EXTERNAL DISEASES OF THE EYE
 
 ATLAS 
 
 OF 
 
 External Diseases of the Eye 
 
 Physicians and Students 
 
 BY 
 
 Dr. Richard Greeff 
 
 PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF 
 BERLIN AND CHIEF OF THE ROYAL OPHTHAL- 
 MIC CLINIC IN THE CHARITE HOSPITAL 
 
 ONLY AUTHORIZED ENGLISH TRANSLATION 
 
 BY 
 
 P. W. Shedd. M.D. 
 
 NEW YORK 
 
 WITH 84 ILLUSTRATIONS IN COLOR FROM WAX MODELS PRINTED ON 64. 
 
 PLATCS WITH EXPLANATORY TEXT. THE ILLUSTRATIONS 
 
 ARE FROM MODELS IN THE PATHOPLASTIC 
 
 INSTITUTE IN BERLIN 
 
 ART Director: f. kolbow 
 
 NEW YORK 
 
 rebman company 
 
 1 123 BROADWAY
 
 vv w q 
 
 CopywGHT, 1909 
 By Rebman Company, New York 
 
 All rights reserved 
 
 MAIL AND tXPRESe JOB PRINT, B-IB MUHRAV 6T . NBW VOPK
 
 DEDICATED 
 
 TO 
 
 MY DEAR COLLEAGUE 
 DR. THEODOR AXENFELD 
 
 Professor of Ophthalmology and Chief 
 
 of the Ophthalmic Clinic in the 
 
 University of Freiburg 
 
 In Remembrance of true and unbroken 
 
 friendship since the days of 
 
 student life
 
 Preface. 
 
 Foe years, in conjunction with the sculptor, F. Koi- 
 bow, I have endeavored to perpetuate in wax models 
 the appearance of important external diseases of the 
 eye. Because of the delicacy and sensitivity of oph- 
 thalmic tissues, the difficulties to overcome were, nat- 
 urally, very great, and only after much experiment 
 were we able to discover the correct method. 
 
 The request of the publishers, Urban & Schwarz- 
 enberg, to prepare an Atlas of the most important 
 external diseases of the eye was acceded to only when 
 I was convinced that modern art could produce pic- 
 tures of distinctly better technic than those hitherto 
 published. 
 
 The plates were obtained by making, after a special 
 method, a mask of the living subject, which was then 
 filled with wax. From the wax models photographic 
 reproduction in four colors was made. 
 
 We thus gain two advantages, viz., we have before 
 us, not a schematic representation, but the actual case 
 as it appeared in the University Ophthalmic Clinic of 
 the Berlin Charite Hospital of which I am chief, and, 
 so to speak, no man's hand has touched it. Further- 
 more, by means of the models, we get a pictorial plas- 
 ticity unattainable by the most accomplished draughts- 
 man. 
 
 Although the work appears under my name, I am 
 fully conscious that only a portion thereof is actually 
 mine. 
 
 To the skill, powers of observation and zealous par-
 
 ticipation of Sculptor Kolbow (Berlin), success in 
 obtaining the beautiful plates is largely due. He is, 
 probably, surpassed by no one to-day in the fabrica- 
 tion of wax models. 
 
 A number of the false eyes inserted into the models 
 simulate the pathologic aspect of the organ, and were 
 prepared in accordance with my specifications by the 
 optical firm of Miiller Bros. (Wiesbaden) and by Hans 
 Huning (Berlin). 
 
 The drawings were made by the expert scientific 
 draughtsman, H. Helbig. 
 
 The execution of the plates in color was undertaken 
 by the firm of Dr. Selle & Co. The difficulties here 
 were so great that at first many of the plates were 
 necessarily rejected. Finally, I may mention with 
 commendation the willingness of the firm to make all 
 alterations and corrections, and that, too, with no 
 diminution of its productive ability. 
 
 The printing of the plates was most carefully and 
 satisfactorily accomplished by the firm of Doring & 
 Huning (Berlin). 
 
 Figs. 4 and 5 were taken from Bockenheimer's Atlas 
 of Surgical Diseases, and Fig. 8 from the Atlas of 
 Skin Diseases by Jacobi, both of which works are pub- 
 lished by the same house. 
 
 Last, but not least, an expression of my gratitude 
 and content is due the publishers. Urban & Schwarz- 
 enberg, who, notwithstanding the enormous expense 
 of the undertaking, have invariably sought to conjoin 
 in the work the best offered by modern science and 
 technic, neglecting no method or experiment necessary 
 to such accomplishment. 
 
 We hope for a substantiation of our aim in prepar- 
 ing this volume. 
 
 Pbof. R. Gbeeff. 
 
 Berlin, February, 1909. 
 
 VIU.
 
 rcclf. Alias. 
 
 Fig. 1. 
 Erysipelas Faciei — Oedema palpebrarum 
 
 ?L-biii.Tii Company, New York
 
 Erysipelas Faciei, Oedema 
 Palpebrarum. 
 
 Plate I., Fig. 1. 
 
 Facial erysipelas, also called St. Anthony's fire 
 (German: Gesichtsrose, Rotlauf), follows, commonly, 
 some slight injury of the skin (vesicle, bleb, eczema, 
 excoriations, rhagades), which serves as a point of 
 entry for the streptococcus erysipelatis. With high 
 fever, sometimes with chills, there develops a sharply- 
 contoured, glistening red swelling of the skin, which 
 extends rapidly, and at last, usually involves the entire 
 face. Within a short time the epiderm is raised up in 
 few or many blebs. 
 
 The eyelids present a markedly reddened skin ; upon 
 their margins the blebs are particularly apt to develop 
 (Fig. 1, right eye) ; and there is great timief action, so 
 that, as a rule, the eyes cannot be opened. The ex- 
 treme inflammatory palpebral edema is due to the loose 
 connection here betwixt the skin and the underlying 
 tissues, to the absence of subcutaneous fat, and to the 
 fact that there is present abundant space for the ex- 
 tension of a tumef active process (C/. infra: Edema). 
 
 Commonly, the temperature gradually falls after a 
 few days ; the blebs or vesicles break, and, with retro- 
 gression of the redness and swelling, there begin ex- 
 foliation and pigmentation of the affected areas. 
 
 The diag'nosis is easily made. The simultaneous 
 appearance of fever with rubescent and glistening skin 
 renders error difficult. 
 
 1
 
 The progri^osis is, in general, good, but should 
 be carefully guarded in expression. When there is 
 high fever and exhaustion, indicative of a general in- 
 fection, death may follow. In very serious cases pal- 
 pebral gangrene may develop as an unpleasant com- 
 plication (vide, p. 11). 
 
 It is to be remembered that in convalescent cases 
 sudden relapses are not infrequent. The disease con- 
 fers no immunity; on the contrary, one attack predis- 
 poses to another. 
 
 Therapy is local in character and consists in 
 the application of unguents which render the tense 
 skin more supple and also have an excellent subjective 
 effect. Neutral unguents (boracic acid, resorcin, etc.) 
 are best. Others prefer cold applications (wet cloths). 
 Where there is menacing tension of the lids and ex- 
 treme pain, scarification of the skin may be considered 
 as a last resort (vide Gangrene, p. 11). 
 
 General treatment, i. e., rest in bed, fever-diet, etc., 
 needs no discussion. 
 
 Erysipelas is extremely infectious, and requires, 
 therefore, the most perfect isolation possible. 
 
 Edema of tlie eyelids is not, commonly, a 
 nosologic entity. 
 
 As we have already remarked, the derm of the lid is 
 not intimately bound to the subjacent tissues, so that 
 fluid exudates find abundant space beneath the palpe- 
 bral skin and, therefore, are often apt to extend to a 
 considerable distance. This is best seen in palpebral 
 hemorrhage {vide Fig. 2). 
 
 Inflammatory edemas may often arise from slight 
 irritations (e. g., bee-stings, fly-bites) and spread un- 
 til the lids appear like bags distended with water, the 
 eye being completely occluded. Palpebral edemas, 
 
 2
 
 then, are mostly secondary phenomena, and are also 
 noted in cases of abscess, chalazion, hordeolum, dacro- 
 cystitis, orbital phlegmon, panophthalmia, etc. 
 
 Furthermore, it is well-known that anasarca, with 
 simultaneous swelling of the ankle, is also apt to de- 
 velop palpebral edema (renal disease). 
 
 A doughy edema of the lids is found in trichinosis, 
 the trichina? having a predilection for the orbital 
 muscle.
 
 Haemorrhagia Subdermalis et 
 Subconjunctivalis 
 
 Plate U., Fig. 2. 
 
 Palpebral sugillation or suffusion, i. e., haemorrhagia 
 subdermalis, is a very striking phenomenon. Because 
 of the spongy tissue beneath the skin, the blood ex- 
 tends easily and far. The red tint soon changes to a 
 reddish-blue and then becomes blue-black (the well- 
 known black eye resulting from a blow). The hem- 
 orrhage is, commonly, sharply limited at the orbital 
 margin, for here the skin is firmly attached to the 
 bone by tense connective tissue. The skin about the 
 root of the nose is, on the contrary, loosely bound to 
 the subjacent tissue. Hence, the hemorrhage beneath 
 the sMn of one eye may extend under the skin of the 
 nasal bridge and appear, with correspondent colora- 
 tion, beneath the sMn of the uninjured optic. It fre- 
 quently happens that, after operation on one eye, hem- 
 orrhagic discoloration develops in both. In such cases 
 one should not be misled to the conclusion that both 
 eyes had suffered injury. 
 
 Sugillation of the lids is particularly a sequela of 
 trauma, notably that due to blows with blunt objects 
 (fist, club, etc.); also of major operations, such as 
 enucleation, where the wound is deep, whilst in cuts of 
 palpebral tissue it is rarely observed, for the blood 
 has abundant exit. 
 
 Spontaneous bleeding may also occur, for the vas- 
 cular channels, from lack of supporting tissue, are 
 
 4
 
 Fig. 2. 
 Haemorrhagia subdermalis et subconjunctivalis. 
 
 ?ebman Company, New York.
 
 easily ruptured, as during violent exertion, by crush- 
 ing, sneezing, coughing, etc. 
 
 Palpebral sugillation is of special significance in 
 diagnosing fracture of the base of the skull. In this 
 grave injury the blood often travels from the seat of 
 fracture forwards along the floor of the orbit, appear- 
 ing, usually after some lapse of time, beneath the con- 
 junctiva {vide infra) and the skin of the lower lid, 
 particularly in the region of the inner canthus. 
 
 The discolored skin permits instant diagnosis, and 
 only the cause of the hemorrhage demands further 
 investigation. 
 
 The prognosis is commonly favorable. The dis- 
 coloration gradually takes on a greenish hue, and in 
 most cases the blood is resorbed after a few weeks. 
 Rarely, the effusion passes into suppuration, thus 
 forming a palpebral abscess. 
 
 Therapy. Cool applications. 
 
 Subconjunctival hemorrhage develops even more 
 easily, for here, likewise, there is very loose attach- 
 ment to underlying tissues, and we have: haemor- 
 rhagia suhconjunctivalis, hyphaema conjunctivae or, 
 briefly, hyposphagma. 
 
 In youth it almost invariably accompanies pertussis 
 and may also be caused by immoderate coughing, 
 pressure or strangling in children. In older individ- 
 uals it is indicative of vascular fragility, of arterio- 
 sclerosis, and often accompanies contracted kidney. 
 
 Conjunctival hemorrhages have, therefore, weighty 
 symptomatic significance. 
 
 The diagnosis is not difficult : the uniform, super- 
 ficial reddening, if once seen, will not be confused with 
 an inflammation of the conjunctiva, where the indi- 
 vidual dilated blood-vessels are easily distinguished. 
 
 5
 
 Local therapy is of little value. The striking 
 phenomenon of a subconjunctival hemorrhage usually 
 terrifies the patient or those about him, but they may 
 Be easily calmed, for the eye is never damaged. How- 
 ever, lead-water or cold compresses should be applied. 
 The constitutional cause of the hemorrhage is to be 
 sought and treated. The phenomenon is frequently a 
 prodrome of cerebral apoplexy.
 
 cff, Atlas. 
 
 Tab. Ill 
 
 Fig. 3. 
 
 Morbilli. Blepharo-Conjunctivitis exanthematica. 
 
 LibiiKiii Company. New York.
 
 Morbilli— Conjunctivitis 
 Exanthematica. 
 
 Plate III., Fig. 3. 
 
 With the efflorescence of the exanthem in the various 
 acute general infections, but notably so in measles, 
 characteristic catarrhal phenomena commonly appear 
 in the form of more or less violent conjunctivitis and 
 blepharitis with redness, photophobia, and secretion, 
 as well as catarrhal conditions in the nose and upper 
 air-passages. These catarrhal conditions may even 
 precede the exanthematous efflorescence by some days, 
 the secretion consisting either of increased lacrimal 
 fluid or, not rarely, of a mucous or purulent exudate 
 drying into scales and crusts along the margin of the 
 lid {vide Fig. 3). Croupous membranes seldom de- 
 velop. 
 
 Prog'nosis. In measles the acute conjunctival 
 catarrh always present is not to be slighted Though 
 spontaneously disappearing, in most cases, after 2-3 
 weeks, it may, if neglected, lead to a redness and sen- 
 sitivity of the blepharo-conjunctival tissues, annoying 
 the patient for years or during his entire life. Serious 
 comi^lications such as a blennorrhoic or diphtheritic 
 conjunctivitis or corneal infiltration or a secondary 
 iritis are not impossible. 
 
 Tlierapy. As with measles in general, cleanli- 
 ness plays a chief role in the ophthalmic treatment. 
 The lids are to be bathed carefully with lukewarm 
 
 7
 
 boracic water and the dried exudate softened and re- 
 moved. In most eases, this will suffice. Where lacri- 
 mation is more abundant, one drop of a slightly as- 
 tringent collyrium (acid, tannicum i%, resorcin i%, 
 zinc sulfate Vifo) may be used daily. With purulent 
 secretion or the formation of membrane, irrigation 
 with a Vio or V*^" solution of silver nitrate is indicated. 
 Where such conditions develop, the globe should be 
 closely watched for pericorneal injection (atropin) or 
 corneal infiltration. 
 
 The room is to be kept moderately darkened and 
 the child not exposed to ordinary light until all oph- 
 thalmic irritation has subsided.
 
 irccff, Atl;is. 
 
 Tab. IV. 
 
 Fig. 4. 
 I'ustula maligna — Anthrax. 
 
 nan Coinpaiiy, New York.
 
 Pustula Maligna— Anthrax. 
 
 Plate IV., Fig. 4. 
 
 The anthrax pustule or pustula maligna not infre- 
 quently appears upon the eyelid. Man is inoculated 
 with the bacillus anthracis from diseased animals by 
 wiping, rubbing or scratching the eyes with the hand, 
 and malignant pustule is therefore found in individ- 
 uals handling animal products — cattle dealers, 
 butchers, tanners, dealers in leather or furs. The 
 affection often begins with a vesicle on the margin of 
 the lid filled with yellow turbid or bloody matter. 
 There is also a violent inflammatory edema of the lid 
 and tense infiltration of the skin. Soon swelling of the 
 preauricular and submaxillary glands and fever de- 
 velop, followed by rupture of the pustule which be- 
 comes covered by a scab. The surroimding skin then 
 turns a grayish color, indicative of commencing ne- 
 crosis. 
 
 Diag'nosis. Similar vesicular formation may 
 also be found in phlegmonous inflammations, carbun- 
 cle, and in glanders. Bacteriologic discovery of the 
 specific bacilli (non-mobile rods with square-cut ends, 
 often in long chains) renders the diagnosis certain. 
 
 The prog'nosis is extremely bad, for the lids 
 usually become necrosed, and the case terminates in 
 death. 
 
 Formerly, the tlierapy was surgical: incision, 
 currettage, or a Paquelin cauterization. We have 
 learned, however, that the less the site of infection is 
 
 9
 
 disturbed, the less danger there is of bacterial en- 
 trance into the blood stream. Bearing this in mind, 
 the best treatment is the application of unguents or 
 aseptic compresses. The scabs and necrotic tissues 
 are left for gradual and spontaneous desquamation. 
 If the infection do not terminate fatally, plastic sur- 
 gery is indicated. 
 
 Fig. 4 shows a malignant pustule of the lid, whose 
 reproduction in this atlas was kindly permitted by 
 Prof. Dr. Bockenheimer. The case is one of external 
 anthrax infection in a laborer employed in a tannery, 
 and developed from a slight scratch in the skin of the 
 cheek. At first, a red nodule appeared, then several 
 vesicles filled with a yellow Quid of bacillary content. 
 There was widespread carbunculoid infiltration, 
 marked edema of the lids and an erysipelatoid redden- 
 ing of the entire cheek. Soon after rupture of the 
 vesicle a scab formed at the site of infection, with an 
 areola of grayish skin gradually passing into necro- 
 sis. The process, with marked systemic involvement, 
 fever, chills, delirium, then extended to the eyelids, 
 which, because of the enormous tumefaction, could no 
 longer be opened even by force. Pustule after pustule 
 developed, with correspondent gangrene of the skin 
 after their rupture. The entire half of the face was 
 protected by an unguental application. 
 
 10
 
 ff, Atlas. 
 
 lab. V. 
 
 Fig. 5. 
 Gangraena palpebrarum— Anthrax. 
 
 1 Company. New York .
 
 Gangraena Palpebrarum. 
 Anthrax. 
 
 Plate V., Fia. 5. 
 
 The delicate texture of the palpebral skin, its thin 
 corium, the loose subcutaneous tissues with their large 
 lymph spaces and the richness of the vascular supply, 
 permit easy extension of a malignant inflammation 
 and trophic disturbance of tissue. We are speaking 
 of gangrene when the breaking-down of tissue ele- 
 ments occurs with decomposition and putrefaction. 
 In such case, we find in the palpebral region a circum- 
 scribed, fetid necrosis surrounded by a zone of in- 
 flammatory reaction. 
 
 According to Romer, to whom we are indebted for a 
 study of the subject, gangrene may develop endo- 
 geously, i. e., by metastasis, or ectogenously, i. e., 
 from some local disturbance. 
 
 I. The Endogenous Form. Metastatic gangrene of 
 the lids develops, but not often, in severe general dis- 
 eases, particularly typhoid, measles, scarlatina. Even 
 in 1794, Himly reported that in grave typhoid the eye- 
 lids became blue and sphacelated within a few hours. 
 Fieuzal gives three cases of palpebral gangrene dur- 
 ing measles, and similar cases are recorded by Knies 
 and Eandall. 
 
 Partial gangrene of the eyelid in scarlatina is de- 
 scribed by St. Martin and Jackson, whilst numerous 
 palpebral abscesses have been observed in influenza. 
 
 In pyemia and sepsis, gangrene of the lid is caused 
 
 11
 
 by infectious emboli, and it has also been attributed to 
 diabetes and alcoholism. 
 
 II. The Ectogenous Form. Here the necrosis may 
 proceed from foci of inflammation in the neighborhood 
 of the eye, or develop primarily in the palpebral tissue. 
 
 Secondary necroses of the lid are observed most 
 frequently as complications of facial erysipelas. The 
 minutest infected wound often plays a role here, and 
 more extensive injuries are not rarely etiologic. 
 Schmidt-Eimpler reports a case where, after a blow 
 from a twig upon the malar bone, timiefaction of the 
 eyelid developed, and five days later the palpebral tis- 
 sue was transformed into an ulcer full of necrotic 
 shreds. 
 
 Among the primary affections of the lid where gan- 
 grene is possible, anthrax is pre-eminent. In Gross- 
 mann's case, we are, doubtless, dealing with pustula 
 maligna. In a broom-maker a pustule as large as a 
 pea developed, with high fever, on the skin of the 
 upi^er eyelid, whence a brawny edema spread, reach- 
 ing even to the thorax. By the third day the skin of 
 the entire lid had become transformed into a black 
 crust. Cure followed, but with extreme ectropion. 
 
 For therapy consult page 9. 
 
 In Fig. 5, we have the case of Prof. Bockenheimer 
 some weeks after the infection. The extensive dermal 
 gangrene, cognizable by the black discoloration and 
 leathern consistency, is already delimited by a zone 
 of pus and iinctuous granulation tissue from the ad- 
 jacent non-gangrenous skin which, however, is slightly 
 reddened and gives evidence of inflammatory infiltra- 
 tion. But the necrosis is still firmly attached to the 
 subjacent tissue. Its forcible removal by the knife or 
 a clumsy extirpation would result only in renascence 
 of the infection. Gradual desquamation was, there- 
 
 12
 
 fore, attained by compresses wet with hydrogen per- 
 oxid and boric acid solution and by applications of 
 ointments. In this ease, after the loosening of ne- 
 crotic tissues and subsidence of inflammatory pro- 
 cesses in the circumjacent skin, the somewhat marked 
 defect caused by the loss of the entire upper lid was 
 plastically corrected by a pediculated flap of skin from 
 the surrounding healthy tissue. Despite the unfavor- 
 able prognosis in facial anthrax and the severity of 
 the local process, the case was cured. 
 
 13
 
 Herpes Facialis. 
 
 Plate VI., Fig. 6; Plate VII., Figs. 7-8. 
 
 Herpes zo.ster is an exanthematous disease of tlie 
 skin, simulating an infection. In the territory sup- 
 plied by some particulate nerve a vesicular eruption 
 occurs with febrile phenomena and general weakness. 
 The number of vesicles is extremely variable in differ- 
 ent cases. Sirring and autumn are the seasons of elec- 
 tion. 
 
 The vesicle contains at first a clear watery fluid 
 which soon becomes turbid and purulent. It then rup- 
 tures and the resulting ulcus crusts over. 
 
 After the ulcers heal, permanent scars remain, and 
 as a rule, the individual is thenceforth immune. 
 
 Of the cranial nerves the trigeminus in all its 
 branches is most often affected and we have a herpes 
 zoster ophthalmicus, usually along the course of the 
 first branch of the nerve. In such case the vesicles 
 are found on the upper lid, the forehead to the hairy 
 margin of the scalp, and on the nose, although, be- 
 cause of the almost invariable onesidedness of the 
 affection, they are plainly delimited by the median line 
 of the face (vide Plate VII., Fig. 7). In Fig. 8, Plate 
 VIII., there are uncompionly numerous, ruptured 
 vesicles covered with crusts which penetrate deeply 
 into the corium. This latter case is borrowed from 
 Jacobi's Atlas of Skin Diseases. 
 
 If the 2nd branch of the trigeminus is affected, the 
 vesicles are located upon the lower lid in the superior 
 maxillary or malar region (Fig. 6, Plate VI). 
 
 14
 
 ff. Alias 
 
 Tal). VI. 
 
 Fig. 6. 
 Herpes facialis 
 
 nan Company, New York.
 
 Qrceff. Athis, 
 
 TO 
 6/3 
 
 O 
 N 
 
 a 
 X 
 
 TO 
 
 en 
 
 O 
 
 N 
 
 Rebman Conipanv, New York
 
 Not infrequently the skin disease is accompanied by 
 an eruption of vesicles on the cornea, a grave compli- 
 cation. 
 
 Herpes zoster ophthalmicus is due to an inflamma- 
 tory involvement of the trigeminus, either of the 
 Gasserian ganglion, of the ciliary ganglion or of the 
 nerve in its peripheral course. 
 
 Diag'nosis of herpes zoster ophthalmicus is easy 
 because of the distribution of the vesicles within a cer- 
 tain neural territory, the one-sidedness, and the syn- 
 chronous febrile development. It is differentiated 
 from simple herpes febrilis (labialis) by the size of 
 the vesicles. In simple herpes the epiderm only is 
 vesiculated whilst in herpes zoster the ulcer sinks 
 deep into the substance of the corium and a cicatrix 
 remains after recovery. 
 
 Prog-nosis is positively favorable. The scars left 
 may later cause some annoyance. 
 
 Therapy. Internally, salicyl preparations are 
 called for; for neuralgic pains, quinine, antipyrin or 
 phenacetin. The affected areas are best powdered 
 with rice-starch, lycopodium, etc., which dry up the 
 vesicles. When crusted over, the ulcerated surface 
 heals. 
 
 15
 
 Variola Vaccina. 
 
 Plate VIII., Figs. 9-10. 
 
 Vaccinal ophthalmia develops from infection of the 
 eye with the lymph, generally by direct transmission 
 by the finger from the vaccination into the optic; but 
 also from dried lymph on bandages or the handker- 
 chief. 
 
 On the eyelids the eruption is usually found along 
 the intermarginal portions. From small, superficial 
 vesicles there develop, with marked inflammatory 
 symptoms, chemosis, palpebral edema, and large, flat 
 ulcers of a diphtheritic appearance. After 8 to 12 
 days healing begins with complete restitutio ad inte- 
 grum in 2 to 3 weeks. 
 
 The extreme brevity of the incubation stadium may 
 in many cases be reduced to 3 to 4 days. 
 
 The variola may also be localized upon the con- 
 junctiva or the cornea. 
 
 The diagnosis of vaccinal infection of the eye 
 can offer little real difficulty, if we consider the mor- 
 bidity (Schirmer). Differentiation from variola vera, 
 where the pustules cover the entire surface of the 
 body and grave constitutional symptoms are present, 
 is easy. 
 
 The ulcus durum (chancre) does not, as a rule, 
 cause such marked inflammatory phenomena in the re- 
 gion affected. 
 
 Confusion with diphtheritic conditions is possible, 
 but in the rarer diphtheritic ulceration on the margin 
 
 16
 
 reeff. Atlas. 
 
 Tab. Vlll. 
 
 Fig. 9. Variola vaccina 
 
 Fig. 10. Variola vaccina 
 
 ;ebnian Company, New York
 
 of the lid, the whitish membrane covering the conjunc- 
 tiva is seldom lacking; furthermore, in the vaccinal 
 ulceration removal of the membrane leaves a clear 
 red base whilst in diphtheria the base of the ulceration 
 is dirty. 
 
 Tlierapy. Treatment should be as unobtrusive 
 as possible : the eye should be kept clean and the ulcer 
 covered with some unguent. Cauterizing applications 
 are dangerous. 
 
 Keratitis profunda or an ulcus cornefe will develop 
 severe complications, and treatment should be that 
 adapted to these affections. 
 
 Prophylactically, the family should be warned that 
 the vaccinal virus may be transmitted to the eye by 
 rubbing, etc. 
 
 17
 
 Ulcus Durum. 
 
 Plate IX., Pig. 11. 
 
 The margin of the eyelid is not rarely the seat of 
 primary infection, usually due to kissing or to trans- 
 mission by the finger. The indurations seldom de- 
 velop on the outer sMn but are almost invariably 
 intermarginal or in the canthi or upon the conjunctiva 
 tarsi. The reason therefor is plain. The cutis of the 
 lid is not especially permeable, but the delicate tex- 
 tures of the canthi where denn changes to mucosa, 
 where the glands of the ciliary follicles and the Mei- 
 bomian glands exude their contents offer facile inoc- 
 ulation of the virus. The pre-auricular and other 
 glands are often so swollen that a diagnosis of mumps 
 might be possible. 
 
 The affection begins with a swelling at whose apex 
 a slight excoriation increasing in depth develops, so 
 that finally an ulcer (rarely deep) with well-defined, 
 indurated margins is present. 
 
