bathing with hot water to which a little biborate of sodium, bicarbonate of sodium, boric acid, or sodium chlorid is added will aid in causing the tissues to resume their normal condition. The irritation caused by caterpillar hairs produces a form of con¬junctivitis to which the name ophthalmia nodose has been applied (see also page 327).

Xerosis (xerophthalmos) of the conjunctiva is a condition in which the surface of the conjunctiva appears to be dry. Two forms are recognized

(a) Sclerosis due to cicatricial degeneration of the conjunctiva (X. parenchymatosa, essential atrophy of the conjunctiva).
(b) Sclerosis accompanying a general disease (X. superficialis, X. epithelialis, X. triangularis, X. infantiH8).

Xerosis due to cicatricial degeneration of the conjunctiva is most frequently caused by trachoma. Pemphigus, burns, and exposure of the conjunctiva to the atmosphere, as in corrosion and lagophtbalmos, may produce it. Sclerosis may be partial or complete. In xerosis the conjunctiva is lusterless; the dryness is due to cicatricial obliteration of secreting tissues in or connected with the conjunctiva. This affection is seldom met with in individuals who have not reached mature years. It is incurable.

Xerosis due to general disease appears both in a mild and in a severe form. The mild form is characterized by the appearance of triangular masses of a foamy, lardaceous secretion, not moistened by the tears, which are located at the margins of the cornea in the horizontal meridian. The bases of the triangles are placed next to the cornea. Nyctalopia (night blindness) accompanies this condition. It appears in children and adults, and is the result of malnutrition. Inmates of prisons, soldiers in barracks or field, railroad laborers, sailors on long voyages, and those who eat a poor quality of' food with but little variety for long periods of time, suffer from this affection.

A severer form, which attacks infants and very young children only, is often associated with kerato malacia (see page 318). The disease extends from the conjunctiva to the cornea, producing complete destruction of that membrane. The secretion, which is of the same nature as that which appears in the mild form, first develops in the conjunctival sac and extends over the eye.

Prognosis. The prognosis in the mild form is favorable. Infants and young children suffering from the severe form seldom recover.

Microscopical examination of the secretion in these cases discloses the presence in almost pure culture of a plump, short bacillus, which usually appears in pairs. This bacillus has been fully described by Leber, and was thought by him to be the pathogenic factor in the disease. Other observers have not been able to support this view.

Treatment. Improvement in the nutrition of the individual is the essential measure to promote recovery.

Amyloid Disease of the Conjunctiva. This disease is rarely met with in the United States. It is characterized by the appearance of yellowish, waxy, translucent masses in the conjunctival sac, taking their origin most frequently from the retrotarsal fold. The entire conjunctiva may participate in the change, the great thickening converting it into large folds which may overlap the cornea and seriously obstruct vision. The tissue is very friable and is almost devoid of blood vessels.

Pathology. The tissue is largely made tip of lymphoid cells which in certain places, notably near the surface, have lost their distinctive characteristics and have undergone a hyalin degeneration, contributing to the formation of a homogeneous mass. The hyalin stage passes into an amyloid stage (Raehlmann), when fresh sections give the starch reaction in the presence of the iodin test. Sarcomatous tissue may be an element in these growths,' and osseous deposits may occur in the mass.

The diagnosis is easy, no other growth possessing the same appearance, and the prognosis is favorable if no malignant element is present. The development is slow. The treatment should consist of thorough removal of the diseased tissue.'

Pterygium is a peculiar fleshy mass of hypertrophied conjunctiva which develops most frequently at the inner, but occasionally at the outer, side of the eyeball. It is wedge shaped, the base lying at the caruncle; its upper and lower borders overlap the conjunctiva, permitting of the introduction of a probe. The apex of the pterygium advances on to the cornea in the horizontal meridian, rarely passing the center of the pupil (Fig. 198). Pterygia are most frequently met with in men, and are peculiar to adult life.

Etiology. Irritating particles that pass the margins of the lids and impinge upon the ocular conjunctiva first produce pinguec (Fuchs), and later pterygia. Miners, stone masons, laborers, and those who inhabit countries where there is much alkali dust present the condition most frequently.

A form of pterygium known as pseudo is also recognized. This is an irregular growth which may encroach upon the cornea from any direction. It follows burns, ulcerative processes, and injuries to the margin of the cornea.

Pathology.-A transverse section through the body of a pterygium shows it to be composed of loose connective tissue, rich in blood vessels, and with more or less small cell infiltration according to the degree of irritation. The epithelial layer is thickened. The tissue of the preceding pinguecula is embodied in that of the pterygium. At the apex of the pterygium an infiltration of' small cells is found which extends for a short distance into the superficial lamelle of the cornea. Avery few fine blood vessels also precede the advance of the growth. Micro organisms find suitable lodgement in the folds of the tissue of the pterygium.

