A METHOD OF INFECTION, TREATMENT, AND PROPHYLAXIS OF PURULENT OPHTHALMIA. BY / f GEORGE M. GOULD, A.M., M.D., OPHTHALMOLOGIST TO THE PHIL"Wt>»WBWIA HOSPITAL, PHILADELPHIA. FROM THE MEDICAL NEWS June n, 1892. [Reprinted from The.Medical News, June n,1892.] 4 METHOD OF INFECTION, TREATMENT, AND PROPHYLAXIS OF PURULENT OPHTHALMIA} By GEORGE M. GOULD, A.M., M.D., OPHTHALMOLOGIST TO THE PHILADELPHIA HOSPITAL, PHILADELPHIA. I. As to the Disease. Almost every case of purulent conjunctivitis indelibly impresses upon the mind of the surgeon two striking and puzzling facts: i. The obstinacy of the disease, its stubborn per- sistence and unaccountable resistance to the most thor- ough and most scientific methods of treatment. We cleanse, we irrigate, we antisepticize, we deplete, we use counter-irritants, we stimulate, we constringe, and we cauterize-and the wretched pathologic processes keep on and on until cornea and eye are irremediably injured or ruined. Various explanations of this fact have been made, but to my knowledge the one that I am about to offer, and which seems to me to be one of perhaps sev- eral contributing causes, has not before been given. 2. With one eye infected we hasten to isolate the good eye, using all the methods, so well known, of shields, bandages, antisepsis, and various cautions to patient and nurse. Despite all our prophylactic measures, carried out with the utmost care and apparent success, the hitherto sound eye is, by-and-by, too often found 1 Abstract of a paper read before the Section of Ophthalmology of the American Medical Association at Detroit, June, 1892. 2 GOULD, infected, and we have to redouble our exertions to save that. Very often, indeed, the eye last affected is most affected and most injured. II. A Method of Infection. The explanation of these two characteristic features, or rather one explanation of them, I believe to be the role played by the nose and the lachrymal excretory apparatus as transferring agents and hiding-places of the specific germs. i. Nose-picking with this class of patients is more common than eye-rubbing. While, therefore, the con- tagium may have been transferred directly to the eye, it is quite as reasonable to suppose that it may first have passed through the nares, duct, sac, and canal- iculus. It is a work of supererogation to set forth before this audience of specialists the well-known facts of the inter- dependence of nasal and ocular disease. I have else- where recapitulated these facts, and need only say that a large number of observers have demonstrated that the ocular drainage-system may be the passagexyay for the transfer of morbific material from the antrum of Highmore, and the nasal or post-nasal cavities, to the eye. Every modern book on rhinology speaks of this, and every physician has seen evidences of it. This, however, has been shown or suggested only in so.far as relates to phlyctenular and sundry of the slighter forms of conjunctival and corneal disorders. It seems strange that no one has taken the suggested step of applying the same explanation to the origin of the more virulent types of gonorrheal and contagious purulent disease. 2. Whether or not the primary contagium may have reached the eye directly or by way of the nose, the canal- iculus, sac, and duct will most certainly be the secondary sinuses and hiding-places of the specific germs or septic material. We kill the gonococcus upon or in the con- PURULENT OPHTHALMIA. 3 junctiva, but do not think of the enemy intrenched just beyond the border, waiting to break over the mo- ment our antiseptic army withdraws. Or the analogy of the Channel tunnel-both ends in possession of the French-may strike the English imagination better. In purulent ophthalmia the congestion of the parts, and doubtless often the stenosis, more or less complete, of the lumen of the canaliculus and duct, prevent any effective antiseptic irrigation of the same by natural capillarity or unaided excretion. Expression of the canaliculus and sac-contents, and aided irrigation in the manner I have advised in dacryo-cystitis (N. Y. Med. Journ.^ June 4, 1892), would perhaps do in light cases, and when the physician does not slit the canaliculus. The thick, purulent, and gummy character of the ocular secretions can find little or no passageway through the tight punc- tum and canaliculus, whose lumen is narrowed or quite closed by the swollen tissues about it or forming it. Hence the living germs lying just beyond the action of our ordinary antiseptic agents, and multiplying by mil- lions in a few hours, have an excellent breeding-ground, whence, continually erupting through the punctum, we have a prolific fountain of fresh infection. 3. Passing down the duct also, is it not natural that the germs should readily find their way around the turbinated bones and up through the opposite duct to the other eye, and thus, despite all our isolation and prophylaxis, infect that by means of the tunnel or secret passageway we had forgotten ? If this seem somewhat too long a journey, repeated direct infections of the nares by the fingers would explain the late appearance of the disease in the second eye. The foregoing explanation finds corroborative support in the fact that the nasal mucous membrane, and prob- ably therefore the lining membrane of the duct, sac, and perhaps (though doubtless to a lesser degree) also of the canaliculus, are more resistant to the microbes of suppur- * 4 GOULD, ation and gonorrhea than the conjunctiva. It is a curi- ous fact, this of the extraordinary sensitiveness of the ocular conjunctiva to the injurious action of these germs, and it indicates that these find in the ocular tissue a food exactly to their liking, which they are therefore continu- ally seeking-trying always to get away from the less fertile ground of the nasal mucous membrane and into the richer soil of the ocular analogue. The granula- tions of trachoma have been found in the canaliculus and sac, but not, I believe, in the nose. A recent German writer has noticed that young in- fants of gonorrheal mothers often show evidences of the specific infection (mucous patches) in the mouth, and that sometimes, following these oral ulcers, there ensues ophthalmia neonatorum. He also alludes to the fact that throughout the entire body the ciliated or cylindri- cal type of epithelium of mucous membrane is very resistant to the gonococcus, whilst in that lined by squamous or round-celled epithelium the microorganism multiplies prodigiously. This, therefore, explains why the nose and duct escape injury, whilst the conjunctiva is destroyed. It may also be added that perhaps the eye of the infant may be infected without the interme- diation of the nose, by means of the hands of the care- less mother or nurse (even by the child's hands), that may convey the virus directly from the mouth to the eyes. III. The Treatment suggests itself. The next case of gonorrheal ophthalmia I have I shall at once slit the canaliculus clear into the sac, cleanse, and antisepticize the latter precisely as I do the palpebral sulci, and thoroughly syringe the duct with the antiseptic solution. This I shall do as often and as carefully as the distinctly ocular cleansing and antisepsis. I shall also direct the same solution or a stronger one to be snuffed up the nose. PURULENT OPHTHALMIA. 5 IV. The Prophylactic Measures are quite as clearly indicated. With one eye certainly infected, I would, besides the usual prophylactic pro- cedures, at once also open the canaliculus of the sound eye, and, while the danger lasts, irrigate the sac and duct thoroughly and repeatedly. The nasal douche also should not be neglected. The patient's hands and fingers should of course be kept aseptic and away from his nose just as carefully as from his eyes. It may be said that this is all theory, and that I should have proved it by clinical experience before advocating it publicly. I have by experience found some confirma- tive evidence of the theory, but at present my only answer is that since the idea first occurred to me I have had no suitable cases, and my interest in your patients leads me to advise you to try the plan. It might save a few eyes that would be ruined whilst I alone were experi- menting. I would prefer to be the father of a false theory rather than that a single eye anywhere should be blind for lack of one little method of treatment that at least seems rational, and the application of which, if it do no good, can certainly do no harm. The Medical News. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820 A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00per Annum. COM MUTA TION RA TE, $7 50 PER ANNUM. LEA BROTHERS & CO. PHILADELPHIA.