ANTETARTUM OPHTHALMIA NEONATORUM(INTRA-UTERINE OPHTHALMIA.)

BY

HARRY FRIEDENWALD, M.D.,of h*i,t;moke.

FROM

THE MEDICAL NEWS,March 9, 1895.

[Reprinted from The MEDICAL News, March 9, 1895.]

ANTEPARTUM OPHTHALMIA NEONATORUM .

(. INTRA-UTERINE OPHTHALMIA.)

HARRY FRIEDENWALD, M.D.,OF BALTIMORE.

A number of States have passed laws with a viewto decrease the still large proportion of blindnessdue to ophthalmia neonatorum. Among theseStates we are happy to name Maryland, whose lastLegislature showed its wisdom in enacting a lawmaking it a punishable offence for a midwife orother person having charge of an infant to treatany ophthalmia, and necessitating the calling of aphysician. These laws are the outcome of the ex-perience that ophthalmia neonatorum is a verytractable disease when properly cared for. Somephysicians have gone so far as to claim that thisdisease is always curable when treated early. Buteven our best ophthalmic surgeons occasionally losea case through corneal involvement, and recentdiscussion proves that it is an unavoidable accidentin an exceedingly small number of cases. 1

It is important to examine into the various con-ditions under which cases are lost and to determinehow they lead to blindness in spite of prophylacticmeasures and of early and proper treatment.

1 Randall: Trans. Amer. Ophth. Soc., 1893. Woods; An-nals of Ophth. and Otol., 1894.

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Ophthalmia neonatorum develops, as a rule, onthe second or third day after birth. Infection usu-ally occurs during the passage of the child’s headthrough the vagina. The intervening time is knownas the period of incubation, during which the eyepresents no signs whatever of disease. This periodlasts at least twenty-four hours. It so rarely hap-pens that the disease makes its appearance earlierthan the second or third day that none of our text-books makes mention of it. And yet there are anumber of cases on record of children born withthe well-marked signs of this disease. In thesecases the period of incubation had passed, and thestage of inflammation was more or less advanced atbirth.

The entire number of such cases that I have beenable to collect in medical literature is eighteen.They are as follows :

1. Hirschberg 1 saw a child, twelve hours old,with well-marked ophthalmia neonatorum; therewas swelling of the lids, pus in the conjunctivalfolds, and a diffuse opacity of both corneae. Laborhad been easy, but the membranes had rupturedthree days before. The final result was a smalleukoma of the right cornea and phthisis bulbi ofthe left eye.

2. Rivaud-Landrau2 has published a case of com-plete destruction of the cornea from ophthalmia twodays after birth.

3. Magnus 3 found ophthalmia fully developedfive hours after birth. The membranes had ruptured

1 Beitr. zur prakt. Augenheilk., Berlin, 1876.2 Cited by Hirschberg.3 Zehender’s Monatsbl. fur Augenheilk., 1887, p. 389.

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almost three days before. Both corneas had grayinfiltrations at birth. Large opacities remained.

4. Paryschev’s 1 case, in which the membranesruptured three days before birth. There was typi-cal ophthalmia when the child was born, and exten-sive opacities of the corneae. The purulent secretioncontained many gonococci. He advises prophylac-tic vaginal irrigation after the membranes have rup-tured, using a solution of mercuric chlorid (1; 2000or 1 : 3000) for this purpose.

5. Krukenberg2 demonstrated a child which pre-sented swelling of the eyelids and conjunctiva, andcloudiness of the right cornea, when born. Gon-ococci were found in the conjunctival secretion (notpurulent) and also in the vagina of the mother.The rupture of the membranes had taken place twodays before birth.

6. He mentions that Keller had a similar case,in which the rupture of the membranes had oc-curred seventeen hours before birth.

7. Feis 3 reports a case of marked ophthalmianeonatorum (great swelling of both upper lids andprofuse yellow, watery secretion) without involve-ment of the cornese. There were gonococci innumbers. The mother had no vaginal discharge,but a greenish-yellow cervical secretion adhered tothe examining finger (latent gonorrhea). Thevagina was frequently irrigated with a percent,solution of carbolic acid. The author believes thatthe infectious cervical secretion was carried to theeyes of the infant by the examining finger. InHaussmann’s Bindehaut-infektion bei Neugeborenen,1882, mention is made of

1 Summarized in Hirshberg’s Centralbl., 1893, p. 64.2 Verhandl. d. Geselisch. f. Geburtsh. und Gynaekol., June,

1891.8 Centralbl. f. Gynaekol., 1892, No. 45.

48. Galezowski’s case of ophthalmia neonatorum

noticed at birth, but the details are not given.9. Feis cites a case that occurred at the Vienna

“Findelhaus ” in 1863. The child was born withboth corneae destroyed and the irides prolapsed,in consequence of intra-uterine ophthalmia.

