THE TREATMENT OF GONORRHEAL OPHTHALMIA
Arthur Edward Smith, M. D.MINNEAPOLIS
In ophthalmology, as in other branches of medical science, the advance in therapeutics has hardly kept pace, in recent years, with that in pathology and diagnosis. Comparatively few of the therapeutic innovations of the past decade have stood the test of time; and, in the main, the ophthalmological materia medica of today bears a striking resemblance to that of fifteen or twenty years ago. Our poverty of therapeutic resource has been notably exemplified in the generally accepted method of treatment of gonorrheal ophthalmia; and the results obtained with the conventional treatment as outlined in the current text-books are far from satisfactory.
Gonorrheal ophthalmia, in both infants and adults, continues to cause an appalling amount of blindness; and only a part of this can, with justice, be ascribed to ignorance and neglect. The number of cases which, in spite of the most careful treatment, go on to corneal ulcer, perforation, panophthalmitis, and irreparable blindness, continues to be considerable. Further, a decided difference of opinion still exists among well-trained oculists of wide experience as to the best method of handling these cases. For over a hundred years silver nitrate has enjoyed an unquestioned pre-eminence in the treatment of the purulent ophthalmias, particularly those cases in which the gonococcus was the etiological factor; and even now to question its right to a place in the treatment of gonorrheal conjunctivitis seems to many to be as heretical as to abandon mercury in the treatment of syphilis. For many years the only difference of opinion in regard to silver nitrate seemed to be as to whether it should be employed in the first stage of the disease, or whether one should wait until the discharge became purulent. Of late years, however, a number of experienced oculists have gone on record as being of the opinion that the majority of these cases do distinctly better without the nitrate than with it. As is well known, the nitrate destroys only those gonococci lying upon the surface or in the most superficial layers of the conjunctiva; and, far from reaching those in the deeper layers, rather forms a film over the surface which protects them from the irrigating solution used later. It also appears to be certain that the use of the nitrate, for a time at least, increases the ratio of extra-to intracellular gonococci in the discharge, which furnishes another valid argument against its use. That a subsequent chronic conjunctivitis with hypertrophy is often a disagreeable sequel in cases in which an energetic course of silver nitrate has been used is a matter of common observation. The vogue of certain of the organic silver salts, such as argyrol, protargol, etc., is no doubt, not so much due to any intrinsic therapeutic merit which they possess as to the fact that the average case gets along better without the local application of strong chemical antiseptics. However one may feel about the abandoning of such a time-honored drug as the nitrate of silver in the treatment of this disease, it must be conceded that it is entirely inadequate to control the process in the severer cases, and as a therapeutic sheet-anchor leaves a great deal to be desired.
The use of cold compresses in gonorrheal ophthalmia continues to be advocated in text-books and practiced in many clinics, especially in America, in spite of the fact that the progressive men in general medicine and surgery seem pretty generally to have abandoned the use of cold applications in the treatment of acute inflammations of bacterial origin. Any merit the cold compresses may have in the reducing of the edema and relieving pain are more than counterbalanced by the fact that the vitality of the tissues is at the same time lowered. In cases in which there is a sufficient swelling of the lids to cause a dangerous pressure on the eyeball, cold should not for a moment be depended upon to control the inflammatory edema but instant recourse had to canthotomy: in cases where this swelling is not marked cold compresses are unnecessary and apart from a certain analgesic effect, of no value.The skepticism, which is becoming more general, in regard to the value of silver nitrate and cold applications has not extended to the third member of the classic trinity,—irrigations,—the efficacy of which seems to be generally conceded. Various substances have been advocated for this purpose,—boric acid, potassium permanganate, bichloride of mercury, normal salt solution, etc., and the consensus of opinion seems to be that it is practically indifferent which one of these is used, the action being mechanical rather than chemical. The ordinary method of half-hourly irrigations has been abandoned by Hosford, Ulbrich, and others in favor of the constant irrigation with the Hosford apparatus or some modification of it.
The English adherents of the constant irrigation treatment, who, for the most part, dispense with the use of silver nitrate altogether, report excellent results; but the method is not without its drawbacks. The apparatus is awkward to use, requires as much or more attention than the intermittent irrigations, and undoubtedly disturbs the rest of the patient at night more. Further, since the lids are, of course, not held apart for the constant irrigation, but the flow of the solution across the palpebral fissure is depended on to cleanse the eye of secretion, one is inclined to question whether the mechanical cleansing is as thorough as when the lids are gently held apart while the eye is being irrigated.
