Diseases of the eye

Front matter

-

YALE

MEDICALJ^RARY

Preface

In preparing the following pages, the author has endeavored to set forth the results of his experience and study in a form that will prove most useful to the busy general practitioner. With this aim in view words have been used very sparingly, and only such remedies, operations, and means of diagnosis recommended as the writer believes will be found to be most useful in our present state of knowledge to the practical physician.

New York, April, iSgj,

Chapter I. Page

Anatomy and Physiology of the Conjunctiva, Cornea, Iris, Ciliary Body, and Sclera, ......... 19

Chapter II. Diseases Of The Conjunctiva

Foreign Bodies — Injuries — Ecchymosis — (Edema — Emphysema — Hyperaemia.

Conjunctivitis — Superficialis — Purulent — Circumscribed — Plastic — Hypertrophic — Exanthematous — Gonorrhceal — Phlyctenular — Lymphatic — Pustular — Vesicular — Scrofulous — Diphtheritic — Croupous — Granular — Follicular — Vernal — Ulcers — Tumors — Hypertrophy — Calcification — Atrophy — Degeneration — Pterygium— Xerosis, ......,.., 25

Chapter III. Diseases Of The Cornea

Foreign Bodies— Inflammations and Degenerations — Phlyctenular Keratitis — Lymphatic — Pustular-- Scrofulous — Marginal — Abscess— Ulcers— Progressive Ulcers — Vesicular Keratitis — Herpes, Febrilis and Zoster — Keratitis Punctata Superficialis — Filamentous Keratitis — Keratitis Bulbosa — Superficial Vascular Keratitis— Parenchymatous Keratitis — Sclerosing Keratitis — Keratomalacia — Keratitis Xeuro-Paralytica — Opacities — Ectasia, . 48

Chapter XIII. Diseases Of The Retina

Opaque Optic Nerve Fibers — Hyperemia — Anaemia — Retinitis — Retinitis Albuminuria — Diabetic Retinitis — Leukemic Retinitis— Proliferating Retinitis — Retinitis Punctata Albescens — Affections of the Retinal Vessels — Embolism — Thrombosis — Spasm of Arteries — Apoplexy of Retina — Perivasculitis — Detachment of Retina — Retinitis Pigmentosa — Ruptures — Burns — Tumors — Cy^toid Degeneration of Retina — Diseases of Optic Nerve — Retro-Bulbar Neuritis — Axial Neuritis — Color Blindness, . 207

CONTENTS. 9

Chapter XIV

Glaucoma— Inflammatory Glaucoma — Buphthalmus — Softening of the Eyeball — Essential Phthisis, 238

Chapter XV

Diseases of the Eyelids — Diseases of the Lachrymal Apparatus — Diseases of the Orbit — Exophthalmic Goitre — Affections of the Extrinsic Muscles of the Eye — Paralysis of the Ocular Muscles . 249

CHAPTER XVI. Operations, 271

LIST OF REMEDIES.

Names.

Abbreviations.

Aeon.

Agar.

Antimonium tartaricum,

Ant. tart.

Apis mel.

Argent, nit.

Arnica radix,

Arnica.

Arsenicum album,

Arsenicum.

Atropine sulphate, Aurum muriaticum,

Atropia.

Aurum mur.

i Belladonna, Boracic acid,

Bell.

Boracic ac.

Bry.

Calc. phos.

Calc. iod.

Causticum,

Caust.

Cinnabaris,

Cinnabaris.

Cocaine,

Cocaine muriate.

Cuprum metallicum, Eserine sulphate, Gelsemium sempervirens, Hamamelis Virginica,

Cuprum met.

Eserine.

Gels.

Hamamelis.

Helleborus niger,

Hell. nig.

Hepar sulphuris calcareum, Hydrobromate of Hyoscine, Iodium,

Hepar sulph.

Hyoscine.

Iodine.

Ipecacuanha Kali iodatum,

Ipecac.

Kali iod.

Mercurius iodatus ruber,

Merc, biniod.

Mercurius cyanatus,

Merc. cyan.

Mercurius dulcis,

Merc. dulc.