10. Haussmann 1 reports a case in which rednessand swelling of the conjunctiva were noticed atbirth, the affection disappearing in several days ; therupture of the membranes had not occurred pre-maturely. The author assumes that the pathogenicsubstances had made their way through the unbrokenmembranes.

11. Winckel2 has reported a case of ophthalmiain a child when born, but we have been unable toget the details.

Bellouard3 reports the following cases as occur-ring in the practice of Dianoux, Guilbaud, andhimself.

12. Dianoux had a patient suffering with vaginalblennorrhea for several months. Fearing ophthalmianeonatorum, he used injections of sublimate (1: 100)and of silver nitrate (1 : 100). Labor was rapid.On account of the numerous injections it was im-possible to tell when the membranes had ruptured.One hour after birth a few drops of a 2 per cent,solution of silver nitrate were instilled. In tenhours the lids were tumefied, but the affection wasrapidly checked by treatment.

13. Dianoux was called to a case of ophthalmianeonatorum which had made its appearance on theday that the child was born. The inflammation

1 Loc. cit.2 Ber. a. d. k. saechs. Entbind. Inst, in Dresden, 1876-78. Leip-

zig, 1879, vol. iii> P- 217.3 fltude sur I’apparition precoce de I’ophtalmie purulente chez

les nouveau-nez,par Bellouard. Paris, 1892. Thesis.

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greatly increased, and one cornea, was much dam-aged. The mother had had a vaginitis, but it hadbeen treated with care. The membranes had brokentwo days before birth.

14. Guilbaud saw a case in which the mem-branes had ruptured sixty hours before birth. Thechild’s eyelids were enormously swollen when itwas born, and pus and blood were discharged whenthe lids were opened. They were treated with boricacid, and later with silver nitrate, and were com-pletely cured. The mother had had a vaginitis.

15. In one of Bellouard’s cases labor began at 3a.m., at which time the bag of waters was foundintact. At 11 a.m. the child was born. Repeatedexaminations were made by students. At themoment of birth the lids were found agglutinated,red, and swollen. A 2 per cent, solution of silvernitrate was instilled. At 4 p.m., thick greenish puswas discharged. Recovery was rapid. The motherhad leukorrheafor four months before labor.

16. In another case of Bellouard’s rupture tookplace nineteen hours before birth, at the beginningof labor. At birth the lids were red and swollen,and three hours later there was an abundant dis-charge of a thick fluid. The eyes were entirelyclosed. The mother had a severe vaginitis, andenormous vegetations. In these cases frequent ex-aminations had been made during labor.

17. In Looten’s case1 the child was admitted tothe hospital one day after it was born, at which timethere was chemosis of the eyelids that had probablyexisted for at least twenty-four hours. The corneaof one eye was involved.

18. Fers2 reports the case of a child, born fifty-1 Thesis, Paris, 1875. Cited by Bellouard.2 North American Practitioner. Cited in Hirschberg’s Central-

blatt, 1893, p. 557.

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four hours after rupture of the membranes, present-ing well-marked blennorrhea of both eyes. Gono-cocci were discovered in the secretion.

19. The following case came under my observa-tion at the “Maternite” of Baltimore. The mo-ther had chancroids and venereal warts. The childwas born July 2, 1890, the mother having been inlabor for two days. The membranes broke at 6.15a.m., and the child was delivered at 9 a.m. of thesame day. Silver nitrate (2 per cent.) was in-stilled immediately ; within one hour after birth,when the child was washed, the nurse noticed thatthere was pus in the eyes, and called the attentionof the resident physician, Dr. S. H. Allen, to it.I was called on the following day, and found theeyes discharging a yellowish fluid; there was notmuch swelling ; there were opacities of both corneas,but no ulcers. The treatment consisted in the ap-plication of cold and silver nitrate. The childwas discharged July 30th, with large opacities ofboth corneas. 1

These nineteen cases are all that I have beenable to collect, though using great care; this in-dicates that intra-uterine infection is very rare.