 Diagnosis of the extragenital sclerosis in the 
 early stadia is extremely difficult, yet error would be 
 fateful where the lesion is facial, particularly if on 
 the eye or the organs protecting it, because of later 
 possible diminution in function. In differentiation 
 from similar morbid sjTidromes : hordeolum, cha- 
 lazion, vaccine pustule, lupus, tuberculosis, diphtheria, 
 chancroid and giunma, the most dependable pathog- 
 nomic indication is the frequently marked, but indo 
 lent, swelling of neighboring glands, in particulate, the 
 
 18
 
 ceff, Atlas 
 
 Tab. IX 
 
 Fig. 11. 
 Ulcus durum palpebrae. Syphilite. Primary affection. 
 
 ?ebrnan Company, New York.
 
 pre-auricular glands. Not rarely, however, only the 
 appearance of secondary phenomena and the result of 
 mercurial treatment permit a decision. 
 
 Kowalewski was the first to render a diagnosis by 
 demonstrating the spirochaeta pallida in a palpebral 
 ulcer. 
 
 Therapy consists in local cleanliness by irriga- 
 tion with weak antiseptic solutions followed by the 
 application of some indifferent salve. Dusting with 
 iodoform may greatly augment the inflammation with- 
 out other benefit. The diagnosis once certain, there 
 is no reason for delaying the constitutional treatment. 
 
 19
 
 Xanthelasma. 
 
 Plate X., Fig. 12. 
 
 Xanthelasma is a flat, straw- or sulfur-colored tu- 
 mor located in the palpebral skin, and generally mul- 
 tiple in both upper and lower lid in the region of the 
 inner canthus. Often a tendency is noted to develop 
 symmetric figures on the two eyes. These tumors are 
 found only in elderly adults and more often in women 
 past the menopause. They grow very slowly and in- 
 jure only cosmetically. When extirpated they rarely 
 return. 
 
 Dermatologists differentiate a X. planum and a X. 
 tuberosima, the first of which is found only upon the 
 Uds. 
 
 Anatomically they are composed of the so-called 
 xanthoma-cells (Touton), i. e. hypertrophied connec- 
 tive tissue cells, lying in nests and filled with fat-drop- 
 lets. These nests are separated from one another by 
 walls of connective tissue. Giant-cells are not infre- 
 quently found in them. 
 
 Therapy is entirely cosmetic and consists of 
 easily executed removal. 
 
 Prognosis. The tumors are absolutely benign, 
 causing only disfiguration. 
 
 20
 
 [. Atliis 
 
 Tab. X. 
 
 Fig. 12. 
 Xanthelasma. 
 
 Company, New York .
 
 Atlns. 
 
 I'lib. XI, 
 
 o 
 
 . CO 
 
 "" o 
 ■ o 
 
 ill £ 
 
 >1 
 
 111 Company, New Vork .
 
 Atheromatous Cyst of the 
 Margin of the Eyelid. 
 
 Plate XI., Fig. 13. 
 
 By atheroma (Griitzbeutel) is meant a retention- 
 cyst, developing from sebaceous glands and hair fol- 
 licles, and containing a gritty, whitish mass of comi- 
 fied, degenerate epithelial cells, fat-droplets and 
 cholesterin. The cyst walls are thin, as a rule, and 
 composed of connective tissue. 
 
 Atheromata develop usually in middle age on the 
 hairy scalp or the genitalia. Not infrequently they 
 are found on the margin of the eyelid, sometimes mul- 
 tiple, and originating in the ciliary hair follicles 
 (glands of Zeiss). The cysts arising from occluded 
 sebaceous glands of the palpebral margin, the so- 
 called glands of Moll, develop only as small translu- 
 cent blebs the size of a pea or cherry. 
 
 Diag'nosis is easily established from the loca- 
 tion, painlessness and form and is rendered certain 
 by the contents of the cyst. In the same location there 
 may also be found congenital dermoid tumors lying 
 beneath the skin of the lid, usually in the upper lid 
 in either canthus. These push into the orbit but, as a 
 rule, so superficially that the globe is not displaced. 
 Beneath the skin they may be palpated as easily mov- 
 able tumors the size of a bean. 
 
 Therapy is surgical, but the extirpation must be 
 thorough, for otherwise they are apt to develop again. 
 
 21
 
 Molluscum Contagiosum. 
 
 Plate XI., Fig. 14. 
 
 Molluscum contagiosum (Cf. Epithelioma) is a 
 growth composed of elevations, generally hempseed in 
 size, rarely as large as peas, yellowish-white in color 
 and occasionally of the hue of mother-of-pearl, cen- 
 trally depressed. From this depression or crater, a 
 gritty matter may be squeezed. These growths occur 
 anywhere on the skin but are most conmion on the 
 genitals and the eyelids, and close observation will de- 
 tect them in the latter location oftener than is sup- 
 posed — usually multiple on the lid margins. 
 
 The tumor is contagious and hence, in persons of 
 uncleanly habits, apt to take on multiple form. If 
 such a growth exist on the margin of the upper lid, it 
 is not long before one develops on the lower lid at the 
 point of contact. A blind individual whom I saw had 
 many hundred moUusca. 
 
 Retzius was the first to demonstrate their conta- 
 giousness by successful inoculation. 
 
 The contents expressed from the nodule contain, 
 histologically, cornified epithelia and numerous oval, 
 very refractive, sharply defined bodies, the so-called 
 molluscum corpuscles, — easily seen in sections of the 
 extirpated tmnor. Virchow, Caspary and Lasser con- 
 sider them bladder-like formations due to an altera- 
 tion of cell-protoplasm. According to Bollinger, they 
 are unicellular parasites, gregarinae, whilst Neisser 
 considers them epithelial cells filled with gregarinae. 
 Croker takes them to be similar to the oviform cocci- 
 
 22
 
 dimn described by Leukhardt. Recently the growth 
 has been carefully studied by Muetze under the direc- 
 tion of Uhthoff and Axenfeld and, according to him, 
 all of the transitions from normal epithelia to the mol- 
 luscal corpuscles are observable. The latter, then, 
 are to be considered as degenerate epithelial cells and 
 not as protozoic. What the contagium is, we do not 
 know. 
 
 The dlag-nosis is easily gained from the form of 
 the tumor with the central depression or crater, from 
 which a core may be expressed in which, microscop- 
 ically, the molluscal corpuscles are demonstrable. 
 
 Therapy. Expression of the contents seldom 
 suffices. It is best to remove the nodules with scissors. 
 
 23
 
 Hordeolum. 
 
 Plate XH., Fig. 15. 
 
 Hordeolum or sty (Gerstenkorn) is the name given 
 a small inflammatory swelling on the free outer mar- 
 gin of the lid, due to suppuration of sebaceous glands 
 and is merely, in other parts of the body, the derma- 
 tologic acne vulgaris, simplex or pustulacea. The se- 
 baceous glands of the free palpebral margin corre- 
 spond to the hair follicles of the eyelashes and lead 
 to them. Anatomically, they are here called the glands 
 of Zeiss. 
 
 The sty, however, is differentiated from ordinary 
 acne by the fact that, although a harmless affection, 
 it causes many more symptoms and more inconvenience 
 and pain than acne, — due to the anatomic structure of 
 its site. 
 
 Usually the first symptom of the coining hordeolimi 
 is a diffuse swelling and redness of the whole lid with 
 a sensation of tension soon becoming painful. Exam- 
 ination of the lid commonly discloses a small inflamed 
 nodule on the free margin between or in front of the 
 eyelashes, hard and extremely sensitive to the touch. 
 Extension of the infiltration from the glands into ad- 
 jacent tissues enlarges the nodule which may become 
 the size of a pea or larger. As a rule, the palpebral 
 skin is very red, the lid swollen and there is consid- 
 erable pain so that the slight local affection may be- 
 come very annoying. After a few days the centre of 
 the infiltration develops a yellow point of suppuration 
 which soon breaks externally on the palpebral mar- 
 
 24
 
 Alias. 
 
 Tab. Xll. 
 
 Fig. 15. 
 Hordeolum 
 
 ioilip.lny. New York
 
 gin; the pus flows out and there is healing within a 
 few days. More rarely the infiltration extends further 
 into the palpebral tissues and develops severe in- 
 flammation somewhat like a furimcle. In such cases 
 the inflammatory phenomena may be quite violent and 
 we have chemosis and marked infiltration of the pal- 
 pebral and bulbar conjunctivae as well as tmnefaction 
 of the Ud. 
 
 The course is always rapid and favorable. Later, 
 only close observation detects the slight scar left by 
 the preceding disorder. 
 
 Dlag'nosis at first is not always easy, for the vio- 
 lent onset, the considerable and rapid swelling and the 
 pains might presuppose some grave affection of the 
 eye. A sty is to be suspected as soon as it is ascer- 
 tained that the cornea is clear, the pericorneal tissue 
 not injected, and the conjunctival sac free from ab- 
 normal secretions, thereby excluding a commencing 
 blenorrhea as well as a deeper-seated morbidity (pan- 
 ophthalmia). It will not be long before a small in- 
 flamed nodule will be found near the palpebral margin, 
 rendering the diagnosis certain. If the finger be gent- 
 ly passed over the surface of the lid, it often locates 
 the swollen, painful spot. 
 
 The hordeolum generally occurs in youth, from 12 to 
 25 years, seldom after this period. Its genesis is 
 favored by an often insignificant chronic blepharitis, 
 which has given the micro-organisms (sometimes 
 hyphomycetic) always present and abundant on the 
 palpebral margin opportunity to multiply enormously, 
 penetrating and occluding the excretory ducts of the 
 hair follicles. The stasis of their secretion together 
 with bacterial activity soon develops suppuration. 
 
 Therapy. When the process is incipient an at- 
 tempt may be made to scatter the infiltration by warm 
 
 25
 
 compresses before the glands develop suppuration. 
 This is rarely successful, yet the warm applications 
 are commendable, for they lessen the tension and 
 swelling of the lids, diminish the pain, and aid and 
 accelerate the breaking through the skin of the pus. 
 Warm or hot cotton compresses dipped into a 2-4% 
 boric acid solution are well borne by the eye, usually 
 afford much relief and are much better than the or- 
 dinary applications of chamomile tea or lead-water 
 which often contain impurities or throw down a pre- 
 cipitate. The compress is applied several times dur- 
 ing the day for a quarter or half hour. If the patient 
 remain in the house it is advisable to wear contin- 
 uously a warm moist compress protected by rubber 
 tissue, which will keep it moist 6 to 12 hours. At 
 night this may be renewed and a bandage applied to 
 hold it in place. If spontaneous rupture occur, the 
 cavity should be well emptied, applying, if necessary, 
 pressure with the finger, after which the slight wound 
 soon heals. If the rupture delay too long and the pa- 
 tient desires freedom from the annoying pain, a small 
 cut with a lancet point may be made perpendicular to 
 the focus of infiltration on the margin of the lid and 
 pus squeezed out, thus materially shortening the pro- 
 cess. After evacuation the pains mostly vanish and 
 the inflammation recedes rapidly. In such case the 
 moist compress should be continued for another 24 
 hours. 
 
 The task now before us is to combat the so frequent 
 relapses or implication of other hair follicles. It 
 should first be determined if there be a chronic ble- 
 pharitis. This, naturally, demands treatment, and the 
 patient should also be warned to avoid for some time 
 such external harmful influences as impure air, to- 
 bacco smoke, coal-dust, etc. Before retiring at night 
 the eyes should be cleansed with a cloth wet with some 
 
 26
 
 collyrium, e. g. lotio Knmmerfeld, or, a thin layer of 
 white precipitate ointment may be applied to the lids. 
 In obstinate cases, paint the palpebral margin once 
 daily with a 1% solution of silver nitrate. 
 
 27
 
 Chalazion. 
 
 Plate XIH., Figs. 16-17. 
 
 By chalazion or Meibomian cyst (Hagelkorn) is 
 meant a circmnscribed swelling on the inner surface 
 of the eyelid beneath the conjunctiva. Its starting- 
 point is a Meibomian gland lying in the tarsus under 
 the conjunctiva and hence the chalazion develops from 
 the tarsus. The Meibomian glands are merely modi- 
 fications of the sebaceous glands of the external skin 
 to which they are similar in histologic structure. 
 Hence, pathologic processes in both species are much 
 alike. 
 
 Chalazion is a chronic affection of the Meibo- 
 mian glands, developing slowly with almost no in- 
 flammatory symptoms, and possibly remaining un- 
 changed for years. During a period of months a 
 small nodule grows in the palpebral tissue, at first 
 causing no trouble and hence noticed by the patient 
 only after it has attained some size. The lid is not 
 reddened and the skin remains normal. If the tumor 
 be minute, so that nothing is observable on the outer 
 surface of the lid, the finger discovers the small 
 spheric growth beneath the skin which is movable 
 over it. Since the chalazion always develops in the 
 tarsal cartilage, it is always mobile with the cartilage, 
 not upon it. In the course of time the growths may 
 become as large as peas, cherry-pits or beans. They 
 cause then a palpebral deformity, particularly when, 
 as is often the case, there is multiple formation, and 
 the shot-like nodules may be seen from afar protrud- 
 
 28
 
 
 
 u 
 
 o 
 o 
 
 
 nan Company, New York.
 
 ing outward beneath the skin. Even in this stadium 
 inflammation of the lid or pain is absent. If the lid 
 become ectropic, a condition often aggravated by the 
 stiffness of the palpebral tissue, we note a more or less 
 prominent yellow-brown or slate-gray fleck with a 
 reddened areola in the conjunctiva projecting into the 
 eye. This may finally break through the conjunctiva, 
 after which a somewhat thick, slimy fluid exudes from 
 time to time and the tumor decreases somewhat in 
 size. Its major portion, however, composed of firmer 
 granulation tissue, remains in its capsule imchanged. 
 In the course of months or years even these masses 
 may so shrink or resorb that the tumor disappears. 
 
 The chalazion is usually noted in adults, seldom de- 
 veloping in children. Generally, there are several on 
 one lid, or, all the lids are deformed by these lumps. 
 In the beginning they cause little trouble, but in the 
 advanced stage are disfiguring and either by the de- 
 velopment of inflammatory symptoms, or by mechan- 
 ical hindrance to the movement of lid and eye greatly 
 annoy their possessor. 
 
 Chalazia develop mostly where there exists a slight 
 but chronic conjimctivitis, leading to occlusion of the 
 excretory ducts of the Meibomian glands and reten- 
 tion of their secretions. The content of the gland then 
 becomes thickened and harder and may change by 
 deposition of calcareous salts into a hard, chalky mass 
 (calcareous infarct of the Meibomian gland or lithiasis 
 palpebralis). These are seen beneath the palpebral 
 conjunctiva as small white or bright yellow spots. In 
 fact, calcareous infarcts of the Meibomian glands are 
 frequently prodromal of chalazia, and are usually 
 noted in considerable number surrounding a chalazion 
 beneath the conjunctiva of the same lid. These thick- 
 ened masses of glandular secretion may exert an in- 
 flammatory action upon the endothelium and adjacent 
 
 29
 
 tissues, because of which these begin to proliferate and 
 become infiltrated with small cells. With the progress 
 of such infiltration, the mass develops into a dense 
 granulation tissue in which, sometimes, even giant 
 cells are found. The center of this granulation tumor, 
 deprived of vascular supply, may finally disintegrate 
 and pass into mucoid degeneration. A dense, tough 
 capsule, foimed of the surrounding tarsal tissue under 
 pressure, commonly develops about such a mass, and 
 the chalazion, therefore, is composed of tough, dense 
 granulation tissue enclosed in a fibrous connective tis- 
 sue capsule. 
 
 Recently it has been maintained by several authors 
 that the chalazion is, as a rule, tuberculous in nature, 
 a statement which has been further supported by the 
 demonstration of numerous giant cells in its tissues. 
 Many investigations, however, prove the fallacy 
 of such assertion, at least in the majority of cases, and 
 the benign clinical course scarcely bespeaks a tuber- 
 culous process. 
 
 Tlierapy. At the beginning and as long as the 
 chalazia remain small, we may try to scatter them by 
 external means, e. g., by rubbing an ung. potass, iod. 
 into the conjunctival sac or by painting the external 
 skin with tr. iod. If this have no effect, small, hard 
 chalazia may be left undisturbed. If they grow or 
 are already so large as to be disfigurative, operation 
 is indicated. 
 
 The query at once arises whether the incision shall 
 be dermal or conjunctival. Although the protrusion 
 is mostly outwards, the skin should never be incised. 
 The natural opening is inward, toward the conjunctiva, 
 and by this path the tumor-masses are most easily 
 reached and there results minimal deformity from the 
 operation. The operation is not so easy and simple as 
 
 30
 
 it might seem, for a single incision does not suflSce and 
 the removal of the tough tissue is essential and often 
 diflScult. The first cut, therefore, should by no means 
 be too small or superficial. Its direction should be 
 parallel to the palpebral margin. 
 
 As the operation is painful, we anesthetize by plac- 
 ing in the conjunctival sac three or four times at min- 
 ute intervals some drops of a 2-4% solution of cocain, 
 or, better yet, by injecting with a Pravaz syringe a 
 few drops subcutaneously at the site of the tumor. 
 The ectropic lid is best fixed with a blepharostat, the 
 conjunctiva is divided with the knife down to the cap- 
 sule and we endeavor to dissect out with forcep and 
 scissors the encapsulated node. This is not always 
 easy for the capsule is apt to be firmly attached to the 
 surrounding tissues. If it cannot be shelled out in its 
 entirety, as much as possible is cut out with scissors 
 and forcep and the remainder removed with the sharp 
 curette. 
 
 To avoid relapses and the formation of new cha- 
 lazia, a chronic conjunctivitis present must be treated 
 and cured. If white calcareous infarcts of the Mei- 
 bomian glands are noted, so that a number of excre- 
 tory ducts are occluded, the glands must be slit open 
 by passing a cataract needle down through the con- 
 junctiva until the calcareous mass is exposed, when 
 the infarct mav be removed with a fine curette. 
 
 31
 
 Blepharitis Marginalis. 
 
 Plate XIII., Fig. 16; Pi^te III., Fig. 3; Plate XIV., 
 
 Fig. 18; Plate XXVIII., Fig. 41; Plate XXIX., 
 
 Fig. 42. 
 
 The various affections of the palpebral margin 
 which begin with symptoms of an inflammatory na- 
 ture, we term blepharitis marginalis. They belong 
 to the most common diseases of the eye seen by the 
 general practician, particularly in the larger cities and 
 among the poorer classes where the anemic and scro- 
 fulous children compose a majority of such patients. 
 The skin of the body becomes very thin and delicate 
 on the eyelids and still more so as it approaches the 
 margins so that here we have the most tenuous and 
 sensitive derm of the whole body. For this reason, 
 it is easily comprehended that in the most various 
 dermal diseases, particularly if located on the face 
 and extending therefrom, we often find the palpebral 
 margin particularly inclined to sympathetic complica- 
 tion. The various skin troubles appearing on the eye- 
 lid and its mai-gin are not, as a rule, differentiable 
 from the adjacent foci of disease and should receive 
 similar treatment, in regard to which special works 
 are to be consulted. 
 
 There frequently appear, however, on the margin of 
 the lid characteristic types of inflammation which here 
 demand special consideration. 
 
 Firstly, we should differentiate from true inflamma- 
 tions of the palpebral margin, a hyperemia of the part, 
 well-termed blepharitis vasomotoria. 
 
 32
 
 Hyperemia marginalis. In many delicate-skinned 
 individuals, and particularly in the blond, the 
 marginal skin is so sensitive that it becomes very red 
 from the least external stimulus or irritation. As soon 
 as these patients enter an atmosphere of tobacco 
 smoke or go out in windy weather or are exposed to 
 a strong light, they develop the ugly "red eyelids" 
 within a few hours or the next morning. The phe- 
 nomenon not only disfigures, thus often spoiling the 
 patient's enjoyment of some harmless pleasure, but is 
 also accompanied by many inconveniences. The eyes 
 itch and burn, forcing the patient to rub the margins 
 of the lids, and furthermore there is a sensation of 
 weight and heat in the eyes often extremely annoying 
 when engaged in diflBcult work. Often it requires no 
 external irritant to evoke the troublesome symptoms 
 which may be caused by unusual bodily exertion, over- 
 use of the eyes, emotional disturbances, etc. If we 
 consider that in most individuals, excesses, a night's 
 carouse, long exposure to impure air laden with to- 
 bacco fumes are quite evident in the eyes the morning 
 after, it is comprehensible how vexatious it is for 
 most youthful patients with hypersensitive margins 
 of the eyelids to go about after the least indiscretion 
 with swimming, reddened eyes which seem to betray 
 an over-indulgence in alcohol or a night spent in tears. 
 Not infrequently the insignificant affection hinders 
 them in business. 
 
 In acute attacks, the margins of both lids are much 
 reddened and if closely observed, there will be found 
 in the redness a number of delicate, bright-red, deep- 
 ly-injected blood-vessels. Coexistent there is often 
 present a slight swelling of the lids and an injected 
 palpebral conjunctiva. Scale formation on the mar- 
 gin of the lid or at the roots of the lashes is usually 
 lacking, but the lacrimal secretion is, as a rule, in- 
 creased, so that the eye "swims in tears." 
 
 33
 
 If the trouble has been of some duration, the acute 
 attacks, at first often repeated, develop a chronic con- 
 dition, i. e. the lids remain red and their margins be- 
 come thickened and heavy. Many thick, distended 
 blood-vessels are seen in the palpebral edge which 
 passes from a red to a violet tint. The patient devel- 
 ops great photophobia, and, because of the ocular 
 trouble, have to be extremely careful of themselves. 
 Even at some distance the ugly red margins are vis- 
 ible. 
 
 The affection, at first insignificant, is most persist- 
 ent, and in many instances resists treatment for a long 
 while. Therapy must be both general and local. It 
 is most important to strengthen and harden the young, 
 delicate, often anemic or scrofulous individuals in 
 whom the trouble first begins. Although it is neces- 
 sary to warn against excesses, over-exertion, late re- 
 tiring, too long reading, exposure to impure air, it is 
 equally essential to avoid coddling. On the contrary, 
 these patients should be as much as possible in the 
 fresh, open air, and, healthful exercise, cold affusions 
 with vigorous massage, bathing out of doors will in 
 time strengthen the organism and harden the sensi- 
 tive skin. Tonics such as quinine, iron, etc., may be 
 given internally. 
 
 Locally, the parts should be kept clean, and cold 
 compresses of some mild astringent, such as lead- 
 water, very weak solution of tannic acid, water con- 
 taining a few drops of eau de Cologne or ethyl alcohol 
 are to be commended. Whatever the agent, care should 
 be taken that the sensitive parts be not irritated too 
 much, and strongly concentrated solutions are to be 
 avoided. The eye-douche is very useful and should 
 be employed once daily or every second day, a finely 
 divided and not too forcible stream being directed for 
 3-6 minutes against the edges of the gently closed lids. 
 
 34
 
 To the douche may be added any suitable astringent 
 and hardening agent (eau de Cologne, alcohol, borax). 
 
 Salves are best dispensed with, for the ordinary un- 
 guents are much too irritant. If the skin of the lids 
 shows a tendency to chap or crack, a very thin film of 
 pure lanolin may be applied at night before retiring. 
 
 In obstinate cases, the margin may be painted with 
 a 1% solution of silver nitrate or 2-3 superficial appli- 
 cation made of lapis mitigatus in substance. 
 
 Of inflammations of the palpebral margin, we have 
 two chief types for differentiation : 
 
 1. Blepharitis marginalis sicca, also called blepha- 
 radenitis, seborrhea marginalis, blepharitis squamosa, 
 is a condition of hypersecretion from inflammatory ir- 
 ritation of the sebaceous glands of the palpebral mar- 
 gin, and hence, more exactly, a seborrhea of the ciliary 
 portion of the eyelid. The sebum soon dries and forms 
 small scales lying between the eyelashes upon the 
 skin of the lid. Recent investigations have dem- 
 onstrated that these scales are not altogether the prod- 
 uct of desiccatetd sebum and dead, cast-off epidermal 
 squams, but that numerous hyphomycetes and their 
 colonies found on the margin of the lid and in the ex- 
 cretory ducts of the glands probably engender the dis- 
 ease in most instances. 
 
 The patient is usually di'iven to the physician be- 
 cause of a continual itching and burning. If the mar- 
 gin of the lid be superficially examined, little that is 
 abnormal is observed, but on closer investigation, or 
 if one rub the finger firmly across the eyelashes, tho 
 numberless minute, whitish-gray scales lying upon the 
 margin of the lid at the roots of the lashes will come 
 into evidence. After such dry massage, the palpebral 
 margin looks as if powdered with flour, and by such 
 pulling and rubbing the lashes may be dusted off. Un- 
 derneath the scales the margin of the lid is reddened 
 
 35
 
 but not ulcerated. The cilia are loosely rooted and 
 easily removed, but in recent cases grow in again as 
 before. When the condition has been of longer dura- 
 tion, the eyelashes are affected, lose their luster, be- 
 come bent and twisted and finally fall out. Formation 
 of crusts or scabs with a glueing together of the lash- 
 es seldom occurs. In such case, the crusts are chiefly 
 composed of the dried mucous secretions of the glands, 
 and beneath them (in blepharitis sicca) there is no 
 ulceration. 
 
 In therapy it is to be well understood that no un- 
 guent nor any other remedy is of the slightest value 
 unless before each application all scales are removed 
 and the lid margin most carefully cleansed. The scales 
 are best disposed of by dropping a little pure olive 
 oil upon the margin and rubbing it in between the 
 lashes. After a few minutes the scales have become 
 loosened and may be removed by rubbing with a piece 
 of flannel and using ciliary forceps until the field is 
 clear. Repetition of this process as soon as new scales 
 are formed should not be neglected because of the 
 slight, transitory swelling and redness of the lid mar- 
 gin following its execution, nor is any harm done if 
 some lashes fall out; when loosely rooted they come 
 out sooner or later, growing again as soon as the mar- 
 gin of the lid becomes healthy. After cleansing and 
 drying the parts, a portion of salve the size of a pea 
 is rubbed into the margin with a glass rod or the fin- 
 ger. Since cleansing, in the first sittings, somewhat 
 irritates the eye, it is best done once a day, before re- 
 tiring. The salve remains upon the margin of the 
 lid in a thin layer during the night, and is washed off 
 in the morning with soap and water. Suitable oint- 
 ments are a 1 to 2% img. Pagenstecheri (hydrarg. oxyd. 
 rubr.) or ung. diach. Hebrae, best attenuated with equal 
 
 30
 
 quantities of vaseline. Carefully treated, blepharitis 
 sicca is not obstinate and soon heals, without sequelae. 
 
 2. Blepharitis eczematosa or blepharitis ulcerosa, 
 scrophulosa, is, as its name indicates, an eczema of the 
 palpebral margin, and, as in dermal eczema, exhibits 
 the most varied types. 
 
 The first three stadia develop rapidly, as a rule, or 
 else are not distinctly observed as such; the fifth sta- 
 dium begins in an eczema already in the process of 
 healing, so that the physician is best acquainted with 
 the fourth stadium, by far the commonest in most 
 cases, the stadium of moist ulceration and crust-for- 
 mation. 
 