Mercurius solubilis,

Merc. sol.

Mercurius corrosivus,

Merc. corr.

Nux vomica, Phosphorus, Pilocarpine, Pulsatilla nigricans, Rhus toxicodendron,

Nux vom.

Phos.

Pilocarpine.

Puis.

Rhux tox.

Scopolamine, Sulphur,

Scopolamine Sulphur.

12 LIST OF REMEDIES.

Thuja, Thuja.

Veratrum viride, Veratrum vir.

Zincum valerianicum, Zinc. val.

The attenuation of the remedies recommended are expressed by the following signs : 6 (the Greek letter theta) means tincture ; ix (or first decimal) means that nine parts of sugar of milk, alcohol or distilled water have been added to one part of the pure medicinal substance • 2x expresses the attenuation of the ix by nine, and so on up the scale. The preparation may be in the form of a powder or tablet triturate, in which case one grain is the amount prescribed ; or it may be in the form of a liquid, in which case one drop is the dose indicated.

Section I. Anatomy And Physiology Of The

CONJUNCTIVA, CORNEA, IRIS, CILIARY

BODY AND SCLERA.

DISEASES OF THE

CONJUNCTIVA, CORNEA, IRIS, CILIARY

BODY AND SCLERA.

Chapter I

ANATOMY AND PHYSIOLOGY OF THE CON- JUNCTIVA, CORNEA, IRIS, CILIARY BODY AND SCLERA.

The conjunctiva is a mucous membrane which lines the eyelids and covers the anterior third of the eyeball. Its epithelium is continuous with that of the cornea. It is loosely connected with the sclera by subconjunctival tissue, which is continuous with the capsule of Tenon and with the tendons of the external ocular muscles. The palpebral portion of the conjunctiva is firmly adherent to the lids. It is reflected from the lids to the ball in the form of loose folds. The loose connection between this part of the membrane and the tissues of the orbit allows the eye great freedom of movement, and also permits of great swelling. The sac formed by the conjunctiva in passing from the lids to the ball is called the "fornix." Mucous glands are found along its course and also along the convex border of the tarsus. Diffuse adenoid tissue, lymphoid cells and circumscribed lymph follicles are found in this membrane, especially along the retrotarsal folds. To view all parts of the conjunctiva it is necessary to evert the eyelids. In the case of the upper one this can be done by taking hold of its central lashes, drawing it upward and outward, at the same time pressing its upper part downward, the patient meanwhile looking at his feet. The lower one can be everted by drawing it downward while the patient looks upward. The blood supply of the conjunctiva is derived mainly from the conjunctival arteries. They anastomose, around the cornea, with the muscular branches of the ciliary arteries and form the " peri-corneal zone." From this are given off vascular loops which penetrate the cornea to the depth of one millimetre.

The cornea is a beautifully transparent membrane forming the anterior sixth of the eyeball ; it projects from the sclera in the form of a section of an ellipsoid ; its radius of curvature is shorter than that of the sclera. The epithelium covering the anterior surface of the cornea is continuous with that of the conjunctiva, though modified, and it rests directly upon Bowman's membrane, which is a homogeneous layer consisting of a condensation of the cement substance of the next layer, which is called the true cornea or "substantia propria" or "stroma." It is made up of parallel laminae of white fibrous tissue ; these are composed of bundles of fibers, and upon each bundle is found a fusiform nucleus. Chondrin-yieldi ng cement substance holds the fibers and laminae together. Lymph spaces are found in the cement substance between the laminae; these are all connected and serve for the circulation of the lymph which nourishes the cornea. The blood-vessels extend into the corneal substance, forming loops which penetrate the substance of the cornea to the extent of one millimetre from its circumference towards its center. But few lymph cells are found in the lymph spaces during health. The true cornea is continuous with the sclera. The posterior limiting, or Descemet's, membrane is not so closely adherent to the true cornea as is Bowman's membrane. It is thin, strong and elastic and is covered with a single layer of endothelium. This membrane and its endothelium are continuous with the tissues of the iris. The nervous supply of the cornea is derived from the anterior ciliary and conjunctival nerves. Being richly supplied with nerves the cornea is exqusitively sensitive.

