Reprinted from the Medical Record, February 16, 1895. THE PREVENTION AND TREATMENT OF OPHTHALMIA NEONATORUM, AND THE NECESSITY FOR MORE EFFICIENT LEGIS- LATION TO PREVENT BLINDNESS FROM THIS CAUSE.1 By CHARLES H. MAY, M.D., NEW YORK. CHIEF OF CLINIC, DEPARTMENT OF DISEASES OF THE EYE, AND INSTRUCTOR IN OPHTHALMOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK ; PRO- FESSOR OF DISEASES OF THE EYE AND EAR, COLLEGE OF PHYSICIANS AND SUR- GEONS, BOSTON ; ETC. It is the purpose of this paper to prove that, although legislation to prevent the occurrence of blindness from ophthalmia neonatorum was effected in September, 1890, it has not been successful in materially reducing the disastrous effects of this disease ; secondly, I wish to suggest a modification of the law which will, if en- forced, be more certain to diminish the number of cases, or at least make it exceptional for blindness in one or both eyes to result. Previous to speaking of necessary legislation, it will be well to review briefly the methods now used to pre- vent the occurrence of ophthalmia neonatorum, and to treat the disease in the exceptional cases in which proper prophylaxis has been unsuccessful, and in oth- ers in which the latter has been omitted. Almost everyone is familiar with the great success which followed the introduction of Crede's method of prevention. Others had recognized the importance of prophylaxis, and had introduced preliminary disinfec- tion of the vagina of the mother and the use of various applications to the eyes of the new-born (cleaning with water ; dry cleansing ; solutions of salicylic acid, of borax, of carbolic acid ; chlorine water). Crede, how- 1A paper read at the meeting of the Medical Society of the County of New York, November 26, 1894. z* r 2 ever, was the first to advocate the use of an efficient germicide. His method is now carried out in the great majority of lying-in institutions all over the world. Immediately after delivery, the eyes are carefully cleansed with water, and then one drop of a two per cent, solution of nitrate of silver is allowed to fall upon the cornea ; this procedure is very often followed by a little redness for a day or two, but no other reaction or inconvenience results. The brilliant results achieved by Crede in his insti- tute in Leipzig, in which the percentage of cases fell from 10.8 to o.i or 0.2 per cent., have been repeated wherever the method was vigorously adhered to. In New York the various lying-in asylums have been prac- tically free from the disease during the past few years ; they all employ Crede's method, using one per cent, or two per cent, solutions of silver, and, in addition, disin- fecting vaginal irrigations previous to delivery. The following statements from some of these institutions will confirm this practical absence of ophthalmia neona- torum : In the Sloane Maternity, Dr. E. A. Tucker, the house surgeon, reports that they have had no case of any ac- count among four thousand births during the past six years ; two per cent, solution of nitrate of silver and vaginal irrigation before delivery are employed. Dr. E. J. Sherow, the house surgeon, has written me concerning the Nursery and Child's Hospital, that from July, 1891, to November, 1894, there have been five hundred and sixty-three births, with but one case of ophthalmia neonatorum, and this case was not a seri- ous one ; one per cent, solution of nitrate of silver is used. I was unable to obtain statistical evidence bearing on this subject from the New York Maternity Hospital on Blackwell's Island, an institution averaging over three hundred births a year. Dr. Benjamin Torrens, the present house surgeon, informs me that cases of 3 ophthalmia neonatorum are very uncommon, and cases which result in impairment of sight are rare. Recently, they have been using a saturated solution of boric acid in place of nitrate of silver, and the impression is that the results are just as good ; it would be in- teresting, however, to have this impression verified by statistics. The table on next page,1 given by Fuchs in his admi- rable essay upon the subject, compares the number of cases of ophthalmia neonatorum occurring before, with those developing after, the introduction of various methods of prophylaxis. Personal inquiry has proven that a case of ophthal- mia neonatorum is rare in the practice of obstetricians among the better classes. Under such circumstances, very few employ nitrate of silver, almost all depending upon the prophylactic effects of vaginal irrigation, gen- eral cleanliness, and cleansing the eyes with solution of boric acid ; in the event of the occurrence of ophthal- mia, proper treatment readily controls the