Kipp: Further Obser-vations on Malanral Keratitis. 33I suggested that he see Dr. Carmalt. Dr. Carmalt wrote me that he had been unable to detect the simulation by the usual tests, and he came to the conclusion that the boy had been shutting one eye without being seen; and at last he caught him doing this. The father was privately told of the trouble, and then the nature of the trouble and the rapidity of the cure were dwelt upon before the boy. He was then given something of an indifferent nature. As he went home, his father would ask him if he could see this or that. Gradually vision came back, and by the time he arrived at home, vision was as good as ever. The supposed blindness was of five weeks' duration. This case shows the importance of knowing the environment of cases in which this trouble ig suspected.

FURTHER OBSERVATIONS ON MALARIAL KERATITIS. BY CHARLES J. KIPP, M.D., NEWARK, N. J.

During the nine years that have passed since I first described this disease * I have had under my care one hundred and twenty additional cases, and a careful study of the same has brought out some facts not previously noted. In all of the cases here referred to the onset of the corneal disease was preceded by several well-marked paroxysms of intermittent fever, for which quinine had been administered. In most cases the paroxysms ceased after the development of the keratitis, but in some they continued for days and weeks. Occasionally the keratitis did not manifest itself till five or six days after the last paroxysm. The disease was observed chiefly in persons between twenty and fifty years of age. Only five cases occurred in persons under five years old. One of these was an infant at the breast, whose mother had intermittent fever; The great majority of the patients belonged to the laboring class. About sixty-six per cent. occurred in males. Cases of this disease came under observation in every month of * On Keratitis from Malarial Fever. Transactions of the American Opthalmological Society, Newport, i88o.

332 Kipp: Furthier Observations oni Malarial Keratitis. the year, but sixty-nine per cent. occurred during the months ot June, July, August, September, October, and November. The smallest number of cases were seen during- December, January, and February. In some years a much larger number came under observation than in others. In all but five of the cases only one eye was affected. In about twenty-five per cent. of the cases the patients had suffered previously, some four or five times, from a similar affection of the eyes, and nearly always in the same eye, in connection with chills and fever. The length of the interval bIetween the attacks varied from one to six years. In a few of these cases the fever returned yearly and was regularly followed by the eye affection. With regard to the character of the eye affection observed in connection with the fever, it should be. stated that in only five of the cases the peculiar narrow, serpiginous, superficial ulcer, with lateral offshoots, which is usually found, was absent, and that instead a large abrasion of the epithelium was present, which was probably the result of the breaking of herpetic vessels. In all of the other cases the form of ulceration above described was developed and its onset was nearly always attended by photophobia, lachrymation, and the feeling as if a foreign body were under the upper lid and rubbing against the eyeball. Sometimes a severe supraorbital neuralgia ushered in the eye disease. In a few cases little or no irritation was present during the whole course of the keratitis. The eyelids were rarely red and swollen, and the palpebral conjunctiva was in only a few cases much injected and swollen. There was always more or less circumcorneal injection. If the eye was examined within a few hours after the appearance of the signs of irritation, there was found in some part of the cornea, usually not far from its margin, a number of small grayish opaque elevations arranged in a line, like a string of beads. On the following day these elevations had disappeared, and in their place was found a narrow furrow with a hazy floor and grayish, ragged edges. At the same time, or perhaps not till some days later, one or several short, grayish, perhaps slightly raised, were seen to shoot from one or both sides of the original furrow into the

Kipp: Fi;rther Otservatio,es on Malanral Keratits. 333 healthy cornea. If examined with a loupe these offshoots were also seen to be made up of a line of minute grayish dots placed closely side by side. In the course of a day or two these offshoots were also changed into shallow furrows. Unless arrested at this stage by treatment, the main furrow and the branches continued to grow gradually in length, without, however, increasing much in depth or width. The epithelium between the branches, especially if they were placed closely together, was, however, often destroyed. In some cases several furrows were developed simultaneously in different parts of the cornea. The length attained by the furrows varied greatly; sometimes they measured only a few millimeters when the disease was arrested, while in other cases they extended across the entire cornea at the time the cases came under observation. They usually followed a crooked or zigzag course. The furrow always remained quite shallow, and probably seldom penetrated Bowman's layer. The width of the main furrow rarely exceeded one millimeter. The floor and the edges of the main furrow and the branches remained of a bluish-gray color throughout the course of the disease in the cases which were properly treated from the beginning; but in some cases in which poultices of bread and milk had been applied, the floor and edges had assumed a yellowish color, and in two of these cases a hypopion was observed. Perforation of the cornea did not occur in any case. Iritis was observed only in the cases with hypopion, and was only slight in degree. Severe pain in and around the eye was present in nearly all of the severer cases and usually continued till the progress of the ulceration was arrested. The sensibility of the cornea was frequently somewhat reduced in the vicinity of the ulceration, but in other parts it was unimpaired. The tension of the eye remained normal throughout the course of the disease. The duration of the corneal disease in the milder cases was from two to four weeks, but in the cases which did not come under my care till the ulceration had made considerable progress, and especially if the fever did not yield to treatment, several months were often required for the cure of the case. With the siubsidence of the ciliary pain, the photophobia, and