 Primarily we have a hyperemia and swelling of the 
 lid margin, due to a serious saturation of tissues 
 and leucoeytic emigration. The tumefaction usually 
 develops in spots so that a number of small, dense red 
 nodules, the size of a hempseed or pinhead are found 
 on the margin (stadium papulosum). 
 
 With an increasing serous infiltration, the epithe- 
 litun of the derm is raised up here and there and cir- 
 cumscribed collections of fluid form between the epi- 
 thelium and the rete mucosum, vesicles filled with a 
 clear watery fluid (stadium vesiculosum). 
 
 Gradually the leucoeytic emigration augments until 
 the contents of the vesicle become more and more tur- 
 bid and finally purulent (stadium pustulosum). 
 
 At last the pustules break and ulcers form, soon 
 crusting over. Beneath the crusts the weeping ulcers 
 persist unchanged (stadium madidans), and in this 
 state the disease may continue for a long time, new 
 vesicles and pustules forming in the neighborhood of 
 the ulceration, so that the various stadia may be syn- 
 chronously observed, the stadium madidans predom- 
 inating. 
 
 When finally the inflammatory phenomena subside, 
 
 37
 
 the exudation and crust-formation lessens. The ulcers 
 heal, and epithelial loss is no longer observed on the 
 superficies of the denn, but, the skin retains for some 
 time the inclination to develop inordinate quantities 
 of epithelial cells which rapidly comify and are cast 
 off. Hence, we find the affected areas covered with 
 layers of scales, the stadium squamosum. 
 
 As mentioned above, the physician is usually con- 
 fronted with the matured eczema in the fourth sta- 
 dium. The margin of the lid is markedly swollen, 
 thickened, and covered with crusts, and not infre- 
 quently vesicles and pustules are seen in the neighbor- 
 hood of the crusts. The pustules are most commonly 
 located about the cilia, and when they rupture the sin- 
 gle cilium is observed rising up out of a deep, crater- 
 like ulcer. The ulcers soon begin to exude, and thick 
 crusts form, which, if removed, expose the deep, easily 
 bleeding ulcus. If the disease remain untreated the 
 lashes fall out and do not return. The angle of the 
 lid-margin is eaten away so that a slight eversion re- 
 sults. The loss of the cilia is due to the fact that their 
 follicles have been destroyed by suppuration. Where 
 this has not happened, the cilia grow again through 
 the crusts and cicatrices, but pervertedly, so that the 
 eye may suffer greatly from their abnormal positions 
 (vide Plate XXII., Pig. 13). Almost invariably the 
 remainder of the palpebral skin and the conjunctivae 
 are affected, and commonly the eczema extends to the 
 cheeks or nose. Eczema of the scalp as well as of the 
 eyelids is often present. The nasal cavities should be 
 watched most carefully, for in them analogous pro- 
 cesses (eczema, purulent discharges, ozena) often de- 
 velop. 
 
 As the cause of the disease, we almost invariably 
 find a general scrofulosis and tuberculosis. The in 
 dividuals affected are usually frail, poorly nourished 
 
 38
 
 children, exhibiting all the signs of scrofula (eczema, 
 glandular swelling, a puffy, bloated appearance, thick 
 lips, etc.) More rarely, local injurious influences (bad 
 air, dust, occupation-noxae) or persistent conjunctival 
 irritation from epiphora or other secretions may de- 
 velop eczema and ulceration of the palpebral margins. 
 
 The diag-nosls of blepharitis eczematosa is not 
 difficult. The disease is differentiated from blepha- 
 ritis sicca, which occasionally begins with crust-for- 
 mation, chiefly by the fact that when the crusts are 
 removed, the deep eczematous ulcers appear. The 
 eczema might be confused with sycosis (Bartflechte) 
 which sometimes locates on the margin of the eyelid, 
 but in sycosis the large, exuding areas and ulcerations 
 are absent. Furthermore, sycosis develops almost in- 
 variably in adult males, whilst blepharitis eczematosa 
 usually affects weakly children. 
 
 The course of an untreated blepharitis eczematosa 
 is extremely chronic. In its chronicity it passes into 
 a stage where the epithelial layer of the skin becomes 
 necrotic, the denuded areas covered with thick, solid, 
 yellow-brown scabs, and in this state, the disease may 
 persist for years. 
 
 With long continuance of the affection, the eyes suf- 
 fer in many ways, and there are a number of sequelae 
 of chronic blepharitis which injure the visual organs 
 to a greater or less degree, e. g. 
 
 Chronic conjunctivitis, which may cause much 
 trouble. 
 
 Destruction of the cilia and the margin of the lid. 
 The hair follicles and glands become implicated in the 
 ulcerative process and are destroyed by suppuration. 
 Finally, all of the lashes fall out or there remain only 
 a few. The lid-margin breaks down, and instead of 
 the normal rectangular form, its delicate edge be- 
 
 39
 
 comes rounded off, so that some portions are shrimk- 
 en, others hypertrophic and thick. 
 
 Trichiasis. The few remaining cilia may be turned 
 inward by cicatricial contraction and thus possibly 
 abrade the cornea. 
 
 Therapy should not only be local, but constitu- 
 tional. The hygienic environments of the patient are 
 to be improved, the delicate children properly nour- 
 ished, moimtain or seashore prescribed when condi- 
 tions permit, and every endeavor made to vanquish the 
 existent scrofulosis. Internally, cod-liver oil, iron, 
 iodine, etc., are indicated, and for the habitual obsti- 
 pation often present, calomel should initiate the treat- 
 ment. Above all, the rarely absent nasal complication 
 must be cured, for as long as it is present an ap- 
 parently healed eye will soon become diseased again. 
 
 Of local measures, the first is a careful, daily re- 
 moval of the crusts. This is accomplished by loosen- 
 ing them with warm water, or still better, with olive 
 oil, followed by rubbing or scratching them off with 
 blunt forceps. Loose or slanting lashes should be ex- 
 tracted with cilia forceps. One should not be fright- 
 ened if the ulcers beneath the crusts bleed easily and 
 reproduce the crusts. In the first days of treatment 
 a light superficial brushing-over of the ulcer's base 
 with the mitigated silver nitrate stick (lapis mitiga- 
 tus) is often helpful. Unguental treatment is partic- 
 ularly applicable in this disease, and, as in all eczemas, 
 care must be taken not to use too irritant salves. The 
 choice of the salve is not of so much consequence as 
 its degree of concentration. In weeping eczema of the 
 eyelid and margin, it is best to prepare a compress 
 suggested by Hebra. The ointment is spread thick 
 upon strips of boracic gauze and these applied shingle- 
 fashion to the eye, i. e. one strip overlying the strip 
 
 40
 
 below. In order not to annoy the patient too much, 
 the eyes may be treated in alternation. The best un- 
 guent is Hebra's diachylon salve; the white and red 
 precipitate ointments are often used but it is wise to 
 prescribe the latter in less strength than originally 
 given by Pagenstecher. Schreiber, of Magdeburg, is 
 very successful with a 14% ointment of silver nitrate. 
 A 1% resorcin unguent is recommended where the eyes 
 are hypersensitive. The bandage should first be 
 changed once, later twice in the 24 hours, and it is im- 
 portant to see that the unguent be freshly made and 
 its base not rancid. 
 
 This unguental treatment generally causes the ec- 
 zema to pass from the stadium madidans into the sta- 
 dium squamosum or desquamation, when it should be 
 stopped, the affected areas of skin usually healing 
 soon with the employment of a dusting powder. 
 
 In particularly obstinate or chronic eczemas, a tar 
 treatment after the unguental is often advisable. The 
 affected areas are painted daily with pure tar or with 
 equal parts of tar and olive oil. 
 
 With needful patience on the part of patient and 
 physician and some care in the use of salves, which are 
 not equally well borne by all patients, it is possible to 
 overcome the most obstinate forms of the disease. 
 
 41
 
 Entropium. 
 
 Plate XIV., Fig. 18; Plate XXII., Fig. 31. 
 
 In entropium, the lid or its margin is turned in so 
 that the free edge and the lashes no longer project 
 outwards but lie directly against the eyeball, upon 
 which the cilia rub with every movement of the lid, 
 thus causing irritant and inflammatory phenomena, 
 i. e. they act like foreign bodies upon the exterior en- 
 velope of the globe. 
 
 Palpebral entropium is differentiated from trichi- 
 asis and distichiasis as follows : In trichiasis the lash- 
 es are correctly placed but the margin of the lid bear- 
 ing them rolls inward toward the globe whilst in dis- 
 tichiasis, the margin lies normally but the cilia grow 
 crookedly or too much in an inward direction so that 
 they impinge upon the eyeball. Frequently, however, 
 we find both conditions present: misplacements of 
 margin and cilia. 
 
 If in a case of marked entropium we look directly 
 at the eye, the edge of the lid is scarcely visible and it 
 is only when the lid is pulled outwards by the fingers 
 that it unrolls, bringing the margin into view, and, 
 when let go, it rolls in again and the margin vanishes. 
 
 The entropium may involve the entire lid, or por- 
 tions only may be turned inwards, a partial entropium. 
 In case of the latter, the lower lid is chiefly affected in 
 the middle and outer third; the upper lid mostly in 
 the outer third. Both lids, the upper and the lower, 
 are about equally subject to the disease. 
 
 Various degrees of inversion may be differentiated. 
 
 42
 
 Atlas, 
 
 Tab. XIV. 
 
 Fig. 18. 
 Entropium Trichiasis following 
 Conjunctivitis simple.^ chronica. 
 
 Company, New York
 
 In the minimal degree the free edge of the lid is turned 
 so far inward that the tips of the cilia impinge upon 
 the eyeball, being so twisted that they lie nearly 
 parallel to the lid margin and glide tangentially across 
 the globe. If the lid margin is turned so far inward 
 that the lashes rest directly upon the eyeball, they 
 gradually assume a position the reverse of natural, 
 i. e. they no longer- curl outward but are bent inward 
 to correspond to the curve of the eyeball so that their 
 tips are directed away frum the cornea toward the 
 conjunctival fornix. In the maximal degree of inver- 
 sion, the palpebral skin lies against the globe whilst 
 the cilia penetrate deeply into the conjunctival fornix. 
 
 Entropium always results in injury to the affected 
 eye, chiefly caused by the internally directed cilia. 
 The patient has the sensation of a foreign body in the 
 eye, and soon there develop extreme laerimation, pho- 
 sophobia, conjunctival and pericorneal injection. If 
 the entropium persist for some time, the cornea, in 
 particulate, suffers, and may be injured permanently. 
 Because of the continual irritation, the corneal epi- 
 thelia become indurated, thickened and cloudy, or, it 
 may happen that the epithelia in divers areas are in- 
 jured by the cilia, and if opportunely infected, a super- 
 ficial ulcer of the cornea may develop. In old chronic 
 cases, the cornea is generally covered with pannus-like 
 opacities and indurations. 
 
 Inversion of the lids is invariably the result of pre- 
 vious definite diseases of the eye, and in most in- 
 stances is due to contraction or shriveling of conjunc- 
 tival scar-tissue. According to their etiology we dif- 
 ferentiate two chief forms of entropium: 
 
 1. Entropium cicatriceura., where, by cicatricial con- 
 traction of conjunctival tissues, the margin of the lid 
 is drawn inwards, the scars being due, generally, to 
 a long-lasting trachoma, to the so-called cicatricial tra- 
 
 43
 
 choma {vide Plate XX., Fig. 31). Each trachoma 
 granule heals cicatricially, whence, where many and 
 recurrent granules have occupied the palpebral con- 
 junctiva, the conjunctival tissue still left, does not 
 sufiSce, because of the long, radiating scars extending 
 chiefly in a horizontal direction, to cover without ten- 
 sion, the entire inner surface of the lid. Consequently, 
 the lid is constricted interiorly from above downwards, 
 and the punctum mobile, the free margin of the lid, is 
 forced to yield and roll inwards. In such cases, the 
 cilia, impinging almost entirely upon the eyeball, are 
 no longer normal, but develop as long, fine hairs or 
 degenerate into short, thick stumps (trichiasis). The 
 free angular margin of the lid is, generally, no longer 
 present, having been rounded off or quite flattened out. 
 
 In other cases the conjunctival scars causing the 
 entropium were due to wounds or burns or cauteriza- 
 tions. 
 
 2. Entropium spasticum. This follows spasmodic 
 contraction of certain fibers in the musculus orbicu- 
 laris. To elucidate the genesis of this form of inver- 
 sion, we must consider briefly the structure and action 
 of this muscle. The musculus orbicularis is a super- 
 ficially extended muscle of the skin, divisible into two 
 portions. The first or inner portion, lying within 
 the lid itself, extends to the palpebral fissure ; which it 
 encircles, and is, therefore, called the portio palpe- 
 bralis. The second, or outer portion, extends peri- 
 pherally from the first to the orbital edge and adjacent 
 parts and, hence, is dubbed the portio orbitalis. As 
 a rule only the palpebral portion governs the move- 
 ments of the lid; the orbital portion merely draws to- 
 gether the facial derm surrounding the eyes and, 
 therefore, aids in firm closure of the lids. The fibres 
 of the portio palpebralis have a double curve: 1. with 
 a concave side toward the palpebral margin, and 2. 
 
 44
 
 with a concave side toward the eyeball, corresponding 
 to its curvature. A contraction in these muscle bun- 
 dles would result in straightening out both curves (to- 
 ward the concave side), thus first closing the lids and, 
 secondly, pressing them against the eyeball. If now, 
 from any cause, there develops an unequal or imbal- 
 anced contraction in the fibers of the orbicularis, e. g. 
 so that the fibers at the lid margin are contracted or 
 spasmodically tense, whilst all other fibers remain lax, 
 the palpebral fibers overcome the others and roll the 
 margin inwards. To accomplish this, however, an- 
 other factor is requisite, namely, that the palpebral 
 derm be not tense but loose and flabby. Both of these 
 conditions are often present in elderly individuals, for 
 which reason, entropium spasticum is most commonly 
 found in this class of patients (entropium spasticum 
 senile), particularly where the eye has been kept 
 closed for some time, as after cataract operations, 
 when it oftener occurs and becomes a very troublesome 
 complication. 
 
 In like manner, the orbicularis fibers of the margin 
 of the lid gain the ascendancy if their tension be not 
 counterbalanced by a normal curvature of the eyeball, 
 which, if lacking, almost invariably develops inver- 
 sion of both lids. But, even after the retrogression 
 of the bulbus into the orbit, often occurring in ema- 
 ciated seniles, entropium may develop, and likewise 
 after a shriveling and atrophy of the bulbus. 
 
 From a spasmodic contraction of the orbicularis 
 (blepharospasmus) found particularly in children, en- 
 tropium may be engendered, and here the portio orbi- 
 talis often acts so violently that the margins of the 
 two lids are pressed against each other until finally 
 one of them rolls inwards. This form of entropium 
 spasticum in youthful patients affects the lower lid 
 alone. 
 Therapy. Entropium in old people due to the 
 
 45
 
 pressure of a bandage commonly disappears when the 
 bandage is removed, but, if for other reasons it is 
 necessary to continue the compress, we may endeavor 
 to hold the lid in its normal position by using adhes- 
 ive plaster and collodium, the application beginning 
 at the palpebral edge and extending downward over 
 the cheek. If the lid be not kept in place by this 
 method, ligation will be necessary. 
 
 If the inversion be due to blepharospasmus, this 
 should be treated and cured, after which the entro- 
 pium disappears of itself. 
 
 In entropium due to cicatricial contractures, it is 
 first essential to remove carefully with cilia forceps 
 all the eyelashes impinging upon the bulbus. A per- 
 manent cure is attained only by operation. 
 
 46
 
 Atlas. 
 
 Fig. 19. 
 Lupus vulgaris faciei. Narhenectropium. 
 
 II Company. New York
 
 Ectropium. 
 
 Plate XV., Fig. 19. 
 
 By ectropium is meant an anomalous position of the 
 Kds where they with their conjunctivae are no longer 
 closely appUed to the bulbus but roll outwards, away 
 from it. When this happens, a larger or smaller area 
 of the conjunctiva may lie exposed to view. There 
 are various degrees of eversion, from the slightest, 
 where the palpebral margin does not quite touch the 
 eyeball, to a degree where the whole lid is turned in- 
 side out. One or both lids may be affected; most com- 
 monly, however, only the lower. 
 
 ' But, even with a minimal eversion, the condition is 
 extremely troublesome, and commonly the ectropium 
 with its sequelae soon develop a state of great irrita- 
 tion in the eyeball. Then, with the separation of the 
 lid margin from the globe, the lacrimal puncta are 
 thrown outwards and no longer drain the lacus lacri- 
 malis. The natural transit of the lacrimal fluid being 
 thus interfered with, the tears trickle over the edge 
 of the lid and down the cheeks, and we have epiphora. 
 
 A further consequence of ectropium is the inflam- 
 mation and hypertrophy of the conjunctiva thus ex- 
 posed to external irritants — air, dust, etc. It tumefies, 
 and the swelUng leads to yet greater eversion. Thus, 
 both conditions alternately aggravate each other. A 
 high degree of ectropium may finally develop grave 
 consequences for the eye, since the cornea, not being 
 adequately covered by closure of the lids, invites the 
 development of a keratitis e lagophthalmo. 
 
 47
 
 According to their etiology we differentiate several 
 species of ectropium: 
 
 1. Ectropium paralyticum. After paralyses of the 
 musculus orbicularis, e. g. as a complication of facial 
 paralysis, there usually develops a slight eversion of 
 the lower lid, explained as follows: The orbicularis 
 whose fibers are paralyzed is no longer able to hold 
 the lid accurately against the globe; hence, the lid, 
 obeying the law of gravitation, sinks down and some- 
 what away from the eyeball. Because of this mechan- 
 ical genesis, it is clear that the lower lid alone will be 
 affected. 
 
 2. Ectropium senile. This form is very similar to 
 the one just described, both in genesis and appear- 
 ance, except that here paralysis is not etiologic but 
 rather the lax, senile skin and musculature of the lid 
 which are no longer able to hold it firmly against the 
 globe. The lid sinks somewhat down and outwards, 
 and there develops a sulcus betwixt lid and globe in 
 which the exposed conjunctiva may be seen. 
 
 3. Ectropium spasticum. Pound chiefly in children 
 and youthful individuals suffering from an acute con- 
 junctivitis with tumefaction, particularly when accom- 
 panied by a blepharospasm. If, with such children 
 we attempt a forcible opening of the eye, it happens 
 that by a strong contraction of the orbital portion of 
 the musculus orbicularis a sudden and spontaneous 
 eversion of both lids occurs. This may also be excited 
 by simple pressure on the lids without touching the 
 eye. For the development of an ectropivmi spasticum 
 a conjunctiva well tumefied and a spasmodic state of 
 the musculus orbicularis, more marked in the portio 
 orbitalis, are necessary. If such a suddenly developed 
 eversion be not speedily corrected, the already swollen 
 conjunctiva will be strangulated by the portio palpe- 
 bralis of the orbicularis and marked edematous tume- 
 
 48
 
 faction will ensue. This may lead to permanent ever- 
 sion until the conjunctivitis has been cured. Ectro- 
 pium spasticum is mostly found in children suffering 
 from a scrofulous conjunctivitis, more rarely in cases 
 of ophthalmia neonatorum. It usually affects both 
 lids simultaneously, and may attain a high degree, 
 so that the bulbus is completely hidden by the swollen, 
 everted lids. 
 
 Lesser degrees of ectropium may develop from sim- 
 ple swelling of the conjunctiva, which becomes not 
 only thicker but broader and, because of the sausage- 
 like tumefaction of the palpebral edge, is pushed still 
 further away from the globe (ectropium mechanicum). 
 The eversion is accentuated when, from pinching or a 
 spasmodic statte, there is contraction of the palpebral 
 portion of the orbicular muscle. 
 
 4. Ectropium cicatriceum. The highest degree of 
 eversion is caused by cicatricial contractures. This 
 demands that a portion of the palpebral edge have 
 been destroyed and replaced by scar tissue. Such 
 conditions are peculiarly apt to develop after burns 
 of the skin of the lid or wounds of the lid, operations 
 upon the cheek, caries of the orbital edge, etc. The 
 scar formed invariably draws the margin of the lid 
 yet farther downwards until finally the entire red- 
 dened and thickened conjunctiva of the lid is fully ex- 
 posed outwards, and of the lid itself only the edge, 
 now far removed from the globe, is visible. 
 
 Tberapy. The earliest possible correction of the 
 eversion is to be sought, for the portion of conjunc- 
 tival tissue turned outwards is continually exposed to 
 the air and the dangerous substances contained in air, 
 and which excite violent irritation of the eye. With 
 increase of the conjunctival swelling, the eversion aug- 
 ments until finally a circulus vitiosus is developed. 
 
 A treatment without surgical intervention is pos- 
 
 49
 
 sible only in ectropium spasticmn. Here, in the be- 
 ginning of the trouble, the everted lids may be re- 
 placed without much diflSculty and, to avoid an ever- 
 ready relapse, they should be kept in the correct posi- 
 tion by strips of adhesive plaster or the use of a com- 
 pression bandage. 
 
 In obstinate cases, an extension cut of the external 
 canthus is to be commended before the correction of 
 the eversion, for the bleeding caused by the cut is very 
 beneficial. After the lids are replaced, the inflamma- 
 tion and swelling of the conjunctiva should be reduced. 
 
 Other forms of eversion are corrected only by means 
 of the ectropium operation. 
 
 50
 
 A(l:is. 
 
 T;ib. XVI. 
 
 Fig. 20. 
 
 Carcinoma epitheliale I. 
 
 Ill Conip.iny. New York.
 
 Carcinoma Epitheliale 
 Palpebrarum. 
 
 Plate XVI., Fig. 20; Plate XVII., Fig. 21. 
 
 Carcinoma is the commonest palpebral neoplasm. 
 It usually occurs as a shallow ulcer, scarcely rising 
 above the superficies and having but a slightly ele- 
 vated wall-like periphery. Actual tumors are few in 
 number. The flat, slowly extending new growth is 
 often called "ulcus rodens," but anatomically it is a 
 genuine cancer of the superficies. 
 
 There are two points of election for the develop- 
 ment of palpebral earcinomata, first the inner canthus 
 where we have a junction of external skin and con- 
 junctiva. It is well known that such dermo-mucosal 
 blendings (the margin of the lips, anus, palpebral 
 margin) are areas of predilection for carcinomatous 
 genesis. The second point of election is the external 
 derm of the eyelid. Carcinomata developing in the 
 first mentioned area are usually more malignant and 
 more rapidly and deeply destructive, whilst those de- 
 veloping in the palpebral derm are mostly benign and 
 therefore of the ulcus rodens type. 
 
 As regards localization the left side of the face is 
 more often affected than the right. It is also certain 
 that the neoplasm is much commoner on the lower lid 
 than the upper, and more apt to be found in the in- 
 ternal canthus and, as first remarked by Valude, in 
 the neighborhood of the lacrimal sac. Here the can- 
 cerous process penetrates deeply and rapidly, destroy- 
 ing the lacrimal sac, then eroding the lacrimal bone 
 
 51
 
 and extending to the nasal cavity, or, the tumor mass 
 pushes through the lacrimal duct into the nasal fossa. 
 
 Fig. 20 on Plate XVI. shows one of these flat dermal 
 cancers of the left upper lid about to pass over the 
 bridge of the nose to the other side. 
 
 The growth of a sxiperficial carcinoma on the eyelid 
 may be extremely slow, sometimes covering a period 
 of 20 or 30 years (Schulz-Zehden). 
 
 Such was the case of an old woman in the Home for 
 Incurables, of whom Dr. Schulz-Zehden (Berlin) kind- 
 ly permitted a wax model to be made, shown in 
 Plate XVII., Fig. 21. The cancer, extending from the 
 margin of the lid, had existed for many years. It had 
 excavated a deep hole in the left side of the face, 
 and the eyelids, the skin of forehead and cheek and 
 the bony margin of the orbits had entirely disap- 
 peared. The deep-simken, shriveled eyeball, in which 
 the cornea is distinctly seen, still remains. The pa- 
 tient had invariably refused operation, keeping the 
 eroded area covered with a moist cloth. Recently, 
 death occurred, and when we consider the many years 
 of its existence, the slow progress of the carcinoma- 
 tous growth is truly remarkable. 
 
 In other cases the nose and cheek are soon impli- 
 cated and upon them the growth progresses by contin- 
 uity. Occasionally, however, autopsy alone demon- 
 strates how extensively the adjacent organs and cav- 
 ities were involved. 
 
 Often the lymph glands remain unaffected for 
 a long period. Thiersch observed glandular involve- 
 ment in two instances only; Winiwarter, in 26 cases, 
 twice ; Mayeda in his series of 195 carcinomata of this 
 type, found eight glandular involvements, a percent- 
 age of 4.1. 
 
 In general, it may be said that the superficial type 
 does not develop carcinomatous processes in the 
 glands nor metastasis to internal organs. 
 
 52
 
 Fig. 21. 
 Carcinoma epitheliale palpebrariini 
 
 man Company. New York.
 
 Etiologieally, we need only remark that cancer in 
 this region frequently arises from constant irritation 
 or rubbing of warts ; also from small wounds, cauter- 
 ization, removal of vesicles, nodules, etc., and possibly 
 from lupus. 
 
 The beginning of the trouble is well described by 
 Unna: "Ulcus rodens commences as a rose- red or 
 pearl-gray nodule the size of a mustard seed, rising 
 a millimeter or less above the surrounding surface, 
 with very slow peripheral extension and the develop- 
 ment of a central depression. Thus, there are found 
 areas, apparently but not actually cicatrized, of a 
 gray-yellow or gray-red color, the size of a pea or cov- 
 ering an area equal to that of a dime or quarter-dollar, 
 sometimes oval in contour, flat and lying in the plane 
 of the healthy skin or slightly depressed, and limited 
 by a delicate, ridge-like margin of the color of mother- 
 of-pearl, from which frequently arise minute nodular 
 thickenings. Any general thickening of the derm or 
 any peripheral inflammation is not cognizable. Even 
 in this stadium of nodular development, slight trau- 
 mata of various parts of the nodule, usually the central 
 portion, result in desquamation of the stratum cor- 
 neum, and a dark crust or scab, formed of bloody se- 
 rum and a new stratum corneum, develops. Left to 
 itself, this crust falls off, after which the affection 
 has its original cicatrized appearance. Repeated 
 desquamation of the stratum cornemn finally leads to 
 permanent ulceration, and thus the second or ulcera- 
 tive stadium begins." 
 
 Therapy is operative, followed eventually by a 
 plastic operation upon the lid. 
 
 Recently, cures with the Finsen light have been ob- 
 tained. 
 
 For amelioration of pain, the ulcerated areas are 
 covered with bandages spread with unguent. 
 
 53
 
 Dacryocystitis. 
 
 Plate XVIII., Figs. 22 and 23. 
 
 Inflammation of the lacrimal sac seldom follows a 
 lesion or infection of the conjunctiva but is often due 
 to some ascending nasal affection, to stasis and de- 
 composition of the lacrimal fluid above a stricture or 
 to lesion of the adjacent bony structures. 
 
