ment, is the same, it seems wiser to look upon the disease as a single one, sometimes implicating one of those structures and sometimes both.

It is often known as scrofulous or strumous ophthalmia. These terms, in a measure at least, indicate its causation. It is most common in delicate children with enlarged lymphatic glands, adenoid growths, and hypertrophied tonsils. A French writer (Pierre) has recently gone so far as to state that the micro-organisms which produce the disease have their origin in these enlarged pharyngeal and faucial tonsils. This statement, clinically, seems a little far-fetched. More likely these affections of the throat and that of the eyes are both results of the depraved general nutrition. It is by improving this that operations for adenoid and hypertrophied tonsils are often of great benefit. The authors of our standard text-books do not sufficiently emphasize the importance of such procedures. Neither Noyes, Roosa, Berry, nor Fuchs allude to the subject. Deschweinitz says merely that phlyctenular keratitis is in close connection with obstructive and inflammatory diseases of the nasal passages. Of course the nasal discharge and the eczema at the margin of the nostril are described by all writers.

That an outbreak of phlyctenular ophthalmia should frequently follow measles and scarlet fever is as natural as that these diseases should frequently be followed by adenoid growths in the naso-pharynx, and is due to the same cause: impoverished general health and irritation of the ocular and naso-pharyngeal mucous membranes. Errors in diet are of all causes the most prolific in producing this form of inflammation in the eyes. Candy, cake, tea, and coffee, pastries, and over indulgence in sugars are all injurious. Bad air and dirty surroundings play a large part. Heredity, to the extent at least of a feeble constitution, is often a predisposing factor. These reasons explain why it is so common to see a number of children in the same family affected.

The characteristic symptom is the phlyctenule. The derivation of this word is from the Greek, signifying a blister, and is somewhat misleading, as is pointed out by Fuchs, "since the efflorescence is never really a vesicle, but a solid though soft projection, formed chiefly by an accumulation of lymphoid cells." The number and size of the phlyctenules, and what is of most importance, their location, vary greatly. The large conjunctival efflorescence is known also as pustular conjunctivitis. The minute miliary phlyctenule at the corneal margin is the variety most likely to be overlooked, erroneously diagnosed, and often maltreated. The most unfortunate situa

tion is in the center of the cornea, just over the pupil. A delicate opacity remaining permanently here is one of the most frequent causes of impaired vision. Lachrymation, with conjunctival or circumcorneal injection, is usually, and pain sometimes, present. But the most characteristic symptom of phlyctenular inflammation of the cornea is the intense photophobia. Indeed a diagnosis may be made with very little chance of error when we see a delicate, pale, strumous child with eczema about the lids and nostrils, a running from the nose, and its face buried in the pillow, or the eyes tight shut and the hands pressed over them. Forcible opening of the eye is followed by a gush of tears and sneezing. The consequences of this corneal invasion may be recovery with no remaining opacity, when only the epithelial layer has been involved, or an opacity of greater or less degree, or a perforating ulcer. To discuss the results of the latter would carry us beyond the limits of this brief paper.

According to Deschweinitz the most dangerous form of the disease is the single pustule at the corneal margin, with yellow infiltrated edge and tendency to perforation. But the most frequent way in which I have seen great loss of sight produced has been by repeated attacks, each leaving a more or less dense corneal opacity. This tendency to recurrence is well known, and must be combated chiefly by proper diet and mode of living. Iwanoff has found the efflorescence to occur along the course of the corneal nerves, and thus is explained the intense sensitiveness to light and consequent blepharospasm.

Treatment must be constitutional and local. Neither can be disregarded with justice to the patient. The diet should be simple, nutritious, and given at regular times. Candy, cake, pastry, and so on, should be carefully avoided. Milk, of course, should be given in place of tea or coffee. A daily sponge bath in salt water is often valuable. Plenty of out-door exercise should be insisted on, the eyes being protected from light by a shade or smoked glasses, or both, but never bandaged.

Among medicines, syrup of the iodide of iron and cod-liver oil hold the first place; quinine is often indicated. The local medication must be determined by the situation and acuteness of the disease. Where the sensitiveness to light is intense, with pain and great injection, atropia should be used. In two forms of the corneal involvement atropia is often decidedly injurious, and eserine should be used in its stead, namely, in the minute miliary phlyctenules at the corneal margin and where there is an ulcer which threatens to per

forate in this situation. It seems that the value of eserine in the miliary form is often overlooked. Neither Berry nor Fuchs nor Swanzy refer to it in this connection; yet I have seen many cases in which the disease persisted and grew worse under the use of atropia (or without it) rapidly improve when eserine was substituted in its place. The form and strength in which I prefer the drug is a solution of a half grain of the sulphate to the ounce of distilled Stronger solutions are apt to cause headache.

The eserine should be dropped into the eye every three or four hours. The two remedies of most general application are calomel and the yellow oxide of mercury salve.