334 Ki.pp: Futrther Observations on Malarial Keratitis. the lachrymation, a marked change was noticed in the appearance of the ulcer. The infiltration of the edges of the furrows disappeared, the edges became smoother, and the furrows began to fill up. Vessels appeared upon the cornea only in cases in which some part of the ulcer was situated close to the limbus conjunctive. After the process of repair had once begun the filling up of the furrows required usually but a comparatively short time. The opacities remaining, although not very dense, were, however, in most cases visible on examination, with oblique illumination for months and sometimes for years afterwards. In a large proportion of the cases a marked disposition existed to a recurrence of the disease with every subsequent attack of malarial fever. Many of the patients have been under my care twice for precisely the same form of ulceration, anld a few of them as many as four or five times at intervals varying from one to five years. In these cases the ulceration occurred usually in a different part of the cornea at each attack. With regard to the five cases previously mentioned in which the form of ulceration here described was absent and in its stead was found a mere abrasion of the epithelium, it may be stated that no attempt at repair was observed for several weeks; that in several cases a shallow font was found some weeks later at the point of abrasion, and that this filled up only very slowly. In one of these cases an ulcer with a yellowish floor developed; which, after increasing considerably in depth, healed without leaving a dense opacity. Diagnosis. In former years I was inclined to look upon the peculiar form of ulceration here described as characteristic of malarial poisoning, and Dr. Hotz of Chicago, who published a paper upon the subject in The Chicago Medical Jouirnal and Examiner for December, i88i, did not hesitate to express the opinion that it was as pathogmonic for malaria as the mucous patches in the mouth are for syphilis. A larger experience has, however, convinced me that it is occasionally, though rarely, seen in persons in perfect health. Since I wrote my first paper on this subject, I have seen at least a dozen cases of this peculiar form of ulceration in persons who were either in the best of health and who lived in localities where malarial fevers

KIp: Further Observations on Malarial Keratitis. 335 were almost unknown, or in persons suffering from some other disease than malarial poisoning. My own experience thus shows that malarial fever was the cause of the corneal disease in about ninety per cent. of all the cases in which the peculiar ulceration was present. Within the last five years there have been published several papers by different authors describing a peculiar form of ulceration of the cornea, which resembles so closely the one observed by me in the great majority of the cases of corneal disease due to malarial poisoning that I have no doubt as to their identity. The first of the papers referred to is by Dr. Hansen-Grut of Copenhagen, and is published in The Transactions of thze International Medical Congress field at Copenhagen in I884. No mention is made of -malarial fevers as the cause of the affection of the cornea. The second paper is by Dr. Emmert of Berne, and can be found in Hirschberg's Centralblatt fur Augenheilkunde, October, I885. Emmert calls the disease keratitis dendritica exulcerans mycotica. He sawv six cases of this disease, all occurring in scrofulous or phthisical patients, and in two of the cases he found a peculiar bacillus in or on the epithelial cells which he had scraped from the infiltrated margin and from the floor of the furrows. Shortly after the publication of Emmert's article, Hock of Vienna, also described, in Hirscheberg's Centralblatt far Augenheilkunde, December, I885, a few cases of a similar affection of the cornea occurring in individuals in good health. In the following year Dr. Gillet de Grandmont published in the Archives D'Ophtalmologie, tome sixieme, p. 422, the history of a case of what he calls kfratite ulc6reuse en sillons Atoil6s, which seems to have much in common with the cases described by the authors above mentioned. Malarial fever was not present in this case. The latest publication on this subject is by Dr. Van Millingen of Constantinople, and is contained in Hirschberg's Centralblattfiir Augenheilkunde for January, i888. In this paper Van Millingen states that in connection with intermittent fever he has seen an affection of the cornea which has a remarkable resemblance with the keratitis dendritica observed by Hock, Hansen-Grut, and Emmert. As in neither of the. above cited papers the article written by OPH.-8