 Most commonly as a result of stricture below, the 
 mucosa of the lacrimal sac will produce abundant pus 
 which flows backwards into the eye, thus presenting 
 a well known phenomenon which may long continue 
 without externally visible inflammatory symptoms of 
 importance. 
 
 The best name for the malady is, therefore, dacryo- 
 cystitis chronica and not dacryocystoblennorrhea. If 
 only the unfortunate term, blennorrhea of the eye- 
 applied to the most heterogenous affections — could be 
 dropped! Nowadays, we are accustomed to differen- 
 tiate etiologically, and this should be done whenever 
 possible. It is anything but conmiendable to Imnp 
 together trachoma, gonococcal infection, pneumo- 
 coccal infection, and pus in the lacrimal sac under the 
 rubric of blennorrhea. 
 
 The chronic lesion of the lacrimal sac often does 
 not betray itself externally save that pus is frequently 
 seen in the eye. If, however, pressure is made upon 
 the lacrimal sac in the inner canthus where it is 
 crossed by the ligamentum canthi internum, it will be 
 seen suddenly, that quantities of thick -pus are exuding 
 from the puncta lacrimalia. 
 
 54
 
 eff, Atlas. 
 
 Tab. XVIII. 
 
 Fig. 22. Dacryo - Cystitis acuta 
 
 Fig. 23. 
 
 Dacryo-Cystitis witli Fistula. 
 
 1 Company, New York ,
 
 The extreme virulence of this pus from the lacrimal 
 sac was known long before bacteriologic investiga- 
 tions were invented. It was known also that the intact 
 eyeball might be long exposed to the regurgitant pus 
 from the lacrimal sac without suffering noticeable in- 
 jury, until some minute lesion of the cornea permitted 
 its entrance. Then a white speck developed upon the 
 injured superficies of the cornea, a bacterial coloniza- 
 tion, from which an ulcus serpens had origin. 
 
 In pus from the lacrimal sac, extremely virulent 
 pneumococci are usually found, sometimes in almost 
 pure culture. 
 
 Such chronic lesion of the sac may also be tubercu- 
 lous, tubercles or tuberculous ulcers developing in the 
 walls of the cavity. 
 
 It is likewise frequent in chronic trachoma, tracho- 
 ma follicles being found in the sac walls. 
 
 Therapy. This should, above all else, be directed 
 against the often etiologic nasal lesion. To cure af- 
 fections of the lacrimal sac and duct, the pus in the sac 
 must be frequently evacuated by pressure with the 
 finger. Then the superior or inferior punctum lacri- 
 male must be slit or enlarged (with a Weber knife) 
 and, after the introduction of an Anel syringe, irriga- 
 tion, first with disinfectant and then with astringent 
 solutions, should be practiced, the fluid running 
 through the nose and into the mouth. If these injec- 
 tions show that the ductus naso-lacrimalis is perme- 
 able, but constricted in places, Bowman's sounds may 
 be used in gradual dilatation. 
 
 If the duct be completely obliterated or if the use 
 of the sounds be ineffectual, the radical operation or 
 removal of the sac is indicated. 
 
 Congenital Lesions of the Lacrimal Sac. 
 Not rarely, pus flows from the lacrimal sac a few
 
 days after birth. The source of the purulency is easily 
 overlooked, and the diagnosis made of blennorrhea 
 neonatorum, gonococcal in etiology. This condition is 
 often seen in children with congenital lues, and the 
 suppuration may be caused by a neighboring osseous 
 lesion. An antisyphilitic medication often suffices for 
 the cure of the trouble. But there may be merely a 
 simple retention in the lacrimal canal, an occlusion in 
 the direction of the nose, and no real blenorrhea, in 
 which case a single forcible pressure upon the dilated 
 sac may open the channel and cause the recurrent pus 
 to disappear. 
 
 Acute Dachyocystitis. 
 
 The syndrome is quite different when, from any 
 cause, the pus breaks through the wall of the sac, for 
 then it quickly spreads through the loose adjacent tis- 
 sues, the lids swell edematously and soon we have a 
 simple, subcutaneous furuncle in the center of which 
 lies the dilated lacrimal sac. 
 
 A case of this sort is seen in Plate XVIII., Fig. 22, 
 to which the name, acute dacryocystitis, is given (ana- 
 tomically, it would be called a pericystitis or cystitis 
 with rupture). 
 
 Diag'nosis must establish where, in the often 
 marked and extensive tumefaction which may attack 
 both eyelid and cheek, the induration is located, which, 
 if pressed upon, causes pain. It is noticeable that in 
 the region of greatest swelling there is frequently a 
 deep horizontal furrow above and below which are two 
 turgid red elevations {vide Fig. 22). The furrow is 
 caused by the ligamentum canthi internum originating 
 in the inner canthus, passing over the lacrimal sac 
 and inserted into the lacrimal bone. 
 
 Therapy. Warning is given against the use of 
 injections or of sounds during the stadium of inflam- 
 
 56
 
 mation, the result of which would be extension of the 
 infection elsewhwere. The lesion should be treated as 
 a furuncle, using warm compresses and poultices and 
 finally making a wide incision. 
 
 If not dispersed, the pus at last breaks through the 
 external skin and flows out {vide Plate XVIII., Fig. 
 23), after which the lesion usually heals. If the sup- 
 puration still continue, it is commonly due to caries of 
 the lacrimal bone. The wound must then be widely 
 opened, curetted, and packed with iodoform gauze. 
 
 After the healing up of all these processes, there 
 may still remain fistulae of the lacrimal sac. 
 
 57
 
 Normal Conjunctiva 
 Palpebrarum. 
 
 Plate XIX., Fig. 24. 
 
 The conjunctiva forms a sac or bag slit open along 
 the line of the palpebral fissure, at the margin of 
 which it is transmuted, without demarcation, into 
 ordinary skin. In the conjunctival sac three areas are 
 distinguished, viz.: 1, the C. palpebrarum; 2, the du- 
 plication or fold, C. fornicis; 3, the C. bulbi or scler*. 
 
 The C. palpebrarum alone has the properties of 
 true mucosal tissue, and hence we find that mucosal 
 lesions, e. g., infections such as gonorrhea, diphtheria, 
 etc. as well as follicular affections, develop only in the 
 conjunctiva palpebrarum. The C. bulbi is epidermal 
 in type, and, therefore, dermal lesions, e. g. eczema- 
 tous, are directly bulbar in location. 
 
 In Plate XIX., Fig. 24, is seen the conjunctiva tarsi 
 of the upper lid after eversion. The mucosa is pale 
 and smooth and beneath it, the glistening yellowish 
 Meibomian glands are distinctly visible. 
 
 58
 
 ircL'fl. Atlas 
 
 liil). .\l 
 
 Fig. 24. 
 
 Conjunctiva. Normal Condition. 
 
 Fig. 25. Conjunctivitis catarrhalis simplex. 
 
 Rebniail Company, New York.
 
 Conjunctivitis Catarrhalis, 
 
 Plate XIX., Fig. 25. 
 
 The conjunctiva is a delicate, sensitive tissue, be- 
 coming hyperemic and irritated from the least stimu- 
 lus, e. g. exposure to air, inundation with water or 
 the salty lacrimal secretion, entropium, etc. If the 
 irritation continue for some time or augment, there 
 develops an inflammation of the membrane, which 
 may exhibit the form of an acute or chronic catarrh. 
 The surface of the swollen and inflamed mucosa does 
 not long remain smooth; elevations and wrinklings 
 are soon in evidence and the conjunctiva presents the 
 appearance of a piece of finely granulated leather or 
 clipped velvet (a papillated appearance, vide Plate 
 XIX., Fig. 25), actually due to wrinkles and furrows 
 in the tumefied mucous membrane. 
 
 If these irregularities increase in volume, become 
 cockscomb-like, they are called papillary elevations, 
 and are to be carefully differentiated from follicles 
 {vide C. follicularis, infra). 
 
 Acute conjunctivitis is mostly due to an infection, 
 whence it may properly be termed, conjunctivitis in- 
 fectiosa. It is capable of transmission and sometimes 
 excites widespread acute epidemics {cf. in contrast, 
 the behavior of trachoma, often confused with this 
 affection). Recent baeteriologic investigation has 
 taught us that there are several species of acute, in- 
 fectious conjunctivitis, also differentiable clinically; 
 e. g. conjunctivitis caused by the pneumococcus, the 
 Morax-Axenfeld diplobacillus, the Koch- Weeks bacil- 
 lus, streptococci, etc. 
 
 59
 
 Chronic conjunctivitis is due either to external noxae 
 (dust, smoke, wind, cold) acting upon hypersensitive 
 membranes or is a sequela of acute infections. 
 
 Therapy. Our treatment is directed towards dis- 
 infection of the infected mucosa, and the lessening of 
 secretion and the enormous dilatation of the blood- 
 vessels by means of astringents. 
 
 Where secretions are dammed up, micro-organisms 
 multiply rapidly, and nothing is more senseless than 
 prolonged bandaging of an eye endeavoring to rid 
 itself of such products. On the contrary, we should 
 seek by frequent changing of compresses and by irri- 
 gation, to provide for unhindered secretion and its 
 removal. Since the conjunctiva bears well both the 
 action of cold and cauterizing agents, we choose cold 
 solutions (water, lead-water, boric acid, sublimate 
 1:5000, etc.) in order to profit by the synchronous as- 
 tringent effect of the low temperature. 
 
 Medicaments may be instilled guttatim into the con- 
 junctival sac, or, after eversion of the lid a thick 
 brush dipped into the solution may be passed over the 
 diseased area. The following drugs are commended: 
 zinc sulfur, % to 1 or 2% ; zinc sozoiodol, 1/2 to 1% ; so- 
 lution of alima 1% ; sod. sozoiodol, 3 to 6% ; resorcin, 1 
 to 2% ; acid, tannic, 1 to 2%. In purulent secretions, 
 the sovereign remedy is silver nitrate, 1/5 to 1% or its 
 substitutes (protargol, argentamin, albargin, etc.). 
 
 60
 
 iff, Atlas. 
 
 
 u 
 
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 o 
 
 man Company, New York
 
 Conjunctivitis Follicularis. 
 
 Plate XX., Fig. 26. 
 
 Another species of elevations on the conjunctiva 
 palpebrariun is the follicular. The follicles at first 
 resemble transparent vesicles ; later, and in malignant 
 forms, they look like frog-spawn or cooked sago 
 grains, and are composed of circumscribed aggrega- 
 tions of round cells underneath the epithelium. They 
 are, therefore, neoplasmic, comparable to lymph folli- 
 cles or lymphomata, and develop in the conjunctiva 
 from the most varied stimuli (chemical, thermic, bac- 
 teriologic). On the other hand, it must be empha- 
 sized that not every stimulus or irritation develops 
 these follicles, nor are they due to the intensity or pro- 
 longed action of the irritation but to its specificity. 
 Simple chronic catarrh, however long its duration, 
 never develops follicles; they are also absent in the 
 most violent conjunctival inflammations we know, viz. 
 gonococcal or diphtheritic infections. Contrarily, the 
 formation of follicles is noted in a large number of 
 conjunctival affections, plainly due not to infection 
 alone, but also to other irritations. The various spe- 
 cies of conjunctivitis may, therefore, be divided into 
 those beginning with the development of follicles, and 
 those where such formation is absent. 
 
 A certain percentage of children with, conjunctival 
 follicles are found in all schools, but the conjunctiva is 
 pale in color and normal and the condition causes no 
 trouble. In such cases, diagnosis of conjunctivitis fol- 
 licularis is incorrect, for there is no conjunctivitis. 
 
 61
 
 The chlorotic and anemic children have merely dilated 
 lymph vessels in the conjunctival superficies, — lymph- 
 ectasia. Follicles develop whenever numbers of indi- 
 viduals are crowded together in a heavy, impure air, 
 as in overfilled public schools, in schoolrooms espe- 
 cially, in orphan asylums, etc. All inmates of peni- 
 tentiaries and prisons show, post mortem, microscopic 
 follicles in the conjunctiva. That in such cases symp- 
 toms of conjunctival inflammation are usually absent, 
 is due, in my opinion, to the fact that, as a rule, it is 
 not a question here of infection, the phenomenon 
 being due to the irritant atmosphere, some authorities 
 attributing it to the ammoniacal vapors, others to the 
 anthropotoxin present, etc. 
 
 There are, however, plainly infectious but mild con- 
 junctivites in which follicles appear, but, generally, not 
 numerous, superficially located and chiefly iB the lower 
 lid. These follicles disappear without leaving scars. 
 
 Therapy. Sojourn in a pure atmosphere and ex- 
 ercise in the open air often suffice. The follicles so 
 often found in school children frequently disappear 
 spontaneously during vacation. In addition, the eyes 
 should be repeatedly washed, and compresses of 2-4% 
 boracic acid solution or leadwater applied. For in- 
 stillation, Forster's 2% solution of sod. biboracicum is 
 best. 
 
 62
 
 Fig. 28. Conjunctivitis trachomatosa 
 
 Fig. 29. Sklerosing Traciioma. 
 
 an Company, New York.
 
 Conjunctivitis Trachomatosa. 
 
 Plate XX., Fig. 27; Plate XXI., Figs. 28-29. 
 
 Trachoma is an infection locating in the mucosa of 
 the lid, and is indubitably a specific morbid entity, 
 whose cause we do not know with certainty. It is not 
 communicable to animals, though possibly transmis- 
 sible in mild form to the anthropomorphous apes. 
 
 Trachoma is distinguished by the formation of large 
 follicles which, accompanied by inflammation and 
 marked papillary tumefaction, constantly increase in 
 size and number and finally lead to necrosis and sub- 
 epithelial shriveling. 
 
 It is a world-wide disease, but its occurrence is not 
 symmetric, i. e. in regions free of trachoma are found 
 here and there larger or smaller areas in which cases 
 of trachoma are always numerous, so-called "tra- 
 choma islets." 
 
 Is it possible to differentiate with certainty tracho- 
 ma and follicular catarrh? In most cases, yes, though 
 at first not always without error, though diagnosis 
 may be invariably established by more extended ob- 
 servation. In follicular catarrh, we have absolutely 
 benign new- formations, usually with no adjacent in- 
 flammation, no reaction, no tumefaction, and which 
 do not lead to any notable swelling of fornices and 
 papillae, and which, in contrast to trachoma, prefer- 
 ably develop in a pale, anemic mucosa. Their lack 
 of malignancy is shown by the fact that they never 
 lead to destruction of mucosal tissue, but sooner or 
 later disappear spontaneously, leaving no trace of 
 their existence. 
 
 63
 
 It is very different with the trachoma granule. It 
 generally presents an entirely different appearance, 
 for, whilst the follicular granule is clear and pale, more 
 like a vesicle, the deeper-seated grannie of trachoma 
 soon becomes gray and discolored. The circumjacent 
 mucosa is deeply reddened, tumefied (so that the tra- 
 choma granule seems to lie deeper below the surface) 
 and the swollen fomices, when the lid is everted, roll 
 out as if enlarged and thickened. Very soon there 
 develop notable papillary proliferations, indicative of 
 the violent reaction excited by the powerful \'irus — 
 phenomena always absent in follicular catarrh. In 
 its course, the malignant character of trachoma is 
 made perfectly evident. The trachoma granule does 
 not, after existing for some time, return to a norm, 
 but is distinguished by its destructive action upon the 
 mucous membrane. It tends notably toward a meta- 
 morphosis of the mucosa into a tough, cicatricial tis- 
 sue and develops a sort of cirrhosis, similar to that 
 caused in lung, liver, kidney by certain inflammatory 
 processes, and because of this we get the common se- 
 quelae of trachoma. The cornea is often implicated 
 and pannus develops. 
 
 Trachoma is at the present time a pre-eminently 
 chronic disease, endemic in many regions, absent in 
 others. When endemic, it pursues its course, and, 
 probably has for centuries; one patient after another 
 is slowly infected, and, of a family of six, possibly 
 three are trachomatous, and, gradually, after months 
 or years, the others will be. The transmission is not 
 easily accomplished, and continual, prolonged associ- 
 ation with those infected, a common use of sleeping 
 places, towels, etc., are requisite. If an individual is 
 infected, it is often a long time before he notices the 
 slightest sign of inflammation, and it may be months 
 or years ere the process becomes malignant. Some- 
 
 64
 
 times, however, the disease, in rare and isolated cases, 
 runs a violent course. If a patient with bad trachoma 
 enter some institution, he usually infects, after some 
 months, a greater or less number of his comrades, and, 
 in this manner there gradually develops a small en- 
 demic. But, I have never found all the inmates of such 
 an institution affected, which is proof that even from 
 long and daily association infection need not follow. 
 Trachoma, therefore, is always present in regions 
 where it is indigenous; one individual after another 
 is slowly infected, whilst other cases recover, so that 
 the number of those diseased varies within certain 
 limits; some years perhaps less, other years, greater. 
 But, the report that a sudden outbreak of trachoma 
 has occurred, has invariably been proven false. Either 
 it was not trachoma, but rapidly spreading innocuous 
 catarrh accompanied by tumefaction, or some other 
 disease, or else in the regions where trachoma had ex- 
 isted for years, attention has been suddenly fixed 
 again upon the disease. 
 
 As insidious and chronic as is the progress of tra- 
 choma from patient to patient, so is its course, which 
 if not interfered with, may extend over years or even 
 a lifetime. Quite a number of cases finally recover. 
 But even the best treatment must cover months, and 
 be extremely energetic, if a sure and permanent cure 
 is to be attained. Relapses are very frequent. The 
 disease is one of the most malignant ophthalmic dis- 
 eases known, and, in common with blenorrhea neona- 
 torum influences largely the number of the blind. Still 
 greater is the number of patients who, while not en- 
 tirely blind, suffer greatly in later life from its se- 
 quel*. 
 
 What happens, finally, to the trachoma granule? 
 
 After long duration, there develops always in its 
 interior a sort of softening, and we find the large cells 
 
 65
 
 in the stadium of necrosis, the nuclei no longer stain- 
 ing, until at last there is left only a granular, crumbly 
 mass in which the original elements have vanished. 
 
 In many cases, the softening does not develop 
 equally throughout the contents of the follicle but 
 begins in foci, but commonly the central portion is 
 most affected. 
 
 The most typical illustration of the softened follicle 
 is the clinical picture of the so-called gelatinous tra- 
 choma (Stellwag). Here the follicular formations 
 stand so closely together that the single, softened fol- 
 licles merge into one jelly-like mass (Fig. 29). 
 
 According to Ralilmann, Addario and others, the 
 rupture of the follicle and exudation of its contents is 
 the natural termination. 
 
 In my opinion, the gradual resorption of the follicu- 
 lar contents is by far the more frequent and natural 
 process. This resorption is found, apparently, not 
 only when the contents are softened, but according to 
 clinical experience, in any stadium. Thus, we have 
 seen minute follicles, where there can be no possible 
 softening, gradually disappear in numerous instances 
 when treated medicamentally, in which cases there 
 was certainly no rupture and exudation of the con- 
 tents. 
 
 For the therapy of trachoma, consult pp. 69-70. 
 
 66
 
 Atlas. 
 
 T.ib. xxn 
 
 Fig. 30. Pannus trachomatosus. 
 
 Fig. 31. Fntropium and Triciiiasis tiirougli scar-tissue. 
 
 n Company, New York.
 
 Pannus Trachomatosus, 
 
 Plate XXII., Pigs. 30, 31 ; Plate XXIII., Figs. 32, 33. 
 
 The trachomatous process may pass from the con- 
 junctiva palpebrarum et fornicis to the cornea with- 
 out attacking the conjunctiva bulbi, and upon the cor- 
 nea develop the pannus trachomatosus, starting al- 
 most invariably at the corneal margin and usually 
 from the upper portion. Here are seen at first, small, 
 circumscribed elevations demonstrable only with a 
 magnifying glass, — minute but distinct points rising 
 above the corneal surface, sometimes attaining the 
 size of a poppy-seed. These solid nodules, gray-white 
 in color are follicles, circumscribed, subepithelial infil- 
 trations of clearly defined masses of Ijmiphoid cells. 
 If the nodules already lie in the transparent corneal 
 tissue, many of them may be seen surrounded by 
 slightly cloudy areola". Later, the nodules become 
 confluent, forming a soft, diffuse mass, rich in cells, 
 which, subepithelially, push forward from the superior 
 margin of the cornea across its transparent tissues. 
 Since tliis neoplasmic layer is not everywhere of equal 
 thickness, the overlying epithelium is humped up here 
 and there. As soon, however, as the layer has pro- 
 gressed a millimeter or more across the transparent 
 cornea, there begins, at its superior edge, a vascular 
 proliferation extending with it across the cornea but 
 always somewhat posterior to the zone of infiltration. 
 These blood vessels do not all extend meridianly to- 
 ward the center of the cornea, but are inclined rather 
 to run in parallel from above downward. 
 
 67
 
 According to the vascular development, the pannus 
 varies in appearance. A fresh pannus, with few of 
 these blood vessels extending downwards, is called 
 pannus tenuis; if they are numerous, pannus vascu- 
 losiis. Sometimes, the new tissue becomes so thick 
 and vascular that it appears like granulation-tissue 
 or raw flesh lying upon the cornea, and is then termed 
 pannus crassus or carnosus; less suitably, pannus sar- 
 comatosus. 
 
 With retrogression of the growth, the zone of infec- 
 tion first recedes and the blood vessels follow the vas- 
 cularity, thus always remaining longer in evidence 
 {vide Fig. 45). Because of this, the progressing and 
 retrogressing panni are always easily differentiated. 
 As soon as the pannus and the blood vessels have 
 somewhat passed the central point of the cornea, the 
 picture changes. The blood vessels no longer run 
 parallel from above but extend in all directions on the 
 corneal surface, in whose central portion they fre- 
 quently anastomose and form varicose swellings 
 {vide Fig. 46), and it is seen from their more indis- 
 tinct, bluish hue, that they now lie, in many areas, 
 deeper in the tissues. An old pannus, with connective 
 tissue metamorphosis, has usually but few blood-ves- 
 sels and these of diminished caliber: pannus siccus. 
 
 Cicatricial Trachoma. 
 
 Finally, and commonly after persisting for years, 
 the trachoma leads to a more or less extensive cica- 
 tricial contraction of the affected mucosa. The tarsus 
 is, as a rule, implicated later. Its tissues, at first 
 densely infiltrated, exhibit marked tumefaction, but, 
 in time contract, and we have a rigid, sclerotic invo- 
 lution (Plate XXni., Fig. 32). 
 
 The tarsal distortion is typical in all cases, i. e. there 
 is not equal curvature of the cartilage but a percep- 
 
 68
 
 Tab. XXIII. 
 
 CO ;i 
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 n Company, New York,
 
 tible notch in its middle portion. It is easily cognized 
 that the callous thickening of the conjunctiva is great- 
 est at a point corresponding to this notch, so that here, 
 in a fashion, the punctum fixum of the cicatricial re- 
 traction is located, because of which the two cartilage 
 margins are displaced by the retractive action of the 
 scar. Hence, the distorted, trough-like cartilage is, 
 because correspondent to the thickest portion of the 
 callous conjunctival cicatrix, more or less indented. 
 
 With the inward bending of the tarsus, the free 
 margin of the lid is also bent inwards, and there de- 
 velops entropium with its well known grave sequelae 
 (Fig. 31). 
 
 If, finally, the conjunctiva becomes so cicatrized, 
 that the cornea is no longer sufficiently moistened, the 
 entire surface of the eyeball becomes rough, dry, epi- 
 dermoid, a condition called xerophthalmus (Plate 
 XXIII., Fig. 33). 
 
 The tberapy of trachoma. We have medical, me- 
 chanical and surgical methods of treatment. Of medi- 
 caments, two are pre-eminently useful: silver nitrate 
 in 2% solution in new cases, particularly where the 
 secretions are copious, applied with a brush or swab; 
 and copper sulfate where the resorption of follicles is 
 desired. The latter is best used in the crystal form, 
 the so-called blue-stone or pencil, with which the en- 
 tire conjunctival surface is gently and equably stroked 
 once daily. Cold compresses are then applied, the use 
 of the stone being discontinued, if the ophthalmic con- 
 dition exhibits progressive irritation. If the patient 
 is not seen daily by the physician, instillation of a V^fc 
 solution of copper sulfate twice daily is prescribed, or 
 it may be used in the form of a 1% unguent. Many 
 physicians prefer Arlt's use of copper citrate, usually 
 as unguent, and now obtainable, under the name of 
 
 69
 
 cuprocitrol, in tubes of 1-5 grams, from the Schiirer 
 V. Waldheimschen Apotheke in Vienna. With a glass 
 rod some of this is rubbed once daily over the con- 
 junctival surface. It is less irritant than other ap- 
 plications, and, therefore, safer for the patient's own 
 use. 
 
 Iodine preparations are also frequently employed: 
 Tinct. iodi, 1.0, glycerine, 15.0 as collyrium ; iodoform 
 as dusting-powder or in unguent; pure iodine (V2-l%) 
 dissolved in glycerine and daubed with a cotton appli- 
 cation over the everted lids, or, a caustic pencil may 
 be made of pure iodic acid moistened with a very lit- 
 tle water until plastic, when it may be rolled on a glass 
 plate into pencil form, and with this, cauterization 
 may be performed about every third day. The pain 
 is intense, but soon passes off. 
 
 Of the mechanical procedures, that of Keinig is 
 worthy of mention. A cotton applicator is dipped 
 into a 1 :3000-5000 sublimate solution, and the cotton 
 rubbed vigorously over the diseased mucosa, repeat- 
 ing this every second day until the granules have dis- 
 appeared. 
 
 Operative methods have the advantage of greatly 
 shortening the duration of the disease, a desideratum 
 in epidemics. But, not all of them are radical, and it 
 is always advisable to follow with medicamental treat- 
 ment. With Knapp's roller- forceps, built on the plan 
 of a clothes-wringer, the new-formed trachoma gran- 
 ules may be expressed. In older, deeper infiltration, 
 excision of the fornices or of the tarsus is recom- 
 mended. 
 
 Trachoma is infectious, and preventive measures 
 are, therefore, to be prescribed- The, most dangerous 
 carriers of the contagium are dirty wash-water and 
 towels. 
 
 70
 
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 Company, New York.
 
 Conjunctivitis Conorrhoica. 
 
 Plate XXIV., Figs. 34-35; Plate XXV., Figs. 36-37; 
 Plate XXVI., Fig. 38. 
 
 Gonorrheal disease of the eye is chiefly caused by 
 infection from the exterior, a so-called gonorrhea by 
 contact, but, we have other types, and these ophthal- 
 mias may be classified as: 
 
 1. Gonorrhea by contact: 
 
 2. Gonorrhea by metastasis from other foci in the 
 body. 
 
 3. Gonorrhea where metastasis occurs to other 
 parts of the body, especially the articulations, nowa- 
 days so much observed and investigated by the sur- 
 gical staff. 
 
 Furthermore, ophthalmic affections due to a con- 
 tact gonorrhea are often divided into conjunctivitis 
 gonorrhoica neonati and hominis adulti, remembering, 
 however, that there is no qualitative difference be- 
 twixt them. Differentiation is, perhaps, advisable, 
 first, because of origin, secondly, because of prognosis. 
 
