Conjunctivitis Purulenta or Blennorrhoica.- (Ophthalmia Neonatorum, Conjunctivitis Gonorrhoica). An acute inflammation of the conjunctiva with a purulent discharge may occur at any time of life, and bears essentially the same features, whether occurring in the infant soon after birth, or in the adult as a result of infection from a gonorrhoeal or other discharge. It is, however, more commonly spoken of under the heading of its two principal causes as ophthalmia neonatorum and conjunctivitis gonorrhoica; but, as the pathology, symptoms, course and treatment are practically the same, they will be generally described under the one heading, reserving for each a brief mentioned of its characteristic peculiarities.
PATHOLOGY.- No great changes take place in the conjunctiva. It simply becomes infiltrated with serum, together with a proliferation of cells and lymphoid elements; the blood-vessels become dilated, the capillaries increased in number and there is also some thickening of the epithelium. the contagiousness of this disease is due to micro-organisms, the gonococci of Neisser, which are found in the pus secreted by the conjunctiva and also in the superficial layers of the conjunctiva itself.
SYMPTOMS.- All those of catarrhal conjunctivitis are present in a much higher degree. The most prominent symptom is chemosis, which may be sufficient to overlap the cornea. This is due to infiltration of the conjunctiva with exudation, which also extends to the lids, causing a violet colored puffiness. The oedema of the lids is so great as to cause ptosis. The papillae of the conjunctiva are elevated and form villi, which bleed easily and give a thick, swollen appearance to the conjunctiva of the lids. Another most prominent symptom is the discharge, which at first is thin, mucopurulent, but soon becomes distinctly purulent, a thick yellow secretion, and is so excessive that the eye and cheek become literally bathed in pus.
At first there is a feeling of heat, smarting and burning pains in the eye, then ciliary pains and shooting pains in the head set in. In some there is a distinct febrile movement. The swelling of the lid becomes hard and tense, making it difficult for even the physician to open them, and of a dusky red color-the upper lid over-hanging the lower.
The first stage, or stage of infiltration, lasts from two to four days, in which the disease has reached its height. The second stage, or that of pyorrhoea, succeeds in which the swelling of the lids and the tense infiltration of the conjunctiva decreases. With this there begins a profuse secretion of pus, which gradually lessens as the swelling subsides, and the mucous membrane finally returns to a normal condition in from four to six weeks.
The great danger is an involvement of the cornea, which may occur in three ways, viz.: First, small facets are formed by a loss of the epithelium, which, if seen and watched, may be prevented from extending; if not, they extend deeper, unite and form an ulcer, which may terminate by perforation. Second, there appear toward the centre of the cornea grayish points of infiltration, which increase in size, fuse and tend to form an abscess. Third, infiltration takes place at the margin of the cornea in the form of a ring; and, if this occupies more than a third of the cornea, it indicates an affection of the nutrition and becomes the starting point of a general necrosis, which almost inevitably causes loss of the eye. The cause of this participation of the cornea is due to either direct action of the infectious matter on the cornea, to direct continuity of inflammation to the substance of the cornea, or to the stoppage of the nutrition of the cornea by the chemosis. A clean cut ulcer will sometimes form at the extreme margin of the cornea, under the chemosis, which is liable to perforate, and is particularly dangerous because it is apt to the overlooked.
CAUSES.- Contagion is undoubtedly the direct cause in nearly every case and the disease breaks out in from a few hours to three days after infection. In infants it usually results from a leucorrhoeal or gonorrhoeal discharge at the time of birth. In adults the infection is introduced from the genitals, by touching the eyes with unclean fingers and is more often the result of infection from gonorrhoea. Girls have been affected from an ordinary leucorrhoeal discharge. Secretions from a diphtheritic conjunctivitis, or an altered or decomposed discharge from a catarrhal conjunctivitis may cause a purulent ophthalmia.
PROGNOSIS is always serious if the cornea is affected, as permanent opacities, staphyloma of the cornea, or even complete destruction of the eye may ensue. Even when the corneal is not affected, do not give a too favorable prognosis, as corneal complications may arise at any time.