Pain is experienced only when the pterygium becomes inflamed. Disturbances of vision result from acquired astigmatism and from invasion of the pupillary area. The condition can scarcely be confounded with any other disease. If early operation is resorted to, the prognosis is good, but recurrence is not uncommon. After the pupillary area is invaded slight nebulous opacities and irregular astigmatism are present after the pterygium is removed.

Treatment. This is always surgical divulsion, excision, or transplantation. Early operation is advised. (See page 561 for technique.)

Pinguecula. This is a small yellowish elevation in the ocular conjunctiva, situated near the inner margin of the cornea in the horizontal meridian ; the growth may also occur near the outer margin of the cornea. Fuchs is of the opinion that pinguecula should be regarded as the early stage of pterygium.

The condition is apparently due to irritation produced by the presence on the ocular conjunctiva of particles of dust and small foreign bodies, and is most frequently observed in those whose occupation brings them in contact with much dust. Formerly supposed to owe its yellow color to the presence of fat cells, it is now known to be a hyperplasia of the white and elastic connective tissue fibers of the conjunctiva, together with a colloid substance. Its epithelial layer is considerably thickened.

The diagnosis is made without difficulty, as there is nothing for which it can be mistaken. Pinguecula may degenerate into pterygium, but in many cases remains practically without change.

Treatment. The growth may be excised or destroyed by the cautery. It is not necessary to interfere in ordinary cases.

Abscess of the conjunctiva is an extremely rare condition. As a consequence of traumatism small abscesses may develop. A suppurating Meibomian gland may produce an abscess that opens on the conjunctival surface. Pus from a suppurative process, taking place in the orbital tissue, may bulge the conjunctiva forward and form a fluctuating tumor. These conditions, however, belong properly to other tissues. The abscess should be opened in the ordinary manner.

Ecchymosis of the Conjunctiva (Subconjunctival Hemorrhage). This is a condition due to the exudation of blood beneath the conjunctiva, and presents the appearance of a bright red or dark red spot of varying dimensions with rather sharply defined margins. The ecchymosis may affect the loose conjunctiva of the globe or lids. The conjunctiva tarsi, because of its close connection with the tarsus, does not permit the blood to pass beneath it.

Etiology and Pathology. The ecchymosis may be traumatic in origin, following squint or other operations, blows, the entrance of a foreign body, or it may be due to the spontaneous rupture of a small subconjunctival blood vessel (see also page 360). The spontaneous exudation of blood usually occurs in elderly individuals, in whom the walls of blood vessels are undoubtedly weakened by atheromatous processes and give way, and may indicate nephritis, but is sometimes seen in children as a result of violent coughing, vomiting, etc. In certain cases of fracture of the skull through the orbit conjunctival ecchymosis occurs in the outer lower quadrant of the ocular conjunctiva. Very small ecchymotic spots accompany acute forms of conjunctivitis. The blood gradually becomes absorbed and the natural color of the tissues is restored.

Treatment. Left to itself, the blood will be gradually absorbed. Absorption may be hastened by bathing the eye with water, at as high a temperature as the individual can bear, three or four times daily, for twenty or thirty minutes each time.

Chemosis of the conjunctiva may be active (inflammatory) or passive (non inflammatory). It is a condition in which the ocular conjunctiva becomes thickened and raised around the margin of the cornea, forming a uniform shallow pit of which the cornea constitutes the floor.

Etiology and Pathology. Inflammatory chemosis is rarely absent in purulent conjunctivitis, and often accompanies pronounced keratitis. When the interior of the eye is the seat of an inflammatory process, as in certain forms of iridocyclitis and infection after cataract operations, chemosis is sometimes produced. It may follow the administration of potassium iodid or succeed an attack of urticaria. It is an occasional accompaniment of nephritis.

Passive chemosis is sometimes observed in alcoholic and gouty individuals.

A section of the tissue in inflammatory chemosis presents an intense infiltration of leukocytes into the subconjunctival tissue at the margin of the cornea, some thin walled, newly formed blood vessels, transuded blood, and fibrin (Fig. 199). In the passive variety the leukocytes are very much less numerous, there are no newly formed blood vessels, and the condition is more nearly one of simple edema.

The chemosis is so great in some cases that the swollen conjunctiva overhangs the cornea and obstructs the vision; it may even protrude between the lids. There are no other symptoms added to those accompanying the condition which has produced the chemosis. The chemosis subsides on subsidence of the accompanying inflammation; if it is intense, scarification may be resorted to.