The iris and ciliary body form the anterior part of the uveal tract, being situated between the cornea and the ora serrata. Their stroma is continuous with that of the choroid, while the pigment layer which covers the inner surface of the ciliary body and the posterior surface of the iris is continuous with that of the retina. The epithelium covering the anterior surface of the iris and some of the elastic fibers found in its stroma are derived from Descemet's membrane of the cornea. The ciliary body is of an annular shape, about two-tenths of an inch wide, with a thick, round edge, directed anteriorly, and a thin edge, directed posteriorly, which is continuous with the choroid at the ora serrata. The ciliary body has a two-fold function: first, to nourish the anterior part of the vitreous and crystalline lens and to secrete the aqueous humor; second, to perform the function of accommodation. For this reason it is divided into two parts : (a) the ciliary processes and folds, about seventy in number, and (b) the ciliary muscle, which consists of meridional, circular and radiating fibers. This muscle is the active agent in accommodation. The ciliary folds secrete the aqueous humor and nourish the lens and the anterior part of the vitreous. These folds are the most vascular part of the uveal tract ; they are bound together by delicate connective tissue stroma, which contains numerous branched pigment cells. The inner surface of the ciliary body is covered by an elastic membrane, which is continuous with the laminae vitrea of the choroid. Upon this elastic membrane are two layers of cells derived from the retina; the cells of one layer are pigmented, those of the other non-pigmented ; they are epithelial in character.

The iris is a membrane, circular in shape, with a central opening, called the pupil, whose function is to regulate the amount of light entering the eye; it does this by contracting and dilating the pupil. The stroma of the iris is made up, principally, of blood-vessels, which run in radiating directions. At a short distance from the pupil they give off branches and form a circle of vessels, which divides the iris into two zones — the pupillary zone, which surrounds the pupil, and the ciliary zone, which extends to the periphery of the iris. The blood-vessels are bound together by connective and elastic tissue containing connective tissue pigmented and non-pigmented cells. Within the stroma, near the pupillary margin and close to the posterior surface, are found circular fibers, whose function is to contract the pupil. As no radiating fibers have as yet been found in the iris of man, and as dilatation of the pupil is known to follow irritation of the sympathetic nerve, active dilatation is probably due to contraction of the blood-vessels, with which the iris is so abundantly supplied, passive dilatation being caused by contraction of the elastic membrane and fibers that are found in the iris. The tissue of the iris forms a very spongy membrane, and around the pupillary and ciliary circles numerous small spaces are found into which the epithelium dips. The iris and ciliary body are connected to the cornea and sclera by the ligamentum pectinatum, which is a mass of spongy tissue passing from the cornea and sclera to the iris and anterior part of the ciliary body. The epithelium of Descemet's membrane passes between the bundles of fibers and supplies all this spongy tissue with an endothelial lining. This spongy tissue forms the inner surface of Schlemm's canal, a circular sinus lying near the corneoscleral junction. The fluids of the anterior part of the eye are supposed to escape through the loose tissue of the iritic angle into Schlemm's canal, and from that into the veins. The iris and ciliary body, with the lens capsule, the ligament of Zinn and the posterior surface of the cornea, form the bounderies of the aqueous chamber, the depth of which averages about 3 mm., though it is subject to great variation in health and disease. The iris divides this chamber into two parts, known as the anterior and posterior chambers. When the pupil is of average size the pupillary zone of the iris rests on the anterior capsule of the lens; it floats free in the aqueous humor when the pupil is dilated. The color of the iris depends upon the amount of pigment contained in its stroma, dark eyes having a large amount, blue eyes little or none. The nervous supply of the iris and ciliary body comes from the third, fifth and sympa-

DISEASES OF THE EYE.

