ANTETARTUM OPHTHALMIA NEONATORUM (INTRA-UTERINE OPHTHALMIA.) BY HARRY FRIEDENWALD, M.D., of h*i,t;moke. THE MEDICAL NEWS, March 9, 1895. FROM [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 view to decrease the still large proportion of blindness due to ophthalmia neonatorum. Among these States we are happy to name Maryland, whose last Legislature showed its wisdom in enacting a law making it a punishable offence for a midwife or other person having charge of an infant to treat any ophthalmia, and necessitating the calling of a physician. These laws are the outcome of the ex- perience that ophthalmia neonatorum is a very tractable disease when properly cared for. Some physicians have gone so far as to claim that this disease is always curable when treated early. But even our best ophthalmic surgeons occasionally lose a case through corneal involvement, and recent discussion proves that it is an unavoidable accident in an exceedingly small number of cases.1 It is important to examine into the various con- ditions under which cases are lost and to determine how they lead to blindness in spite of prophylactic measures and of early and proper treatment. 1 Randall: Trans. Amer. Ophth. Soc., 1893. Woods; An- nals of Ophth. and Otol., 1894. 2 Ophthalmia neonatorum develops, as a rule, on the second or third day after birth. Infection usu- ally occurs during the passage of the child’s head through the vagina. The intervening time is known as the period of incubation, during which the eye presents no signs whatever of disease. This period lasts at least twenty-four hours. It so rarely hap- pens that the disease makes its appearance earlier than the second or third day that none of our text- books makes mention of it. And yet there are a number of cases on record of children born with the well-marked signs of this disease. In these cases the period of incubation had passed, and the stage of inflammation was more or less advanced at birth. The entire number of such cases that I have been able to collect in medical literature is eighteen. They are as follows : 1. Hirschberg1 saw a child, twelve hours old, with well-marked ophthalmia neonatorum; there was swelling of the lids, pus in the conjunctival folds, and a diffuse opacity of both corneae. Labor had been easy, but the membranes had ruptured three days before. The final result was a small eukoma of the right cornea and phthisis bulbi of the left eye. 2. Rivaud-Landrau2 has published a case of com- plete destruction of the cornea from ophthalmia two days after birth. 3. Magnus3 found ophthalmia fully developed five 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. 3 almost three days before. Both corneas had gray infiltrations at birth. Large opacities remained. 4. Paryschev’s1 case, in which the membranes ruptured three days before birth. There was typi- cal ophthalmia when the child was born, and exten- sive opacities of the corneae. The purulent secretion contained many gonococci. He advises prophylac- tic vaginal irrigation after the membranes have rup- tured, using a solution of mercuric chlorid (1; 2000 or 1 : 3000) for this purpose. 5. Krukenberg2 demonstrated a child which pre- sented swelling of the eyelids and conjunctiva, and cloudiness of the right cornea, when born. Gon- ococci were found in the conjunctival secretion (not purulent) and also in the vagina of the mother. The rupture of the membranes had taken place two days 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. Feis3 reports a case of marked ophthalmia neonatorum (great swelling of both upper lids and profuse yellow, watery secretion) without involve- ment of the cornese. There were gonococci in numbers. The mother had no vaginal discharge, but a greenish-yellow cervical secretion adhered to the examining finger (latent gonorrhea). The vagina was frequently irrigated with a percent, solution of carbolic acid. The author believes that the infectious cervical secretion was carried to the eyes of the infant by the examining finger. In Haussmann’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. 4 8. 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 with both corneae destroyed and the irides prolapsed, in consequence of intra-uterine ophthalmia. 10. Haussmann1 reports a case in which redness and swelling of the conjunctiva were noticed at birth, the affection disappearing in several days ; the rupture of the membranes had not occurred pre- maturely. The author assumes that the pathogenic substances had made their way through the unbroken membranes. 11. Winckel2 has reported a case of ophthalmia in a child when born, but we have been unable to get the details. Bellouard3 reports the following cases as occur- ring in the practice of Dianoux, Guilbaud, and himself. 12. Dianoux had a patient suffering with vaginal blennorrhea for several months. Fearing ophthalmia neonatorum, 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 ten hours the lids were tumefied, but the affection was rapidly checked by treatment. 