Complete Text (Part 4)

frequently af- fecting the cornea, causing its destruction and the consequent loss of vision. What are the symptoms of purulent conjunctivitis ? Occurring in the new-born, it first becomes noticeable to the parent in from two to three days after birth. The lids are slightly swollen and somewhat red, are glued together, particularly in the morning, and pro- duce a rather thick, purulent secretion, which escapes from between them when they are separated. The child appears to experience but little pain at the outset. As the disease advances the conjunctiva and lids become much swollen, the purulent discharge becomes more plen- tiful and thinner, and the child loses its appetite and is restless and ap- parently in considerable pain. In many cases a haziness of the cornea appears, followed by ulceration and perforation, which frequently result in total destruction of the cornea and escape of the lens. The secretion gradually diminishes in quantity, the lids become of normal thickness, the conjunctiva returns to a normal condition, the globe shrinks, and recovery occurs with loss of vision. In those cases that recover without injury to the cornea the discharge gradually ceases and the normal state is regained. What are the symptoms of purulent ophthalmia, or gonorrhoea of the conjunctiva, as occurring in the adult ? After the inception of the contagious principle slight irritation, refer- 36 THE EYE. able to the conjunctiva, and redness of this membrane are noticed by the patient, Lachrymation and a mucoid secretion follow in about twenty- four hours. At the end of forty-eight hours swelling of the lids, hyper- trophy of the conjunctiva, and a purulent secretion are present. The height of the inflammatory trouble is reached about the end of the third day, at which time the amount of secretion is very great and the swelling of the lids pronounced. The secretion escapes from between the lids and runs down on the cheek in thin yellowish masses, and gives the in- dividual an appearance characteristic of the disease and never to be forgotten when once seen. Destruction of the cornea in the manner described as occurring in ophthalmia neonatorum takes place here, but is usually more rapid. Pain is in proportion to the severity of the affec- tion. Total destruction of the cornea, with complete loss of vision, oc- curs in probably one-third of all cases where treatment is not undertaken in the early stage of the disease, and is not carefully and judiciously car- ried out. Pseudo-membrane is not an infrequent accompaniment of purulent conjunctivitis, and is usually found in the severer forms. All ages are subject to this affection, which is usually most severe in advanced life. What is the cause of purulent conjunctivitis ? Up to 1879 no specific cause for this condition was recognized, although it was known to be dependent in the adult on infection from gonorrhceal pus. In 1879, Neisser published his studies of the pathogenic micro- organism in gonorrhoea, and gave it the name of gonococcus. It is a double coccus, and can be readily found in all gonorrhceal pus. Puru- lent conjunctivitis in the adult and in the infant in probably every case occurring before the child has reached the age of three days is probably due to the entrance of the gonococcus into the conjunctival sacs. Other causes, indefinite in nature, have been mentioned as being instrumental in the production of purulent conjunctivitis, but they are scarcely worthy of consideration. What is the treatment of purulent conjunctivitis ? The treatment in ophthalmia of the new-born is prophylactic and cura- tive. The prophylaxis consists in the thorough cleansing of the eyes of the infant at birth. Crede of Bonn introduced into the lying-in wards of his hospital the practice of instilling into the eyes of new-born infants one or two drops of a 2 per cent, solution of the nitrate of silver. This practice reduced the percentage of ophthalmia neonatorum occurring in the hospital with which he was connected from 13 per cent, to less than 2 per cent. Other accoucheurs are content to thoroughly cleanse the eyes with a solution of boric acid, salt, and water, or of the bichloride of mercury in the strength of 1 : 4000-5000. These measures suffice to reduce ophthalmia neonatorum to a relatively small percentage. Since the infection is obtained during the progress of the child through the THE CONJUNCTIVA. 37 genital tract, the removal of the infections material can be brought about with great certainty by the ernplojTnent of these methods. In the adult prophylaxis is of little avail except for the prevention of the communication of the disease from one eye to the other. Various devices have been employed for hermetically sealing the fellow-eye during the time of the treatment of the affected eye. It has been found, how- ever, that in spite of hermetically sealing the eye infection has resulted, and those who treat many cases of gonorrhceal ophthalmia in the adult are accustomed to limit their prophylactic measures to occasional cleans- ing of the sound eye with antiseptic lotions, and employing great care to prevent the carrying over of secretion from the affected eye. Treatment directed to the cure of purulent ophthalmia is similar in all cases. During the acute stage cold applications should be made con- tinually, and the eye should be cleansed with some mild antiseptic lotion frequently enough to keep it fairly free from secretion. A solution of boric acid, 3 per cent,, is admirably suited for this purpose. Frequent cleansing and cold applications should be continued throughout the acute stage. The application of astringents in the form of a 1-2 per cent, so- lution of the nitrate of silver, made thoroughly to the conjunctival sur- face once or twice daily, is advocated by many, and certainly gives excel- lent results in a certain proportion of cases. It is the custom of many oculists, however, to defer the employment of nitrate of silver until the subacute stage is established. In the