THE EYE.

ttUSCULUS C.'UARIS^

OURAU SHEATH thetic nerves. The blood supply is from the anterior and long posterior ciliary arteries. Nearly all the blood is carried off by the vense vorticosae. The anterior ciliary veins which anastomose with the conjunctival veins carry off but a small amount of blood when the eye is free from disease. The sclera is a dense white, fibrous membrane, extending from the cornea to the optic nerve entrance. It is about i mm. in thickness around the cornea and i.i mm. around the optic nerve entrance. It gives shape and support to the eyeball. All the ocular muscles are attached to it. A system of lymph canals, resembling those of the cornea, are found in this membrane. It is but scantily supplied with nerves. Its blood-vessels form a wide capillary network, and it is pierced by the nerves, arteries and veins that supply the intra-ocular tissues.

Chapter II. Diseases Of The Conjunctiva

Foreign Bodies — Injuries — Ecchymosis — (Edema — Ephysema — Hyperaemia.

Foreign bodies may lodge upon any part of the conjunctiva. If upon the conjunctival part of the lower lid or lower retrotarsal fold they may cause very little irritation, unless they are of a size or nature to interfere with the movements of the eyeball or to cause destruction of tissue. Very small particles on the inner surface of the lid or on the upper part of the ocular conjunctiva may cause only a sensation of roughness under the lids, or they may cause great pain with hyperaemia of the conjunctiva, lachrymation and spasmodic closure of the lids, and, if allowed to remain, a violent conjunctivitis may result. A careful examination of the conjunctiva should be made, a magnifying glass being used if necessary, first the lower then the upper lid being everted. If no foreign substance be found a 4 r/f solution of Cocaine mur. should be dropped between the lids. A piece of absorbent cotton about the size of a pea should be wrapped upon a probe, and after being dipped into the solution of Cocaine it should be passed between the everted upper lid and the eyeball so as to carefully explore the upper fornix. This procedure will often bring out a foreign body that was hidden from sight. The cornea should also be carefully examined. Foreign bodies are best removed by means of a small piece of absorbent cotten or clean blotting paper. If adherent to the conjunctiva they may be removed by a gouge. If buried in the membrane, the foreign body with the adhering part of the conjunctiva should be lifted up with a small pair of fixation forceps and snipped off with a pair of curved, blunt-pointed scissors. For some time after a foreign body has been removed from an eye the patient may have the same sensations as before its removal. For the relief of these sensations a drop of Cocaine solution should be instilled between the eyelids. If the conjunctiva is congested give Aconite 2x, a tablet every hour; also direct the patient to bathe his eyelids every few minutes with cold water. In a short time this treatment will give relief.

Injuries to the Conjunctiva.

Lime, acids and molten metals splashed into the eye are the most frequent causes of injuries to the conjunctiva. The destruction of tissue may be very great, and not limited to the conjunctiva, but the cornea, sclera and even the whole eyeball may be destroyed. If the subconjunctival tissue is injured, healing will take place by the formation of a cicatrix, the contraction of which may cause distortion of the eyelids, interference with the passage of tears or limitations to the movements of the eyeball. If the epithelium of the neighboring parts of the palpebral and ocular conjunctiva or cornea are destroyed the lids may grow to the eyeball. Such a condition is called symblepharon. If the patient is seen soon after injury, the eye should be flooded with a bland oil and all the particles of foreign substance removed. Cocaine should be put into the eye to relieve the pain and permit of a thorough examination. Give Aeon, ix every hour. Put two drops of Almond oil in the eye every half hour, and bathe the eye frequentlv with cold water. If the burn has been an extensive one, symblepharon will probably form in spite of any treatment. (See Operation for Symblepharon.)

Wounds of the conjunctiva may be penetrating, clean-cut or lacerated. Thev should be washed with a solution

DISEASES OF THE KYK. 2"

(.0001) of Merc, corr., and if they gap they should be sutured with sterilized iron-dyed silk. If this is not done granuloma may develop to the patient's great annoyance. If granuloma have formed do not attempt to remove them at once, but wait until their attachments become narrowed ; then snip them off with scissors.

Ecchymosis.

Ecchymosis of the conjunctiva may result from blows on the head or eye, or it may be due to rupture of one of the conjunctival blood-vessels caused by violent coughing, sneezing or straining. It may occur during Bright's disease or scurvy, and it may be the forerunner of apoplexy. Hamamelis 0, a drop three times a day, seems to hasten absorption of the effusion.

