138 BACTERIOLOGY OF THE EYE 



thick purulent secretion. Within a few days after the inflammatory 

 symptoms commence they reach their maximum. 



The lids redden along their margins, are slightly swollen, and stick together in 

 the morning ; but, except rarely in very severe cases, 1 they can be spontaneously 

 opened. A muco-purulent secretion collects on the margins and angles of the lids, 

 and is profusely discharged, mixed with tears. The secretion of the meibomian 

 glands is often markedly increased (Bishop Harman, Pollock). There is often 

 photophobia ; the eyes are hot and painful. In bad cases severe circurnorbital pain 

 and headache may occur. In the early stages of very severe cases Morax observed 

 pain in the upper jaw, and a painful swelling of the pre-auricular gland. There is 

 well-marked redness of the conjunctiva palpebrarum, which is distinctly swollen, 

 and generally appears smooth and shiny. Not infrequently slight pseudo-membranes 

 form (when they occur in the ' forme suraiguii ' they may be well marked). The 

 development of follicles does not occur in inoculation cases. When follicles are 

 found in large numbers a mixed infection may be presumed (Wilbrand, Saenger, 

 Staehlin, Pollock). Markus and Gromakowski consider that in cases which begin 

 subacutely, or continue chronically, the follicles are partly caused by the Koch- 

 Weeks bacillus. In Egypt and in trachomatous countries we often find a granular 

 conjunctivitis along with the Koch-Weeks catarrh (Kartulis, Miiller, Morax, 

 Luerssen, etc.). In the same way scars are seen. 



The conjunctiva, bulbi is very red ; in severe cases this redness is intense, some- 

 times with a bluish tint, and at the height of the disease there is slight chemosis. 

 Miiller states that the conjunctiva bulbi is mainly affected, and has a characteristic 

 bluish tint. Sometimes (in Markus' epidemic very often) we find small haemor- 

 rhages in it : these are commonest in the upper part ; according to Stephenson, 

 more often in adults than in children. Morax considers these haemorrhages 

 characteristic, but they can occur in pneumococcal conjunctivitis. At the limbus 

 conjunctivae small cloudy vesicles often form. Morax distinguishes these from true 

 phlyctenules in that they are true vesicles filled with fluid, and not nodules of 

 leucocytes, like true phlyctenules. In Egypt L. Miiller saw phlyctenules only in 

 scrofulous children. 



In the several members of a family infected from the same source the symptoms 

 may vary considerably in severity, and in children especially they are often 

 much milder than in adults. I have often found, for example, the father with 

 a very severe conjunctivitis and the children with a mild catarrh, but all showing 

 large numbers of Koch- Weeks bacilli. 



Infiltrates sometimes form in the cornea, near the margin or else centrally, and 

 not infrequently more severe ulceration may develop (Morax and Petit, Shumway, 

 Meyerhof, Terlinck). Severe corneal complications are relatively more common in 

 adults than in children (Morax, Meyerhof). They occur in the first few days of the 

 disease. 



The acute cases of moderate severity usually last two to four weeks ; it is rare 

 for the appearance of a severe conjunctivitis to remain for months. The duration 

 depends very much on the treatment. Untreated, the condition can be so prolonged 

 that, as Hofmann and Markus have recorded, a considerable papillary hypertrophy 

 of the conjunctiva remains, especially in the upper fornix, in the crevices of which 

 the bacilli seem to linger. After a long continuance the discharge and the inflam- 

 matory reaction abate, and the appearance of a moderate chronic conjunctivitis 

 develops ; these cases are liable to recurrence, and are capable of infecting other 



1 L. Miiller considers the cases called ' conjonctivitcs suraigues ' by Sameh as belonging 

 to this class. There is, however, no bacteriological evidence yet available of their identity 

 with Koch- Weeks conjunctivitis. 