336 Kipp: Further. Observations on Malaial Keratitis. myself on this subject -in i 88o is referred to, it seems fair to assume that it was unknown to the authors of the same. As regards the bacillus found by Emmert, I may state that I have searched for it several times since his paper was published, but have thus far failed to find it in the epithelium scraped from the edges of the furrows. So far as I know, Emmert's discovery has not thus far been confirmed by any writer. Treatment. Besides remedies for the general disease, which. should be conquered with all possible speed, I have used locally warm fomentations, with two to four per cent. solution of boric acid, the pressure bandage, cocaine, atropine, and eserine; and in all cases with muco-purulent secretions of the conjunctiva have applied a one per cent. solution of silver nitrate to the palpebral conjunctiva. Encouraged by the apparently more rapid recovery of the cases treated by the application of silver nitrate to the conjunctiva, I was induced to apply at first a one per cent. solution and later a two per cent. solution of the same directly to the furrows in cases which had failed to yield to the warm fomentation and atropine. Previous to the application of the silver nitrate to the floor of the furrows, these were scraped with a delicate sharp spoon. Under this treatment I had at first very excellent results; but very soon I came across cases which were made worse rather than better by it. In such cases I tried thorough scraping alone for a while, and if this did not arrest the march of the ulcer, have applied the actual cautery to the advancing parts of the ulcer. In most cases where the actual cautery was applied, the pain was speedily relieved and the progress of the ulceration arrested by one application, but in others it had to be applied several times before the disease could be brought to a standstill. In a few cases none of the remedies here mentioned seemed to have the slightest effect on the corneal disease, and this more especially the case in patients suffering from chronic malarial poisoning. In these cases no improvement in the eye disease took place till the general health was much improved. I append a few sketches taken from my case-book of seven cases of keratitis from malarial fever.

MALARIAL KERATITIS.

Kipp: Further Observations on Malarial Keratitis. 337 DISCUSSION.

DR. HENRY D. NOYES, New York. -This paper interested me very much, because it appears to me that while a great deal of merit attaches to some of the statements, there is a little confusion in classification with respect to the influence of malaria in producing inflammation of the cornea. My observation on this subject dates back some fifteen or twenty years, and I am in print since i88i as to the existence of the disease. In the cases which I have seen the process was simply a superficial keratitis. It was rare to find the deeper tissues affected. If that occurs, it is due to some complication. I have been led to consider malaria the cause of the inflammation chiefly by two symptoms: first, exaggerated tenderness over the supra-orbital nerve, which is invariably found; and second, notable anesthesia of the surface of the cornea. This has attracted my attention to the history, and I have then found a malarial history. In addition to the ordinary treatment of superficial keratitis, I have used strong doses of quinine. As regards the existence of a form of keratitis due to malaria, I am entirely convinced. The second point which I wish to make is in regard to this peculiar type of keratitis of which the Doctor has given us this interesting sketch. - I recognize that keratitis at once. I remember very well all the papers to which he has referred. The first case published was by Hansen-Grut in Transactions of the International Congress at Copenhagen, 1884. The title given to this condition by Emmert was keratitis exulcerans dendritica mycotica. That kind of a case is in my opinion not essentially malarial. It may co-exist with malarial poisoning, but that it is essentially a mycotic disease I fully believe. The observations of Emmert give strong testimony in this direction. I have a case in mind which is sufficiently convincing. During the time of the blizzard in March, I888, a number of men who for four days were exposed to these severe atmospheric conditions in digging out the Long Island Railroad were taken with what is called snow blindness. Two of them were brought to the eye infirmary. One had intense photophobia and suffered intense pain. By instilling cocaine freely into his eyes, I was able to examine the cornea. On both sides there were present the signs of dentritic mycotic keratitis. The so-called snow blindness was nothing but mycotic keratitis. Assuming that to be the correct diagnosis, my reasoning was: Let me destroy the cocci and I shall cure the trouble. I secured sufficient anaesthesia by cocaine and scraped out every line of infiltration. The following day the man was comfortable and in a few days

338 Kipp: Further Observations on Malarial Keratitis. was well. I think that it is unnecessary to resort to the actual cautery. That involves healthy tissue. Simply scraping out these lines of infiltration removes the intrinsic cause, and then simple treatment is all that is necessary. DR. T. Y. SUTPHEN, Newark.-Since Dr. Kipp called my attention to these peculiar cases fifteen or sixteen years ago, I have taken a great interest in them. They are always associated with malaria. Where there has not been a distinct chill, the patients have been living in malarial districts. I have seen one case of hypopyon with iritis follow this ulceration, and it was necessary to perform paracentesis once or twice before recovery. These cases relapse, but each relapse is less severe than the former, taking the character of softened corneal scar. In those cases where quinine has not acted as rapidly as I thought it should, I have had great benefit from the use of Fowler's solution continued for a long time. Many of these cases will yield to arsenic which do not heal under quinine and local treatment. I think that Dr. Kipp is right in considering this disease as

