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Thoaa too large to be entirely included in one expoaura are filmed beginning in the upper left hand corner, left to right and top to bottom, aa many framea aa required. The following diagrama illuatrate the method: Lea cartea, planchea, tableaux, etc., peuvent Atre fiimAa A dea taux de rMuction diffArenta. Loraqua ie document eat trop grand pour Atre reproduit en un seul clichA, 11 est fllmA A partir da I'angle aupAriaur gauche, de gauche A droite, et de haut Bn baa, an prenant la nombre d'imagea nAcaasaira. Lea diagrammea suivanta illuatrent la mAthoda. 1 2 3 1 2 3 4 5 6 \^u lalaoatcv /,; f^'' HERPES OF THE FACE AND CORNEA By CASEY A. WOOD, C^l., M.U., PntholdKiMt til the IlliiioiH Eye and Ear Infirmary, Prufeiknor of Qrnduate Medical Hcliooi. )|ihtbnh>i'llowed with nuich better success. I attended last summer one Oj these cases in the service of Dr. W. F. Smith, at the Alexian Brothers' Hospital here, a short account of which I shall give: J. S., a Swiss, twenty-three years of age, had four days before I first saw him a chill followed by fever, fast pulse and difficulty of swallowing. Two days afterwards he noticed upon the skin near the right outer canthus a collection of vesicles surrounded by a reddened area. This was followed very shortly by similar eruptions on the lower lid, cheek and nose. The pain about the eye was intense and followed especially the distribution of the infra-orbital nerve as well as along the forehead and temple. When first seen his temperature was 102°, pulse 100; he had a flushed face, sore throat, and great pain on swallowing. An examination showed that he had an acute follicular tonsillitis on both sides. The herpetic vesicles were well developed and appeared in clusters of from four to seven. He described the pain as burning in character, and that it ran along his nose and cheek. There was no anaesthesia of the skin covering the face and forehead. The lower eyelid was swollen and red. A profuse discharge issued from the eye and so copious was it that suspicion of gonorrhoeal ophthalmia was aroused in the mind of the physician who first saw him. This diagnosis was rendered probable by the fact that the patient, was at the time suffering from gonorrhoea. On making a careful examination of the eye there were plainly to be seen in the inner- upi)er (luadrant of tlu* corntMi ii row of l)roken vphicIoh lookinj^ just as if thoro had Imhmi a HUcceHsion of n^coiit oonuml abraHioitH. There was considerable pericorneal injection, photophobia and lachrymation. The cornea itself was not markedly aniesthetic. The iris was unaffected and the pupil, although souiewlmt contracted, acted readily to light. The conjunctiva of the lower lid especially was much injected, swollen and dotted over with streaks of pus. In a few days the affected cornea showed several small irregularities of surface corresponding to the seat of the vesicles, the epithelium came away and a number of superficial ulcerations resulted. In two weeks' time faintly marked opacities still occupied the site of the original erup- tion. Appropriate treatment was given for the sore throat, the pain in the face was relieved by anodynes, while the corneal disease was treated by the instillation of weak eserine drops — ns DeWecker advocates — combined with the frequent use of boracic acid in a mild solution of mercuric chloride. When last seen the patient was entirely well with the exception of reddened patches of skin and small peripheral nebulae comese that showed where the herpetic eruption had been. There was no cuticular tender- ness or anaesthesia, or periosteal soreness about the face. Vision was normal. Miss Josephine Kendall,' an American lady, collected and published a list of 115 cases of febrile herpes cornete attending Prof. Horner's klinik in Zurich. Of these, 7 occurred with simple fever; IfS with pneumonia; 2 with intestinal catarrh; 2 with rheumatism; 2 were puerperal cases, and 36 accompanied coryza, acute sore throat, or cough. In the remainder the cause was a mixed one or was imknown. Only 1 5 cases occurred in females; 4 were under five years of age, and 74 were over fifty. Although, clinically, the above mentioned division of corneal herpes is very useful, I do not think that from a pathological standpoint it can be maintained. The herpetic vesicles in the severe as well as in the mild form of this disease — like herpes zoster in other parts of the body — follow the distribution of the superficial sensory nerves and the essential lesion is a true neuritis. In all forms of herpes frontalis it is the ophthalmic division of the fifth nerve (giving off its main branches the ' Uber Herpes CornaB. In Aug. Dissertation, Zurich, 1880. mmm •taouS liichrymnl nnd frontal) tlmt wp hnvp to doiil with. Whon tho nonritic procoHH jifTcctK th(» main trunkK of tin* riprv<* or rnachoH Htill further back wo hav« true zona ophthalmica ; when only th« terminal lilamentH are inflamed a lesH Beriou8 Uwiun iH produced. That vesicular eruptionH ojcur along the cotirse of the Mnisory and mixed nerves after injury of tli'> lattnr has loiijj be»*r. recognized, but it was not until quite I'l . ntly thai the existence of morbid alterations in the nervous tissues were HhtabliKhed ixjst- raortem. The work done in this department is described in Zeigler's Pathology." Turning to ophthalmic herpes Wiedner found at the autopsy of a man dead five years after a severe attack of facial herpes, that there were changes in both the connective tissue and ganglionic cells of the Gasserion ganglion. Thence the first division of the fifth to its distribution upon the face furnished decided evidence of structural alterations. Section of the lachrymal gland showed it to be enlarged, infiltrated and the seat of a small central abscess. There were collections of pus underneath tl-.e conjunctiva; the choroid and iris were infiltrated by leucocytes, and ulcerations were present on the anterior surface of the cornea. The best described instance is, however, the well-known and much quoted case examined by Wyss." There had been during life a recent history of herpes following the terminal distribution of the ophthalmic division of the fifth nerve. The trunk of the nerve was found to be healthy until it reached the Gasserion ganglion. The ganglion itself was larger than normal, having been swollen from hemmorhage within its substance. This extravasation being on the inner side involved chiefly the first division of the nerve, whose sheath was bathed in pus. When minutely examined the second and third divisions were found to be healthy, while alterations in structure were detected in the ophthalmic branch. Small extravasations of blood and collections of lymph cells surrounded the long ciliary nerves. Wyss thinks that these changes appeared to be the result of a true acute neuritis. Several other post-mortem examinations serve to complete the evidence upon this point, and I think we are justified in assuming that the duration, the severity and the " Am. Edition, p. 523. ' B Archiv. der Heilkunde, S. 263, 1871. n offoctH of troiitiiHMit ar« largely (lotoriuiiuHl l)y t.h(' «>xt