Emphysema of the Conjunctiva. Subconjunctival emphysema is characterized by a non inflammatory Tabulated swelling of the conjunctiva, which emits a peculiar fine crackling sound on pressure. It is due to the entrance of air beneath the conjunctiva from injuries to the lids, fracture of the margin of the orbit extending into the frontal sinus, ethmoid sinus, or nasal cavity. The air is absorbed and the condition disappears spontaneously.

Lymphangiectasis conjunctiva is a benign condition which affects the ocular conjunctiva, and is of much more frequent occurrence in its outer half than it) any other part. It consists of a small chain or cluster of vesicles which vary in size from very minute ones to those the size of a grain of wheat. They are transparent, and are freely movable over the subconjunctival tissue. The cause is not known. The disease is found most frequently in those who suffer from chronic conjunctivitis. The condition is one of dila¬tation.. of the lymph channels, the small pockets containing a clear fluid. The diagnosis is not difficult, as there is nothing else with which it may be confounded. The vesicles may be excised.

Syphilis of the Conjunctiva. Chancre, papular syphilides, coppercolored spots, mucous patches, gummata, nodular syphilides, and syphilitic ulcer may affect the conjunctiva.

Chancre appears most frequently on the palpebral conjunctiva near the margin of the lid, where it presents an indurated circular red elevation of perhaps 1 centimeter in diameter, usually with a shallow ulcer at the top, having a gray base. Occurring in the transition fold or in the ocular conjunctiva, the base of the mass is distinctly indurate(], and when grasped by the forceps is much like a piece of parchment lying in the mucous membrane.

Grouped papular syphilides are of rare occurrence; they accompany the same form of syphilide on the face and lids ; the same may be said of the copper colored spots, which are rarely seen.

Mucous patches are more common ; they resemble the mucous patches as they appear on other mucous surfaces, are slightly raised, with a gray, even surface, and have a border of injected mucous membrane around them.

Gummata of the conjunctiva are extremely rare. Morrow states that they appear as small discrete tumors of the conjunctiva the size of a pea or bean.

Gummy tumor of the episcleral tissue and of the lids, affecting the conj is met with. The growth is elevated and is soft. It may cause extensive destruction of tissue. It is differentiated from sarcoma by tile effect produced on it by antisyphilitic treatment.

Nodular syphilides, manifestations of the later stages of syphilis, sometimes occur in the lids and produce conjunctival ulcers. Sloughs of large extent may result. In all of the conjunctival manifestations of syphilis the preauricular and cervical glands are more or less enlarged. Pain is not a prominent feature.

If recognized early, the prognosis in all cases of syphilitic affections of the conjunctiva is favorable. The condition responds readily to treatment.

Treatment. If an ulcerated surface exists, it may be cleansed with a weak bichlorid solution (I : 3000 or I : 5000), and calomel dusted on afterward. Vigorous antisyphilitic constitutional treatment should be given as early as possible.

Tumors and Cysts of the Conjunctiva. Congenital. Dermoid Tumors. These usually develop near or at the selero corneal margin; they may be small, slightly elevated, and have a very few fine hairs pro ectino, from them. They may cover a large part of the ocular conjunctiva, be markedly elevated, pigmented, covered with coarse hair, and contain numerous sebaceous glands. A dermoid growth sometimes develops in the conjunctiva and presents between globe and lid at the upper outer quadrant of the globe. It has much the appearance of a thickened nictitating membrane, is flat, has a rounded border, is pale, and often bears a few very fine hairs: movements of the eye downward and inward bring it readily into view. Dermoid tumors may be cystic; they may also contain much lipoinatous tissuelipomatous dermoids.

Vascular Tumors. Telangiectatic tumors and cavernomata are observed. The former are often associated with similar growths on the lids. Both are benign, but tend to increase in size.

Benign Tumors. Tbose that are not congenital are fibroma, lipoma, myxoma osteoma, granuloma, papilloma, simple cystic tumors, and cysts due to cysticerci and echinococci.