quite unique. DR. JOHN GREEN, St. Louis. - Keratitis complicating malarial fever is quite common in the vicinity of St. Louis. The patients give a history of an attack of intermittent fever followed within a few days by inflammation of one eye or of both eyes. When such cases have come under my care they have presented the usual characteristics of acute or sub-acute keratitis, generally superficial and not infrequently aggravated by neglect or by irritating applications. As a rule the patients have already undergone a course of constitutional treatment by quinine, etc.; the corneal affection commonly yields to simple local treatment. DR. EMIL GRUENING, New York. - I am well acquainted with this form of keratitis (keratitis dendritica), but I have been in the habit of associating this disease with the condition of the teeth. In every case of this form of keratitis I find the teeth covered with so-called tartar, and all of these patients were in the habit of applying saliva to the eyes in some manner. I think that the mycotic origin seems to be well-established, and I think that the source of the infection is in the mouth. I have also resorted to the treatment mentioned by Dr. Noyes, and removed the gray masses. I find that in some cases the furrows do not heal; they are clear and clean, but remain open, the epithelium not re.-forming for as long as six months. DR. SAMUEL THEOBALD, Baltimore. - I have also for a num-

KIpp: Furthier Observations on Malarial Keratitis. 339 ber of years recognized these cases of keratitis following malarial attacks. It is not uncommon for me to meet with cases such as have been described, but I have not observed the typical form of ulceration. These cases do not always show ulceration of the cornea. There is sometimes a little raised spot of inflammation. I have been impressed with the fact that anaesthesia of the cornea is so frequently present. I have regarded this variety of keratitis as belonging to the general order of herpes zoster. I have once or twice seen iritis associated with keratitis following malaria. In one case where the malarial history was clear, there was the usual form of superficial keratitis and also typical herpes zoster upon the temple. I have therefore re garded these cases not as of mycotic origin but as being of the herpes zoster variety, and due to changes in the ganglionic matter connected with the fifth nerve. DR. HENRY W. WrLLIAMS, Boston. - I wish to add my testimony to the harmlessness of cocaine in corneal affections. I do not think that any one who has seen the constringing effect of cocaine upon the corneal and conjunctival vessels would consider the use of this agent irrational. If it constricts the vessels we should suppose that it would be useful, and experience proves this. I have seen no harm from a two per cent. solution. I have no doubt that a four per cent. solution may cause abrasion of the cornea and be mischievous. A two per cent. solution does not cause the mischievous dilatation of the pupil that atropia does and increase the photophobia, and it does not cause the painful brow sensations that eserine does. It appears to have a soothing influence, not merely for the time being, and by its action upon the corneal and conjunctival circulation it seems to be one of the most effective agents that we have. In ulcerations of the cornea, especially in children, it is especially serviceable when combined with pilocarpine, which does not cause pain in the supra-orbita] nerve, but contracts the. pupil and shuts off the light, thus lessening the photophobia and the consequent spasmodic friction of the upper lid upon the ulcerated corneal surface. DR. H. KNAPP, New York. - I only want to say that superficial ulceration of the cornea is in a number of cases a symptom of acquired syphilis. There is a very superficial loss of tissue, and it heals only under anti-syphilitic treatment. DR. H. G. MILLER, Providence. - I am inclined to agree with Dr. Kipp as to the malarial origin of the form of keratitis which he describes. Up to seven or eight years ago, we in our part of New England were exempt from malaria. At that time a form

340 Kipp: Further Observations on Malarial Keratitis. of intermittent fever appeared and spread from the southwest to the northeast, crossing this part (Rhode Island and Connecticut) of New England. Within a few months of the occurrence of the intermittent fever, this form of keratitis began to show itself. I had not seen it before. Since then it has been exceedingly common. I have observed it take this dendritic form in many cases and develop in the way that Dr. Kipp describes. DR. CHARLES J. Kipp, Newark. -I have no doubt of the mycotic nature of the disease. I have sought for the bacillus, but have not found it. This I have attributed to my incompetence. In ninety per cent. of these cases the inflammation has followed immediately upon a paroxysm of intermittent fever. The attack usually begins as a series of small dots like minute phlyctenule. The next day the epithelium is thrown off and the furrow is open. These furrows rarely increase in width, but extend in a serpiginous manner. In the treatment of the affection I have used scraping, but this is not more effective than the application of nitrate of silver. In my first paper I referred to the use of Fowler's solution. DR. T. Y. SUTPHEN, Newark. - Of all the cases of herpes of the cornea which I have observed, none had the peculiar appearances which so distinguish this form of keratitis.

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