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neal substance or actually perforate it, the resulting scar will be of greater or less size and density. In case of perforation anterior synechia will occur and great damage and impairment of vision may result.

One of the most unfortunate peculiarities of the malady is its tendency to recur again and again. This occurs either by new nodules singly or in crops replacing those that have run their course or by fresh outbreaks taking place after weeks or months of apparent cure. It often happens that a new attack appears in an unaffected eye just as the fellow eye seems to be recovering or completely recovered. This may go on for years. The subjective symptoms are usually conspicuous. They are photophobia, lachrymation, blepharospasm and pain usually worse in the morning. In conjunctival catarrh with which phlyctenular conjunctivitis is oftenest confounded these symptoms are absent unless the disease be complicated by ulcer of the cornea. The discomfort in conjunctival catarrh is moreover greater in the evening and it is characterized by a mucus discharge which is absent in phlyctenular ophthalmia. Phlyctenular ophthalmia, a common disease everywhere, rises to especial importance here, in the South, owing to our immense population of negro blood.

So far as I am aware, no study of the relative liability of the white and the negro to its attacks have ever been published, nor has anyone called attention to the greater severity of the malady and its curious varieties in the latter race. So long ago as 1884 I began to be sceptical about the local treatment of this disease, and therefore to keep it in mind and to notice it with an especially observant eye. It has been my habit to treat cases with different local remedies and to watch the effect of the unlike plans of treatment pursued by my assistants. Of late, certain statistical enquiries have led to the review of all the cases of phlyctenular ophthalmia treated in my clinic during the past ten years, and the result seems to be worth communicating.

Out of 17,311 cases treated during 9 years, of which 6,290, or 36+% were of negro blood, there were 5,052 (or 29+%) cases of conjunctival disease. Of these 5,052 cases, 2,002 were persons of color; that is to say 39+%, or about 3% more than the ratio of such persons to the total attendance. This at first blush

would appear to indicate that the negro is especially liable to affections of the conjunctiva. On the contrary, further examination of my figures confirms the general impression that the race is less liable to these affections than the white. Save the purulent form, to which liability is about equal in the two races, with the exception of phlyctenular conjunctivitis the negro is singularly free from affections of the conjunctiva. Thus of 3,050 whites with conjunctival disease only 438, or 14+%, were phlyctenular cases; while out of 2,002 blacks with conjunctival affections 789, or 39+%. Or, to illustrate this liability in another way; of the 5,052 conjunctival cases, of whites there were 438 or 8+%, and of negro 789, or more than 15% with phlyctenular disease. To put it in still another way although those of negro blood comprise only about 36% of all who attend my clinic, of all of both races with phlyctenular opththalmia the blacks form about 64%. These figures leave no doubt of the greater liability of those of negro blood to the disease in question.

But not only this; the period of life over which liability to attack extends is longer in the negro than in the white. Mackenzie (Edition 1855), says: It seldom attacks infants at the breast; from the time of weaning till about eight years of age, is the period of life during which it is most prevalent. It is rare indeed for adults to be affected with it, unless they have suffered with it from an early period of life. And Fuchs (1892): In very young children, those under the age of one year, it occurs but seldom and it ceases at the time of puberty. Adults are attacked by it only in case they have carried the disease along with them from their childhood. In negroes, children at the breast are not seldom attacked and their liability continues long past the age of puberty. In them the disease is frequently seen in adults, even of middle age, though, of course, these may have been victims of the disease in childhood also.

In four groups in which the races were divided into "whites " and "negroes," all those of negro blood being classified under the latter head, we find in:

Group No. 1. 116 whites and 66 negroes; the youngest white was 1 year old, the youngest negro 2 years; the oldest white was 56,

the oldest negro 65; the average age of the whites was 152 years, that of the negroes 18 years.

Group No. 2. 46 whites and 79 negroes; the youngest white was 1 year old, the youngest negro 18 months; the oldest white case was 38, the oldest negro 50; the average age of the whites was 8, that of the negroes 14 years.

Group No. 3. 54 whites and 80 negroes; the youngest white was 3 years old, the youngest negro 2; the oldest white was 23, the oldest negro 45; the average age of the whites was 9, that of the negro 14.

Group No. 4. 27 whites and 111 negroes; the youngest white was 12 years, the youngest negro 1 year old; the oldest white was 34, the oldest negro 40; the average age of the whites was 91/2 years, that of the negroes 152.

In another group classified into whites, mulattoes and negroes: Group No. 5. Whites 14, mulattoes 22, negroes 76; the youngest white was 1 and 5/12 years old, the youngest mulatto 1 and 8/12 years, the youngest negro 1 year; the oldest white was 27, the oldest mulatto 36, and the oldest negro 59; the average of the whites was 1034 years, of the mulattoes 122, and of the negroes 18 1-5 years.