The more one sees of these cases, the more one is impressed with two things: first, that a certain percentage of them would make a complete and uncomplicated recovery, even if they were entirely untreated (undoubtedly this number is larger than we think, especially in children); second, that the usual treatment is entirely inadequate in those cases in which there is an especially virulent infection or a lowered resistance of the tissues. When antigonococcic serum was first developed and its action observed in cases of acute gonorrheal ophthalmia, the results were, as in acute urethritis, disappointing. Many oculists are of the opinion that the serum is entirely without value in acute blenorrhea, even though its use be indicated in metastatic eye disease of gonorrheal origin. Of late, however, at least two men in America have written enthusiastically of serum-therapy in acute gonorrheal conjunctivitis, advocating its employment in the usual manner and also its use locally, i.e., dropped into the conjunctival sac in place of the usual antiseptics. It would seem that the data now available hardly warrant a positive statement in regard to the serum-therapy.
The pathological findings in gonorrheal ophthalmia are simple but significant, in that the gonococcus of Neisser is found, not only on the surface and in the superficial cells of the conjunctiva, but also, often within forty-eight hours, has invaded the deeper layers of the epithelium and the subepithelial connective tissue. This at once makes clear the reason for the inefficacy of the local antiseptics, particularly those like silver nitrate, the action of which is very superficial. Organic silver preparations and irrigations of various kinds are equally powerless to reach any but the most superficially situated of the bacteria.
Since the destruction of the bacteria lying on the surface is not sufficient to control the disease, it may be stated that the problem of the destruction or inhibition of the deep-lying bacteria is the essential problem in curing gonorrheal ophthalmia.
The gonococcus numbers among its biological peculiarities an unusual intolerance of extremes of temperature, its growth in culture being inhibited by temperature above 38° C. or below 18° C. Text-books on bacteriology state that exposure to a temperature of 60° C. for a period of ten minutes destroys the gonococcus. Experimentation in the laboratory of the Dimmer Clinic in Vienna in April and May, 1913, with cultures from forty-two cases of acute gonorrheal urethritis, seemed to indicate that this point may be placed from one and one-half to two degrees lower than this, i.e.,—from 58° C. to 58.5° C.
Thus, theoretically, at least, it would appear that, if the conjunctiva could be subjected to a temperature as near as possible to this without injury to the tissues, a marked effect should be observed in the course of the disease, particularly if the heat can be applied in such a way as to penetrate as deeply into the tissues as does the gonococcus. This theoretical requirement has, in my opinion, been perfectly met practically by the local use of steam as practiced in the Dimmer Clinic since February, 1913, with the apparatus devised by Lauber and modified by the writer. Goldzieher of Vienna was probably the first to employ steam in the treatment of the purulent ophthalmias; and in his first series of cases reported fifteen patients treated with the application of steam passing through a nozzle held at a distance of about four centimeters from the eye, the temperature of the steam striking the tissues being about 45° C. (113° F.). Although the resultsindicated that the method was a distinct step in advance there were still a number of important details to be worked out, in order to get the best possible results. First of all, experiment showed that the temperature of the steam at a given distance from the nozzle was not constant, so that an arbitrary distance could not be set. This suggested the advisability of providing the apparatus with a sliding-guard, which could be set at the exact distance from the nozzle where the steam was shown by the thermometer to be at the desired temperature. Secondly, it was determined that the tissues would sustain without injury a considerably higher temperature than that set by Goldzieher, and that the effect upon the diseased process was markedly better when the temperature was raised. Steam at from 50° C. to 53° C. gave the best results; and in one case in which a temperature of 55° C. was inadvertently reached no injury was done the tissues. Further experience naturally suggested other changes in the original technic. In the first place, the lids were held apart by an assistant in the usual manner; but, even with gloves on, the exposure of the fingers to the steam was more or less painful, and gauze wound on little sticks was substituted. The time of exposure was finally set at six minutes; and since the application of the steam could not be borne for longer than from forty-five to sixty seconds without severe pain it usually took twenty minutes or so to complete the six-minute exposure. This was done once every twenty-four hours, and was combined with half-hourly irrigations with potassium-permanganate solution. No other treatment was used. The results attained with this method in 34 cases (7 adults, 2 children and 25 infants) has left nothing to be desired. In no case has there been any corneal complication; swelling and pain subsided with unusual promptness; and the course of the disease was notably shortened, whereas, after the first application of silver nitrate a considerable increase in the number of gonococci in the discharge is often observed. A striking diminution in the number is noted after the initial application of the steam. In 8 of the cases in the series mentioned (all infants), the disease affected both eyes; and in 5 of these cases the experiment was made of treating one eye with steam in the manner described and the other with applications of silver nitrate in the usual manner, using the permanganate irrigations in both. The difference in the results attained was very striking. In every instance the eye in which the steam was used was brought much more quickly under control than the one under nitrate. In cases brought under treatment early the edema of the lids did not become severe; and the course of the disease seemed, in general, to be shortened by about one-third. There were no corneal complications, except in one case in which there was a corneal ulcer present when the man presented himself at the clinic. In no case was canthotomy necessary; and no case was followed by a chronic hypertrophic conjunctivitis. The application of the steam is undeniably painful, but not unbearably so.