XXIX.

INDOLENT ULCERS OF THE CORNEA.

Synonyms: PHAGEDENIC CORNEAL ULCER; HYPOPYUM-KERATITIS; ULCUS SERPENS CORNEA OF SÆMISCH.

BY W. A. PHILLIPS, M.D., CLEVELAND, O.

THE cause and the therapeutic and surgical treatment of indolent ulcers of the cornea, have been studied by acute observers, with a care and persistence which have been rather more creditable in point of industrious research than satisfactory by way of unquestionable conclusions.

Like many other prominent lesions of the eye, the cause is to be sought in deeper and more obscure structures than the parts immediately involved; accordingly, the functions of the sympathetic and fifth nerves have, respectively, been vigorously interrogated to solve the problem containing the unknown quantity in the factors constituting the sum total of the symptoms peculiar to this disease. Though it is reasonably certain that nerve disturbance is at the foundation of phagedenic ulceration of the cornea, it is equally certain that any line of medication directed at the trouble as a neurosis, has not proved so effective as to establish by curative results the primary seat or cause of the destructive process. While our inability to arrest the disease by orthodox dose and potency probably rests more in not knowing exactly what to prescribe, than in the impossibility of the affection being really amenable to drug action, it is still very questionable practice, in view of results, for any practitioner, general or special, however much confidence he may have in his own sagacity, or in

the profound influence of medicine, to entirely ignore local and surgical measures in his attempt to arrest this most formidable variety of ulceration. Statistics show that in somewhat less than 40 per cent., the ulcer is caused by an injury, such as a chip of steel, or a bruise, while the majority, or about 60 per cent., are due to constitutional disturbances, the nature of which is not altogether apparent; and hence the difficulty of fixing upon any medicinal agent with any degree of accuracy.

The commencement of the disease is seen to be a circular grayish opacity, at or near the centre of the cornea, accompanied at first by only slight irritation. The impairment of vision follows, and is commonly the first symptom that alarms the patient. Very soon loss of substance occurs. The characteristic feature of the ulcer, however, is a swelling and grayish discoloration of its edge, in the form of a crescent. The destruction of tissue spreads slowly in one direction, growing deeper and broader, the base of the ulcer becoming covered with sloughed tissue, the edges being more or less densely infiltrated. In the majority of cases severe ciliary irritation occurs; as the process advances, pus may accumulate in the anterior chamber, as a result of suppurative iritis, and the danger of perforation, the formation of staphyloma and phthisis of the globe is imminent. But even if one or all of these unfavorable terminations be avoided, a dense opacity is liable to result, which will greatly impair the function of the eye. If, now, our patient reaches the stage of danger in spite of the "mild power that subdues," it is a duty we owe to the patient and to the profession that severer measures be adopted than the administration of potentized drugs, which measures are to be in the line of surgical interference.

The clinic conducted by Professor Sæmisch, of Bonn, has furnished a careful record of fifty cases of this kind of ulcer, together with a passing notice of thirty others whose history was incomplete, and the results obtained by means of the surgical procedure first recommended and practiced by Professor Sæmisch are somewhat remarkable, and so far as I can learn quite unequalled. Of the eighty cases operated upon only two were lost.*

* Arch. Ophthal. & Otol., vol. iii, No. 1, pp. 238.

To show how unsuccessful other means have proved, Dr. Bull, a prominent writer, in speaking of this form of ulcer, says: "As regards treatment, almost everything within our scope has been employed-antiphlogistics, irritant applications, paracentesis, iridectomy, atropia, and firm and long-continued pressure, but with rarely a favorable result."*

The case I have to report is a typical one, and one of peculiar interest in view of the extent of the ulceration, its duration, the amount of skilled treatment it had received at the hands of New York oculists, and its ultimately favorable termination.

The patient, a Rev. Mr. W., of Yonkers, N. Y., forty years of age, of good physique, and previously of uniformly good general health. I first saw him August 15th, 1877, rather more than a year after the trouble first made its appearance. At this time the ulcer covered fully two-thirds of the whole cornea of the right eye, extending from above downwards. Its upper border reached entirely across the cornea in a wavy, crescentic, horizontally-directed line, was abrupt, cleanly cut, somewhat clouded by infiltration, and apparently involving fully one-half the thickness of the corneal tissue. The pupil, which was partially dilated by atropine, was about three-fourths covered by the floor of the ulcer. The bottom of the ulcer at the upper portion was clear and free from detritus, while the lower and larger portion was covered with inflammatory products. No blood vessels were visible in any part of its extent. The globe was congested, lachrymation profuse, and the ciliary neuralgia severe; while the pain and anxiety he had endured, together with the large amount of morphine administered, had told visibly upon his general health.

The second day after the first examination (August 17th), assisted by Dr. N. Schneider, who had recommended the case to my notice, I made what is known as Sæmisch's operation, which consists in making an incision through the floor of the ulcer, the extremities of the cut being in healthy tissue.

This wound was opened twice daily with a probe-pointed knife, for six days, at which time the incision had so nearly healed that it was allowed to close completely. But as no evidence of im

*N. Y. Med. Jour., vol. xiv, No. 4, p. 379.