 Conjunctivitis Gonorbhoica Neonatorum. 
 
 Ophthalmic gonorrhea following birth is due to in- 
 fection from outside: a so-called contact-gonorrhea. 
 
 Neisser's gonococci enter the conjunctival sac dur- 
 ing birth and often, because of lack of cleanliness, 
 after birth. After brief incubation, varying, with the 
 severity of infection, from a few hours to days (com- 
 monly after 2-3, more rarely, after 4-5 days), the dis- 
 ease breaks loose. The lids become very red and 
 swollen, but chemosis is rare. Out of the palpebral fis- 
 
 71
 
 sure flows a secretion at first turbid, tlien wholly 
 purulent, in which, lying within the leucocytes or des- 
 quamated epithelia, are found, usually in pairs and 
 very numerous, the gonococci, not staining by Gram's 
 method. After some weeks the thick, creamy pus be- 
 comes thinner, and at last ceases. There is no chronic 
 conjunctivitis gonorrhoica. When there is stasis of 
 the pus it generally corrodes the corneal epithelium, 
 which then, in greater or less measure, disintegrates 
 by suppuration. After cession of the inflammatory 
 phenomena, the defect is hidden beneath an opaque, 
 whitish cicatricial tissue (Plate XXIV., Fig. 35). In 
 Fig. 35 in the upper part of the leucoma is a small 
 black line, an anterior synechia, i. e. after slight per- 
 foration of the cornea, a portion of the iris has fallen 
 forward and through and healed fast {vide also Fig. 
 55 on Plate XXXVIII., leucoma corneae totale, where 
 the destruction of the cornea was due to variola, ex- 
 actly similar in appearance, however, to that caused 
 by conjunctivitis gonorrhoica.) If the cornea be to- 
 tally destroyed by suppuration, a protective partition 
 is formed by the contraction of the freely exposed iris 
 across the pupillary area {vide Plate XXVI., Fig. 38), 
 but later, intraocular pressure drives this curtain for- 
 ward and we have a total staphyloma corneae {vide 
 Plate XIJ., Fig. 59). 
 
 If pus find its way into the interior of the eye there 
 develops, after long and violent inflammation, a grad- 
 ual wasting of the eyeball: phthisis bulbi {vide Plate 
 XXV., Figs. 36-37). 
 
 The conjunctiva is markedly red and swollen, the 
 papillae spring up in ridges or cockscomblike, but 
 there is never formation of follicles (as in conjuncti- 
 vitis follicularis or in trachoma), nor, after the dis- 
 ease has run its course, do we find cicatrices in the 
 conjunctival tissues. 
 
 72
 
 Allns. 
 
 Tab. XXV. 
 
 Fig. 36. IMithisis biillM incipiens. 
 Adhesion form of Keratitis. 
 
 
 '^m'' 
 
 m 
 
 Fig. 37. 
 Phthisis bulbi quadrata. 
 
 Comnanv Mpw Vnrlf
 
 Conjunctivitis Gonorrhoica Adultorum. 
 
 One might suppose that the eye of the adult was but 
 slightly sensitive to the gonococcal virus, and, ap- 
 parently, the supposition is supported by statistics. 
 In the large cities gonococcal urethritis is extraordi- 
 narily common, but the percentage of ophthalmic in- 
 fection is extremely small, perhaps not one in a thou- 
 sand individuals with urethritis gonorrhoica are ocu- 
 larly affected, so that it would seem true that the eye 
 has very slight receptivity. And yet the cases where 
 the eye has actually become infected disprove this. 
 This is due to the protection afforded the eyeball, mak- 
 ing infection difficult, and to the fact that the gono- 
 coccus is a very delicate and easily destroyed micro- 
 organism. 
 
 The fresh pus must be brought directly into the eye, 
 and even rubbing with the infected hand does not al- 
 ways infect the eye, for we are not in the habit of 
 touching conjunctival tissues, and on the derm, on the 
 skin of the lid, the gonoeoccus finds no point of attack. 
 At any rate, cases where the virus has actually got in- 
 to the eye, show its extreme sensitivity to the gono- 
 eoccus. 
 
 Conjunctivitis gonorrhoica in adults begins vio- 
 lently, much more so than in the newborn, and it is 
 important to know this. The numerous patients with 
 a urethritis gonorrhoica, and who know that the dis- 
 ease is transmissible to the eye, are in constant anx- 
 iety. If it happen that a few reddened blood-vessels 
 show in the eye, such a patient, naturally, is greatly 
 disturbed, for he suspects infection. Such individ- 
 uals are very numerous in the consultation room. And, 
 when we see a conjunctivitis with marked redness, we 
 can usually tell from its period of duration whether 
 it be gonorrheic or not. Gonorrheic phenomena do 
 not begin with redness and inflammation of the con- 
 
 73
 
 junctiva, but with extremely violent lacrimation, with 
 hourly aggravation of the symptoms, so that if in the 
 morning the tears were clear, at midday they are tur- 
 bid, and by night the gonorrheal picture, a wave of 
 pus rolling from the eye, is in evidence. When we 
 learn, therefore, that the symptoms were present yes- 
 terday or the day before, and still the characteristic 
 syndrome of a gonorrheic ophthalmia is not before us, 
 we may usually exclude an infection and pacify the pa- 
 tient. When such syndrome develops, we have the 
 marked swelhng and edema of the lids, the conjuncti- 
 val chemosis, and the specific trickling of pus from 
 the conjunctival sac. 
 
 In adults, the cornea is much more apt to become 
 affected than in the newborn, so that even the most 
 careful treatment is not always able to hinder an un- 
 fortunate termination. 
 
 Conjunctivitis Gonorrhoica Metastatica. 
 
 Besides the above-described conjimctivitis from con- 
 tact or direct infection, we have a conjunctivitis gon- 
 orrhoica metastatica, somewhat frequently observed 
 in modern times. As we have learned to recognize 
 affection of the joints as, not rarely, metastases of 
 gonorrhea, so the ophthalmic metastasis has been 
 often noted. The eye is peculiarly apt to metastases. 
 
 The picture of ophthalmia gonorrhoica metastatica 
 is entirely different from that induced by contact or 
 direct infection. We do not have the marked suppura- 
 tion ; we see merely a conjunctivitis with some circum- 
 jacent edema, and often an iritis, differing little from 
 any other iritis. In the great majority of cases also, 
 there are no gonococci found in the secretions. Ap- 
 parently, we are dealing with a mixed infection, for 
 we know that the plastic inflammations often present 
 in precisely this form of iritis are not due to gonococci. 
 
 74
 
 In short, we have in the eye a number of symptoms 
 found also in gonorrheic affections of the joints. 
 
 Finally, there are cases in which metastases to va- 
 rious parts of the body have proceeded from gonor- 
 rheic affections of the eye. 
 
 The prog'nosls of conjunctivitis gonorrhoica ne- 
 onatorum is favorable when the treatment is correct; 
 and the morbidity is almost always removed without 
 sequelae. Without treatment, the stagnating pus 
 erodes the cornea and more or less destroys it. 
 
 In adults, the result is not so certain, for even most 
 careful treatment does not always prevent corneal 
 lesion. 
 
 Prophylaxis plays a chief role. Adults with gonor- 
 rheic urethritis or a gleet are to be warned against 
 touching the eyes, and the hands should be thoroughly 
 cleansed with soap and water after each contact with 
 the pus. With the newborn, in suspicious cases, 
 Crede's method of instilling a drop of 2% solution of 
 silver nitrate into each eye is to be recommended, or 
 better, this too strong solution may be reduced to Va 
 per cent. Water used in bathing must not come in 
 contact with the eyes. 
 
 Therapy. Where but one eye is affected in 
 adults, the sound eye should be protected by a watch- 
 glass or a piece of mica held in place peripherally by 
 adhesive plaster. In treatment, silver nitrate or one 
 of its substitutes, protargol or argentamin, is best. 
 The classic method of von Grafe's school was a daily 
 painting over with a 3% solution, but I prefer a weaker 
 (Vio-V"'^'') silver solution with which the eye is fre- 
 quently irrigated during the day and the pus washed 
 out. In this procedure, all friction must be avoided, 
 for the cornea may be easily injured (particularly 
 by unskilled hands), with serious results. A piece of 
 
 75
 
 cotton wet with the solution, or a vial with slit cork 
 should be held at a distance from the eye and the so- 
 lution allowed to driy) in betwixt the lids which are 
 simultaneously opened and closed, thus washing out 
 all pus. Where the lids are much swollen ice-com- 
 presses may be applied for one or two days only. 
 
 To avoid maceration of the cornea by the pus, many 
 authors commend one application daily of unguent. 
 Recently, the 5 or 10% Lenicet ointment (Dr. Eeiss, 
 Berlin) in original tubes, or Euvaseline (Eeiss) in 
 original packages has become quite famous. 
 
 Against leucoma corneae, all therapy is ineffectual. 
 If partial and in the center of the cornea, one may, by 
 excision of a side of the iris (optic iredectomy) to- 
 gether with the cicatricial turbidity, form an artificial 
 pupil {vide Plate XXIV., Fig. 35). For a better cos- 
 metic effect, the white spot may later be tinted black 
 with Chinese ink. 
 
 76
 
 Fig. 38. 
 
 Conjunctivitis g-onorrhoica adultorum. 
 
 Prolapsus iridis totalis. 
 
 Fig. 39. 
 Pterygium und Pinguecula. 
 
 ebinan Cotnpany. New York.
 
 Pinguecula, Pterygium. 
 
 Plate XXVI., Fig. 39. 
 
 Pinguecula (Lidspaltenfieck) belongs with the se- 
 nile degenerations. In the region of the triangular 
 portions of the conjunctiva bulbi lying on each side 
 of the cornea when the eye is open, there develop in 
 time thickenings of the conjunctival tissues which 
 gradually become straw-colored elevations. Their 
 evolution is favored by weather disturbances, living 
 in an atmosphere of smoke and dust, by a hot, sun- 
 struck climate, etc. 
 
 As the name denotes, it was formerly believed that 
 the Pinguecula was composed of fat (pingue, fat), but 
 it is actually a hypertrophy of elastic tissue associated 
 with granular pigment. 
 
 Progrnosis. The growth has no significance, and 
 merely disfigures. Sometimes its appearance greatly 
 terrifies the patient or his family, and hence it is im- 
 portant to recognize the nature of the phenomenon. 
 It needs no therapeutic intervention. 
 
 From Pinguecula, a pterygium may develop. 
 
 Pterygium is a triangular fold of mucous mem- 
 brane, growing horizontally from either side of the 
 conjunctiva bulbi toward and over the cornea. The 
 blunt apex of the triangle lies in the transparent cor 
 nea to which it is firmly and immovably attached. 
 
 In a pterygiimi, we differentiate the head or blunt 
 apex, then the thin neck, and, finally, the broad body 
 lying upon the sclera. 
 
 77
 
 It grows gradually and without inflammation across 
 the cornea and is rich in blood-vessels. Usually, it is 
 progressive and in the course of years may reach and 
 pass beyond the center of the cornea. It is found in 
 elderly individuals and is more common in hot cli- 
 mates than with us. Pterygium evolves from a Pin- 
 guecula. The latter begins to grow suddenly toward 
 the cornea, and pulls after it a flap of conjunctival 
 tissue. 
 
 Prog-nosis. Pterygium causes visual disturb- 
 ances as soon as it enters the corneal field and when 
 it covers the pupil entirely, the eye becomes practi- 
 cally blind, though able to cognize light. As, com- 
 monly, it is progressive, the prognosis is unfavorable 
 unless the growth be removed by operation. 
 
 Therapy comprises the ablation of the growth 
 and suturing of the conjunctival wound. This should 
 be done as early as possible, for the corneal area af- 
 fected by the ablation will never regain its smooth 
 surface. 
 
 Hence, after the removal of far-advanced ptery- 
 gium, there always remain disturbances of vision. 
 
 78
 
 ff, Atlas. 
 
 Till) XXVU. 
 
 Fig. 40. 
 Conjunctivitis diphtherica. 
 
 oiiipaiiy, Xtw York.
 
 Conjunctivitis Diphtheritica. 
 
 Plate XXVII., Fig. 40. 
 
 Infection of the conjunctival tissue with the Klebs- 
 Loffler bacillus we term conjunctivitis diphtheritica. 
 
 Von Grafe was acquainted only with the grave, 
 deeply penetrating, necrosing form of ophthalmic 
 diphtheria, which usually begins with corneal impli- 
 cation. Later, a mild, superficial form, accurately 
 differentiated, however, from the true form, was de- 
 scribed as croup of the conjunctiva. These nosologic 
 viewpoints were altered only by the discovery of the 
 active cause, for in 1886 the diphtheria bacillus was 
 first demonstrated by Babes in conjunctival diphtheria 
 (Prager med. Wochenschrift, 1886, Nr. 8). 
 
 Still later, the bacillus was also found in the mild, 
 superficial form. To-day it is certain that both forms 
 should be classified imder the head of conjunctivitis 
 diphtheritica. We must, therefore, in every conjuncti- 
 vitis with superficial, pseudo-membrane and of benign 
 course, harbor the suspicion that we are dealing with 
 diphtheria. I say, "harbor the suspicion," for we 
 cannot be clinically sure without a bacteriologic ex- 
 amination, for gonococci and, even more frequently, 
 streptococci may form membranes. And, conversely, 
 virulent diphtheria bacilli may develop merely a sim- 
 ple conjunctival catarrh (simple catarrhal form) with- 
 out the formation of a membrane. We thus see the 
 importance of bacteriologic examination. 
 
 Why the virulent bacilli develop now a benign, su- 
 perficial morbidity, and again, one deeply penetrating 
 and necrotogenic, we do not know. 
 
 79
 
 Id most ophthalmic diphtherias, the diphtheria ba- 
 cilli are not found in pure culture, but mixed with 
 staphylo- and streptococci, and finally, with avirulent 
 xerosis bacilli (pseudo-diphtheria bacilli). It ap- 
 pears, however, that these mixed infections have no 
 influence upon the course of the disease. 
 
 Diag'nosis in the superficial form is not easy, for 
 staphylo- and streptococci as well as slight cauteriza- 
 tions occasionally develop membranes. Demonstra- 
 tion of Loffler's bacillus renders the diagnosis certain. 
 
 Prognosis is always dubious. Many cases 
 recover unharmed, but even the mildest type may sud- 
 denly become malignant, destroying the cornea, de- 
 veloping gangrene of the lids, or, by general infection, 
 threatening life. 
 
 Therapy. Immediate isolation. Injection of 
 Behring's serum beneath the skin of the abdomen or 
 the eyelid. Frequent cleansing of the conjunctival sac 
 with sublimate 1 :5000 or potass, perm. 1 :5000. 
 
 Membranes and coatings are to be removed only 
 when this can be accomplished by a gentle brushing, 
 and forcible divulsion of deep-lying membranes is to 
 be avoided most carefully. 
 
 80
 
 Tab. XXVlll. 
 
 Fig. 41. 
 Blepharitis and Conjunctivitis eczematosa. 
 
 m Coiiipany, New York
 
 Tab. XXIX. 
 
 Fig. 42. 
 
 Conjunctivitis and Keratitis phlyctaenuiosa. 
 
 Eczema faciei. 
 
 nn Company, NcwYork.
 
 Conjunctivitis and Keratitis 
 Phlyctaenulosa. 
 
 Plate XXVIII., Fig. 41 ; Plate XXIX., Fig. 42 ; Plate 
 XXXII., Fig. 47. 
 
 The above disease boasts a numerous array of syn- 
 onyms. Besides conjunctivitis phlyctaenulosa we have 
 C. eczematosa, C. scrofulosa, C. lymphatica and kera- 
 titis superficialis. 
 
 The disease is characterized by an eruption of 
 phlyctenules, i. e. eczema pustules on the surface. 
 These are cone-like elevations of the epithelium about 
 the size of a millet seed, and their favorite location is 
 the corneo-scleral boundary of the margin or limbus. 
 where they are apt to develop in rows {vide Plate 
 XXIX., Fig. 42). Soon a number of superficial blood- 
 vessels are seen extending toward the growth, and 
 these develop likewise in the superficies of the cornea 
 after the appearance of phlyctenules in that region 
 (Plate XXXII., Fig. 47), in which case the lesion is 
 called : keratitis fasicularis. 
 
 After a somewhat brief period, the phlyctenules 
 rupture, i. e. the apex of the cone falls off, and we have 
 left small gray ulcers which heal rapidly and become 
 covered with epithelium. The disease may pass 
 through these phases within 3-4 days. Commonly, 
 there is also present an eczema upon head or face. As 
 a rule, the basic factor in the disease is scrofulosis. 
 
 Progri^OSis. The individual phlyctenule may run 
 its course rapidly and safely, but relapses invariably 
 
 81
 
 occur as long as the primary disease remains untreat- 
 ed. If the phlyctenules persist, they cause corneal in- 
 filtration which heals cicatricially, the scar being 
 termed a macula comeae. 
 
 Therapy must first take into consideration the 
 underlying scrofulosis. Diet, iron, cold baths, -brine 
 treatment, living in the open air and all the hygienic 
 measures suited to scrofulous children. Since obstipa- 
 tion often exists, the treatment should begin in children 
 with the internal administration of calomel, after 
 which the eczema of the head, nose or ears, or on the 
 face should be handled. Otherwise, relapses occur 
 {vide Therapy, page 40). Once daily, application of 
 unguentum flavum (hydrarg. oxid via humid, parat 
 0.1 : vaselin. flav. 10.0) should be made to the area af- 
 fected, spreading it over the surface by movements of 
 the lids. In the later stages, the cicatricial cloudiness 
 of the tissues may be cleared up by insufflation of the 
 finest calomel powder. 
 
 82
 
 recff, Atlas. 
 
 Tab XXX. 
 
 Fig. 4;'). Conjunctivitis vernalis. 
 Ciianges in tiie Conjunctiva. 
 
 Fig. 44. Conjunctivitis vernalis. Changes in the Limbus. 
 
 ri Company, New York.
 
 Conjunctivitis Vernalis. 
 
 Plate XXX., Fig. 43 and 44. 
 
 Conjunctivitis vernalis or spring catarrh is a some- 
 what rare disease, affecting chiefly the male sex in 
 youth. The disease begins in spring-time, usually in 
 both eyes, and after some months disappears or be- 
 comes milder. It continues thus, with relapses, for 3 
 or 4, even 10 and more years. 
 
 Those afflicted are greatly annoyed by itching and 
 burning in the eyes. 
 
 There are two very characteristic anatomic changes 
 in conjunctivitis vernalis; the first above the tarsus 
 of the upper lid, the second at the limbus corneae. At- 
 tacks may occur where only the one or the other 
 change is present, and many authors therefore differ- 
 entiate a palpebral form and a bulbar form. Usually, 
 however, both conditions develop, and these are the 
 characteristic cases. Others do not exhibit these typ- 
 ical anatomic insignia, but we find the conjunctiva in- 
 jected and with an equally distributed thickening. In 
 such cases diagnosis may be arrived at only by the 
 history. 
 
 In palpebral tissue-changes, the conjunctiva tarsi 
 exhibits broad but flat papills which, when numerous, 
 give this part of the lid the appearance of being set 
 with small cobblestones. These papill?e often have a 
 diameter of several millimeters, an elevation some- 
 what less. They have a rounded periphery, unless 
 pressed flat and angular by neighboring growths; the 
 superior surface is flattened from above, or even some- 
 
 83
 
 what concave. The papillae feel hard to the touch. 
 Homer fittingly compared the growths to colonies of 
 mould. Sometimes they are of the density of car- 
 tilage. The conjunctiva above the excrescence and ad- 
 jacent to it, has a peculiar, blue-white, milky shim- 
 mer, so that its surface appears pallid rather than in- 
 flamed. The "mushrooms" are soon present in large 
 numbers, sometimes crowded together, sometimes iso- 
 lated, thus giving the impression of having been 
 rubbed off, their primary seat distinguished only by 
 the delicate furrows left. 
 
 The conjunctiva of the lower lid is, as a rule, only 
 thickened, without furrows, and of the same pallid, 
 milky appearance, whilst tissue alterations of the for- 
 nices, violent inflammation and follicles are lacking. 
 
 The changes in the conjunctiva bulbi are much more 
 conspicuous and earlier observed. Correspondent to 
 the palpebral fissure, we note some of the peripheral 
 blood-vessels approaching the limbus corneae, and in 
 the limbus itself are found hard, knobby elevations of 
 a bluish-white tint, and found mostly situate on the 
 internal and external margin of the cornea. They 
 may also be seen as a narrow band of thickened, gel- 
 atinous consistency encompassing the entire limbus. 
 Sometimes the elevations are flattened, and may per- 
 sist for years; in other cases, nodular tumors are de- 
 veloped from them. 
 
 Anatomically, we have not a syndrome of conjunc- 
 tival inflammation, but a purely hypertrophic process 
 in the areas affected. The epithelium, in particulate, 
 is much thickened, giving to the conjunctiva its macro- 
 scopic, bluish-milky luster. Superficially, the eleva- 
 tions are usually three times thicker than the norm, so 
 that often there are as many as 30 cell strata superim- 
 posed, one upon the other. The epithelium also sends 
 cell-cords into the deeper tissue, cells in cords and 
 
 84
 
 nests with the formation of the most varied figures, 
 the syndrome reminding one of carcinoma, but not 
 penetrating so deeply into the tissues. 
 
 Diag-nosls. The disease may be sometimes con- 
 fused with trachoma, but the compactness of the ele- 
 vations, their pave-stone appearance, the milky shim- 
 mer permit its recognition. The diagnosis becomes 
 certain if we also have present the characteristic 
 thickening of limbus tissue. 
 
 The progrnosls is favorable in that the disease 
 finishes its course without injury to the eye, but un- 
 favorable since no remedy is capable of abbreviating 
 the process. 
 
 Therapy. Strong cauterization of the affected 
 areas is to be shunned for it only aggravates the 
 condition. The use of a mildly astringent coliyrium, 
 as in conjunctivitis catarrhalis, is indicated here. A 
 xeroform or anesthesin dusting-powder or the instil- 
 lation of acid. acet. dil. 1 :1000 several times daily is 
 commended for the relief of itching. For the prolifer- 
 ations in the limbus, massage with 2 or 5% yellow pre- 
 cipitate unguent may be employed. 
 
 When the papillary proliferations become very 
 large, they may be removed with scissors or the gal- 
 vanic platinum loop. 
 
 85
 
 Tumors of the Corneo-Scleral 
 
 Margin. Xeroderma 
 
 Pigmentosum. 
 
 Plate XXXI., Fig. 45. 
 
 Epibulbar tumors usually develop in individuals of 
 middle or advanced age, and begin almost invariably 
 in the corneoscleral margin, very seldom in the cen- 
 tral area of the conjunctiva bulbi. According to Vir- 
 chow, there occasionally appear deeply pigmented con- 
 nective tissue cells in the corneal margin, also small 
 black flecks (melanomata) composed of such cells, and 
 these are genetic in the formation of new growths. 
 Often no reason for their development can be discov- 
 ered; in other instances they follow some slight in- 
 jury or evolve from scar-tissue in the margin of the 
 cornea. Long-continued irritation, such as working in 
 a dust-laden atmosphere, is presumably favorable to 
 their genesis. In most cases, a pigment fleck in the 
 limbus conjunctivae is first seen, which slowly attains a 
 fungoid growth. Sarcomata usually have a smaller 
 stem or trunk, extend more superficially, are of soft 
 consistency, have many blood-vessels, and look like 
 more or less pigmented, reddish nodules. Carcino- 
 mata develop a wider growth. At first glance, they 
 often appear as if firmly and extensively attached to 
 the corneal surface, but a careful examination with a 
 blunt sound demonstrates that it is a mere superimpo- 
 sition and that, generally, there is no union of tissues. 
 
 86
 
 f, Atlas. 
 
 Tab. XXXI. 
 
 Fig. 45. 
 Xeroderma pigmentosum. Tumor epilnilbaris. 
 
 Cniiipaiiy, New York
 
 Progressing backwards, they unite with the conjunc- 
 tiva and with it are movable over the eyeball, a sign 
 tLat the neoplasm has not penetrated deeply. 
 
 If the tumor be not removed, its periphery slowly 
 extends, attacks conjunctiva and cornea, and in time 
 forms an enormous neoplasm. 
 
 If patients come, as is commonly the case, with more 
 or less pigmented, fungoid tumors of the size of a len- 
 til or pea, the thorough removal of the neoplastic tis- 
 sue suffices. The nodule is severed with scalpel or 
 scissors, and its base cleaned up with the sharp 
 curette, followed by cauterization with the Paquelin. 
 A soft tumor is generally rooted in the superficial lay- 
 ers of the tissue. One should not fail to warn the pa- 
 tient of the malignancy of the growth and emphasize 
 the necessity of his appearing from time to time in 
 the consultation room. 
 
 In a number of cases, the removal of the timaor leads 
 to a cure, yet relapses occur in a majority of cases, 
 though these exhibit an extraordinarily slow growth. 
 With very large and extensive tumors, the exenteratio 
 orbitae or enucleation of the eye is, conditionally, com- 
 mended, though in such cases there has occurred me- 
 tastasis to the inner organs, and the patient dies from 
 exhaustion or tumor formation elsewhere. 
 
 Xeroderma. 
 
 By xeroderma pigmentosum we mean a peculiar 
 morbid syndrome first described by Kaposi (1870) in 
 his textbook on Diseases of the Skin. Altogether, up 
 to the present day there have been reported a little 
 over 100 cases, which is not many when we consider 
 that the growths are sometimes multiple, most apt to 
 be among members of the same family, and further 
 that, with the great interest aroused by a case, it is 
 unlikely that a single one has escaped publication. 
 
 87
 
 Some cases have also been reported several times by 
 different authors. 
 
 The disease is accepted by most authors as due to a 
 congenital pre-disposition, to which corroboration is 
 given by the fact that the morbidity in almost all of 
 the reported cases was found in children of the same 
 family, e. g. in one instance in seven brothers. And, 
 in single eases it aifected only children of the same 
 sex, in other cases both sexes were involved, facts sim- 
 ilar to those observed in other inherited diseases. In 
 our own cases, there were two brothers affected, in the 
 elder of which the disease was far advanced. But, 
 neither in our cases nor in those of others were there 
 any morbid conditions in the parents demonstrable as 
 having any definite relationship with the disease af- 
 fecting the children. Neither consanguinity, constitu- 
 tional or dermal conditions, nor even weakliness were 
 present. The children were bom with a normal derm, 
 but even in the first period of extrauterine life, the ini- 
 tial phenomena appeared. Under the action of the 
 sun's rays during the first, or, at most, the second 
 year of life, there developed on the exposed portions 
 of the body, face, neck, hands and forearms, on the 
 feet and legs of children going bare-foot, circum- 
 scribed, red spots which disappeared in a short time 
 with slight desquamation, but invariably reappeared 
 after further exposure to the sun. Lukasiewicz him- 
 self was able to observe a diffuse redness of the skin 
 as the initial stage of the disease. As often as his 
 little patient remained but a short time in the open air 
 on sunny days, there appeared after a few hours a 
 diffuse reddening and swelling of the diseased areas 
 of skin. The rubescence paled under pressure of the 
 fingers, which caused pain. There was no elevation of 
 temperature but a well-marked state of depression in 
 the patient. For a few days these symptoms were 
 
 88
 
 aggravated, then diminishing with slight degeneration. 
 There was frequent repetition of the above syndrome, 
 particularly in spring and summer, whilst in winter, 
 when the patient remained indoors, the eiythema never 
 made its appearance. 
 