making of cold applications care should be taken not to produce undue pressure on the lids and globe, as it is very easy to interfere with the nutrition of the cornea and cause it to slough. Careful nursing and the carrying out of these simple meas- ures will do as much as can be accomplished by any form of treatment. Recently the use of vaseline, combined with boric acid, and employed to fill the conjunctival sacs in the intervals of cleansing, has been advocated, and has been found to answer admirably in a certain proportion of cases. Should ulceration of the cornea occur, atropine may be instilled, just as in ulcer of the cornea unaccompanied with purulent conjunctivitis. What is granular conjunctivitis ? Granular conjunctivitis, which is also known as trachoma, is a condi- tion in which the conjunctiva is studded with small elevations, discrete in the early stages, coalescing and forming large hard masses as the disease progresses. Fig. 5. The lids become rough, and friction against the cornea produces ulceration, vascularity, opacification, and. in not a few cases, partial destruction of the cornea with loss of vision. It is contagious, affects all ages and classes, but is most commonly met with in children and in the uncleanly. It runs a very chronic ^S^^Z-^^-^ s course and shows little tendency to sponta- ^wM^v neous recovery. Granular Lower Lid (after Eblej. 38 THE EYE. What are the symptoms of granular conjunctivitis ? They vary very much according to the case. In certain forms the patient experiences no inconvenience, and is scarcely aware of the pres- ence of granulations in the conjunctiva until they have fully formed and eversion of the lid discloses a conjunctiva studded with sago-like bodies distributed throughout its entire surface. In the acute forms of tra- choma the disease begins more as an acute conjunctivitis ; redness and hypertrophy of the conjunctiva and moderate swelling of the lids are observed. Secretion of the muco-purulent type is plentiful. In the early stage the swelling of the conjunctiva may entirely hide the granu- lations, but as the disease progresses the swelling diminishes and the sago-like deposits become visible. The process is accompanied by much annoyance to the patient, consisting of a sensation as of a foreign body in the eye, pain due to friction against the cornea, and the swelling of the lid. In this form of trachoma the cornea is very apt to become in- volved and superficial ulceration ensues, with more or less vascularity of the surface of the cornea — a condition known as pannus. Photophobia or dread of light is present, and the patient's life is rendered miserable. What are the causes of granular conjunctivitis ? Trachoma usually appears among the lower classes, in whom the sani- tary conditions are very poor and cleanliness is not observed. The re- searches of Sattler and of Michel make it extremely probable that trachoma is of microphytic origin. But their researches have not been verified to a sufficient extent to make the proof positive. The instilla- tion of medicated solutions sometimes produces trachoma. This is par- ticularly true of the long-continued use of solutions of atropine that have stood for some time and have become stale. The treatment of this particular form of trachoma is as in the forms from other causes. It usually responds to treatment, and recovery takes place in a relatively short time. What is the treatment of granular conjunctivitis ? The treatment may be considered under two heads, medical and sur- gical. The medical treatment of trachoma consists in cleanliness secured by bathing the eye with salt and water or a solution of boric acid, and of applications to the conjunctival surface of a crystal of sulphate of copper, of alum, or of the pure or mitigated stick of nitrate of silver. Solutions of nitrate of silver, acetate of lead, and sulphate of zinc are also employed. When ulceration of the cornea exists, atropine and other medicinal substances used in ulcer of the cornea from other causes may be employed. Applications of copper, alum, or silver are made in the following manner : The lid is everted and the smooth crystal is passed quickly and gently over the diseased surface, care being taken to reach every part. After the application is made it is well to brush water over the surface. In cases where the vascular pannus is marked an infusion of the THE CONJUNCTIVA. 39 jequirity bean has been employed to produce a violent inflammatory condition of the conjunctiva for the purpose of curing the granulations and of clearing up the pannus. The infusion is made in the following manner : 3 grammes of the bean aro pulverized and permitted to mace- rate in 500 cc. of water for twelve or twenty-four hours. To this is added 500 cc. of hot water, and the infusion is filtered. The applica- tion is made by everting the lids and brushing the solution freely over the conjunctival surface. This is repeated every twenty-four hours for two or three days, until an inflammation of sufficient height has been produced. The pulverized bean is dusted on the conjunctival surface for the purpose of exciting the inflammatory reaction by some oculists, with the same result as when the infusion is used. The surgical treatment of trachoma consists in removing the contents of the granules by expression or by excising the fornix folds. For the removal of the contents of the granules forceps have been devised with which the folds of conjunctiva are squeezed, and by a stripping motion the contents of the follicles are forced out. The forceps used by Noyes and those devised by Knapp are among the most popular for this pur- pose. The treatment of trachoma by expression is applicable to the first stage of trachoma, that stage where the granules are still discrete. After the squeezing process the conjunctiva should be brushed with a solution of the bichloride of mercury, 1 : 500 or 1 : 1000. The after-treatment consists in keeping the eyes clean by frequent bathings with some mild antiseptic lotion, and