(Edema.

CEdema of the conjunctiva is found as a symptom of inflammation ; also in Bright's disease, in senile degeneration and in general debility. Apis mel. 3X is the remedy.

Emphysema.

Emphysema of the conjunctiva may be the result of rupture of the lachrymal sac or of fracture of the nasal sinuses. A firm bandage should be applied to the eye.

Hyperemia.

Hypereemia of the conjunctiva may be the first symptom of a conjunctivitis, or it may be an essential condition. Of the latter form there are many causes, the most common being errors of refraction, accommodation or convergence I also diseases of the cornea, iris, ciliary body or orbit. It is very common in those persons who spend a large part of the time in foul, dusty or smoky places. The excessive use of stimulants, over-feeding, disease of the digestive organs, rheumatism and disease of the nose are frequently accompanied by this trouble. Hypersemia of the conjunctiva may be acute or chronic; if acute, the vascularity of both the palpebral and ocular conjunctiva will be greater than normal, the flow of tears and mucus will be increased, the conjunctiva will be swollen, and the patient will complain of a rough burning sensation with the feeling as of a foreign body under the eyelids, and generally of a lack of ability to use the eyes for any length of time, more especially by artificial light. In the chronic form the symptoms are the same, though less in degree, and the ocular conjunctiva, as a rule, is not affected. The pathological changes seem to be a dilatation of the blood-vessels, with an abnormal change in the amount of secretion of the mucous and lachrymal glands but no abnormal increase of tissue change. The treatment must depend upon the cause. Any existing refractive or muscular error must be corrected with great care. (See Errors of Refraction.) The eye symptoms are not sufficiently characteristic for the prescription of remedies. Consult Nux vomica, Belladonna, Ipecac, Arsenicum, Rhus tox , and Sulphur. Bathing the eyes with hot water will often give great relief.

CONJUNCTIVITIS.

(INFLAMMATION OF THE CONJUNCTIVA.)

Superficial — Purulent — Circumscribed — Plastic — Hypertrophic — Exanthematous.

Superficial conjunctivitis may be divided into simple and toxic. Some of the synonyms for these forms are catarrhal, muco-purulent, epidemic and autumnal conjunctivitis. Slight redness of the palpebral conjunctiva, a watery discharge and a tendency of the lids to stick together may be the only symptoms in mild cases of superficial conjunctivitis. In the severe cases other symptoms are added, such as photophobia, lachrymation, a mucous discharge, oedema of the ocular conjunctiva, swelling of the eyelids, Small hemorrhages in the conjunctiva, a feeling as of sand in the eyes and pain in and around the eyes. The disease may be acute or chronic, and may last from a few hours to many months. The pathological changes of this form of conjunctivitis are dilatation of the blood-vessels, stasis of the circulating blood, exudation of corpuscles and of lymph which contains all the elements for the formation of fibrin. These are the changes which cause most of the swelling found in this trouble. In addition to the vascular changes, the epithelial cells rapidly proliferate and are cast off in an immature condition. These imperfectly developed epithelial cells, together with some wandering cells form the cellular part of the secretion. The death of some of these elements cause the discharge to become muco-purulent. The mucous glands are filled with and secrete a larger quantity of mucus than under normal conditions. The inflamed membrane regains its normal state by its vessels regaining their tone, by the cessation of exudation and the absorption of the remaining exudates, by the epithelia maturing and the secretion of the mucous glands becoming normal.