 In typical cases, permanent alterations soon occur. 
 During this period, which may be termed the second 
 stadium, pigmentation sets in. On the exposed parts 
 of the body, numerous freckle-like spots develop, 
 whilst elsewhere pigmentation diminishes, so that 
 there are areas free of pigment and perfectly white. 
 Altogether, the pigmentation increases so that the af- 
 fected areas, compared to the normal skin, appear 
 brown and even black. 
 
 Further along in the disease, there is much vascu- 
 lar dilatation, usually in the form of small, flat but 
 numerous telangiectases, more rarely angiomatoid tu- 
 mors. 
 
 The skin, in general, becomes atrophic, smooth, and 
 the normal furrows and folds disappear. If a piece of 
 such skin be examined, there is found a degenerative 
 process analogous to that of senility in the sense of 
 an atrophy, a thinning and flattening of the papillsB 
 and their epidenn. 
 
 With this, we find, microscopically, a typical pene- 
 tration of the rete cells into the chronically altered 
 cutis, hyperplasia of the sebaceous glands and ectasia 
 of individual blood-vessels (Lukasiewicz). These fur- 
 nish the needful conditions for the development of the 
 last stage of the disease : multiple carcinoma. Here and 
 there, correspondent usually to folds of the skin, ele- 
 vations appear which develop into wart-like processes 
 so that often the brown-black areas of the affected 
 parts are wholly covered with them. From a greater 
 or less number of such nodules, there then develop 
 genuine epithelial carcinomata, which, though like 
 
 89
 
 other epithelial cancers, are steadily progressive, by 
 disintegration lead to enormous ulceration, or by rea- 
 son of the gradually increasing cachexia cause death, 
 though apparently without metastasis to internal 
 organs. 
 
 90
 
 iff. Atlas. 
 
 Tab. XX> 
 
 o 
 tr. 
 c 
 o 
 
 Eg 
 
 
 
 Rebin;in Company, New York.
 
 Lipoma Subconjunctivaie 
 Congenitum. 
 
 PiATE XXXII., Fig. 46. 
 
 This lipoma is a not very infrequent congenital tu- 
 mor, located in the external canthus beneath the con- 
 junctiva bulbi and between the insertions of musculus 
 rect., externus and the musculus rect. superior. With 
 the conjunctiva (somewhat thickened over the tumor), 
 it is easily movable upon the subjacent tissue. The lipo- 
 ma, commonly the size of a lentil or pea, has a yellow- 
 ish shimmer through the overlying conjunctiva. To- 
 ward the corneal side the tumor appears shorn off, 
 cliff-like, whilst on the temporal side it gradually flat- 
 tens and passes into the fatty orbital tissue. If the 
 lipoma be small, it may not be noticed at first glance, 
 and is first seen by a side-glance toward the nose. 
 Microscopically, it is composed essentially of hyper- 
 plastic fatty tissue. 
 
 Diagnosis of this lipoma is infallible, for no other 
 tumors are found in this region. 
 
 The prog-nosis is absolutely favorable. The tu- 
 mor may begin its growth at puberty, but is always 
 comparatively benign, though it may push out through 
 the palpebral fissure, and thus hinder exact approx- 
 imation. 
 
 Tberapy. If small, the tumor may be left to it- 
 self. It is better, however, to remove it, as it may 
 cause disfigurement. The extirpation of the fatty 
 mass after splitting the conjunctiva is simple and 
 need not be absolutely radical. 
 
 91
 
 Keratitis Parenchymatosa 
 Sive Interstitialis. 
 
 Plate XXXHI., Pig. 48; Plate XXXIV., Pig. 49-50; 
 Plate XXXV., Pig. 51 ; Plate XXXVI., Pig. 52. 
 
 (Synonyms: Keratitis interstitialis, profunda, dif- 
 fusa, syphilitica, uveitis anterior.) Parenchymatous 
 inflammation of the cornea is a distinctly characterized 
 disease, usually beginning and running its course in a 
 very typical manner. Exact knowledge of it is the 
 more important because it must always be considered 
 as a constitutional malady. Its appearance, therefore, 
 renders it the duty of the physician to make an accu- 
 rate and thorough examination of the patient, for, with 
 the commencing keratitis parenchymatosa as the first 
 symptom, there will almost invariably be found other 
 symptoms pointing to a hitherto latent constitutional 
 disease, in most cases syphilis hereditaria (keratitis 
 syphilitica or keratitis ex lue congenita). 
 
 As for the name given the disease, keratitis paren- 
 chymatosa is most- used, though not the best, for, of 
 course, all diseases of the cornea implicate more or 
 less its parenchyma. Keratitis syphilitica correlates 
 it with the etiology, but is not suited to all cases, and, 
 moreover, is not characteristic of direct lues, but only 
 of inherited syphilis. Keratitis profunda denotes 
 correctly that the morbid process is carried on in the 
 deeper layers, but corneal ulcers also penetrate the 
 deepest strata. Hence, keratitis interstitialis or kera- 
 titis diffusa would serve best for the equable, diffuse 
 
 92
 
 ecff, Atlas. 
 
 Tab. XXXllI. 
 
 Fig. 48. 
 Keratitis interstitiaiis. 
 
 in Company, New York.
 
 progress of the disease over the entire cornea, which 
 is perfectly characteristic. The recently justified 
 term, uveitis anterior, we shall discuss later. 
 
 The disease usually begins in one eye, though also 
 in both, with a delicate pericorneal injection, soon aug- 
 menting in intensity and immediately pointing to a 
 more violent and deep ophthalmic affection. Soon 
 there is noticed in some part of the cornea a turbid, 
 lusterless area, generally triangular in form, begin- 
 ning at the periphery and thence extending to the cen- 
 ter of the cornea. 
 
 The turbidity, observed with the naked eye, seems 
 uniformly gray, but with a lens or even by focal il- 
 lumination it is seen to be composed of a number of 
 small, whitish flecks. To this turbid area first discov- 
 ered, others are added which become confluent, and 
 finally implicate the entire oornea in the same manner. 
 The cornea looks like a piece of glass which has been 
 breathed upon or rubbed over with fat, and the deeper- 
 lying parts but shimmer through it or else are barely 
 discernible. In differentiation from superficial kera- 
 titis it is important to note that the corneal surface 
 exhibits no gross changes, no nodules, vesicles, etc., 
 nor indentations, epithelial defects or ulcers. But 
 with the lens we see that the epithelium is raised up in 
 many minute elevations equally distributed over the 
 whole corneal surface, giving it a finely granular ap- 
 pearance. This is beautifully seen with the kerato- 
 scope of Placido; nowhere are the concentric rings, 
 mirrored against the cornea, broken, but the circum- 
 ferences exhibit rounded margins or edges. 
 
 With the development of corneal turbidity, there 
 begins an extensive vascular proliferation in its tissue. 
 The new-formed vessels extending from the marginal 
 network stop at the limbus or pass just into it, form- 
 ing a reddish plaque around the cornea. The deeper- 
 
 93
 
 lying episcleral vessels, on the contrary, frequently 
 push into the deep corneal strata, their advance always 
 being a little behind that of the corneal opacity, with 
 whose progress, however, they advance further. In 
 mild cases, few blood vessels are found in the cornea, 
 and these are often imbedded in the opacity and diffi- 
 cultly seen. When the malady is more violent, the 
 vascular growth is steadily forwards until the entire 
 cornea is finally of a dirty, raw-meat hue. These 
 blood-vessels have a very characteristic appearance. 
 Whilst in pannus trachomatosus they usually twist 
 and interlace, here they pursue a direct course in par- 
 allel; even after dividing, the branches run directly 
 and in parallel toward the center, thus resembling the 
 hairs of a brush. 
 
 Simultaneously with the parenchymatous keratitis, 
 there develops a more or less noticeable involvement 
 of the uveal tract, varying from a simple hyperemia 
 of the iris to an intense irido-chorioiditis. The fre- 
 quent, almost invariable iritis is betrayed by the peri- 
 corneal injection, the swollen, discolored appearance 
 of the iris, and the tendency of the pupils to contract. 
 If, in this stadium, there be no artificial dilatation of 
 the iridic opening, intense cases will develop a perma- 
 nent posterior synechia and even occlusion of the 
 pupil. Even after the frequent instillation of atropin, 
 the pupil often exhibits the tendency to contract. If 
 one has the opportunity to use the ophthalmoscope at 
 the beginning of the disease whilst the cornea is yet 
 transparent, he will see in the anterior portions of 
 the fundus oculi, large, black spots, indicating a cho- 
 rioiditis or uveitis anterior. This chorioiditis would 
 probably be considered one of the most frequent phe- 
 nomena accompanying keratitis parenchymatosa, did 
 not the opacity of the cornea rapidly interfere with 
 ophthalmoscopic examination. 
 
 94
 
 f(. Atlas. 
 
 Fig. 49. Hutchinson's Teetii. 
 
 Fig. 50. 
 Rhachitic Teeth. 
 
 NTn,,, V^^I.
 
 In some cases, alterations of intraocular pressure 
 occur, it being occasionally lowered. Increase in pres- 
 sure is rare, and develops only after long continuance 
 of the disease. 
 
 Vision in this affection is always considerably les- 
 sened. Generally, the coarsest print cannot be read 
 and only motions of the hand are cognized. Both 
 the testing of vision and the examination of the eye 
 are hindered by the often violent photophobia and the 
 accompanying profuse lacrimation of the affected 
 eyes. In the initial stage of the disease, there are 
 often strikingly few subjective symptoms and no pain, 
 but later there is suflScient pain, though if the disease 
 be properly handled, the pains are not intense. Pho- 
 tophobia, as a rule, troubles the patient most. 
 
 To the disease syndrome, with its complications, 
 above described, may be added, according to the in- 
 tensity of the inflammation, a number of variations, 
 but the disease commonly presents enough of the char- 
 acteristic symptoms to make diagnosis easy. As con- 
 trasted with a superficial keratitis, one should note 
 that here we have no ulceration and almost never any 
 gross elevations of the corneal surface, so that in kera- 
 toscopic observation, though the contours of the circles 
 be not sharply defined, they are still concentric and 
 circular. Furthermore, the general habitus of the 
 patient aids in the determination of an extremely im- 
 portant differential diagnosis. Superficial keratitis 
 is, usually, a symptom of the scrofulous constitu- 
 tion with its nasal troubles, eczemas, glandular affec- 
 tions; parenchymatous keratitis is commonly a symp- 
 tom of hereditary lues. 
 
 Keratitis parenchymatosa almost always attacks 
 both eyes, not always synchronously but with a short 
 interval of time between ; more rarely there are inter- 
 vals of weeks and months. The disease usually de- 
 
 95
 
 velops between the 6th and 18th years of life. Ex- 
 ceptionally, individuals over 20 years of age have been 
 attacked, and these cases, as a rule, run an atypic and 
 milder course, and with them in rare instances, one 
 eye alone may be affected. The disease commonly ap- 
 pears in pallid, unhealthy children who appear badly 
 nourished. 
 
 Etiolog*y. The disease is never a local affection. 
 Formerly, it was classified as keratitis lymphatica seu 
 scrophulosa and Hutchinson was the first to declare it 
 due, as a rule, to hereditary lues. At the same time, 
 he called attention to another symptom often found 
 with it and considered as a certain indication of exist- 
 ent hereditary syphilis, viz. Hutchinson's teeth {vide 
 Plate XXXIV., Fig. 49). 
 
 By Hutchinson's teeth we mean a dental form where 
 the two middle upper incisors of the second dentition 
 have, instead of a straight cutting-edge, a half-moon 
 notch or indentation and converging sides. This 
 notching of the free margin of the tooth is commonly 
 observable up to the 25th year, after which the cor- 
 ners are broken or worn off. With this typical form 
 are often found other dental abnormalities, e. g. ab- 
 normal smallness of the canines, wide intervals be- 
 tween teeth and irregular location and formation of 
 the teeth in general. 
 
 Such teeth are not to be confused with rachitic 
 teeth, in which we find horizontal furrows and ridges 
 and defective enamel {vide Plate XXXIV., Fig. 50). 
 
 With the two symptoms described, the interstitial 
 keratitis and the Hutchinson's teeth, there is most fre- 
 quently associated a third, vis. hard hearing, and this, 
 as a rule, without objective clinical cause. The three 
 phenomena form the so-called Hutchinson triad, and 
 they diagnose absolutely the existence of hereditary 
 
 96
 
 Greeff, Atlas. 
 
 Tab. XXX> 
 
 Fig. 51. 
 Rhagades on face in liereditary Lues. 
 
 ;bman Company. New York.
 
 CL'if, Atlas. 
 
 Tab. XXXVl. 
 
 Fig- 
 Head formation in 
 
 52. 
 iiereditary 
 
 I .lies. 
 
 n Company, New York .
 
 syphilis. I have, however, seen no case where the 
 Hutchinson triad was present and with it, other symp- 
 toms. 
 
 Arlt and Forster have called attention to a fre- 
 quently occurring affection of the knee-joint, either 
 preceding or following the disease. 
 
 Eecently, more attention has been given to the fre- 
 quent occurrence of articular troubles in hereditary 
 syphilis. According to Fournier, these were found 
 82 times in 212 cases. 
 
 The knee is most often affected, then the elbow, 
 more rarely, other joints. The articular inflamma- 
 tion generally precedes or develops with the intersti- 
 tial keratitis, seldom following it. The articular 
 trouble often develops on both sides of the body. 
 
 We are concerned here almost invariably with 
 serous effusions into the joints, usually sequent to 
 moderate, drawing pains and beginning without fever 
 or with but slight elevation of temperature. Accord- 
 ing to Fournier these articular troubles are dependent 
 upon affections of the bones, whilst other syphilo- 
 graphs hold that they may be primary synovites. 
 
 We should also note the state of the lymph glands, 
 the peculiar formation of face and skull (vide Fig. 52, 
 Plate XXXVI.), the often sunken nasal bridge (Fig. 
 48), an ozena perhaps present, blenorrhea of the 
 lacrimal sac, rhagades at the corners of the mouth or 
 over the entire face {vide Plate XXXV., Fig. 51), etc. 
 Together with the objective findings, the anamnesis 
 is important. Inquiry should be made concerning a 
 possible earlier infection of the parents, whether pre- 
 mature or dead children preceded the birth of the pa- 
 tient, whether many children died in infancy, etc. 
 
 Often a glance or two will establish the diagno- 
 sis ; often the most careful investigation and examin- 
 ation are necessary, and there will always be cases 
 
 97
 
 where hereditary lues cannot be considered. In such 
 cases, other diseases are etiologic, such as scrofula, 
 chlorosis, and above all, tuberculosis. Of rarer etio- 
 logic factors, we may mention articular rheumatism, 
 and finally, malaria and influenza. 
 
 Course. The disease runs a very slow course, its 
 briefest duration being several months and it is often 
 six months or a year before the inflammatory phe- 
 nomena subside and the opacities clear up. As an 
 average we may reckon on a half year. It is there- 
 fore recommended that the physician inform the pa- 
 tient of the possible duration of the disease and ad- 
 monish him to cultivate fortitude. And likewise, when 
 the disease begins in one eye, the patient should be 
 told of its rapid appearance in the other, lest he be 
 terrified at the new outbreak, and also that he may 
 not become suspicious of the therapy employed. 
 
 The prog'nosis, despite the fact that no medical 
 assistance can abbreviate or arrest the disease, is rela- 
 tively favorable. Even after long duration, the corneal 
 opacities usually clear up, the process commonly be- 
 ginning at the margin so that the center of the cornea 
 is the last to clarify. As a rule, the eye regains a fair 
 or, at least, endurable degree of vision, and rarely are 
 there any dense opacities left. 
 
 Tberapy must be local and constitutional. In 
 the beginning, warm, moist compresses commonly mit- 
 igate the symptoms of irritation and inflammation. 
 The compress is made by placing a large, moist piece 
 of absorbent cotton over the eye, then some gutta- 
 percha tissue followed by a gauze roller to keep the 
 compress in place. Renewal of the dressing once or 
 twice daily may be indicated. Another method of 
 attaining the same result is frequent irrigation or
 
 bathing of the eye with warm water. The warm, moist 
 compress is particularly serviceable at night when a 
 permanent bandage is required. The best solution 
 with which to moisten the cotton is a 2-4% boric acid, 
 the ancient household friend, chamomile tea is less 
 cleanly, and apt to carry dust particles into the eye. As 
 soon as iridic involvement is noted— and this is seldom 
 absent — the first and most important measure is the 
 repeated instillation of atropin (1%) until the pupil 
 dilates fully, a procedure which must be again prac- 
 ticed later in the disease. If these measures be neg- 
 lected, posterior synechia, possibly complete occlusion 
 of the pupil will surely ensue, and the eye will be per- 
 manently and seriously injured. Furthermore, the eye 
 should be well protected against the light by moderate 
 darkening of the room, and later, by a sun umbrella 
 and protective eyeglasses. 
 
 When there has been a long-continued, excessive 
 vascular development, a peritomy of the cornea has 
 been done, /. e. with a scalpel a circular corneal in- 
 cision through the blood-vessels has been made or else 
 a circular strip, 1-2 mm. wide, removed at the corneo- 
 scleral junction. Experience, however, has taught 
 us that the blood-vessels unite again after a time, and 
 a more violent state of irritation has so often followed 
 the operation that most ophthalmologists have aban- 
 doned it. If the inflammation have subsided, we en- 
 deavor to clear up the opacity by irritant measures, 
 such as : the insuflBation of calomel powder or massag- 
 ing with yellow ointment, which is used at the Berlin 
 University Clinic in somewhat less strength than that 
 originally prescribed by Pagenstecher. 
 
 As already emphasized, it is extremely important to 
 note the general constitution of the patient. In feeble 
 individuals a roboraut diet is indicated (good food, 
 eggs, meat, etc.) and iodine preparations are partic- 
 
 99
 
 ularly desirable (iodide of iron, cod liver oil with 
 iodine, iodine mineral waters). In the later stages, 
 living in the country, in good air, is to be strongly rec- 
 ommended. 
 
 In the numerous cases where hereditary syphilis is 
 etiologie, this, naturally, should receive first consider- 
 ation, using the ordinary remedies, mercury and iodide 
 of potash. 
 
 If tuberculosis be the specific cause or fundament of 
 keratitis parenchymatosa, the nutrition of the patient 
 should be first attended to. Internally, kreosote or its 
 active principle, guaiacol (which is less unpleasant to 
 the taste and better borne) is recommended. 
 
 Malaria, of course, demands the administration of 
 quinine, and, in the various forms of rheumatism, 
 treatment by sweating, together with sod. salicyl., as- 
 pirin, or light-baths. 
 
 100
 
 n 
 a. 
 
 ■ooZD 
 
 1) 
 
 o 
 
 
 b/j 
 
 I Company, New York.
 
 Ulcus Serpens Sive Hypopyon- 
 Keratitis. 
 
 Plate XXXVII., Figs. 53-54. 
 
 The normal epithelium of the cornea is so dense in 
 structure, that the common excitants of suppuration 
 are unable to gain entrance. Pus containing staphylo- 
 or streptococci cannot penetrate the intact cornea, 
 and even the virulent pus found in a dilated lacrimal 
 sac and in which pneumococci are chiefly found, may 
 constantly and for a long time flow over the eye with- 
 out causing any noticeable inflammation, the cornea, 
 at least, remaining unaffected. Gonococcal pus alone 
 is able to penetrate intact corneal epithelium, though 
 this takes considerable time, and is due to maceration 
 of the epithelium by stagnating pus. Other excitants 
 of suppuration require an artificial entrance for their 
 penetration into corneal tissue, and such entrance is 
 usually due to a wound, even if only a slight and super- 
 ficial abrasion. If pyogenic germs present in the con- 
 junctival sac, on or in foreign bodies, in the secretions 
 of the lacrimal sac then enter the wound, the colonies 
 which flourish luxuriantly beneath the epithelium 
 cause its desquamation and there develops what mod- 
 ern science most suitably terms a septic ulceration of 
 the cornea. It is characteristic of this lesion that there 
 soon develops in the anterior chamber a collection of 
 pus, called a hy|)opyon (whence the older nomencla- 
 ture, hypopyon-keratitis). Because of its pronounced 
 tendency to burrow rapidly and uninterruptibly be- 
 
 101
 
 neneath the epithelium, the name, ulcus serpens, is 
 very descriptive. 
 
 As soon as the ulcer has attained a certain growth, 
 iritis regularly sets in. 
 
 In Fig. 53 is seen the disk-shaped ulcer with its yel- 
 low, up-turned margin. The circumjacent cornea is 
 edematously opaque and misty. Below, in the ante- 
 rior chamber lies the narrow, sickle-shaped hypopyon, 
 and a commencing pericorneal injection denotes the 
 initiation of an iritis. 
 
 Fig. 54 shows an ulcus serpens which has destroyed 
 the greater part of the cornea. The hypopyon fills 
 more than half of the anterior chamber. There is a 
 slight palpebral swelling, and a marked pericorneal 
 injection denotes the existence of an intense iritis which 
 we are no longer able to observe directly. 
 
 Prog'nosis. Ulcus serpens, a frequent and se- 
 rious disease of the eye, will, if left to itself, lead 
 within a few days to permanent blindness. It is, there- 
 fore, a grave condition and the cause of much blind- 
 ness. After eating off the entire surface of the cor- 
 nea, the process commonly works downward until a 
 rupture occurs, after which it usually halts. The loss 
 of substance caused by it, is replaced with scar-tissue. 
 
 Tberapy. In many cases the source of infection 
 is in some diseased condition of the lacrimal sac, 
 which should be split open from the outside and tam- 
 ponned with iodoform gauze or else thoroughly ex- 
 tirpated, for the use of the sound is profitless. Every 
 two hours a few drops of undiluted and freshly pre- 
 pared aqua chlori should be poured upon the ulcer, 
 when, if it still advances, the platinima loop should be 
 used in cauterizing the edges. Application of iodo- 
 form powder follows the cauterization, or better, airol 
 in the form of a fine powder placed within the con- 
 
 102
 
 junctival sac where it forms a paste, soon hardening 
 to a firm crust over the ulceration. In far-advanced 
 eases the cornea should be obliquely split (method of 
 Samisch). 
 
 A pneumococcic serum has been manufactured lately 
 and used subcutaneously with success in ulcus serpens. 
 
 103
 
 LeucomaCorneae from Variola 
 
 Vera. 
 
 Plate XXXVni., Fig. 55. 
 
 Only the epithelium of the cornea regenerates and 
 becomes transparent again. After destruction of cor- 
 neal substance, there develops an opaque cicatrix of 
 various degrees of density and thickness, according to 
 the thickness of the lost substance. A delicate, super- 
 ficial, yet visibly gray scar is called a nubecula; a 
 thicker one, macula; a perfectly opaque, white scar, 
 a leucoma corneae. 
 
 This last form is either partial, as in Fig. 35, Plate 
 XXIV., or total, as in Fig. 55. 
 
 In many leucomas, a piece of the iris has become ad- 
 herent, forming a synechia anterior or leucoma ad- 
 haerens (seen in Fig. 35 above the black, streak-like 
 scar), a sign that perforation of the cornea has taken 
 place. 
 
 Therapy. In thick leucomas there is nothing to 
 be hoped for from therapeutics or from time. If they 
 cover the entire pupil, vision is lost save for a sense 
 of light. If partial, an artificial pupil may be inserted 
 in the remaining portion of the cornea (vide Fig. 35 >. 
 To lessen the disfigurement, India ink has been stip- 
 pled into the leucoma, thus simulating more the black 
 iridic aperture. 
 
 In slight corneal opacity, a certain degree of cure is 
 got through time alone. This may be accelerated by 
 irritants (insufiflation of calomel, pencilling over with 
 
 104
 
 eff, Atlas. 
 
 Tab. XXXVIII. 
 
 Fig. 55 
 Leucoma corneae totale.
 
 yellow mercuric oxide salve, 2-5%, and by hot va- 
 pors), to induce more rapid metabolism, but, such 
 therapy is suitable only tn fresh cases. Recently dionin 
 (5-10% sol., later in substance or powder form) has 
 been much recommended. 
 
 There are, also, congenital opacities; the corneae of 
 both eyes have a milky and sclerotic appearance. These 
 opacities are not defects of development, as formerly 
 believed, but the residua of a keratitis interstitialis in 
 utero e lue hereditaria. Treatment, then, must be 
 antisyphilitic. 
 
 A non-inflammatory, physiologic opacity is the arcus 
 senilis or gerontoxon corneae, appearing, sooner or 
 later, with advancing age. The opacity is character- 
 istic — a narrow, gray line, concentric with the corneal 
 margin. It almost invariably begins at a point in the 
 superior margin; then the lower margin develops a 
 similar bow or arch. With the further extension, the 
 superior and inferior sections meet at the inner and 
 outer sides, and the ring or circle of the arcus senilis 
 is complete. Its outer side is sharply marked and in- 
 variably separated from the limbus by a strip of trans- 
 parent cornea (vide Plate L., Fig. 74). 
 
 Prog'nosis. The arcus senilis is not a progress- 
 ive opacity, for when the circle is completed and has 
 attained a breadth of 1-2 mm. the process stops. 
 
 To the non-inflammatory corneal turbidities belongs 
 the girdle-like or ribbon-shaped opacity {vide Plate 
 XXV., Fig. 36). It is a broad, white band (2-4 mm. 
 in breadth) extending horizontally just below the mid- 
 dle of the cornea. A narrow, transparent line of nor- 
 mal corneal tissue separates the opaque band at its 
 two extremities from the corneal margin. It develops 
 slowly in the course of years and usually in eyes blind- 
 •ed by an insidious irido-chorioiditis. It is due to a 
 
 105
 
 deposition of lime salts following a disturbance of 
 nutrition in the cornea. 
 
 Therapy. There is none. As it generally devel- 
 ops in eyes already blind, it is a condition of no prac- 
 tical significance. 
 
 106
 
 ccff, Atlas. 
 
 a. 
 
 lO ^ 
 
 b£< 
 
 X 
 
 lO c 
 
 o 
 
 bi-S 
 
 binjii Company, New York.
 
 reeti, Alias. 
 
 lat). f 
 
 Fig. 58. 
 Buphthalmus. Cornea globosa. 
 
 I^tbMi;iri Company, New York.
 
 Ectasias of the CorncaB. 
 
 Plate XXXIX., Fig. 56: Keratoconus. 
 
 Plate XXXIX., Fig. 57 : Staphyloma corneae partial*^ 
 
 Plate XL., Fig. 58: Cornea globosa; Buphthalmia. 
 
 Plate X LI., Fig. 59 : Staphyloma cornese totale. 
 
