PHLYCTENULAR DISEASE OF THE EYES. Hr OLIVER F. WADSWORTH, M.D. OF BOSTON. Read at the Annual Meeting of the Massachusetts Medical Society, June 12, 1883, and printed in the “ Communications ” of the Society for that year. PHLYCTENULAE DISEASE OF THE EYES. The affection to which I desire to call your attention to-day is characterized by the eruption of vesicles or pustules on the conjunctiva or cornea, and often attended by much apparent photophobia. It is one with which you are doubt- less all more or less familiar under some of the many names given to it. Phlyctenular, pustular, scrofulous, lymphatic ophthalmia, conjunctivitis or keratitis ; herpes or eczema of conjunctiva or cornea; fascicular keratitis; ulcer of the cornea,—such are some of the designations it has received. The extended statistics collected by Cohn show that affections of the conjunctiva and cornea make up half the sum of eye diseases. Horner found the same to be true as regards children alone, with this difference, that whereas when all ages are considered, the conjunctival affections out- number much those of the cornea, with children the pro- portion is reversed; in them the cornea being implicated in 27.2%, the conjunctiva in 21.7% of all cases. Moreover, according to Horner, phlyctenular conjunctivitis and keratitis comprise more than half of the disease of these membranes in the child. Arlt also says, this is without question the most frequent of inflammations of the eye. The very frequency of its occurrence makes its discussion appropriate before an assemblage of general practitioners. But its frequency is by no means the greatest of its claims to our interest. Its habitual obstinacy ; its tendency to re- lapse or recur on the least provocation : the variations in 4 PHLYCTENULAR DISEASE OF THE EYES. form which it manifests ; the fact that its appearance is of itself alone evidence, almost invariably, if not wholly without exception, of some deterioration or imperfection of the general health; and, finally, the frequent permanent im- pairment and occasional destruction of sight that it causes, are sufficient reasons for its careful consideration and study. According to Birch-Hirschfeld, 6% of the inmates of the blind asylums of Saxony lost their sight from this disease. Such a percentage is undoubtedly higher than would be found in this country. The number made blind by it bears, however, but a small proportion to the number of those whose sight, in one or both eyes, is more or less seriously and irretrievably injured. While the vast majority of those afflicted are young children, adi Its are not wholly exempt, though with them the disease is comparatively rare. In my experience, also, the course is usually mild in adults, even if sometimes prolonged. It is in children chiefly that severe forms are seen and disas- trous effects produced. Unfortunately, by the laity the malady is very generally looked upon as a troublesome but innocent accompaniment of teething, safe to take care of itself, and to pass away so soon as the irritation attendant on dentition has subsided, or as a sequela of measles or other exanthem, not specially re- quiring treatment. In consequence of this opinion the child is only too often made the subject of experiment with " household remedies,” or allowed, even aided to aggravate the disorder by following its own inclinations. For the physician, the understanding of the affection is made somewhat more difficult than need be by the prevailing habit in text books of treating of eye diseases according to their anatomical situation. There is justification for this method of division, but as a result of it, diseases of the conjunctiva and of the cornea are separated more or less widely, and where, as in the present instance, the disease is PHLYCTENULAR DISEASE OF THE EYES. 5 essentially the same whether its habitat be conjunctiva or cornea, the identity does not always appear with sufficient clearness. Other reasons for confusion are to be found in the multiplicity of titles, some of them implying a relation- ship with other diseases which does not exist, and in the fact that by some authors certain variations of the disease have been described under different names and as if distinct affections, by others different affections have been grouped under the same name. The term herpes applied here is a misnomer. There is no evidence that the eruption has any such special connection with the sensitive nerves as is the case with herpes generally ; Ike lesion of the cornea which may accompany herpes zoster as quite other in character than the phlyctenulae, and the same is, usually at least, true, when corneal or conjunctival affection is coincident with the ordinary herpes febrilis. Eczema, on the other hand, is a frequent accompaniment of phlyctenulae, as it is also a common affliction of young children. But a considerable proportion of the eczema ob- served in this connection is a secondary condition, due to irritation of the skin by overflow of tears and rubbing, or, on the lip and ake nasi, by the catarrhal flow from the nos- trils often present at