inflammation, and loss of sight is a rarity. Thus it is evident that cases of ophthalmia neonatorum occurring in New York, are confined to the infants of the poorer classes in whom prophylaxis is omitted by the physician, nurse, or mid- wife ; and even in such cases, blindness would rarely result if proper treatment were applied at a sufficiently early period. In regard to treatment, there is a practical unanim- ity of opinion among oculists : 1, Frequent cleansing ; 2, cold (or hot) compresses ; 3, applications of one per cent, solution of nitrate of silver ; 4, treatment of corneal complications. Every case should be treated as soon as the slightest redness or swelling of the lids is noticed ; for we can never be certain, at an early stage, whether such a con- dition is merely dependent upon a mild catarrhal con- junctivitis, which is seen very frequently in the new-born, 1 Fuchs : Die Ursachen und die Verhiitung der Blindheit, p. 129. A Comparison of the Frequency of Occurrence of Ophthalmia Neonatorum without Prophylaxis, with the Results of Various Preventive Methods. •• Author. No Prophylaxis. After Prophylaxis. Births. Cases of Oph- thalmia Neo- natorum. Per cent. Prophylactic Method. Births. Cases of Oph- thalmia Neo- natorum. Per cent. Abegg1 Schirmer 2 .... Bischoff 3 Olshausen *... Olshausen.... Kruckenberg 6 Koenigstein 9 . Crede7 Koenigstein... Kruckenberg . Felsenreich ... Felsenreich .. Simpson 8 .... Bayer9 55° 1,266 1,092 2,897 1,889 1,106 69 92 5i 314 82 136 5-6 12.5 7.3 4.8 10.8 4-3 11.76 12.3 Cleansing with water Dry cleansing Salicylic acid Carbolic acid, two per cent. ; used after ligating the cord... •Carbolic acid, two per cent. ; used before ligating the cord. Carbolic acid, two per cent Carbolic acid, one per cent Nitrate of silver, two per cent Nitrate of silver, two per cent Nitrate of silver, two per cent Nitrate of silver, two per cent. First period Nitrate of silver, two per cent. Second period Nitrate of silver, two per cent Nitrate of silver, two per cent 50 137 166 82 I<541 1,160 1,250 730 3,000 2,100 361 0 12 6 21 i or 2 9 58 21 0 3-o 0 2.6 8.8 3.6 33-4 i-4 0.1 or 0.2 0.7 0.14 1.9 1.0 5-o 0 5Archivfiir Gynakologie, Bd. 12, p. 329. 9 Archiv filr Kinderheilkunde, 1882. 7 Archiv filr Gynakologie, Bd. 21, p. 181. "Annales d'Oculistique, 90, p. 145. * Archiv fur Gynakologie, Bd 30. 1 Nagel's Jahresbericht f. Augenheilkunde, 1881, p. 337. 2 Koenigstein. 3 Horner: Handbuch der Kinderkrankheiten ; v. Gehrhardt, Bd. 5, Abth. 2, p. 264. 4 Berliner klin. Wochenschrift, 1881, No. 8. 5 or whether we are dealing with the commencement of a true (blenorrhceic) ophthalmia neonatorum. The eyes should be cleansed very often-the fre- quency depending upon the amount of discharge ; in severe cases, as often as every half-hour ; in less severe cases, every hour. The head of the child being grasped between the knees of the physician or nurse, the hands held, and the feet permitted to remain free, the lids are separated gently with the fingers and a stream of luke- warm solution of boric acid is allowed to wash out all accumulated secretion. In separating the lids, we must be careful not to injure the cornea with the nails or with instruments, since the slightest abrasion will serve as a favorable point for the entrance of germs contained in the conjunctival discharge. If the lids are very much swollen, it may be necessary to employ retractors to separate them when we wish to inspect the cornea ; but this will not be necessary for irrigation, and will rarely be necessary even for inspection of the cornea, if we remember to place the fingers at the tarsal margin of the infant's lids and not at some distance from the edges. As the discharge sometimes spurts when the lids are separated, the physician or attendant must be careful that none of this material enters his eyes. Various instruments have been devised to facilitate cleansing ; one of these consists of a hollow retractor with numerous openings which allow the cleansing so- lution to washout the conjunctival sac after insertion ; another is a hollow eye-speculum arranged in the same manner ; a third consists of an instrument resembling an ear-speculum. But none of these has found any degree of favor, and all are open to the objection of tending to injure the protective corneal epithelium. A lukewarm, saturated solution of boric acid is em- ployed most frequently as a cleansing fluid ; or a solu- tion of salt in the proportion of a teaspoonful to a pint of water maybe used. Solutions of corrosive sublimate have been employed, but possess no advantage over 6 boric acid or salt, and there is some question whether they may not act unfavorably upon the epithelium of the cornea. I am in