DISEASES OF THE EYE Lymphatic conjunctivitis or keratitis, i.e., scrofulous or phlyc tmular keratitis, is a localized disease, distinguished from all other inflammatory affections of the conjunctiva, and representing rather a diffused catarrh of the connective tissue.
The disease begins with the appearance of a conical vesicle in the limbus, together with fascicular, and radiating vascular injections. At the top of the cone an abscess forms, which spreads until it reaches the conjunctiva, and then goes on to a cure. Usually there are a number of vesicles which may develop beyond the limbus, and even on the cornea. These little nodules or abscesses often heal in about a fortnight, but relapses are very frequent; in fact almost the rule, so that the disease, first attacking one eye, then the other, may trouble a patient for years. The vesicles of the cornea may heal without opacity, but, on the other hand, deep abscesses do occur, permeating Bowman's mem brane, which can only heal with permanent opacity. Furthermore the ulceration on the cornea may assume a serpigenous character and accompanied by vascular adhesions may cover larger or smaller areas of the cornea. Within the confines of this vascular adhesion permanent opacity regularly occurs. Finally instead of a localized affection, a diffuse neoplasm, which is known as "Pannus scrofulosus corneve" may develop. This neoplasm is generally thin and capable of disappearing.
Photophobia is the subjective symptom of paramount importance. It is nearly always present and severe in form; less frequently it is of a mild character. The children retire into dark corners, lie down on their faces, press their heads tightly into the pillows and resist most energeti cally any attempt to open their eyes. The blepharospasm may reach so severe a form that it is impossible without resorting to the use of the speculum to see the condition of the eye. As a result of the inflamma tion there is a profuse flow of tears. On account of the almost constant moisture on the lids, blepharitis, in an intense form develops, in conse quence of which an irregular position of the cilia as well as eczema of the eyelids may be observed. This latter condition may in permanent cases become so intense, that it may lead to deformity or eversion of the lids, e.g. ectropion. In addition to this in long standing cases as a result of the constant irritation of the tears, a diffuse inflammation of the palpebral conjunctiva may occur. This inflammation as such has nothing to do with the real scrofulous disease of the eye. In summing up all of the evidence we come to the conclusion that the disease is founded upon a localized affection of the exterior coverings of the eye ball. Its stubbornness, and the repeated relapses, indisputably charac
terize its scrofulous nature. Whether the chronic diffuse inflammation of the lids, skin, etc., which arises in consequence, is caused by recur rences of the scrofulous disease of the eyes in particular, or by a special vulnerability of the tissues in chronic scrofula (habitus scrofulosus) must still remain a mooted question. The prognosis of the ocular affections is in general a favorable one, particularly, if the severity and long duration of the pathological phenomena are taken into consider ation. In the majority of cases there occur only slight permanent injuries to the power of vision. Serious disturbances or total blindness arc very rare.
With very few premonitory symptoms a patient is attacked by a severe and remarkably obstinate chronic cold in the head. There is a marked swelling of the submucosa. A limited quantity of a sticky niucoid secretion appears, which however soon dries up forming a crust and soon leads to intense irritation of the skin and to excoriations in the nasal orifices. The irritation of the neighboring skin, particularly of the upper lip, causes the appearance of a chronic eczema, which at first does not differ from any other eczema, but later assumes a peculiar character of its own on account of its great obstinacy and the chronic swelling of the affected parts which appears in consequence of the infiltration of the subcutaneous connective tissues. The pernicious effects of the diseased eyes, described above, together with the con sequences arising therefrom, give the face that repulsive appearance, peculiar to scrofula, and which in reality reminds one of the appear ance of a pig (see Plate 39). Of course the secondary changes of the skin arising from the ocular disease and the rhinitis may assume differ ent aspects. The eczema is apt to spread over the entire face and the hairy scalp as well, forming thick crusts. Furthermore, through infec tion of the eczematous skin, multiple abscesses and ulcers may form which stubbornly resist all measures used for their cure. Frequently the eczema extends to the external auditory canal. The result is an intense otitis externa, with much swelling of the auditory canal and copious formation of crusts often completely obstructing the external auditory canal. This condition be it observed, may occur without an accompanying otitis media; though in many cases this does exist and through its secretions there may result eczema of the auricle and the auditory canal.