 (a) Among corneal ectasias, staphyloma cornese 
 should be first mentioned. It is com])osed of a iiro- 
 lapsed, cicatrised iris, and, therefore, at its point of 
 exit, the cornea has been entirely destroyed, and the 
 intraocular pressure forces forward the yielding cica- 
 tricial tissue of the iris. We differentiate a staphylo- 
 ma partiale (Fig. 57) and totale (Fig. 59). At first, 
 and with small staphylomas, the black pigment of the 
 iris is predominant in the extruding mass, but later 
 the iris becomes so cicatrized and enlarged that the 
 staphyloma appears gray-white, traversed by dilated 
 blood-vessels. 
 
 Staphyloma is the end-product of a corneal sup- 
 puration. Its genesis is shown in the left eye of Fig. 
 38, Plate XXVI., where we see how, after destruction 
 of the cornea, there has developed a total prolapse of 
 the iris, which has already begun to buckle forwards. 
 
 Therapy. A partial staphyloma must be 
 removed. The open wound then closes usually with 
 firmer connective tissue than the delicate iridic tis- 
 sues are capable of producing. 
 
 After removal of a total staphyloma, the resulting 
 large wound is best sutured together, which, however, 
 leaves but the stump of an eye. 
 
 107
 
 (b) Keratoconus is a rare disease generally af- 
 fecting both eyes. Very gradually and with no in- 
 flammatory phenomena, the central portion of the 
 cornea begins to protrude forwards, cone-like. This 
 corneal area remains transparent for a long time, un- 
 til finally the apex of the cone, subjected as it is to 
 enormous dilatation, begins to develop opacity from 
 cicatrization. 
 
 The etiology of the disease is unknown. Because 
 of some disturbance of nutrition the central portion 
 of the cornea becomes thinner and hence so much the 
 less able to withstand the anteriorly directed intraoc- 
 ular pressure. 
 
 Therapy is rather impotent. In conjunction with 
 a strengthening diet, the instillation of a miotic (eserin, 
 pilocarpin) may be practiced for a long period to re- 
 duce permanently the intraocular pressure, though an 
 iridectomy for the same purpose is better The apex 
 of the cone may be destroyed by galvanic cautery in 
 order to obtain a more resistant cicatrix. 
 
 (c) Keeatoglobus-Buphthalmus. In keratoglo- 
 bus or cornea globosa, the transparent cornea in all 
 its parts is symmetrically thrust forward, so that in- 
 stead of its normal "watch-glass" projection from 
 the globus, its form resembles that of a "cover- glass" 
 used to protect cheese. It is only one of the phenom- 
 ena accompanying the general enlargement of the eye- 
 ball in hydrophthalmus or buphthahnus or the total 
 sclerectasia resulting from increase of pressure in the 
 eye of childhood, whilst the sclera is still yielding in 
 its structure (in the first years of life). We have, 
 therefore, an infantile glaucoma. 
 
 The nature of the disease, however, is not fully un- 
 derstood. Possibly it is due to a congenital misplace- 
 ment of the natural exits for ocular fluids. 
 
 108
 
 rcetf. Athis. 
 
 Tab. XI 
 
 Fig. 59. 
 Staphyloma orneae totale. 
 
 hiiiaii Company, New York.
 
 The eye is often enormously enlarged in its periph- 
 ery, and the attenuated sclera is bluish because of the 
 perlucence of the chorioid. Anteriorly, the enlarged 
 cornea, of a misty or milky-white opacity, stands out 
 like a cheese cover glass against the bulbus. The an- 
 terior chamber is, likewise, very deep. 
 
 Prog'nosis is most unfavorable, and, left alone, 
 the process gradually leads to absolute blindness, very 
 rarely halting in its progress. Anatomically, there is 
 a total glaucomatous excavation of pupil and globe. 
 
 Therapy. It is very advisable, to perform, as 
 soon as possible, a broad iridectomy or sclerectomy. 
 
 109
 
 Lepra. 
 
 Plate XLIl., Fig. 60; Plate XLIII., Fig. 61. 
 
 Lyder Bortlien emphasizes as an important phe- 
 nomenon, that the outbreak of the nodular form of 
 lepra almost always begins in the eyebrows. It is di- 
 agnostically valuable to know that the loss of the eye- 
 brows is the first, and sometimes for years, the only 
 sign of the disease. As initial symptom in the eye- 
 brows, the formation of nodules is more frequent than 
 diffuse infiltration. The eyelashes also are regularly 
 involved. The disease consists of the falling out of 
 the hair, or atrophy, partial or total. 
 
 The skin of the eyelids is frequently and early dis- 
 eased, either infiltrated or nodulated. The infiltration, 
 often edematous in appearance, may be synchronous 
 with that of the eyebrows, or, separated from it by 
 healthy skin, may occur along the margins of the lids. 
 
 In the lids, the nodes themselves are particularly 
 large, and most often located along the free palpebral 
 margin. It is peculiar that the lid-nodules may ap- 
 pear symmetrically on the correspondent eyelids. 
 
 The maculo-anesthetic type, i. e. blotches or spots, 
 is also often found in the eyebrow though not so fre- 
 quently as in nodular leprosy. 
 
 If, in the nodular type, an infiltrated area of the 
 skin of the eyebrow be excised and the humor pressed 
 out, the diagnosis may be rendered certain by demon- 
 stration of the lepra bacillus. 
 
 The disease seems to begin in the middle layers of 
 the skin, and usually in the center of the node a blood- 
 
 110
 
 reeff, Atlas. 
 
 Tab, XL 
 
 Fio-. 60. 
 Lepra. Keratitis punctata. 
 
 brn.Tti Company, New York
 
 Fig. 61. 
 Lepra. — Efiipulbar l.eprome. 
 
 ^brn.Tii Company, New York
 
 vessel, lymph-channel, often a capillary, is demon- 
 strable. The bacilli are, therefore, carried by both the 
 blood and lymph systems. Not rarely they are found 
 in the cells of the intima, seldom in the white cor- 
 puscles in the lumen of the blood-vessel. If capillaries 
 or small vessels are the points of nodule formation, 
 marked dilatation with hemic engorgement occurs with 
 the bacillary invasion. Infiltration of the tissues sur- 
 rounding the vessels develops late, and only when the 
 bacilli begin to flourish outside of the vessel. Then 
 there occurs an accumulation of emigrated leucocytes 
 and a great increase of nuclei through the prolifera- 
 tion of the fixed cells of the connective tissue. 
 
 Further growth of the node is accomplished by the 
 bacilli attacking the cells adjacent to the blood or 
 lymph channel. The leprous virus is by no means as 
 active as, for example, that of the tubercle bacillus, 
 wliich, in a comparatively short time, kills the cells. 
 Hence, in lepra nodes many bacilli can be seen in cells 
 of normal appearance and still retaining their power 
 of proliferation. This minimal tendency to destruc- 
 tion of cells permits leprous proliferations to take on 
 the appearance of veritable tumors (H. P. Lie). 
 
 Affections of the eyeball are frequent, in fact, al- 
 most the rule, in lepra, and the most common is a kera- 
 titis punctata or nodosa, in which small white or gray 
 nodules develop beneath the epithelium with very little 
 ophthalmic irritation {vide Fig. 60). The nodules are 
 chiefly composed of lepra bacilli. 
 
 A true keratitis parenchymatosa with iritis is not 
 infrequent. 
 
 Finally, the granulation-tumors described as on the 
 lids are also found as epibulbar upon the cornea, and, 
 as with other epibulbar tumors they extend outwards 
 from the limbus corneae. 
 
 Ill
 
 Scleritis. Sclerectasia. 
 
 Plate XLIV., Fig. 62 ; Plate XLV., Fig. 63. 
 
 In inflammation of the sclera we may differentiate 
 forms affecting only the superficial layers (epi- 
 scleritis) from a true scleritis, confined to the middle 
 and deep strata. 
 
 In the superficial form there is usually first found 
 a circumscribed morbid focus close to the cornea. The 
 area is puffed up, and forms a more or less steep hill- 
 ock or hump, at first dark-red and later more of a 
 blue or violet hue. It is hard to the touch, not mov- 
 able, and very sensitive. Toward it and through it 
 run dark-red, deep-lying (episcleral) blood-vessels, 
 and the injected conjunctiva covering it is movable. 
 The ocular surface elsewhere is almost non-irritable 
 (vide Fig. 62). 
 
 This infiltration shows little tendency to destruc- 
 tion of tissue or to ulceration, and sooner or later the 
 exudate is resorbed, though commonly with the de- 
 struction of some scleral tissue, for, in the area of in- 
 flammation, the sclera has a delicate smoke-gray tint 
 which, with a higher degree of intensity, becomes 
 slate-gray. We have to do, then, with an attenuation 
 of the sclera (cicatrized tissue) through which the 
 black chorioid shimmers, but, however, much less 
 noticeable in this superficial form than in the deeper. 
 The bulbus, furthermore, is commonly not injured. 
 
 The deep form of scleritis is rarer, and at first more 
 diflScult to diagnose, for it is not possible, without 
 autopsy or dissection, to determine how deep the scle- 
 
 112
 
 [■cff, Atlas. 
 
 Tab. XLIV 
 
 Fig. 62. 
 
 Scleritis. 
 
 bm.Ki Company, New Yorl<.
 
 Ireeff, Alias. 
 
 Tab. XLV 
 
 Fig-. 63. 
 Sclerectasia. 
 
 man Company. New York
 
 rotic inflammation extends. We deduce this from the 
 unfailing involvement of other ocular membranes 
 (iritis, chorioiditis, sclerosing keratitis), and hence 
 the disease is called scleritis complicata by many au- 
 thors, and develops during its course the resultant 
 marked thinning of the sclera, whose rupture is due to 
 intraocular pressure. At the beginning we again find 
 a dark-red or bluish hump-like projection or swelling 
 in the affected area. The projection, in general, is not 
 sharply circumscribed and has a great tendency to ex- 
 tend farther, so that later, the entire cornea is sur- 
 rounded by these elevations. 
 
 In this form, also, there occurs no direct disintegra- 
 tion, and there is left, finally, only a marked, cicatricial 
 thinning of the sclera, often so prominent that the 
 chorioid beneath shimmers through with a bluish tint. 
 Often, however, after resorption of the exudate, the 
 sclera has lost so much of its firmness that it is unable 
 to offer sufficient resistance to the intraocular pres- 
 sure, and there results a bulging out, — ectasia, — of 
 the affected areas. 
 
 Fig. 63 shows such anterior scleral staphylomata, 
 which, because^ they often surround the cornea like a 
 ring, are termed annular staphylomata. In such cases, 
 however, the staphylomata do not become entirely con- 
 fluent, but between the individual lumps there are al- 
 ways retractions, so that the comparison with a piece 
 of large intestine or black-pudding sausage (Blut- 
 WTirst) is not inapplicable. 
 
 The eye in Fig. 63 is held open by the Desmarre 
 speculum ; in Fig. 62 by the von Grafe dilator. 
 
 Scleritis, therefore, is an extremely chronic disease, 
 developing in middle and old age. Relapses are easy. 
 Fundamentally, gout, tuberculosis, syphilis or rheu- 
 matism is causative. 
 
 113
 
 Prognosis in the superficial form is fairly good, 
 if we do not consider the long duration of the disease. 
 In the deep form, blindness is a frequent sequela 
 (pupillary atresia, secondary glaucoma, etc.). 
 
 Therapy is somewhat powerless. Atropin to full 
 dilatation of the pupil, warm, moist compresses, wet 
 packs, eventually subconjunctival injection. The 
 nodes may be massaged with mercurial ointment. 
 
 Constitutional treatment, according to the nature 
 of the fundamental affection, is very important. If 
 increase of intraocular pressure develop, iridectomy 
 is indicated. 
 
 114
 
 Cll, Atl.lS. 
 
 Fig. 64. 
 Iritis, i'apulous Syphilite. 
 
 Fig. 65. Synecliiae posteriores following Iritis 
 
 Fig. 66. Condylomata iridis. 
 
 iiiati Ci)ni|i;iMy, New York.
 
 Iritis. 
 
 Plate XLVI., Figs. 64-66; Plate XL VII., Figs. 67-69. 
 
 Iritis is a common and serious lesion, and knowl- 
 edge of it is essential to every practicing physician, 
 for its non-recognition or improper treatment will 
 lead, in a few days, to adhesions of the iridic margin 
 wliich cannot be corrected, disabling the patient dur- 
 ing his entire life, even if such neglect do not, as is 
 common, finally lead to loss of the eye. 
 
 The sjTnptoms of iritis are: (1) A pericorneal or 
 episcleral injection (vide Plate XLVI., Fig. 64) com- 
 posed of violet-red, deep blood-vessels, branching like 
 the wisps of a broom, close to and surrounding the 
 cornea like a ring. These vessels lie beneath the con- 
 junctiva upon the sclera, and by their marginal 
 branchings nourish the deep layers of the cornea and 
 then, at the junction of cornea and sclera, turn in- 
 ward and penetrate to the iridic attachment. In vio- 
 lent inflammations, not only is the red ring around the 
 cornea present, but the entire eyeball is red. We 
 must, however, verify that the redness augments as 
 it approaches the corneal margin, whilst in simple 
 conjunctival redness it decreases {vide Plate 
 XXX^^L, Fig. 54). 
 
 (2) Alterations in the pupil. Very early the pupils 
 contract and exhibit a tardy reaction (because of 
 cramp in the muse, sphincter iridis). If left in this 
 contracted state, fibrinous exudates develop on the 
 posterior surface and adhere to the anterior capsule 
 of the lens (synechiae posteriores), first at one point, 
 
 115
 
 then at several, finally including the entire iris. The 
 synechifE are sometimes first seen after the instilla- 
 tion of atropin, when the free areas of the iridic mar- 
 gin respond with dilatation whilst the adherent areas 
 are directed inwards like well-defined serrations {vide 
 Plate XLVI., Fig. C5; also, Figs. 67-68). 
 
 Finally, in the still free, contracted pupil, surround- 
 ed by adhesions, a fibrinous deposit may be observed, 
 entirely occluding the pupil : Occlusio pupillae, due to 
 an inflammatory membrane {vide Plate XLVII., Fig. 
 69). 
 
 (3) Changes in iridic tissue. The hyperemia of the 
 iris soon leads to a change of color, so that the blue 
 iris becomes a dirty green, the brown iris a rusty red. 
 
 In some few cases, characteristic nodules form on 
 the surface of the iris. Those appearing on the pupil- 
 lary margin, multiple, and, because of the rich vascu- 
 lar supply, having an orange-yellow tint, are to be 
 considered as luetic papules or condylomata {vide 
 Plate XLVL, Fig. 66). 
 
 The pale-gray tubercles, poor in blood-vessels, are 
 mostly shown about the small iridic circumference or 
 in the corner of the anterior chamber (Plate XLVII., 
 Fig. 68). 
 
 Gummata may develop as large yellow nodes, usu- 
 ally isolated (Plate XLVII., Fig. 67). 
 
 (4) The cornea is often mistily opaque. 
 Subjectively, we have photophobia, lacrimation, and 
 
 frequently violent pains, which may extend to the fore- 
 head and temples. 
 
 Course of the disease. Iritis may be either 
 extremely insidious or else violent with much pain. It 
 is always to be considered as a very serious lesion. 
 Its course may extend over weeks or months, the pe- 
 riod depending largely upon the treatment. 
 
 116
 
 Etiologrically, it should be thoroughly under- 
 stood that we are dealing with a constitutional dis- 
 ease, for the idiopathic iritis of olden times does not 
 exist. 
 
 Most often a new syphilitic infection, acquired some 
 months previously, is etiologic, but it is also found in 
 old cases. Next in frequency as an etiologic factor is 
 tuberculosis, and the iritis is directly due to metastasis 
 from some gland. 
 
 It is not a rare metastasis in gonorrhea, and may 
 develop even after the urethral lesion has been cured. 
 
 As a rare phenomenon it may occur in various in- 
 fectious diseases. 
 
 That a simple iritis may be caused by a violent cold 
 is very dubitable. 
 
 Naturally, disease germs entering the eye through 
 an abraded or injured surface may develop an iritis 
 traumatica. 
 
 Prognosis, when correct treatment has been em- 
 ployed, is commonly good, and in the great majority 
 of cases, the eye may be spared any injury, whilst by 
 non-recognition of the trouble the eye may be se- 
 riously and permanently injured or lost within a few 
 days. 
 
 Therapy. In iritic inflammation atropin is the 
 greatest remedy ; by its narrowing of the iris the blood 
 supply is lessened, and it hinders the development of 
 adhesions between the pupillary margin and the cap- 
 sule of the lens (posterior synechia). With an in- 
 flamed iris, mydriasis is much more difiScult than when 
 the iris is normal. The action of the drug is accent- 
 uated if used warm and cocain added (thus dilating 
 the lymph spaces and increasing the resorptive pow- 
 ers). Atropin (1%) is instilled 6-12 times at inter- 
 
 117
 
 vals of a few minutes until the pupil is fully dilatod, 
 or it is seen that adhesions have already formed and 
 hence, further dilatation is impossible. After mydri- 
 asis is obtained, the pains usually abate. Cold is 
 poorly borne; warm compresses (chamomile or boric 
 acid 2-4%) are, on the contrary, very helpful; event- 
 ually, warm, moist packs are indicated; where the 
 pains persist, cupping of the temporal region may be 
 resorted to. Thorough sweating (Schwitzkuren) often 
 affords marked relief. If an annular posterior 
 synechia exist, iridectomy should be done after sub- 
 sidence of the inflammation, in order to avoid second- 
 ary glaucoma. 
 
 Above all else, the etiology of the iritis should be 
 determined, and the indicated constitutional treatment 
 pursued. 
 
 118
 
 irccif, Atlas. 
 
 ab. XI.VI 
 
 Fig. Gt. 
 Gumma iridis. Syiiecliiac posteriores 
 
 Fig. 68. 
 Tubercles of tiie iris. Synechiae posteriores. 
 
 o)'-?i 
 
 Fiff. 69. 
 Occlusio pupillae 
 Alembrana pupiiiaris infiammatoria. 
 
 Fig. 70. 
 .Wembrana papillaris perseverans. 
 
 laii Conip.iny, Ne\i' York .
 
 Congenital Anomalies of the 
 
 Iris. 
 
 I. Coloboma Iridis Congenitum. 
 
 Plate XLVIII., Fig. 71. 
 
 II. Membrana Pupillaris Perseverans. 
 
 Plate XLVII., Fig. 70. 
 
 Coloboma iridis congenitum may be subdivided into 
 a typical and an atypical form. In the typical form, 
 there is a split or fissure in the iris, inclining down- 
 wards and, sometimes, a little towards the nose. Its 
 form resembles most that of a Gothic window, the 
 apex extending either to the ciliary edge (coloboma 
 fotale), or the process stops before it reaches the line 
 of the eyelashes (coloboma partiale). The coloboma, 
 with its apex invariably rounded off, enters into the 
 pupilla, and, in this area there are sometimes found, 
 extending in a horizontal direction, cords or strings of 
 connective tissue passing over the coloboma, (bridge 
 coloboma, Briiekenkolobom). An unpigmented band 
 or cord extending downwards is termed pseudo-colo- 
 boma. 
 
 Of atypical colobomata there are numerous reports 
 in the literature, the defects extending in all direc- 
 tions. 
 
 The congenital coloboma is the result of imperfect 
 closure of the palpebral fissure in utero. 
 
 119
 
 n. 
 
 The membrana jmpillaris perseverans, the re- 
 mainder of fetal pupillary membrane, is not extremely 
 rare. It is differentiated from inflammatory deposits 
 upon the capsule of the lens by the fact that the 
 threads or cords of tissue never have origin in the 
 pupillary margin, but always upon the anterior sur- 
 face of the iris, most commonly from the circulus 
 arter. iridis minor. 
 
 In the fetal eye it is well known that the hyaloid ar- 
 tery passes forward through the central canal (canalis 
 Cloqueti) of the vitreous. On reaching the posterior 
 pole of the lens, it branches and forms a vascular net- 
 work, the membrana capsularis, investing the entire 
 posterior surface of the lens. These vascular branches 
 pass over to the anterior surface of the lens and unite 
 there with blood-vessels derived from the anterior 
 surface of the iris (especially those from the circulus 
 arteriosus irid. minor). In the pupillary region, a 
 membrane thus developed, is called the membrana 
 pupillaris. 
 
 Fragments of the pupillary membrane are not in- 
 frequently noted but it is extremely rare to find por- 
 tions of the membrana capsularis on the posterior sur- 
 face of the lens. 
 
 The normal pupillary membrane in the fetus is 
 finely granular with oval nuclei irregularly distrib- 
 uted in it. The anterior surface is covered with an 
 epithelium at first unimpaired and continuous, but 
 later it becomes more and more defective. On the 
 posterior surface, blood-vessels covered with an endo- 
 thelium spread out. With retrogression of the dis- 
 ease, the epithelium disappears first, then the blood- 
 vessels, and the membrane itself serves as endothe- 
 lium for the iris. 
 
 120
 
 The membrane, when it persists, is found to be a 
 tough tissue, poor in nuclei, but with scattered pig- 
 ment cells. Upon both the anterior and posterior sur- 
 faces, the layer of endothelium is, usually, imperfect. 
 The filaments or threads directly penetrate the iridic 
 tissue from whose structure they cannot be differen- 
 tiated. The blood-vessels in it are abnost invariably 
 empty. 
 
 121
 
 Glaucoma. 
 
 Plate XLVIII., Fig. 72. 
 
 The essential nature of glaucoma (griiner Star) is 
 the heightened pressure within the globe. It may de- 
 velop rapidly (glaucoma aeutum or inflammatoi'ium ) 
 or very gradually (glaucoma chronicum or simplex). 
 
 The actual reason for the increase in pressure is not 
 known. Anatomically, we usually find the angle of the 
 anterior chamber where the humor is drained off 
 through the spaces of Fontana into the canal of 
 Schlemm, occluded by inflammatory adhesions. 
 
 True glaucoma generally exhibits prodromal symp- 
 toms. The patient, from time to time, has obscuration 
 of vision, sees as through a fog, and lights used for 
 illuminating purposes (candle, gas, etc.) are sur- 
 rounded by colors, rainbow tints : stadium prodromale. 
 These phenomena may be called forth by slight in- 
 crease in pressure. 
 
 Earlier or later, more violent attacks occur: sta- 
 dium evolutum. In acute glaucoma there is marked 
 pericorneal injection, violent, even unbearable, pains. 
 The cornea is mistily opaque, the anterior chambei 
 much diminished in volume, the iris discolored, the 
 pupil spontaneously enlarged, and vision, more or less 
 noticeably impaired. The bulbus is distinctly hard to 
 the touch. 
 
 In chronic cases all these phenomena of inflamma- 
 tion are absent, and, generally, the increase in pres- 
 sure is not felt manually. The patient is conscient 
 only of poor vision. Diagnosis is best and earliest as- 
 
 122
 
 ireeff, Atlas. 
 
 c 
 
 be 
 
 n 
 
 . o 
 
 ,-. u 
 
 C/3 
 
 tils 
 
 o 
 
 _o 
 o 
 U 
 
 m;iii Company, New York.
 
 certained by determining the limits of the field of 
 vision, which starting from the periphery diminishes 
 slowly but continuously by sectors, particularly on 
 the nasal side. If this diminution be already notice- 
 able, then the second sure sjrmptom of chronic glau- 
 coma is present, i. e. the ophthalmoscopically visible 
 excavation of the papilla nervi optici. 
 
 Left undisturbed, the disease leads surely, sooner 
 or later, to absolute, incurable blindness: glaucoma 
 absolutura. 
 
 All the optic nerve fibres are broken at the margin 
 of the deep, kettle-like excavation and become atro- 
 phied. Later, there almost invariably develops a to- 
 tal opacity of the lens. 
 
 Therapy. The miotics, physostigmin (=eserin) 
 and pilocarpin are suitable remedies for reducing the 
 pressure. They act as long as the iris is not atrophic ; 
 i. e. as long as it is capable of contraction. Their ac- 
 tion, also, is not permanent, for with the subsidence 
 of miosis, the heightened pressure returns, so that 
 we have only palliative, not curative, remedies. Be- 
 ware of atropin, for it augments intraocular pressure. 
 If the diagnosis of glaucoma is absolutely sure, iridec- 
 tomy should be done as soon as possible. Other au- 
 thors recommend sclerotomy in its stead. 
 
 Generally, one may expect to save whatever vision 
 is left by a well-executed, broad, peripheral iridec- 
 tomy. 
 
 123
 
 Disturbances of Iridic IVIotility. 
 
 Plate XLIX., Fig. 73 (Tabes). 
 
 Disturbances of iridic motility are shown by the 
 behavior of the pupil. 
 
 Normal pupils are, as a rule, equally large, whilst 
 inequality (anisocoria) always indicates a patholoj?ic 
 condition. Either the pupil is continuously and per- 
 manently abnormal in regard to its contraction or dila- 
 tation (e. g. often and very early in cerebral syphilis), 
 or else the condition changes so that one pupil sud- 
 denly becomes much dilated or contracted (Springende 
 Pupillen, an early symptom of progressive paralysis). 
 
 Normally, the pupils contract equally when light is 
 thrown into them, and it is a matter of indifference 
 into which eye the light is cast, for the other eye reacts 
 similarly (consensual reaction). 
 
 Above all else, we investigate the pupillary reaction 
 from direct light and the convergence reaction of both 
 eyes. If the pupils remain inactive in these two tests, 
 there is an absolute pupillary immobility; if they do 
 not react to light but respond to the convergence test, 
 it is termed a reflex immobility. 
 
 The case represented in Fig. 73 is that of a man, 
 aet. 45, who, when 30 years of age, was infected with 
 syphilis. 
 
 Anisocoria is present, the left pupil is strikingly 
 contracted (spinal miosis) and, furthermore, it is 
 clearly seen that the pupils are not circular, a condi- 
 tion very indicative of tabes and paralysis (entrun- 
 dete Pupillen), not to be confused, however, with the 
 
 124
 
 Tab. XLIX, 
 
 Fig. 73. 
 Anisocorid. Reaction of pupils in Tabes. 
 
 jbin.TU Cotnpany, New York.
 
 dentated pupil from synechiae, adhesions due to in- 
 flammation. 
 
 There is also a reflex immobility of the pupil, i. e. 
 both pupils remain unaffected by light but react to 
 convergence. 
 
 The accomodation also is paretic, a fact which, pri- 
 marily, led the patient to the oculist. 
 
 Vision and the field of vision are normal and hence 
 there is no atrophia nervi optici tabetica incipiens 
 present. 
 
 The patient, with the exception of a little rheuma- 
 tism, considers himself perfectly well. Lancinating 
 pains, however, with anesthetic areas in the lower 
 limbs, absence of knee-jerk, and the presence of Eom- 
 berg's sign confirm the diagnosis of tabes dorsalis 
 already arrived at by the oculist. 
 
 125
 
 Cataract (Crauer Star). 
 
 Plate L., Fig. 74 ; Plate LI., Fig. 75 ; Plate LII., Figs. 
 
 76-79. 
 
 Morbid alteration of the lenticular tissue is usually 
 due to disturbance of nutrition, which exliibits itself 
 as opacity of the lens : cataract {Kara and pijyw/^t, to 
 fall down, descend). 
 