by the employment of mild astringents, as may seem necessary. For the treatment of the second stage of trachoma scarification should be combined with squeezing, and the use of the bichloride solution should be carefully carried out. Destruction of in- dividual follicles by means of the gal vano -cautery point is employed by some. What is phlyctenular conjunctivitis? This is a form of conjunctivitis characterized by the development of small conical vesicles on the conjunctiva of the globe, usually occurring near the margin of the cornea. They first appear as red points, soon become vesicular, and eventually contain pus : they break down and form small superficial ulcers. Considerable irritation of the conjunctivae in the vicinity of the vesicles is always present. If the phlyctenule affect the conjunctiva only, there is usually little photophobia and the patient experiences but little annoyance. However, as soon as they invade the cornea pain and photophobia become prominent symptoms. What are the causes of phlyctenular conjunctivitis ? This disease is unquestionably analogous to eczema of the skin. It is dependent on infection of the conjunctiva, the presence of the vesicles and of the pustules in all probability being due to the entrance of the staphylococcus pyogenes beneath the epithelium of the conjunctiva. The disease usually occurs in children of the so-called strumous diath- 40 THE EYE. esis, and is almost always accompanied with an eczematous eruption about the head or face. It is not identical with herpes, which disease depends upon derangement of nerve-terminals, usually from the fifth cerebral. What is the treatment ? Since in this disease the constitutional condition is usually much below par, it is necessary to employ tonic remedies and to place the patient in good hygienic surroundings in order to more rapidly efi'ect a cure. The local treatment consists in observing cleanliness and in the use of some medication, such as the yellow-oxide-of-mercury ointment rubbed into the eye once or twice daily. What is diphtheritic conjunctivitis? Probably the most rapidly-destructive form of conjunctivitis is the diphtheritic. Its onset is sudden, and destruction of the cornea may occur within forty-eight hours after the first evidence of the disease is manifest. What is the cause of diphtheritic conjunctivitis ? Diphtheritic conjunctivitis is undoubtedly due to infection from the Loner bacillus, as is the case in diphtheria of the pharynx. In the majority of cases the infection is primary in the conjunctiva, but in a certain proportion of cases the disease is communicated to the con- junctiva from the nose in cases of diphtheria of the nose, either by way of the tear-passages or indirectly by some other medium. Diphtheria of the conjunctivae is seldom found as a complication of diphtheria of the pharynx. What are the symptoms of diphtheritic conjunctivitis ? Soon after the infection the conjunctivae become red, the lids swell rapidly, and the patient experiences quite severe pain referable to the eye. But little secretion other than a free flow of tears is at first observed. After the end of twenty-four hours a false membrane begins to appear, the lids become greatly thickened, and so distended by the presence of a fibrinous exudation into the loose tissue of the lid that the skin becomes tightly stretched and glistening. It assumes a purplish hue. At this stage the pain is intense and it is quite impossible to evert the lids. On holding the lids from the globe the conjunctival surface is found covered with a thin pseudo-membrane, which extends well up into the fornix, and eventually passes on to the ocular conjunctiva. The pressure on the cornea from the thickened lids soon causes it to become hazy, and sloughing rapidly takes place. As the disease progresses the pseudo-membrane becomes thicker and of a dirty-yellow color. It is firmly attached, and leaves a bleeding surface when removed. When recovery advances the membrane separates, leaving a swollen granular conjunctival surface : the secretion assumes more of a purulent nature, and gradually disappears. THE CONJUNCTIVA. 41 What is the treatment for diphtheritic conjunctivitis? Cold applications should be constantly applied from the very first, and the eye should be kept as clean as possible by frequent bathing with a solution of boric acid. Should the pressure of the lid be so great as to threaten the integrity of the cornea, a free canthotorny may be made, or the lid may be split through its centre to the depth of the conjunctival cul-de-sac. As the swelling is reduced and the membrane softens, the membrane should be gently removed and applications of a 1 per cent, solution of silver nitrate made to the conjunctival surface every twenty- four hours. The applications of cold should be continued until the swell- ing becomes much reduced. Resolution may then be hastened by the use of hot applications. This treatment may be continued until the parts assume a normal condition. What is spring catarrh? This is a peculiar form of disease, rarely met with in this country, in which the cornea becomes partly or wholly surrounded by an elevated, fleshy mass which encroaches to a slight extent upon its margin. This elevation is usually smooth, but may be somewhat nodular. It is accom- panied by a roughened condition of the conjunctivae of the lids. The process is unaccompanied by severe pain. There is little secretion. It is supposed to depend on a specific cause, but this cause has not yet been determined. The disease is very persistent, recurring in the same per- son year after year. It is worse in the summer, and almost entirely dis- appears in the winter months. What is the treatment ? The treatment is very unsatisfactory. Remedies that appear to favor- ably influence other forms of conjunctival inflammation have no apparent effect upon this. The use of astringents and the careful observance of cleanliness will aid in keeping the disease in abeyance. Applications of the galvano-cautery appear to