the same time. The ocular changes do, indeed, resemble in some degree those found in eczema, yet there seem hardly grounds enough for adopting the title of eczema of the conjunctiva and cornea which Horner has proposed. The main characteristic of the disease is the eruption of vesicles or pustules ; these may be single or multiple, may vary in size from that of the head of a small pin to a diam- eter of several millimetres; the process may be exhausted with the eruption of one phletenula, or successive crops ap- pear at irregular intervals; they may be situated on the conjunctiva, or cornea, or both, either successively or simul- taneously, or may extend from one to the other. The dura- PHLYCTENULAR DISEASE OF THE EYES. tion of the individual efflorescence depends in the main upon its size and its situation ; on the cornea the course is slower than on the vascular conjunctiva. The amount of irri- tation is far from being in definite relation to the severity or danger of the disease. € . . On the conjunctiva the eruption developes almost inva- riably in the near neighborhood of the cornea, and shows itself in two forms, the typical cases of which are sufficiently distinct in appearance. The more common is that of an isolated efflorescence. Beginning as a localized, elevated congestion, the centre soon becomes greyish-white or with a tinge of yellow, due to an agglomeration of lymphoid cells. The epithelial surface is thrown off, the mass cells beneath escapes, and there is left a depression with raised edges, which gradually flattens and is again covered by epithelium, while the congestion fades. Ai’ound the pustule, both conjunctival and sub-conjunctival vessels par- take in the congestion ; toward the fornix, where the con- junctiva passes from globe to lid, the conjunctival congestion extends, diminishing in amount, but often increasing in breadth as it recedes from the focus of inflammation, so that the whole congested region assumes a fan shape. Comparatively seldom, however, does the patient present himself with this typical form of congestion. Oftener, other pustules appear in various positions, simultaneously or before the first has healed, and the congested area thus becomes a wide one, with reddening of the lid conjunctiva also. If the individual pustule is small and superficial, it may run through its whole course in a very few days. From this there is every gradation to the sluggish, somewhat deep ulceration, three or four millimetres in diameter, its base ragged, greyish, infiltrated, which may be a fortnight in healing over. The other, less frequent, type consists in the almost simultaneous development of small, often very minute riIYLCTENULAR DISEASE OF THE EYES. 7 phlyctenulae, studded along a part or the whole of the limbus conjunctivas, close to the corneal border. The at- tending congestion is more general, though greatest in in- tensity here also at the site of the eruption. The duration of the individual phlyctenulae is short, but successive crops follow each other more or less rapidly, and extend the time indefinitely. Both forms begin with a sensation of burning or smarting as of a foreign body, more marked in the latter variety. So long as the affection is confined to the conjunctiva alone the subjective symptoms are comparatively light, and the prognosis is positively favorable, even if the course be somewhat prolonged. Yet, until convalescence is fully es- tablished, the danger that the cornea too may be implicated is always threatening, and when that occurs the situation becomes more serious. The manner in which the cornea becomes involved varies. A pustule may form astride of the corneal edge, half in con- junctiva and half in cornea. Should the pustule be small it will genei’ally heal readily and do no damage, but a large pustule in this position may give rise to a deep, funnel-shaped ulcer and to infiltration of the cornea beyond it. It is not so very uncommon for such an ulcer to extend in depth and cause perforation. The so-called fascicular keratitis com- mences as a pustule in this position. Here, instead of fol- lowing the normal course, the infiltrated raised edg;e of the O 7 O ulcer is pushed farther and farther into the cornea, the tissue breaking down and leaving a groove in the corneal sub- stance behind it. At the same time, a bundle of new formed vessels extends from the conjunctiva, keeping pace in its growth with the progress of the infiltration, filling, or more than filling, the groove, while only a scarcely perceptible depression separates its corneal extremity from the grey, crescentic wall which precedes it. Usually the infiltration moves at first toward the centre of the cornea, but it general- 8 PHLYCTENULAR DISEASE OF THE EYES. ly swerves a little from a straight line. It may stop at any part of its course, or cross nearly to the conjunctiva on the opposite side. It never perforates, but the vessels disappear when the process is at an end, leaving a greyish cicatrix which is exceedingly persistent and characteristic. Different again is the behavior where there are numerous small