 Cataracts vary much in regard to species and com- 
 position, and may, therefore, be classified from various 
 points of view, viz. : 
 
 I. Progressive {e. g. cataracta senilis, which contin- 
 uously augments with age, although with various de- 
 grees of rapidity) and stationary {e. g. cataracta zonu- 
 laris, which remains unchanged for years or even a 
 lifetime). 
 
 II. According to maturity. A cataract is said to bo 
 mature when the lens is completely opaque, even to the 
 capsule and into the periphery. In accordance with 
 this, we differentiate as progressive forms : Cataracta 
 incipiens, nondum, fere matura, hypermatura, the last 
 indicating a retrogressive process following maturity, 
 and characterized bj' shriveling, proliferation of cap- 
 sular endothelium, calcification, etc. 
 
 III. Simplex or complicata. A better nomenclature 
 would be "primary" or "secondary," but the latter is 
 already used to designate another form of cataract, 
 i. e. the more or less thick membrane left after extrac- 
 tion of the lens, or which is formed anew from the 
 residual capsule, endothelium, and fragments of the 
 lens not extracted. Cataracta simplex is present when 
 
 126
 
 ff, Atlas. 
 
 Tab. L. 
 
 Fig. 74. 
 Arcus senilis corneae. Cataracta senilis matura. 
 
 'onipniiy. New York
 
 eff. Atliis. 
 
 Tail. LI. 
 
 Fig. 75. 
 Cataracta morgagniana.
 
 ceff, Atlas. 
 
 Tab. Lll. 
 
 Fig. 76. 
 Cataracta zonularis 
 
 Fig. 77. 
 Cataracta zonularis willi Cataracta stcllata 
 
 Fig 7<s. 
 Cataracta senilis iiicipiens. 
 
 Fig. 79. 
 Cataracta capsularis. 
 
 an Comnanv. New Yi)r]<.
 
 the lens alone is affected but is yet able to perceive 
 light, the eye being otherwise sound. We speak of 
 cataracta complicata when, to an internal blindness, 
 there is added an opacity of the lens. Both forms 
 may, externally, look alike, but clinically they are eas 
 ily differentiated by the tests for light and projection. 
 
 IV. According to the age of the patient : Cataracts^ 
 congenita, mollis or juvenalis, dura or senilis. The 
 congenital cataract or that found in youth is not al 
 ways amenable to strict classification, and offers 
 scarcely any pathologic or anatomic deviations. We 
 have no precise knowledge in many cataract forms 
 whether they were congenital or first developed in the 
 early years of life, and we are often dependent upon 
 anamnesis only. Contrarily, there is great difference 
 between the soft and hard forms. In youth, the lens 
 is of a soft and uniform consistency, and when re- 
 moved with its capsule endeavors to assume a globu- 
 lar form In the course of years the central portions 
 gradually become denser and harder, and usually 
 when the patient attains the age of 30 there is present 
 a firm, unyielding, unchangeable nucleus or kernel 
 which does not react to contact with the aqueous hu- 
 mor. After that age, therefore, we consider the cat- 
 aracta dura as important from the viewpoint of oper- 
 ative ophthalmology. 
 
 V. According to the form. Cataracta zonularis is 
 the most frequent and characteristic form in youth. 
 In this zonular or lamellar form, a cloudy or opaque 
 stratum develops between the center, which remains 
 transparent, and the cortex {vide Plate LIL, Fig. 77). 
 Sometimes from this, small, densely opaque projec- 
 tions push peripherally into the transparent zone 
 (Plate LII., Fig. 76). From cataracta zonularis, a 
 number of other forms may develop, for example: 
 
 127
 
 If the opacity extends through the center, we have 
 a cataracta centralis (not miclearis, since no nucleus 
 is present before the age of 30). 
 
 If the periphery also is Ukewise involved, we have a 
 cataracta totalis. These three forms may pass into 
 or develop from one another, and the cataracta totalis 
 may undergo the following modifications: 
 
 Its contents may reach such a degree of softening 
 that they become thin and milky, cataracta lactea, or 
 clear so as to resemble a cyst, cataracta cystica. Later, 
 not only the subcapsular stratum but the contents may 
 calcify, become hard and chalky-white, cataracta cal- 
 carea. If the watery contents be early resorbed so 
 that there is left only a thin wall, composed of capsule 
 and some epithelial proliferations, we have a cataracta 
 membranacea, or if the epithelial cells beneath the cap- 
 sule calcify, thus forming a thin, stiff, chalky-white 
 stratum, we have cataracta papyracea. If, however, 
 the capsule is not reduced to a papyracous layer, but 
 remains distended after resorption of its contents, it 
 is called cataracta aridosilicata. 
 
 Cataracta fusiformis (spindle-shaped cataract) or 
 axialis is a congenital and rare form, having a spindle- 
 shaped opacity in the axis of the lens, joining the an- 
 terior and posterior poles. 
 
 Cataracta capsularis. There is no actual opacity of 
 the capsule. The opacity is in the anterior surface of 
 the lens beneath the capsule, and, after calcification, is 
 white in color (vide Plate LII., Fig. 79). If such an 
 opacity is located like a point or dot just at the ante- 
 rior or posterior pole, we have, respectively, a catarac- 
 ta polaris ant. or post. The former may project like a 
 pyramid or cone into the anterior chamber, cataracta 
 pyramidalis. 
 
 In cataracta stellata the cement substance of the 
 lenticular fibers is clouded so that the star becomes 
 
 128
 
 visible on the anterior or posterior surface. In Fig. 
 77 (Plate LII.) this star figure is seen at the anterior 
 pole of a cataracta zonularis. 
 
 Cataracts appearing in middle life often consist of 
 gray points, cataracta punctata, or stripes, cataracta 
 striata. 
 
 VI. According to origin, we have: Cataracta se- 
 nilis (cortiealis or nuclearis), beginning, usually, with 
 spoke-like opacities lying between the nucleus and cor- 
 tex, and which, wedge-like, push from periphery to 
 center, thus resembling spokes in a wheel {vide Plate 
 LII., Fig. 78). This grayish clouding of the cortex, 
 which later becomes more homogeneous (Plate L., Fig. 
 74), is to be distinguished from an opacity of the nu- 
 cleus, which is more of a brownish-red in color (Fig. 
 78-79). 
 
 Cataracta nigra is a peculiar form of senile cataract, 
 where the pupils appear black although the lens is 
 opaque. It is due to extreme sclerosis of the nucleus. 
 
 Cataracta morgagniana is a senile form where the 
 cortex has liquefied so that the brown nucleus floats 
 about in it. When the patient stands, the nucleus sinks 
 (vide Plate LI., Fig. 75). 
 
 Other forms are cataracta diabetica, nephritica, 
 traumatica. Forms due to some general disease are 
 called constitutional cataracts, the best example of 
 which is the cataracta diabetica, also the nephritica, 
 and, according to many authors, the senilis. Poison- 
 ings may likewise cause cataract formation, e. g. from 
 ergotin. The ergotin cataract is similar to the experi- 
 mentally developed naphthalin, sugar, and salt cat- 
 aracts. 
 
 If, moreover, a cataract has become adherent to the 
 iris, an iritis with the formation of posterior synechia 
 must have preceded it, and it is called cataracta ac- 
 creta. 
 
 129
 
 Dermoids. 
 
 Plate LIU., Figs. 80-81. 
 
 Dermoids are congenital, cystoid tumors, whose 
 walls are dermal in structure, although the tumors 
 are found where, normally, dermal elements are ah 
 sent. 
 
 In the eye they are found especially in two places: 
 (1) At the corneo-scleral junction, and (2) under the 
 skin on the bony margin of the orbit. In rare cases 
 they extend from these sites farther into the orbit, 
 thus interfering more or less with the eyeball. 
 
 ( 1 ) The dermoid tumors of the corneo-scleral junc- 
 tion are dense, of a porcelain-white or dull-rose color, 
 and most often found at the external margin of the 
 cornea between the muscle-insertions. They are but 
 little elevated above the surface of the bulbus, but are 
 deeply and immovably imbedded, partly in the corneal 
 substance, partly in that of conjunctiva and sclera. 
 They are always congenital, and so characteristic as 
 to be difficultly confused with other tumors. 
 
 Microscopically, the structure' is like that of a piece 
 of skin : an epiderm of several strata, and below it a 
 connective tissue stroma with sebaceous glands and 
 hair follicles. The superficies is often covered with 
 a fine down. Von Duyse attributes their development 
 to adhesions betwixt amnion and the surface of the 
 eyeball, whilst Remak considers them fetal invagina- 
 tions of ectoderm. 
 
 Dermoids in children are usually small, on an aver 
 age about the size of a lentil, but in later life they may 
 
 130
 
 Tab. 
 
 Fig. 80. 
 Derinoidcyst of the Cornea-scleral margin. 
 
 Fig. 81. 
 Dermoidcyst of the orbital rim.
 
 begin to grow. Because of this and the ugly disfigure- 
 ment of the eye, their early removal is to he commend- 
 ed. With most of these dermoids, the bulbus, as such, 
 remains intact congenitally and is well formed. But 
 a second, though rare, group show, in varying degree, 
 a congenital interference of the dermoid with the de- 
 velopment of the eyeball. 
 
 Schmidt-Rimpler described such a dermoid, the lens 
 having been dislocated. On the cornea of a calf's eye 
 was a piece of skin with hair, which began on the inner 
 margin of the cornea, covering the greater part there- 
 of. The iris had adhered to the corneal rudiment, and 
 there was no anterior chamber. The lens projected 
 through the pupil into the dermoid, thus being trun- 
 cated. 
 
 A still more interesting case is from von Griife's 
 clinic. The timior was congenital, and during the 
 eight months of the child's life had nearly doubled in 
 size. It was divided into two large portions. The en- 
 tire cornea, excepting a narrow border, was covered 
 with an ordinary dermoid which was connected by a 
 short stem with a dermoid of cherry-size projecting 
 out of the palpebral fissure. The tumor was covered 
 with cutis on which were a few hairs. Apparently, 
 there was no lens in the globe. Microscopically, the 
 dermoid showed cutis with hair, sebaceous glands, iso- 
 lated papillff, hair follicles. The cornea was lacking, 
 its place being taken up by connective tissue, to which 
 the iris, recognizable by a thick stratum of pigment, 
 had grown. 
 
 Bernheimer describes a child, aet. 6 months, with two 
 cherryrsized tumors in the right eye, which almost 
 touched one another, keeping the lids apart. Later, 
 they increased in size, entirely covering the cornea. 
 Anatomically, there was a total corneal staphyloma 
 with iridic proliferation. 
 
 131
 
 In a ease of Manfredi the well-formed orbit con- 
 tained, not an eye, but a sphere the size of a pea. The 
 abnormality increased somewhat with the growth of 
 the child. The eyeball stump was covered anteriorly 
 with a white, hairy skin. An excised portion showed 
 the histologic structure of a dermoid. 
 
 Wagenmann examined a tumor from the orbit of 
 a new-born child. Posteriorly it was joined to the or- 
 bit by a stem, the size of a quill. This stem was cut 
 through and the orbit of the otherwise healthy and 
 well-formed infant was precisely like that resulting 
 from enucleation. The cavity was covered with a 
 mucous membrane. On section, the tumor was found 
 to contain a piece of bone and a rudimentary eyeball. 
 A cross-section showed the tumor covered by a cutis 
 about 1 mm. thick, with fine, down-like hairs. 
 
 II. Dermoid cysts of the skin of the lids or of their 
 subcutaneous tissues are almost always located exte- 
 riorly on the orbital edge. They are not very infre- 
 quent, usually as large as a pea or plum-pit, though 
 they may later increase in size. Commonly they are 
 firmly adherent to the periosteum of the orbital mar- 
 gin. These, too, are congenital cysts with firm walls, 
 and the pap-like contents are composed of desquamat- 
 ed, cornified cells and detritus, sometimes fat and 
 hairs. 
 
 The tumors are to be considered as due to a stratimi 
 of germinal epithelium deposited on the areas affected. 
 
 It is well known also, that such dermoid cysts may 
 be found deeper in the orbit. 
 
 132
 
 Fig. 82. E.xophthalmiis caused l)y Tumor retrobulbaris. 
 
 '4 
 
 Fig. S3. 
 Tiie Tumor after Exstirpation. 
 
 Fig. 84. Microscopic section of the tumor. 
 
 an Company, New York.
 
 Exophthalmus. 
 
 Plate LIV., Pigs. 82, 83, 84. 
 
 By exophthalmus we understand a remarkable con- 
 dition where the eyeball is, more or less, thrust for- 
 ward out of its orbit. Exophthalmus is not to be con- 
 fused with a condition where the eyeball is enlarged, 
 and hence projects somewhat from the orbit, but still 
 remains in its place. 
 
 Fig. 82 is the case of a woman, set. 60, in whom the 
 right bulbus in course of 2 years gradually, painlessly 
 and without inflammatory symptoms advanced out- 
 ward, forward and downwards. 
 
 In this case, the first species of exophthalmus, the 
 inflammatory, could be excluded, for it develops sud- 
 denly, as a rule, or rapidly from exudates, often from 
 collection of pus, or follows inflammation (periostitis, 
 ostitis) of structures posterior to the eyeball. Fre- 
 quently it follows the outbreak of pus from some cav- 
 ity adjacent to the orbit. The lids become very edema- 
 tous, swollen and red, chemosis sets in, etc. In our 
 case there were only a few small blood-vessels of the 
 conjunctiva bulbi dilated. 
 
 Nor were we dealing with a pulsating exophthalmus, 
 iphich is usually caused by an aneurysma arterio-veno- 
 sum due to a rupture of the carotid in the sinus cav- 
 ernosum. In such case, the palpating hand distinctly 
 feels a pulsation of the bulbus or the pulsation may be 
 seen with the naked eye. 
 
 A non-inflammatory, simple exophthalmus is found 
 
 133
 
 (a) in morbus Basedowii, (b) with retrobulbar tumors. 
 The first possibility was easily excluded in this case. 
 
 We had to do, then, with a retrobulbar tumor, and, 
 because of its very slow growth, with a relatively be- 
 nign one. 
 
 Two circumstances permitted the elimination of a 
 tumor of the optic nerve, which is not rare. In the 
 first place such a tumor commonly drives the bulbus 
 directly forwards, and secondly, vision was still fairly 
 good, whilst in optic nerve tumors it is soon lost from 
 compression of the optic fibers. (Moreover, the optic 
 nerve lies behind the bulb in the form of the letter S, 
 and hence, when pulled upon by an exophthalmus, is 
 able to stretch or yield without danger.) 
 
 Nor were we dealing with one of the relatively more 
 frequent tumors of the lacrimal gland, which would 
 have pushed the eyeball downward and toward the 
 nose. 
 
 The eyeball was quite movable ; hence, the tumor was 
 not adherent, and probably did not rise much above 
 the adjacent tissue (e. g. the muscles). The nose and 
 all cavities near the orbit were free, so that the tumor 
 probably had origin in the orbit, and had remained 
 there. Pressing inward with the finger on the upper 
 lid between bone and eyeball, two hard nodes were en- 
 countered. Hence, cysts, entozoa (echinococcus, cysti- 
 cercus) and lipomata, which are softer, were likewise 
 eliminable. 
 
 We thus arrived at the exact diagnosis of a hard, 
 probably capsulated, fibroma, whose site and size were 
 just as accurately demonstrable. 
 
 Tberapy. Removal of the tumor was indicated 
 by the slow but steady growth. As soon as an exoph- 
 thalmus attains a size which prevents closure of the 
 lids, the situation becomes very tormenting. 
 
 134
 
 As operative measures were discussed: The clear- 
 ing out of the whole orbit, thus sacrificing- the eyeball ; 
 the anterior removal of the growth, saving the eyeball ; 
 removal by the temporal route (Kronlein's method), 
 saving the eyeball. 
 
 Since the tumor was indubitably benign and encap- 
 sulated, the first operation was not indicated ; further, 
 as its site was on the nasal side, the Kronlein proced- 
 ure was abandoned. 
 
 After finding the tendon of the muse, rectus int. bulbi, 
 which was caught up and cut, the bulb was drawn 
 down and outwards with dull tenacula, and a hard tu- 
 mor, the size of a small hen's egg, and attached to the 
 deeper tissues only by a thin stem, was shelled out 
 (Fig. 83), Microscopically, it proved to be a dense 
 connective tissue growth, rather rich in cells (Fig. 
 84). 
 
 The eyeball was replaced and the muscle tendon sut- 
 ured. There has been no return of the tumor, and the 
 eyeball is in good condition. 
 
 135
 
 Index 
 
 Anisocoria . . 
 Anthrax . . . 
 A reus senilis 
 Atheroma . . 
 
 Blepharitis marginalis 
 Buphthalmus 
 
 Carcinoma epibulbare 
 
 Carcinoma epitheliale 
 
 Cataracta capsularis 
 
 Cataracta morgagniana 
 
 Cataracta senilis 
 
 Cataracta stellata 
 
 Cataracta zonularis 
 
 Chalazion 
 
 Coloboma iridis artificiale 
 
 Coloboma iridis congenitum. . . 
 
 Condj'lomata iridis 
 
 Conjunctivitis catarrhalis . . . . 
 Conjunctivitis diphtheritica . . 
 Conjunctivitis exanthematica 
 Conjunctivitis foUicularis . . . . 
 Conj. gonorrhoica adultormn . 
 Conj. gonorrhoica metastatiea 
 Conj. gonorrhoica neonatorum 
 Conj. gonorrhoica : Sequelae . . 
 
 Conjunctiva normal 
 
 Conjunctivitis phlyctenulosa . . 
 
 Conj. simplex chronica 
 
 Conj. trachomatosa 
 
 PAGE 
 
 124 
 
 9,11 
 
 105 
 
 21 
 
 32 
 
 108 
 
 86 
 51 
 
 128 
 129 
 127 
 128 
 127 
 
 28 
 
 76 
 119 
 116 
 
 59 
 
 79 
 7 
 
 61 
 
 73 
 
 74 
 
 71 
 
 75 
 
 58 
 
 81 
 
 33 
 
 63 
 
 PLATE 
 
 XLIX. 
 IV. V. 
 
 L. 
 
 XI. 
 
 XIII. 
 XL. 
 
 XXXI. 
 
 XVI. XVII. 
 
 LII. 
 
 LI. 
 
 L. LII. 
 
 LII. 
 
 LII. 
 
 XIII. 
 
 XLVIII. XXIV. 
 
 XLVIII. 
 
 XLVI. 
 
 XIX. 
 
 XXVII. 
 
 IIL 
 
 XX. 
 
 XXVI. 
 
 XXIV. 
 XXIV. 
 
 XIX. 
 XXIX. 
 
 XIV. 
 XX. XXI. 
 
 FIG. 
 
 73 
 4,5 
 74 
 13 
 
 I 3,16,18, 
 i 41, 42 
 
 58 
 
 45 
 20,21 
 
 79 
 
 75 
 74,78 
 
 77 
 76,77 
 16,17 
 35,72 
 
 71 
 
 66 
 
 25 
 
 40 
 
 3 
 
 26 
 
 38 
 
 34 
 
 35, 36, 87 
 
 24 
 
 42 
 
 18 
 
 27, 28, 29 
 
 137
 
 Conj. vernalis 
 Cornea globasa 
 
 Corneal opacities 
 
 Dacryocystitis acuta . . 
 Dacryocystitis chronica 
 
 Dermoid cyst 
 
 Dermoid tumor 
 
 Ectasia eorneae . 
 
 Ectasia scleras . . 
 
 Ectropium 
 
 Entropium 
 
 Episcleritis 
 
 Erysipelas faciei 
 Exophthalmus . . 
 
 Gangrene of Lids 
 
 Gerontoxon, (Arcus senilis) 
 
 Glaucoma 
 
 Gumma iridis 
 
 Haemorrhagia subconjunctivalis 
 
 Haemorrhagia subdermalis 
 
 Herpes facialis 
 
 Herpes zoster gangraenosus . . . 
 Herpes zoster ophthalmicus . . . . 
 
 Hordeolum 
 
 Hutchinson 's Teeth 
 
 Hyperemia marginalis 
 
 Hypopyon-Keratitis 
 
 Iritis 
 
 Keratitis 
 
 Keratitis fasicularis 
 
 Keratitis interstitialis . . . 
 Keratitis parenchymatosa 
 Keratitis phlyctaenulosa . 
 
 Keratitis punctata 
 
 Keratoconas 
 
 Keratoglobus 
 
 PAGE 
 
 PLATE 
 
 83 
 
 XXX. 
 
 43,44 
 
 107 
 
 XL. 
 
 58 
 
 93 
 
 ( XXXIV. ) 
 
 jxxxvin. L. • 
 
 35, 55, 74 
 
 56 
 
 XVIII. 
 
 22 
 
 54 
 
 xvin. 
 
 23 
 
 130 
 
 Lin. 
 
 81 
 
 130 
 
 LIII. 
 
 80 
 
 107 
 
 1 XXXIX. XL. ) 
 j XLI. 
 
 56, 57, 58, 59 
 
 112 
 
 XLV. 
 
 63 
 
 47 
 
 XV. 
 
 19 
 
 42 
 
 XIV. XXII. 
 
 18,31 
 
 112 
 
 XLIV. 
 
 62 
 
 1 
 
 I. 
 
 1 
 
 133 
 
 LIV. 
 
 82 
 
 11 
 
 V. 
 
 5 
 
 105 
 
 L. 
 
 74 
 
 122 
 
 XL VIII. 
 
 72 
 
 116 
 
 XLVII. 
 
 67 
 
 4 
 
 II. 
 
 2 
 
 4 
 
 II. 
 
 2 
 
 14 
 
 VI. 
 
 6 
 
 14 
 
 VII. 
 
 8 
 
 14 
 
 vn. 
 
 7 
 
 24 
 
 XII. 
 
 15 
 
 96 
 
 XXXIV. 
 
 49 
 
 33 
 
 XIV. 
 
 18 
 
 101 
 
 XXXVII. 
 
 53 
 
 115 
 
 XLVI. XLVII. 
 
 ( 64, 65, 66, 
 
 \ 67, 68, 69 
 
 92 
 
 XXV. XXXII. 
 
 36,47 
 
 92 
 
 XXXII. 
 
 47 
 
 92 
 
 XXXIII. 
 
 48 
 
 92 
 
 XXXIII. 
 
 48 
 
 81 
 
 XXIX. XXXII. 
 
 42,47 
 
 111 
 
 XLII. 
 
 60 
 
 107 
 
 XXXIX. 
 
 56 
 
 107 
 
 XXXIX. 
 
 56 
 
 FIG. 
 
 138
 
 Lacrimal Sac: Congenital Affections of. 
 Lepra 
 
 Leucoma cornese 
 
 Lipoma subconjunctivale 
 Lupus vulgaris 
 
 Membrana papillaris inflammatoria 
 Membrana pupillaris perseverans . . 
 
 Molluscum contagiosum 
 
 Morbilli 
 
 Occlusio pupillaj . . . . 
 Oedema palpebrarum 
 
 Pannus 
 
 Pericorneal Injection . . 
 
 Phlyctenula 
 
 Phthisis bulbi incipiens 
 Phthisis bulbi quadrata 
 
 Pinguecula 
 
 Primary Infection 
 
 Pterygiiun 
 
 Pupillary Difference . . 
 
 Pupillary Fixity 
 
 Pustula maligna 
 
 Rachitic Teeth . 
 Rhagades faciei 
 
 Saddle nose 
 
 Selerectasiae 
 
 Scleritis 
 
 Seclusio pupillae 
 
 Skull formation in hereditary lues. 
 
 Staphyloma corneaj partiale 
 
 Staphyloma eorneje totale 
 
 Synechiffi posteriores 
 
 Syphilide (papular) 
 
 Tabes 
 Teeth 
 
 PAGE 
 
 55 
 110 
 
 104 
 
 91 
 49 
 
 120 
 
 120 
 
 22 
 
 7 
 
 116 
 1 
 
 67 
 115 
 
 81 
 72 
 72 
 
 77 
 
 18 
 
 77 
 
 124 
 
 124 
 
 9 
 
 96 
 97 
 
 97 
 112 
 112 
 116 
 
 97 
 107 
 107 
 115 
 116 
 
 124 
 96 
 
 PLATE 
 
 XLII. 
 
 XXIV. XXXVIII. 
 
 XLIII. 
 
 XXXII. 
 
 XV. 
 
 XLVII. 
 XLVII. 
 
 XI. 
 
 III. 
 
 XLVII. 
 I. 
 
 XXII. 
 
 XLVI. 
 
 XXIX. 
 
 XXV. 
 
 XXV. 
 
 XXVI. 
 
 IX. 
 XXVI. 
 XLIX. 
 XLIX. 
 
 IV. 
 
 XXXIV. 
 XXXV. 
 
 XXXIII. 
 
 XLV. 
 
 XLIV. 
 
 XLVII. 
 
 XXXVI. 
 
 XXXIX. 
 
 XLI. 
 
 XLVI. XLVII. 
 
 IX. XLVI. 
 
 XLIX. 
 XXXIV. 
 
 PIG. 
 
 60,61 
 
 35,55 
 
 46 
 19 
 
 69 
 70 
 14 
 3 
 
 69 
 1 
 
 30 
 64 
 42 
 36 
 37 
 39 
 11 
 39 
 73 
 73 
 4,5 
 
 50 
 51 
 
 48 
 63 
 62 
 69 
 52 
 57 
 59 
 65, 67, 
 64 
 
 69 
 
 73 
 
 49,50 
 
 189
 
 Trachoma 
 
 Trachoma (cicatrix) 
 
 Trichiasis 
 
 Tubercles of the Iris 
 
 Tumor of Corneo-scleral Margin 
 Tumor retrobulbaris 
 
 Ulcus durum 
 
 Ulcus serpens 
 
 Ulcus serpens progressivum .... 
 
 Variola vaccina 
 
 Variola vera 
 
 Xanthelasma 
 
 Xeroderma pigmentosum 
 
 Xerophthalmus trachomatosus. . 
 
 PAGE 
 
 63 
 68 
 38 
 
 116 
 86 
 
 134 
 
 18 
 101 
 102 
 
 16 
 104 
 
 20 
 
 86,87 
 
 69 
 
 PLATE 
 
 XXI. XXII. 
 
 XXIII. 
 
 XXII. 
 
 XLVII. 
 
 LIII. 
 
 LIV. 
 
 IX. 
 XXXVII. 
 XXXVII. 
 
 VIII. 
 XXXVIII. 
 
 X. 
 XXXI. 
 XXIII. 
 
 FIG. 
 
 27, 28, 29 
 31,32 
 
 18 
 68 
 45 
 
 82 
 
 11 
 53 
 54 
 
 9,10 
 55 
 
 12 
 45 
 33 
 
 140
 
 
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 iiniii»i'*i"' 
 
 000 224 995 1 
 
 WW17 
 GT93a 
 
 1909 
 
 Greeff, Richard 
 
 Atlas of external diseases of 
 the yey... 
 
 J 
 
 WW17 
 G793a 
 1909 
 Greeff, Richard 
 
 Atlas of external diseases of the eye 
 
 MEDICAL SCIENCES LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664
 
 •mjini/r'? 
 
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