It can be determined also in group No. 4, that of the whites 5 out of 27, or 18+% were over 15 years of age, while of those of negro blood 50 out of 111, or 45+% were over 15. In group No. 5, of the whites 4 out of 14, or 28+%, of the mulattoes 9 out of 22, or 40+%, and of the negroes 42 out of 76, or 55+% were over 15 years.

In those of negro blood, and especially in the black, the disease is much more severe than in the white, many of the cases may be described as malignant and almost hopeless. I can not recall having seen an eye lost in a Caucasian as the result of phlyctenular ophthalmia, though the occurrence of a phlyctenule at the centre of the cornea, will, of course, impair vision for years in a child; in an adult, or one of almost adult age, perhaps permanently. But in negro children it is quite common to see corneal phlyctenulæ become deep, intractable ulcers, causing great loss of substance and in spite of all we can do leading to perforation and prolapse, with, perhaps, escape of the lens and the passage of the eye into atrophy. Or, from early youth to middle age the disease seems to pursue

certain individuals and crop after crop of phlyctenules make their appearance, until the whole cornea is tattooed with the characteristic scars and v. is reduced to the perception of large objects or of light only. So far as I have been able to see, treatment, while it may assist in relieving particular attacks, seems to be of little avail in the case of these doomed negroes.

Ignorance, shiftlessness and filth, of course, play here important roles and preclude the possibility of acting through improved hygienic conditions. They do not, however, explain wholly the susceptibility which is plainly seen in the well to do of the race.

The varieties of the disease manifested in members of the black race are many and strange and unlike any I have seen in the white. Infiltration with the phlyctenular material may take place over large areas of the bulbar conjunctiva. Often all that part of the membrane exposed in the palpebral fissure, on one or both sides of the cornea, is infiltrated. We have become accustomed in my clinic to call this form phlyctenule en plaque. Sometimes the cornea is surrounded by gelatinous-looking, often pigmented, ring, and I have seen this form taken for Spring Catarrh by those unfamiliar with the varieties of the disease in this race. The palpebral conjunctiva, however, is never infiltrated and these plaques and rings go through the same course of ulceration and healing as the discrete nodules. Ulceration does not take place over the whole ring or plaque, but only over larger or smaller disseminated areas. The form described by Fuchs in which the limbus and the neighbouring corneal surface seem sprinkled with very fine grains, only to be seen by viewing the eye obliquely in certain lights, is quite common. The following cases serve to illustrate such forms of the disease.

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Case No. 1. L. C., a black cook, aet. 22, comes to the clinic April 20th, 1901. Her general health and appearance are good. She says that the L. E. has been sore for 3 mos. V., R. E.=15/cc, L. E. 20/xxx. In L. E. there is an ordinary, discrete phlyctenule on the corneal margin, outward. In R. E. there is an area of infiltration involving the whole of the outer part of the corneal margin and nearly all the conjunctiva exposed in the palpebral fissure. This cornea presents several nubecula. Calomel is dusted into both eyes daily at the clinic. On April 23, 1901, she is practically well and is discharged cured.

Case No. 2. R. W., a black washerwoman, aet. 20, comes for treatment April 21st, 1902. She says her eyes have been red and sore one month. There is phlyctenular infiltration of the margin of the cornea both out and inward, in each eye, closely resembling the infiltration of Spring Catarrh. There is. however, no infiltration whatever of the palpebral conjunctiva and the ring around the cornea shows imperfect outlines of phlyctenulæ in L. E. Calomel is dusted into both eyes daily, at the clinic. May 30 1902, she is discharged cured. V., O. U. on admission and discharge, =20/xx.

Case No. 3. A black-very black-" laborer," aet. 13, comes to the clinic January 6th, 1903. General appearance well nourished and good. He says he has had something in R. E. for a week, V., 0. U.=20/xx. A large, raised, red plaque occupies the whole of the conjunctiva of the ball that shows in the palpebral aperture from the corneal margin to the outer canthus. A shallow ulceration involves about one-half of the surface of the plaque. He is treated by instilling one drop of a 50% solution of enzymol daily at the clinic; nothing else.

January 9, looks a shade better.

January 12, decidedly better.

January 16, Almost well.
January 21, Practically well.
January 28, discharged cured.

For the purpose of studying the natural history of the disease, and of determining if possible whether the topical remedies have any curative merit, I have for some time interested myself in trying many methods of local treatment. It is, of course, well understood that the disease is one of the manifestations of a dyscrasia, that, whatever our views are to its origin and pathology, we all recognize clinically as the scrofulous state. Phlyctenular ophthalmia is the scrofulous disease of the eye. Its association with eczema especially of the upper lip and eye lids has long been determined. It goes without saying, therefore, that such treatment, and above all hygienic measures, as immemorial experience has shown to act favourably upon the scrofulous will always be indicated. Unfortunately with our hospital patients, the very ones in whom the disease is most frequently seen, and in its worst forms, little can be done to improve the conditions under which

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