the habit of using the small glass douche, known as the undine, holding from two to four ounces, and find that this method answers admirably for irrigation, and is far superior to the employment of bits of cotton with which to soak up the solution. Iced cloths should be employed in the following manner : half a dozen small compresses, four-fold and one inch square, are placed directly upon a block of ice ; from this they are transferred to the eyes, two at a time, the change being made every minute or two, depending upon how rapidly they become heated. Lint or lintine, which is cotton closely pressed into sheets, answers best for this purpose. The amount of exposure to these cold compresses depends upon the intensity of the inflammation ; if the latter be very severe we should continue the applications uninter- ruptedly day and night ; then, as the inflammation sub- sides, it is well to use the cold less continuously, say every other hour or every third hour, etc. This is a part of the treatment which requires some judgment and experience, for excessive use of cold favors ulceration of the cornea. I have seen numbers of cases in which the cornea was sacrificed by this mistake. Unfortunately, in these cases we cannot re- ceive information from the sensations of the patient- a valuable guide in cases of blenorrhoea in the adult. In general, it may be stated that as long as the lids continue red, swollen, and tense, cold is indicated, es- pecially if the cornea remains perfectly clear. When the swelling, redness, and tension of the lids subside, we must be careful to reduce the length of exposure to the cold compresses ; after these have subsided, if corneal ulceration is present, cold is positively harmful and hot compresses are indicated, just as in any other case of corneal ulceration. It is not always a simple matter to decide when to 7 reduce or stop cold, and when to apply heat. It is easy enough in cases occurring in robust infants, and when the cornea remains clear ; we can then be guided entirely by the appearance of the lids. But given a case of ophthalmia neonatorum occurring in a feeble child (in whom we know that cold in general is not well borne), presenting marked and persistent swelling, red- ness and tension of the lids, and in whom the cornea shows ulceration, and we are confronted with a condi- tion the treatment of which requires great judgment; it is difficult in such a case to decide whether to con- tinue cold, to stop it, or to change to heat. In every case of this sort we must carefully watch the effect of any change in the temperature of the compresses. Applications of one per cent, solution of nitrate of silver are useful after the first stage, when the lids be- gin to assume an appearance approaching the normal, and when the discharge becomes decidedly purulent and creamy. There is no advantage, and there is sometimes harm, in making these applications at an earlier period, and there does not seem to be anything gained by using a solution stronger than one per cent. After the lids have lost their angry appearance, they should be turned out gently and brushed with the silver solution once a day ; excess of action is prevented by irrigation with water or solution of boric acid or of salt, immediately after the application, or after half a minute or a minute if we wish more decided action. There is now a ten- dency, among men who have had much experience with the treatment of this disease, to postpone the use of silver until the third or fourth week, and to use it then merely for the purpose of acting favorably upon the papillary swelling of the conjunctiva existing at this time. Any extensive consideration of the treatment of com- plications, such as corneal ulceration and sloughing, staphyloma, prolapse of iris, etc., would not properly come within the scope of this paper. When corneal 8 ulceration exists, it is well to instil one drop of a one- half per cent, solution of atropine once a day ; though if the ulceration occur at the periphery and there is a tendency to prolapse of iris, one-third per cent solution of eserine may be indicated. There is a general ten- dency, even among oculists, not to make direct appli- cations upon ulcers of the cornea occurring in the course of this disease ; while this holds good for very extensive ulceration or sloughing, circumscribed ulcers can be advantageously treated by touching them from time to time with tincture of iodine, or even the actual cautery, especially if the inflammation of the lids has subsided. Recently I have seen a number of cases do well under cauterization ; and there seems to be no reason at all why such ulcers should not be treated and prevented from