The toxic forms of this trouble are without doubt due to micro-organism, and as a consequence they are contagious. As there is no way of distinguishing the toxic forms from the simple forms — except by a bacteriological examination — the physician will do well to treat all forms as if they were contagious, and to warn the patient and those about him of the danger they are in if they do not observe proper care and cleanliness. To destroy and remove the bacilli and free the eye of irritating secretions that tend to keep up inflammatory conditions, a non-irritating disinfectant should be freely used as an eye-wash ; this will not only put the patient in a condition to recover, but will tend to prevent the spread cf the disease to others; and, if only one eye is affected, rigid cleanliness may prevent the disease from spreading to the other eye. But it should be clearly understood that these measures will not take the place of the homoeopathic remedies unless • the solution happens to contain the indicated remedy. It requires something more than bacilli to set up a conjunctivitis; for one thing the tissues must be in a condition to nourish the bacilli or they will die. It is to remedy this state of the tissues and to remove the conditions remaining after the cause of the inflammation has been removed, that internal medication is used. Among the remedies found to be of most value are Aconite for the first stages, when the hypersemia is great and the discharge slight, especially if the patient is intolerant of pain ; it is frequently indicated in traumatic conjunctivitis, to be given in firsl_decimal and the dose frequently repeated.

Apis when there is a marked oedema of the conjunctiva and eyelids, the cedematous swelling of the ocular conjunctiva having a translucent appearance, first or third decimal in frequent doses. Ant. tart, in the chronic forms with a tendency to thickening of the membrane and obstruction of the ducts of the tarsal glands, to be given not lower than the third decimal, morning and night. Arnica in the traumatic forms where the hypersemia is not great but the feeling of soreness is marked, third decimal, a dose every hour. Arsenicum for both the acute and chronic forms when the discharge is free and watery with a tendency to excoriate the skin of the face, burning pain, a feeling of soreness when moving the eyeballs, photophobia and twitching of the eyelids, to be given three times a day not lower than the third decimal or higher than the sixth. Aurum muriaticum when the conjunctivitis is chronic with follicular enlargements, the third decimal, given three times a day. Belladonna in both the acute and chronic forms when the conjunctiva looks red and the eyes feel very dry and hot, with swelling of the eyelids and a flickering of light before the eyes, first or third decimal, a dose every two hours. Euphrasia ix in the mild muco-purulent forms with a free discharge somewhat acrid in character, with a tendency of the mncns to adhere to the cornea and accumulate in the corners of the eyelids, dose to be repeated hourly. Ipecac in the subacute forms when the conjunctiva is swollen and not very red, and when the discharge is almost pure mucus, third decimal, three times a day. Merc. sol. in both acute and chronic forms, with itching of the eyes and a muco-purulent excoriating discharge, and a feeling as though the eyelids were stuck to the eyeball, marked dread of artificial light, third to the sixth decimal, three times a day. Puis, in acute and chronic conditions, discharge thick, yellow and bland, with puffy eyelids and a tendency of the discharge to spread all over the eyeball, first decimal, three times a day. Sulphur in the chronic forms which show a tendency to relapse, with sticking pains worse in the morning, third or sixth decimal, once a day. The best disinfectant for the eye-wash seems to be a .0001 solution of Merc. corr. in distilled water. In severe cases the eyes should be washed every hour by freely dropping this solution into the conjunctival sac and wiping away the secretion with absorbent cotten, which should be immediately burnt after being used. Neither bandages, poultices, wet or dry rags, nor anything that tends to retain the secretion within the eyelids should be tolerated, for all such things have a tendency to convert slight cases into severe ones. A small quantity of bland oil may be spread on the edge of the eyelids at night to keep them from sticking together. The cornea and iris should be examined during the course of superficial conjunctivitis, for inflammation of the cornea and iris sometimes accompany this condition.

PURULENT CONJUNCTIVITIS.

(PURULENT INFLAMMATION OF THE CONJUNCTIVA.)

Gonorrheal Conjunctivitis — Ophthalmia Neonatorum.

The most characteristic picture of purulent conjunctivitis is presented in the gonorrheal form, as seen in the adult. There is scarcely a doubt that this form is caused by direct contact with gonorrheal secretion, as gonococci have been repeatedly found in its secretion. Pure cultures of the baccili found in gonorrheal secretion and placed on the conjunctiva have set up purulent conjunctivitis. The bacilli may be conveyed to the eye from the sexual organs or from an eye suffering from purulent conjunctivitis, generally by the fingers or by towels that have been used by persons suffering from gonorrhea or gonorrheal conjunctivitis. In opening the eyes of a person suffering from this disease great care must be used, as the secretion may spurt from the palpebral opening with great force and for a considerable distance. Many eyes have been lost in this way, for the disease thus set up is generally violent.