phlyctenulae along the edge of the cornea, in the lim- bus. Then, if the condition persist some time, vesicle fol- lowing vesicle, the irritation excites the growth of vessels from the edge into the cornea close beneath the epithelium. The progress of the vessels depends on the degree of the inflammation at the site of the efflorescence, and they extend farther where this is greatest, but the regularity with which a fringe of straight vessels is formed along the whole cir- cumference of the cornea is sometimes very striking. With the subsidence of the inflammation in the limbus the corneal vascularity vanishes without leaving a trace. More than a superficial ulceration of the cornea, hardly extending deeper than the epithelial layer, I have never seen with this form, but an infiltration, leading to annular ulceration of serious amount, is described as a very rare complication. If the cornea is affected independently the pustules show the same variation in their behavior as on the conjunctiva. There is the same difference in size and number, the same irregularity in the time of their successive appearance and in their duration. They may present themselves at any part without distinction. There seems to be no place of least resistance. Congestion about the pustule is, of course, wanting, but there is circumcorneal congestion, chiefly on the side nearest the inflammatory focus, and fading toward the fornix. A small pustule may be absorbed without com- ing to ulceration, but this is uncommon. From the super- ficial, greyish, subepithelial swelling, which, losing its cover- ing, readily heals without leaving any sign, there is every degree to the extensive, deep, yellowish infiltration, causing PHLYCTENULAR DISEASE OF THE EYES. 9 deep destruction of the corneal tissue, even perforation, healing slowly, generally with the assistance of vessels growing out from the conjunctiva to its edge, and only by the formation of permanent cicatricial tissue. Through this tendency to the formation of vessels on the cornea there is sometimes, when the eruption has been x-epeated and long continued, a sort of pannus developed. Such a pannus mostly may be distinguished by the greater irregularity of its form and distribution from trachomatous pannus, which latter almost always starts from above, while its lower edge is approximately horizontal. Seldom, indeed, a sluggish, deep infiltration is complicated by hypopion and a low form of iritis. When it is borne in mind that, besides all the variations that have been indicated, a catarrhal conjuncti- vitis, with even considei’able swelling of the membrane and mucous secretion, may be superadded, the possible divex’sity in the appearances px’esented is manifest. The degree of injury to the’eye as an ox’gan of vision de- pends chiefly upon the situation of the lesion ; a considei'able opacity near the ch'cumference of the cornea may be of little moment in this respect, yet without directly interfering with the entrance of light to the pupil it may still do harm by changing the proper curve of the cornea. The gx’owth of vessels toward the ulcex’ation is always a welcome manifest- ation, since the repax-ative process is hastened by their means, and it may be said in genei’al that the perfection of recovexy, the eventual freedom from opacity and changes of curvature is the greater, the nearer the ulcer is to the ch’cumference and the shorter the time till healing is accomplished. Of the subjective symptoms the most prominent axxd most troublesome is usually photophobia, so-called. With an isolated eruption on the conjunctiva or a single pustule on the cornea this symptom may be but little px’onounced. As a rule, however, it is px-esent, and especially if the efflox’es- cences are nurnei’ous and x’epeated does it often reach such a 10 PHLYCTENULAR DISEASE OF THE EYES. degree as of itself to become almost a distinguishing charac- teristic of the disease. A child thus affected may never open its eyes even in a moderate light for days or weeks ; it buries its head in its hands, in the pillow, or in the clothes of its attendant, resisting violently any attempt to turn its face toward the light. It seems sometimes as if there were an effort to drag all the features, forehead, cheeks, lips, to one common centre and heap them up over the eyes. To some extent in accord with the amount of the photophobia is the quantity of watery secretion poured out, which, by keeping the lids continually moistened, causes excoriations and in- creases the irritation. Yet it would be a mistake to suppose that the severity of the ocular affection is to be accurately guaged by the photophobia. Rarely, indeed, where this is pronounced is the conjunctiva alone involved; there may, however, be but few pustules on the cornea and those small and near the periphery. Precisely the worst cases, those with large, sluggish infiltration, extending deeply and causing large loss of substance (dense permanent cicatrices), or per- foration with its consequences, have this symptom usually but little marked. The title scrofulous ophthalmia, though it affirms too