13. Dianoux was called to a case of ophthalmia neonatorum which had made its appearance on the day 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. 5 greatly increased, and one cornea, was much dam- aged. The mother had had a vaginitis, but it had been treated with care. The membranes had broken two days before birth. 14. Guilbaud saw a case in which the mem- branes had ruptured sixty hours before birth. The child’s eyelids were enormously swollen when it was born, and pus and blood were discharged when the lids were opened. They were treated with boric acid, 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 3 a.m., at which time the bag of waters was found intact. At 11 a.m. the child was born. Repeated examinations were made by students. At the moment of birth the lids were found agglutinated, red, and swollen. A 2 per cent, solution of silver nitrate was instilled. At 4 p.m., thick greenish pus was discharged. Recovery was rapid. The mother had leukorrhea for four months before labor. 16. In another case of Bellouard’s rupture took place nineteen hours before birth, at the beginning of 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 entirely closed. The mother had a severe vaginitis, and enormous vegetations. In these cases frequent ex- aminations had been made during labor. 17. In Looten’s case1 the child was admitted to the hospital one day after it was born, at which time there was chemosis of the eyelids that had probably existed for at least twenty-four hours. The cornea of 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. 6 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 child was born July 2, 1890, the mother having been in labor for two days. The membranes broke at 6.15 a.m., and the child was delivered at 9 a.m. of the same day. Silver nitrate (2 per cent.) was in- stilled immediately ; within one hour after birth, when the child was washed, the nurse noticed that there was pus in the eyes, and called the attention of the resident physician, Dr. S. H. Allen, to it. I was called on the following day, and found the eyes discharging a yellowish fluid; there was not much swelling ; there were opacities of both corneas, but no ulcers. The treatment consisted in the ap- plication of cold and silver nitrate. The child was discharged July 30th, with large opacities of both corneas.1 These nineteen cases are all that I have been able 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 ; She was called to attend a colored girl in her second confinement, March 17, 1893, and was informed that the membranes had ruptured eight hours before 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 tightly closed. When forced open to use Crede’s preventive, silver nitrate, muco-pus jetted out. The eyes were washed as thoroughly as possible with a solution of mercuric chlorid, and a 1 per cent, solution of silver nitrate was dropped in. Nine hours later much pus was again found in both eyes. The condition of the corneee was not noted. After the fifth day the case passed out of her treatment, and nothing further was heard of it. 7 When did infection occur in these cases ? Probably soon after the rupture of the membranes, the in- fectious material being carried in most cases by the finger of the examining physician or midwife. In seven cases the rupture occurred between forty eight and seventy-two hours before birth. In seven the time of rupture is not stated; in two it occurred from seventeen to nineteen hours before birth, and in one (Bellouard, x) it took place within eight hours; in another (Haussmann) it is said to have occurred shortly before delivery, while in my own case it appeared to have taken place only three hours before. Haussmann assumed that the pathogenic agents passed through the unbroken membranes. Bellouard thinks that there was a lateral rupture of the mem- branes, sufficiently large to admit the entrance of the poison, but not permitting the entire fluid to escape, for the bag was distinctly felt eight hours before the child was born. In my case the inflammation had passed through the period of incubation, and there was pus in the conjunctival sacs at birth; infection must have occurred at least twenty-four hours before birth, and twenty-one hours before the araniotic fluid escaped. I am unwilling to accept Hauss- mann’s explanation,1 that the poison passed through the 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 ophthalmia in an infant born in unbroken membranes. The child was taken out of the sac by the physician with the greatest care. And yet the 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 by the diffusion of a poisonous substance which was capable of producifig an inflammation similar to that due to the gonococci, 8 that there is an error of observation, i.