Fibromata develop most frequently on the tarsal conjunctiva of the upper lid as a result of a chronic conjunctivitis; they are multiple, flat, and elevated one to two millimeters. Lipoma appears as a yellowish soft mass, usually in the retrotarsal folds. Myxoma appears in the form of polypoid masses developing from the margin of a wound or sinus, rarely from the conjunctival surface itself. Osteoma is a flat tumor developing in the ocular conjunctiva. Granuloma develops from wounds and from ulcerating surfaces. Papilloma is most frequently met with at the caruncle as a soft, various mass. It may appear on any part of the ocular or palpebral conjunctiva, and is often mistaken for granulation tissue. It is very prone to recur after removal, provided the removal is not complete. There is no tendency to the destruction of tissue. Cystic tumors are observed near the openings of the lachrymal ducts, in the retrotarsal fold, and at the caruncle. They are often due to chronic conjunctivitis. Cysticercus cysts are large, and usually present a white spot on the outer wall. Echinococcu s cysts maybe very large and extend far back into the orbit. Daughter cysts and booklets may be found as part of the contents.

Treatment. The most satisfactory treatment is excision. The vascular tumors should be removed as early as possible the cavernomata especially as they may reach such enormous proportions if neglected that subsequent removal is impossible.

Malignant Tumors. Epithelioma and sarcoma are the most, common. A, peculiar tumor, known as cylindrarna, has been described by Hensel; it is probably a form of sarcoma.

Epithetionia of the conjunctiva accompanies epithelioma of the lid, although it may develop spontaneously from any part of the ocular conjunctiva. It appears as a small reddish elevation which soon presents an irregular, grayish, ulcerated patch with slightly raised borders and a congested base.

Sarcoma may develop in the shape of pigmented or non pigmented polypoid masses springing from the retrotarsal fold and growing rapidly. It may also develop at the limbus conjunctiva. It appears in this location as a small red or pigmented spot; it may develop rapidly, but may also remain in a quiet state for a long period. Metastasis to the cervical glands or to remote parts of the body may occur.

Treatment. Thorough removal of all diseased tissue by knife or solitary is the only way to make a favorable issue possible.

Leprosy of the conjunctiva occurs in connection with leprosy of the general system in nearly all cases; however, it may begin primarily in the conjunctiva. Morrow' cites one case in which a leprous tubercle appeared on the eye and was mistaken for sarcoma. Cutaneous tubercles followed. Nodular masses may form in the conjunctiva which may persist for a long time, and may finally disappear, leaving non vascular cicatricial tissue. The bacillus lepre, to which the disease is due, is represented in Fig. 200. The writer has observed a mild persistent irritation of the Conjunctiva accom leprosy, producing slight redness of the palpebral conjunctiva and increased lachrymation. Treatment is of little avail.

Lupus erythematosus is mentioned by Bowen' as attacking the conjunctiva. It appears as irregular plaques which are covered with small punctate excoriations or with grayish masses of exudation and superficial cicatrices. The condition is accompanied by lupus erythematosus of the face. The etiology is obscure. The disease progresses extremely slowly, and is accompanied by slight irritation and increased lachrymation. When accompanied by the same disease on the face the diagnosis is easy. Treatment is of little avail.

Tuberculosis of the Conjunctiva. This affection presents two quite distinct clinical pictures, which will be considered separately:

First. When tuberculosis of the conjunctiva appears as an extension from adjacent mucous or cutaneous surfaces (1upus vulgaris) it presents slightly elevated, irregular patches having uneven, ulcerated surfaces, from which small granulations project; the patches may be small or large, and may appear on the palpebral (where they are most frequently, met with) or on the ocular conjunctiva.

Pathology. The tissue of the neoplasm shows loss of epithelium at the site of the ulcer, granulation tissue, granular detritus, new formed connective tissue elements, giant cells, and numerous leukocytes, which gradually diminish as the normal tissue is entered. A few tubercle bacilli are found in the tissue (see Fig. 201). The infection is most frequently by way of the lachrymal canals.

Symptoms. There is slight irritation of the eye, accompanied by a scanty mucom purulent secretion which may persist for many months. Enlargement of the preauricular gland on the affected side is present.

Diagnosis and Prognosis. The coexistence of lupus on the nasal mucous membrane or on the integument of face or lids, with a history of long duration, is usually sufficient. In a large percentage of the cases the mucous membrane at the inner canthus will be involved as a result of the continuation of the disease from the lachrymal passages. The condition may be confounded with epithelioma. If doubt exists, a piece of the tissue may be excised and examined microscopically, or the iris of a rabbit may be inoculated with the tissue. The prognosis is favorable in nearly all cases.

Treatment. Excision of the diseased parts or destruction by means of the cautery is indicated.

Second. When tuberculosis of the conjunctiva is the result of direct inoculation the early stage is marked by a distinct congestion of the conjunctiva and the appearance of numerous small, discrete, grayish nodules in the ocular or palpebral conjunctiva which do not present an ulcerated surface. The tubercle bacilli are commonly introduced through wounds in the conjunctiva, made either accidentally or during operation involving the conjunctiva. The nodular masses present all the characteristics of miliary tubercles.