The calomel is especially valuable in the conjunctival pustules. A little should be dusted on with a camel's-hair brush or some absorbent cotton. Its action often seems almost like a specific in such cases. According to Fuchs, recent investigations have proven that the action of calomel is a chemical one, and that minute quantities of it are generally transformed by the sodium chloride in the tears into corrosive sublimate. Whatever the explanation of its action, there can be no question of its value in many cases. The yellow oxide of mercury should be used in a salve of a strength generally of about one grain to the dram. It should be rubbed into the conjunctival sac once or twice daily. It is often of value in corneal ulcers and in the opacity which remains after their healing. As to the use of cocaine in corneal ulcers there is some diversity of opinion. Thus Koller, to whom we are indebted for our knowledge of this wonderful anesthetic, strongly disapproves of its use in corneal disease. After alluding to its brief effects he says: "It can be shown that the use of cocaine in corneal affections is positively harmful. Cocaine is a general protoplasmic poison, as more recent biological researches have proved; it first stimulates the protoplasma and afterward paralyzes it, prolonged and repeated action finally causing mortification. It is very easy to demonstrate that repeated instillation of cocaine into an eye causes a general slight haziness and dotted erosions of the epithelium. I noticed these phenomena in my first experiments with cocaine, and was at first inclined to ascribe them to dryness and evaporation due to arrested secretion of tears and diminished winking of the lids brought on by the local anesthesia. But a series of experiments undertaken on rabbits established beyond doubt that although dryness plays some part in the haziness and exfoliation of the epithe

lium, it is chiefly due to necrosis of the epithelium brought on by the direct action of cocaine."

Such words from such an authority deserve great consideration. Deschweinitz also cautions against the prolonged use of cocaine in corneal ulcers. Yet I must say that my own experience with its use has been favorable. I often combine it with eserine, and use it in conjunction with atropia also. The same principles of cleanliness and antisepsis hold true in phlyctenular as in other forms of corneal ulceration. To discuss this phase of the subject fully would exceed the limit of my paper. I have above alluded to the importance of an examination of the upper air-passages. Very great benefit is to be obtained from removing adenoid growths and enlarged tonsils when they exist, and from attention to the nasal mucous membrane.

LOUISVILLE.

DISCUSSION.

DR. J. G. CARPENTER, Stanford: In persons with feeble constitutions, in the young or in old people, we must be exceedingly careful how we use cocaine in their eyes. I have seen local necrosis occur twice, once in a feeble child, and the other in an aged man. I find that there is no treatment more salutary than direct treatment to the nasal passages, and in phlyctenular ophthalmia, aside from feeble constitution and dyscrasias, I believe the most powerful local cause is disease of the naso-pharynx. Treat that properly and the eye trouble subsides.

DR. J. MORRISON RAY, Louisville: The subject of phlyctenular ophthalmia is an exceedingly interesting one, for the reason that a very large percentage of the eye diseases we encounter, especially in children, are the result of so-called phlyctenular or strumous ophthalmia. In the examinations I have made of the inmates of the Institution for the Blind, among white children 15 per cent had relapsing attacks of phlyctenular ophthalmia, while in the colored inmates there was 32 per cent.

We all recognize the importance of constitutional treatment, the internal administration of syrup of iodide of iron, cod-liver oil, and other tonics. We also recognize the importance of this trouble with the nose, and there are a great many of these cases that are associated also with extensive eczematous inflammation about the nose, about the angles of the mouth, ears, and about the head. In fact, nearly all cases of persistent relapsing attacks of phlyctenular keratitis have associated with them eczematous conditions about the head; therefore, at the same time, we should use local medication in connection with constitutional treatment. We must use something to correct the eczematous condition.

I have never made a routine practice of the use of cocaine in the eye as a therapeutic agent. I do not think cocaine is indicated in any ulcerations about the corneæ. I sometimes use it to allay pain in superficial inflammation about the eye. As a therapeutic agent it is absolutely of no importance whatever.

DR. P. R. TAYLOR, Louisville: As regards the cause of phlyctenular ophthalmia, as a rule we have constitutional trouble with local manifestation in the eye, and at the same time more or less irritation in the nose, from the fact that the nerve supply to the conjunctiva and floor of the nose is about the same. We find that authorities describe two characters of this trouble. One will tell you that it extends from the face to the cornea; another, that it is limited exclusively to the cornea, and we do not have an eruption on the head or even on the face. It is well to use local treatment to the nose in connection with the constitutional treatment. Were it possible to keep a patient relieved of photophobia, excessive lachrymation, and pain, we would get rid of the trouble strictly by constitutional means. As to the use of cocaine, I have been using it extensively in the last three or four years. I read an article before the Society at Frankfort, in which I advocated its use in twenty-per-cent solution. I have had very beneficial results from it. I use it, in combination of course, with the yellow oxide of mercury, or mercury in some form.

DR. GEORGE W. Beeler, Clinton: It occurs to me that the eye specialists of the present day want to monoplize the subject of the treatment of the eyes, and I think they ought to in view of the fact that they give their whole attention to it. When we have these meetings, and when they talk upon the subject of the eye, we, as general practitioners, say very little about these subjects. We listen to them and we are benefited by their advice. When I commenced the practice of medicine we did not have a respectable oculist in the State of Kentucky. We did not recognize eye specialists in those days, as some of the old physicians here will remember very well. In speaking of phlyctenular ophthalmia, years ago we used to treat diseases of the eye as well as other parts of the body. I have noticed that children with a strumous diathesis are more liable to this trouble, and, as some of the gentlemen have remarked, we find also some affection of the nasal passages in the great majority of cases, and one of the speakers has suggested that in order to be successful in the treatment of phlyctenular ophthalmia we must treat also the nasal mucous membrane. In the treatment of this trouble I have used nitrate of silver with a compressed bandage about the eye, and, while I do not recall the number of cases I have treated, I do know that a good many of them do better than when we use the yellow oxide of mercury and calomel in the eye.

With regard to the use of cocaine, I do not like it; neither do I like atropia, because it dilates the pupil of the eye, and as soon as the eye is exposed to light the patient suffers more pain. As constitutional treatment I would use the syrup of iodide of iron and cod-liver oil.