spreading, exactly in the same manner as in the case of other infected ulcers. In the course of time, corneae which seem hopelessly involved, some- times clear up to an extent which permits some vision. In treating cases of this disease we must not lose sight of the fact that the favorable response to our in- terference depends, to a certain extent, upon the gen- eral bodily condition of the infant, a fact to prove which Dr. Knapp cites some very forcible illustrations ; it is a well-known fact that the most stubborn and dis- appointing cases are those in which the affection at- tacks the eyes of feeble and puny subjects. In considering the subject of legislation for the pre- vention of blindness from ophthalmia neonatorum, we are justified in assuming that the loss of an eye from this disease means ignorance or negligence on the part of someone. In other words, blindness from this cause is practically preventable ; hence the importance of the subject becomes the greater. Statistics from various countries show that about twenty per cent, of all blind- ness is due to this cause. Magnus1 found twenty- 1 Magnus: Die Blindheit: Ihre Entstehung und Ihre Verhiitung, Breslau, 1883. 9 three per cent, of the blind among young persons, and over ten per cent, among adults a larger proportion than from any other single cause. In the Illinois State Institution for the Education of the Blind, twenty- four per cent, of the cases were due to ophthalmia neonatorum.1 In the New York State Asylum at Ba- tavia, 19% per cent, were blind from this disease,2 and a similar proportion was found in the New York Institution for the Blind. There are at present over fifty thousand blind persons in the United States, and the last census (1890) shows eight hundred and five blind for every million inhabitants. If we consider that twenty per cent, of these fifty thousand were made blind by ophthalmia neonatorum, we can safely count upon a rapid decrease in the number after the intro- duction of effective legislation. That blindness is on the increase in the United States is shown by the fol- lowing table :3 Table Showing Number of Blind from 1850 to 1890. United States Census. Number of blind. Population. Number of blind to 1,000,000 population. 1850 9,794 23,191,876 422 i860 12,658 403 1870 20,320 527 1880 48,928 976 1890 50,411 62,622,250 805 It is claimed that the apparent decrease in the proportion of blind from 1880 to 1890 is due to the fact, that in 1880 there were supplementary additions to the returns of the enumerators, such additions having been omitted in 1890. An examination of the history of legislation for the prevention of blindness from ophthalmia neonatorum, 1 Prince : Medical Record, August 26, 1893. 3 Howe: Proceedings of the American Ophthalmological Society, 1890. 3 Bettmann: Journal of the American Medical Association, May 19, 1894. 10 shows that Switzerland was the first country to adopt such laws (1865) ; Prussia followed in 1878, Austria in 1882, and France in 1888. In this country, New York was the first State to inaugurate laws of this sort (1890). Since then similar legislation has been effected in Maine (1891), Rhode Island (1893), and in several other States. The New York law was passed chiefly through the efforts of Dr. Lucian Howe, of Buffalo, N. Y., and since its provisions have not become gener- erally known, it may be well to add a copy : An Act for the Prevention of Blindness.- " 1. Should any midwife or nurse having charge of an infant in this State, notice that one or both eyes of such infant are inflamed or reddened at any time within two weeks after its birth, it shall be the duty of such midwife or nurse so having charge of such infant, to report the fact in writing, within six hours, to the health officer or some legally qualified practitioner of medicine of the city, town, or district in which the parents of the infant reside. " 2. Any failure to comply with the provisions of this act shall be punishable by a fine not to exceed one hundred dollars, or imprisonment not to exceed six months, or both. " 3. This act shall take effect on the first of Septem- ber, eighteen hundred and ninety." This law would appear to answer every indication ; it provides that the management of such cases be taken out of the hands of midwives or nurses, and be en- trusted to "legally qualified practitioners." We would expect a material reduction in the number of cases, or at least in the number of cases in which blindness re- sults in one or both eyes. But my investigations have proven that such is not the case ; the ophthalmic dis- pensaries of New York City treat almost as many cases of ophthalmia neonatorum, in proportion to the total number of eye cases, as they did before the passage of this law. The following tables will prove this ; 11 Table Showing the Number of Cases of Ophthalmia Ne- onatorum Treated at the Various Eye Clinics of New York City, from 1888 to 1894. Year. Total number of eye cases. Number of cases of ophthalmia neonatorum. Cases per 1,000 eye- patients. 