Symptoms. Marked irritation of the eye, redness of the conjunctiva, increased lachrymation, and a muco purulent secretion are present. The disease advances quite rapidly, producing hypertrophy of the conjunctiva and superficial ulcers. The preauricular and cervical glands on the affected side enlarge and break down. Ulceration of the cornea may develop.

Diagnosis and Prognosis. Acute trachoma and syphilis are the only diseases with which this form of tuberculosis may be confounded. A section of a nodule, stained for tubercle bacilli and examined microscopical ly, will settle the question beyond doubt. The disease runs a very long and persistent course, and may involve other parts of the system. The eye may be completely destroyed.

Treatment. It is doubtful if anything short of early removal of the affected conjunctiva will have any effect. After the active Enlargement of the cervical glands has been established appropriate constitutional treatment, with attention to local symptoms as they arise, is all that can be done.

Pemphigus. This disease of the conjunctiva is characterized by the appearance of very transient bulle, followed by red, and later by grayish, areas on the conjunctiva of the lids and of the globe. As these areas heal the conjunctiva becomes atrophic, other patches appear, and further atrophy takes place; soon meridional bands between lids and globe are formed, and the condition known as Symblepbaron posterius is the result. The conjunctival surface becomes dry and shiny, the cornea opaque, and vision is lost. The condition is very rare : Horner observed it but 3 times in 70,000 eye cases.

Etiology. Pemphigus usually accompanies pemphigus Bulgaria or pemphigusfoliaceus, and depends on a dyserasia of the system. Individuals of all ages are attacked. A history of syphilis was obtained in only I of the 28 cases reported by Morris and Roberts.'

Pathology. The red raw surfaces evidently follow destruction of the upper layer of the epithelium due to a process which on the skin would produce blebs. The conjunctival epithelium, being thinner and much weaker, is cast off early. A deposit of fibrin soon forms over the affected area, and the grayish patch is the result. Sections of the atrophied conjunctiva show cicatricial connective tissue containing a few blood vessels. The epithelium is thin and irregular.

Symptoms. The, progress of the affection is extremely slow; there is little secretion. With the advance in the atrophy of the conjunctiva dimness of vision increases. Both eyes are attacked.

Prognosis. This is very unfavorable. The disease lasts for years, and usually results in loss of vision.

Treatment is of little avail. Arsenic may be given internally. Ointments and mucilaginous remedies may be employed to relieve the dryness of the conjunctiva. Surgical interference is seldom satisfactory.

Argyria Conjunctivae (Arqyrosis). Long continued use of nitrate of silver on the conjunctiva, particularly of a solution dropped into the eye, produces a discoloration which affects the ocular and palpebral conjunctiva, most marked in its lower half. The color varies from a light ochre hue to a deep brown. In some cases slight hypertrophy of the conjunctiva, with slight irritation, results. In one case observed by the writer the hypertrophied, noninflamed conjunctiva formed a fold which projected into the palpebral fissure. At the request of the patient this fold was excised and the condition corrected. The stain formed is indelible. A solution of hyposulphit of sodium or of iodid of potassium in the strength of I : 10 of water has been suggested for the removal of these. stains.

Affections of the Caruncle and Semilunar Membrane. Inflammation of the caruncle is sometimes observed as a result of infection of one or more of its sebaceous glands. When this occurs the caruncle swells, becomes enlarged, and is much congested. The abscess opens spontaneously or may be opened with the knife; recovery will follow.

The hairs of the caruncle may become unusually large and numerous (trichosis caruncule) and produce more or less irritation. Epilation, or excision of the hair bulb will give relief.

Papilloma of the caruncle and semilunar fold occurs as a pink, soft, Villous mass, with numerous papilla , which are bathed in muco pus. The mass bleeds easily and tends to increase in size. It is attended by a slight sensation as of a foreign body at the inner canthus, but gives little or no pain.

Papilloma is prone to recur, and will do so unless thoroughly and completely removed. The knife or cautery should be employed.

Congenital telangiectasia of the caruncle has been observed.

The term encanthis is applied to an enlargement of the caruncle and semi fold from any cause. Enlargement of the caruncle accompanies all forms of conjunctivitis, and subsides with the subsidence of the conjunctivitis. Cystoid enlargement is at times seen. Adenoma may develop. Chalky deposits may form in the glands of the caruncle, which may cause it to become enlarged. Carcinoma and sarcoma (encanthis maligna) may develop primarily at the caruncle.

Treatment. In the case of tumors at the caruncle and semilunar fold early operative procedure should be resorted to.

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