much, yet indicates rightly the general direction in which the cause of the disease is to be sought. Not that all indi- viduals afflicted are scrofulous, even when the most extended application is allowed to the term ; many are so, and it is in such that the most serious and persistent cases are to be found, notably the sluggish form, as well as those with great blepharospasm. But a condition of health below the norm, which carries with it an impaired power of resistance to harmful influences, is always present. Exposure to rapid changes of temperature while imperfectly protected by cloth- ing, followed by the onset or exacerbation of catarrhal in- flammation of the mucous membrane of the nasal passages and fauces, too often coincides with the beginning or increase PHLYCTENULAR DISEASE OF THE EYES. 11 of the ocular symptoms to be denied an influence as a causa- tive factor. The exanthemata—measles, scarlet fever—may be regarded as acting to depress the tone of the general system, while the congestion of the mucous membranes they cause, in which the conjunctiva shares, may well prepare the ground in some measure for the local affection. To form a definite diagnosis we must obtain a view of the eye. In many cases this presents no special difficulty, in others the ingenuity and patience of the physician are taxed to the utmost if he wishes to avoid the use of forcible measures, and often in vain. If the child can be coaxed to open its eyes, this is, of course, preferable; occasionally the application of cold to the lids will relieve, temporarily at least, somewhat obstinate spasm. Yet whatever means are employed they will fail in many instances, and then the only resource is the elevator of Desmarres, the child being placed on its back, and its head fixed between the knees of the operator. The use of the fingers to raise the lids in such case can never be as effective, and must produce pain- ful and sometimes dangerous pressure on the eye. Inspection of the eye is also necessary for the formation of our prognosis. Hesitation or mistake as to this may forfeit the confidence of the parents, a confidence often tried at the best by the persistency of the disease, and without which careful attention to the details of the treatment is scarcely to be expected. It is not to be forgotten, however, that only a provisional prognosis can be given from the con- dition at the moment, and the state of the general health is always to be taken into account. Although the central portion of the cornea may have escaped hitherto, no one can safely predict that it will not be affected later. More- over, we do well to warn the parents before dismissing the case from treatment, that, for several years, with any depre- ciation of the general health the disease may reappear. The treatment may be divided into general and local. 12 PHLYCTENULAR DISEASE OF THE EYES. What has been said of the etiology indicates both the im- portance and direction of the general treatment. It should never be neglected even in the lightest cases. The diet O o should be easily digestible and nourishing, and attention to it in detail is always advisable ; healthy action of the skin is to be promoted by frequent bathing; iron, malt, and cod liver oil to be prescribed according to the case. The ad- vantage of fresh air and light can hardly be overestimated. Even in the coldest weather it is usually better that the patient, properly clothed, should be taken out for a time daily, and this is the more needed the poorer are the hygienic surroundings at home. Blepharospasm, so-called photophobia, is to be feared, not for itself, but for the prejudicial consequences it entails. The violent action of the orbicularis irritates still farther the already inflamed cornea, incites to friction and consequent excoriation of the skin of the lids with the result to increase the general nervous excitability, and prevents the free bodily movement so necessary, in children especially, for the pre- servation of health. In considering the means for its re- lief, we should constantly remember that the stimulus that excites it starts from the irritated terminations of the trigem- inus, not from any hyperaesthesia of the retina. The in- dication then is to relieve the abnormal sensibility of these terminations. It is the irritation of the corneal nerves that chiefly excites the blepharospasm, and so far as they are concerned the local narcotic effect of atropine makes this our most reliable agent. The alleviating effect of even the first application is sometimes very great. A two-grain solu- tion may be employed every other day, or two or three times daily, and if the case is seen early the spasm may thus be kept within bounds. But should the photophobic habit, if I may be allowed the expression, be once firmly established, relief is more difficult. When the lids are per- sistently kept closed it is commonly useless, or worse than PHLYCTENULAR DISEASE OF THE EYES. 13 useless, to intrust the application of this or any collyrium to the parents or attendants. In the efforts to force open the lids of a struggling child with