The eyelids should be separated by slowly drawing down the lower lid to allow the secretion to escape and then lifting the upper one. Fresh air, sunlight, dilution and drying tend to destroy the infective power of the secretion. If the disease is to be very intense the first symptoms will be manifest in a few hours from the time of the infection ; the milder forms may not show any marked symptoms for three days. In the first stage of a severe case the eyelids are red, hot and swollen to such an extent that it is very difficult to open them. The palpebral conjunctiva and the retrotarsal folds are intensely hyperaemic and greatly swollen; the ocular conjunctiva is also red and swollen to such an extent that the cornea is often lost to view. This swelling of the ocular conjunctiva is called chemosis. The eyelids are sensitive and feel hard to the touch. In places the conjunctiva may appear of a grayish-yellow color, or a whitish membrane may cover its surface. The discharge at this stage is thin, watery and of a reddish-yellow tint. In the second stage the swelling grows less, the eyelids wrinkle and the discharge becomes free and seems to consist entirely of pus. The lymphatic glands in front of the ear may be swollen, and the patient's temperature is apt to be increased. Resolution may take place at the end of this stage or the disease may pass into a third stage, called the chronic form, which is characterized by a thickening and velvety appearance of the palpebral conjunctiva and scant}- discharge from the eye. In a mild case the symptoms may be those of a muco-purulent conjunctivitis and only distinguished from it by an examination of the micro-organimis contained in the discharge. The pathological changes in purulent conjunctivitis differ from those found in catarrhal inflammation in that the inflammatory changes involve the deeper tissues of the conjunctiva and the inflammatory lymph exuded into the conjunctival and subconjunctival tissues tend to coagulate w7ithin as well as on the surface of the conjunctiva. The greatest danger of this distast — the destruction of the cornea — is attributed to thtse changes, as well as to the infective nature of the discharge and the marked tendency to death of the cellular elements and consequent rapid formation of pus. The exudation within the conjunctiva is sometimes so great as to cut off all nutrition from the cornea, so it dies from necrosis, the whole membrane sloughing away with the exception of a narrow rim around its circumference; if this takes place the iris and ciliary body will become involved in the destructive changes; panophthalmitis may result, leaving in place of the eye a more than worthless stump, which may in time set up sympathetic iufla nmation in the other eye. If the cornea escapes the dangers of this stage, it may suffer from various forms of ulceration at a later stage.

The most dangerous of these is the circular ulcer that forms around the circumference of the cornea, sometimes causing destruction of this membrane. Small or large ulcers may form on any part of the cornea. The later in the course of the disease that ulceration of the cornea appears the more chance there will be of limiting its extent and the more favorable will be the prognosis. The course of the disease may extend from a few days to many weeks, depending upon its severity and the treatment adopted. The first step in the treatment is to put the patient to bed, and if only one eye is inflamed to protect the other one ; this can be done by placing a watch crystal over the sound eye, holding it in place by a piece of rubber plaster from which a hole has been cut, leaving the center of the glass uncovered so that the patient can see through it and to also allow the attendant to inspect the eye. The piaster should be made to adhere closely to the face, except at the lower edge, where a small opening should be left to allow the tears to find an outlet. The patient must not be allowed to sleep on the side that contains the sound eye. Two nurses should be employed, one to serve all night and the other to serve all day. They should wash and remove all secretion from the eye every fifteen minutes. For this wash a .0001 solution of Merc. corr. should be used in the first stage of the disease. A quantity of this solution should be put into a large vessel containing a large piece of ice. Small pieces of cotton cloth that have been cooled on this ice should be placed on the eyelids and changed as often as they become warm ; at the same time they must not be used to reduce the temperature of the lids below the normal on account of the danger of depriving the cornea of its nutrition. No strong or irritating solutions should be used at this stage, but the eye must be kept free from any accumulation of its secretion. If the swelling of the eyelids is so great that they can not be opened, the outer canthus should be cut through with a pair of strong scissors ; this will allow the eyelids to open and it will also