1888 5,212 36 7.0 1889 5,517 3° 5.0 1890 6,052 18 3-° 1891 6,367 43 7.0 1892 7,355 31 4.0 1893 6,961 20 3-o New York Ophthalmic and Aural Institute. 3 years. 1888 16,781 84 5-° 1889 1890 3 years. 1891 1892 20,683 94 4-54 1893 i888'7 6,081 28 4.0 1889 6,511 41 6.0 1890 7,197 28 4-0 1891 8,362 4° 5.0 1892 9,72° 35 3-° 1893 10,640 44 4-0 Manhattan Eye and Ear Hospital. 3 years. 1888 19,789 97 5-0 1889 1890 3 years. 1891 1892 28,722 119 4-33 1893 1888'" 12,057 88 7.0 1889 12,782 81 6.0 1890 13,382 93 7.0 1891 14,502 117 8.0 1892 15,381 74 5.0 1893 14,425 65 4-5 12 New York Eye and Ear Infirmary. 3 years. 1888 1889 1890 38,221 262 6.85 3 years. 1891 1892 44,308 256 5-77 1893 1889 657 4 6.0 1890 918 5 5-o 1891 1,027 1,196 7 6.0 1892 4 4-0 1893 1,557 8 5-o New Amsterdam Eye and Ear Hospital. 2 years. 1889 1890 I ) 1,575 9 6.0 3 years. 1891 1892 1893 3 years. 1888 3,78o 19 5-o 1889 1890 76,366 452 5-92 Total of Four Institutions. 3 years. 1891 1892 1893 97,493 488 5-o A glance at the results given by these tables shows that among 76,366 cases for the three years, 1888, 1889, and 1890, there were 452 cases of ophthalmia neona- torum (5.92 per thousand) ; while during 1891, 1892, and 1893, among 97,493 cases, there were 488 cases (5.00 per thousand). Thus there has been a reduction of less than one case per thousand since legislation has attempted to diminish blindness from this cause. The 13 actual reduction becomes still less, if we allow for the great increase in the proportion of cases of errors of refraction in dispensary practice, for the past three years, as compared to the previous three years, statistics from these same institutions showing this proportion to have increased from twenty-two per cent, during the first period to thirty per cent, during the second. I am aware of the fact that there might be diminu- tion in the number of cases of blindness, even though the cases of ophthalmia neonatorum which present themselves at the dispensaries showed but slight reduc- tion in number ; but this would imply that the general run of such cases was of a milder type than formerly ; clinical experience, however, shows that the proportion of cases in which infants are brought for treatment with the cornea hopelessly involved, is just as great as ever. And in the short period of three years the data furnished by the institutions for the care of the blind would be of no value, since such admissions are not made until some years after. If in these four institutions 137 cases have been treated during the year 1893, it is safe to assume that at least 500 cases apply for treatment at the various dispensaries in New York City annually ; of these, probably one-half result in blindness of one or both eyes, owing to the fact that irremediable damage has been done before proper authorities have been con- sulted ; thus, 250 cases of such blindness are seen in the dispensaries alone. It is, of course, impossible to say how many other cases, which are never brought to dispensaries, are sacrificed to ignorance or negligence. Dr. Howe has estimated that the cost of supporting the blind in New York State amounts, directly and indi- rectly, to a million and a half dollars per annum. Aside from philanthropic motives, therefore, the passage of a really efficient law would be of immense advantage from an economic standpoint. There are several reasons why the present New York 14 law has not had the desired effect. To enumerate briefly : i. The provisions of the law have not become gener- ally known among the profession and among midwives and nurses. No attempt has been made to call atten- tion to it. This being the case, midwives would be- come aware of its existence only through a large num- ber of convictions, with consequent fines and imprison- ment for violation. Not more than twelve cases have been prosecuted and convicted since the law became operative. 2. The term " legally qualified practitioner of medi- cine " allows the midwife or nurse great latitude in the selection of someone to whom to report. 