Ophthalmia Neonatorum.-The ophthalmia of the newly born child is undoubtedly solely the result of inoculation from a leucorrhoeal or gonorrhoeal discharge from the vagina or cervix and occurs during birth, or later from the the solid linen or sponges. It is only in case where the eyes are prematurely opened that they contract the contagion, when due to contact with the virus fourth day after birth. When resulting from solid linen, etc., it is usually later in presenting its appearance, and, when beginning later than the first week, is almost certainly due to some extraneous source of inoculation. The symptoms are those just described under purulent conjunctivitis, and are generally less severe than under gonorrhoeal. The prognosis is therefore more favorable, because with less swelling there is less danger of corneal ulceration.
Statistics have shown that in former years a very large proportion of all cases of blindness have resulted from this disease, in different countries varying all the way from 20 to as high as 79 percent. In late years the attention that has been paid to the prevention of this disease has very materially lowered the percent. Still we are daily meeting cases of permanent blindness from this disease which should be attributed wholly to the ignorance of those attending these cases. Much of this fatality could be obviated by careful disinfection of the vagina at the time of parturition and in cleanliness in the linen and the sponges used and the hands of those coming in contact with the child or mother. In all cases of gonorrhoeal or leucorrhoeal discharge in the mother, the method recommended by Crede should always be employed. This consists in carefully cleansing the child’s eyes with clean water and then the instillation between the eyelids of a drop of the 2 percent. solution, gr.x. ad 3i of nitrate of silver. This method is practiced by many obstetricians in all cases, and since its general adoption the percentage of cases of blindness from ophthalmia neonatorum have been gradually reduced.
Conjunctivitis Gonorrhoica.-This disease is always due to infection. Its onset is often accompanied by a severe arthritis. The inflammatory process is usually very intense and runs a rapid course. The lids are greatly swollen, as is also the palpebral conjunctiva. There is excessive chemosis and purulent secretion.
The disease usually develops in about forty-eight hours; it may occur in either acute or chronic gonorrhoea, and the more active the gonorrhoea is, at the time of infection, the more severe will be the inflammation. The virus of gonorrhoea may also cause diphtheritic conjunctivitis.
The right eye is more often first affected, and it is more frequently found in males than in females. The physician must always handle all cases of purulent conjunctivitis with extreme care, on account of possible infection. This variety of purulent conjunctivitis is more severe than when due to any other cause, as about one-half of all eyes attacked with this disease are lost, while hardly one-third of the other forms of purulent conjunctivitis are fatal.
TREATMENT of conjunctivitis Purulenta-If the attack is very severe, the patient may be confined to a darkened room, or even to bed; if only one eye is affected, the other should be harmetically closed in order to prevent any of the matter coming in contact with that eye, for this discharge is very contagious, especially in the gonorrhoeal form, and in that found in new-born children. The healthy eye is best protected by means of a watch- crystal held in place over the eye by strips of adhesive plaster. In this way the eye is hermetically sealed; the patient can use the eye for necessary vision, and it is always under the observation of the surgeon. The examination of the cornea to see if ulceration is present is always essential, but care must be taken to make no pressure upon the eye in opening it, on account of the danger, if ulceration should be present, of causing rupture of the cornea and escape of the lens. There is also danger of some of the purulent secretion spurting into the eye of the surgeon. Owing to the contagiousness of the secretions great care should be exercised both by the nurse and physician, to protect their own eyes and those of others, by providing that the sponges, towels, etc., are used only by the patient; also, that their hands are thoroughly cleansed before touching another eye, for often the physician and other patients have been inoculated and vision destroyed through carelessness on this point. If, by accident, and of the discharge should have entered a healthy eye, lukewarm water should be at once injected under the lids to wash it away; after which, drop in a strong solution of chlorine water, or a weak solution of nitrate of silver (gr.ij.ad zi). Fresh air and nourishing diet are important aids. But the special and primary point to the attended to in the treatment is cleanliness. To ensure this, the discharges should be often removed by dropping warm water into the inner canthus until all the pus has been washed away, or by cleansing with the palpebral syringe. This should be done at intervals of from fifteen minutes to an hour during the day, and occasionally through the night, according to the severity of the case. The use of peroxide of hydrogen is of great aid in the through cleansing of the eye, so essential in purulent affections.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.