the fingers, more harm is 0(3 D O 7 likely to be done than the atropine will counteract, and the increased flow of tears excited by the struggle will rapidly re- move the small amount that has been instilled. The elevator is hardly safe in untrained hands. The application may, per- haps, be made when the child sleeps, but otherwise in such cases it is better left to the physician. Sometimes, however, reliance must be chiefly placed on less direct treatment. The benefit of cold applied to the lids has already been referred to. All friction of the lids must be prevented. Excoria- tions of the skin about the eyes may be washed with a solu- tion of silver nitrate, or an ointment, containing ten grains of zinc oxide, or three or four grains each of zinc oxide and white precipitate to the drachm, be applied. The same treatment may be employed for eczema of the upper lip and alas nasi, or elsewhere about the face, if present. Irri- tants are harmful. Darkness only aggravates the symptom. Within doors the light should be moderate and even, and be increased as the condition improves, but sudden changes of light, producing, as they do even in a state of health, con- traction of the orbicularis, are to be carefully avoided. In the open air a dark shade, large enough to protect both eyes, though only one be affected, and arranged to stand out free from them, with a veil or smoke-glasses if required, are of use. It is by attention to details that success is to be attained. When the eruption is limited to the conjunctiva a simple collyrium of borax in water or camphor water is often all the local treatment needed. Calomel, dusted lightly upon the conjunctiva from a camel’s hair pencil, every day or two, till congestion has disappeared, seems to have a good effect in preventing relapses. But it must be employed with precaution. It should be pure and dry, only a very 14 FITLYCTENULAR DISEASE OF THE EYES. thin film of it should be formed on the conjunctiva, and the lower fold should be inspected after a moment or two, that if any have collected there in a clump or thread it may be removed. The action of calomel was for a long time un- known ; now it has been demonstrated that it is soluble, to a slight extent, in salt water, and it probably acts as a weak solution of bichloride. In the presence of iodine there is produced a biniodide of mercury, and it should, therefore, never be used when the patient is taking any preparation of iodine, else a troublesome eschar may be the result. Properly used it is painless, and I have myself never seen any ill effect from it. In general, astringents are to be avoided, but when the condition is complicated with a catarrhal inflammation of the conjunctiva, mild collyria of alum, zinc, or silver nitrate are in place. Yet these should be employed cautiously, and their action watched if any fresh eruption exists. With an eruption on the cornea, I rely, with most oculists, on the action of atropine. Its soothing influence has already been alluded to. The frequency of its application is to be governed in the main by its effect on the pupil, and it is to be continued till the ulceration is again covered by epithelium. Here, also, calomel is apparently of benefit, but is, in contra-distinction to the conjunctival affection, only to be applied after epithelial regeneration is well under way. Yet I would make one exception to this last state- ment. In the fascicular form of keratitis, it has seemed to me that calomel, applied somewhat freely during the prog- ress of the band across the cornea, has sometimes checked its course. So erratic, however, is this variety, and the opportunity for studying it so comparatively infrequent, that I am willing to admit it may have been coincidence rather than effect that I observed. With the ointment of yellow oxide of mercury, much used in the same conditions as is calomel, my experience has been limited, and it has appeared to me at least less agreeable to the patient. PHLYCTENULAR DISEASE OF THE EYES. 15 The sluggish, deep infiltration, whether at the edge of the cornea or more central, showing little or no tendency to the formation of vessels, demands, besides atropine, the ap- plication of hot fomentations, continued half an hour or an hour three or four times daily. These help to relieve the pain, sometimes considerable, and invite the vascular out- growth from the conjunctiva needed to furnish material for repair. Should perforation occur, pain usually ceases as by magic, and the reparative process begins. The subsequent care after perforation does not differ from that required in similar circumstances arising from other cause. Many and various have been the remedies recommended to promote the absorption of corneal opacities left by this or other diseases. My own belief is that none of them are of special value, and that the opacities are best entrusted to nature to reduce, as she certainly will in part. Our task, after the immediate attack has passed, is to see to it that measures to improve and preserve the general health are continuously carried out, and thus recurrence prevented.