3. The process of prosecution of an infringement of the law involves so much loss of time to the informant -the general practitioner or oculist-that the lack of enthusiasm shown in this direction is not surprising. The New York Society for the Prevention of Cruelty to Children is not only willing but anxious to prosecute every case of violation, but it can only obtain necessary information from the physician who sees the case after the damage to the eyes is done. Through the courtesy of Mr. Jenkins, the superintendent of this society, I have obtained much information concerning the steps necessary in prosecuting. The physician who meets with a case in which non-compliance with the law has resulted in injury to one or both eyes of a child, reports the case to the society ; the latter conducts the prose- cution, but the physician remains the main reliance in securing a conviction, and without his attendance at the courts they cannot succeed. This involves a loss of time, first at the Police Court on one or two occa- sions (twice, if the midwife secures an adjournment- and this the law allows) ; if she is committed, her trial takes place at some future date in the Court of General Sessions. In the Police Court trials, it can generally be arranged to have the case called at an hour suiting 15 the physician's convenience. In the second trial, he must present himself at 10.30 a.m. and wait until the case is called. If the woman possesses a few dollars with which to engage a lawyer, she can secure an ad- journment ; in such a case, the physician is compelled to be on hand some other morning at 10.30 a.m., and wait for his chance to testify. After such a tedious process he may have the satisfaction of having caused the punishment of a woman who has added to the number of blind through her ignorance or carelessness ; but even this feeling of satisfaction is apt to be limited when the midwife is fined but a small amount; he has lost a great deal of time and considerable practice- practically he has given up two mornings and one or two afternoons, and has suffered many inconveniences. Is it surprising that his philanthropic ardor becomes colder after one such experience ? Since September, 1890, there have been but twelve prosecutions ; all of these resulted in convictions. In every case a fine was imposed ; in most cases it was small, in many only $10, in one case $100. In no case was the misdemeanor punished by imprisonment. For these reasons some modification of the law is ab- solutely essential. I would suggest the following as answering every indication, and as tending to be effec- tive : Every case of ophthalmia neonatorum should be reported to the local board of health or health officer- whether such a case occurs in private practice or in an asylum, whether under the care of a practitioner of medicine or of a midwife or nurse. In the case of a practitioner, whether in private practice or in an asylum, the board of health or health officer need not inter- fere. In the case of a midwife or nurse, it should be the duty of this board, or of the health officer of the locality, to send an inspector, upon whom the respon- sibility of the case will then rest. If he finds that the midwife or nurse has called in a competent physician and that the child is being properly treated, there will 16 be no occasion for further interference ; but if he dis- covers that this has not been done, it shall be his duty to assume charge of the case and to see that the child is properly treated, either at its home or at some hos- pital or dispensary. He will then also be able to serve as a witness in the prosecution of such cases, and since he is in the employ of the city or town, he will not be justified in finding fault if part of his time is occupied in the courts. I would suggest that the Medical Society of the County of New York appoint a committee who shall draft a bill on these lines, or modified as they see fit. This subject is extremely important, both from a philanthropic and an economic standpoint. Every case of blindness prevented means a saving of a large sum to the city or State. Under such circumstances the State or city could well afford the salary of the neces- sary inspectors. As showing the possibilities of proper legislation for the prevention of blindness from ophthal- mia neonatorum, I cannot do better than to close with the remarks of Dr. A. E. Prince, of Springfield, Ill., who in speaking on this subject before the Illinois State Medical Society, at its meeting in May, 1893, said : " Professor Horner became the champion of the legisla- tive efforts, and devoted himself, through his personality and skill, toward increasing the efficiency of the law. During his lifetime he proudly enjoyed the knowledge of the fact that no child, born since 1865, was admitted into the large institution for the blind of Zurich with sight lost from ophthalmia neonatorum." If this result was possible in Switzerland, we should at least make every effort to duplicate it in New York. 692 Madison Avenue.