1 Since writing this paper the following notes have been re-ceived from Dr. Edith Eareckson, of this city ; Shewas called toattend a colored girl in her second confinement, March 17, 1893,and was informed that the membranes had ruptured eight hoursbefore she arrived. The labor was tedious, there being a face-presentation, and the child was not born till seven hours later.At birth the eyelids were much swollen and tightlyclosed. Whenforced open to use Crede’s preventive, silver nitrate, muco-pusjetted out. The eyes were washed as thoroughly as possible witha solution of mercuric chlorid, and a 1 per cent, solution ofsilvernitrate was dropped in. Nine hours later much pus was againfound in both eyes. The condition of the corneee was not noted.After the fifth day the casepassed out ofher treatment, andnothingfurther was heard of it.

7When did infection occur in these cases ? Probably

soon after the rupture of the membranes, the in-fectious material being carried in most cases by thefinger of the examining physician or midwife. Inseven cases the rupture occurred between forty eightand seventy-two hours before birth. In seven thetime of rupture is not stated; in two it occurred fromseventeen to nineteen hours before birth, and in one(Bellouard, x) it took place within eight hours; inanother (Haussmann) it is said to have occurredshortly before delivery, while in my own case itappeared to have taken place only three hours before.Haussmann assumed that the pathogenic agentspassed through the unbroken membranes. Bellouardthinks that there was a lateral rupture of the mem-branes, sufficiently large to admit the entrance of thepoison, but not permitting the entire fluid to escape,for the bag was distinctly felt eight hours before thechild was born. In my case the inflammation hadpassed through the period of incubation, and therewas pus in the conjunctival sacs at birth; infectionmust have occurred at least twenty-four hours beforebirth, and twenty-one hours before the aranioticfluid escaped. I am unwilling to accept Hauss-mann’s explanation, 1 that the poison passed throughthe unbroken membranes, and think it more likely

1 This assumption is also made by Nieden, Zehender’s Mo-natsbl., 1891, p. 353, to explain the appearance of an ophthalmiain an infant born in unbroken membranes. The child was takenout of the sac by the physician with the greatest care. And yetthe eyes became inflamed in twenty-four hours in the character-istic manner, though gonococci were not to be found in the se-cretion. Nieden assumes that the amniotic fluid was infected bythe diffusion of a poisonous substance which was capable ofproducifig an inflammation similar to that due to the gonococci,

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that there is an error of observation, i. <?., that therewas an earlier rupture than stated, with probablypartial discharge of the fluid, as is assumed by Bel-louard.

As the infection occurs at varying lengths of timebefore delivery we should expect to find the in-flammation in different stages of development.This is actually the case. Thus, in some the in-flammation began to show itself a few hours afterbirth, and in one the eyes were completely destroyedat birth.

The number of eyes that were thus lost by cornealinvolvement is exceedingly large. The result is statedin fourteen of the cases ; in five of these the corneaescaped, but in nine corneal opacities resulted.Though the total number of cases reported is notlarge, still we do not hesitate to call this form ofophthalmia exceedingly dangerous. We would attri-bute the virulence of these cases in part to the pro-longed contact of the eyes with the poison. Incases in which infection occurs during the shorttime that it takes for the head to pass through thevagina, the contact may be very short, and then theeyes are almost always immediately washed. Theduration ofcontact in cases of intra-uterine infectionmay be hours or even days.

It is interesting to consider the question of pro-phylaxis as applied to these cases. The applicationof Crede’s method would appear to us to be of ser-vice in those cases only in which the infection wasthough less intense and more rapidly cured. We are, however,unwilling to accept this explanation, and believe that direct in-fection took place, even though much care was exercised.

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very recent. Bellouard ascribes much benefit to itin Cases 12 and 15, but it was used in my case with-out benefit. Bellouard suggests the use of vaginalinjections, especially in those cases in which themembranes rupture early. Pareschev used injectionsof mercuric chlorid (1 : 2000 or 1 : 3000) withoutbenefit. Feis made frequent irrigations with one-and-a-half per cent, solution of carbolic acid, with-out preventing the appearance of the inflammationat birth ; Dianoux applied mercuric chlorid (1:100)and silver nitrate (1 : 100) frequently in the formof vaginal injections, besides Crede’s method, andstill the ophthalmia developed ten hours afterbirth. Aside from the danger of the use of suchstrong solutions of mercury, it appears that theirbenefit is far from having been proved, though theywould seem to be indicated.

This form of ophthalmia neonatorum is for-tunately very rare, as is shown by the meager num-ber of cases reported, as well as by the fact thatsuch large statistical tables as those of Crede ap-pear to be unaffected by it.

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