PURULENT OPHTHALMIA NEONATORUM AS A CAUSE OF BLINDNESS. BY FREDERICK E. CHENEY, M. D„ Instructor in Ophthalmoscopy, Harvard Medical School; Assistant Surgeon, Massachusetts Charitable Eye and Ear Infirmary. Reprinted from the Boston Medical and Surgical Journal of April 14, 1842. BOSTON: DAMRELL & UPHAM, Publishers, 283 Washington Street. 1892. S. J. PARKHILL & CO., PRINTERS BOSTON PURULENT OPHTHALMIA NEONATORUM AS A CAUSE OF BLINDNESS.1 BY FREDERICK E. CHENEY, M.D. Instructor in Ophthalmoscopy, Harvard Medical School; Assistant Surgeon, Massachusetts Charitable Eye and Ear Infirmary. The term, purulent ophthalmia neonatorum, is used in preference to ophthalmia neonatorum in this paper, for the reason that the latter seems to me objectionable, including as it does, all inflammation of the conjunc- tiva occurring in the new-born. A very large propor- tion of these cases are extremely mild in character; they recover rapidly with the use of " borax and cam- phor," or some other mild collyrium, and stand in the same relation, as regards importance, to the purulent variety, that simple catarrhal conjunctivis in the adult, does to gonorrhoeal ophthalmia. If purulent ophthalmia neonatorum could be more generally applied to the disease so much discussed and written about as a cause of blindness it would undoubtedly save much confu- sion. The character of this affection is so well-known that more than a brief mention of its symptoms and appearances is unnecessary. It usually begins within three or four days after birth, - occasionally as late as the seventh or eighth. At first, the discharge is thin and watery, but it soon becomes thick, yellow, and co- pious. The conjunctiva is greatly injected, the lids are considerably swollen, and if they be everted, the palpebral conjunctiva will be found infiltrated and thickened, with an intensely red, velvety look, and will bleed easily on slight irritation. We have, in fact, a purulent inflammation of the conjunctiva caused by in- 1 Read by invitation before the Obstetrical Society of Boston, Feb- ruary 13, 1892. 2 fection from some morbid vaginal secretion, and which to all appearances, differs from gonorrhoeal ophthalmia only as regards its lesser intensity. By an unfavora- ble termination of the disease, we understand that a secondary inflammation of the cornea has taken place, which has resulted in an impairment, or entire loss, of sight. It is but natural that the gravity of the affec- tion should be more fully realized by the oculist, who is continually seeing the unfortunate results, than by the other members of the profession who, perhaps, see but one or two such cases in a lifetime. Statistics as to the cause of blindness, from various asylums are, however, so nearly uniform in the per cent, attributed to this disease, that there can be no question of exag- geration as to its importance. For example, the asy- lums of Switzerland, give 26.02% to this cause, of Germany, 25.83%, of Hungary, 20.47%, while in this country, the New York State Asylum, at Batavia, gives 19.5% (Howe), the Philadelphia Blind Asylum, 20% (Harlem), and the Perkins' Institution for the Blind, with the Kindergarten at Jamaica Plain, 18.6% (Derby). In an article entitled " Legislation for the Preven- tion of Blindness," Dr. Howe, of Buffalo, writes con- cerning this disease as follows: " There is a perfect unanimity of opinion that when these cases are seen at the very outset, the eye can be saved in almost every instance with little or no injury, while, on the other hand, ulceration and perforation often occur when the children are neglected until the disease is far ad- vanced." If it is a fact, and I believe it is, that purulent oph- thalmia neonatorum terminates favorably in almost every instance, when recognized and properly treated from the beginning, neglect or ignorance is accountable for about one-fifth of all the cases of blindness occur- 3 ring in early life. For obvious reasons, the affection is more prevalent among that class of patients who are the least able to comprehend its serious nature, and who, consequently, often fail in obtaining proper med- ical advice until it is too late to be of any value. In a hope of rectifying, in a measure, this unfortunate state of affairs, at the recommendation of Dr. Howe, made in a paper read before the New York State Med- ical Society, February 18, 1886, on "Purulent Con- junctivitis of Infancy and Blindness," the following law, headed "An Act for the Prevention of Blind- ness," was adopted by the New York legislature : Section 1. Should any midwife or nurse having charge of an infant in this State notice that one or both eyes of such infant are reddened or inflamed 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 equally qualified practitioner of medicine of the city, town or district in which the parent of the child reside. Sect. 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. Sect. 3. This act shall take effect on the first day of September, eighteen hundred and ninety. This law has been in force for so short a time, that it is impossible to arrive at any definite conclusions as to the amount of good it is capable of accomplishing. If the per cent, of blindness from this cause can, how- ever, be decreased in the least decree by the adoption of such laws, other States should not be slow in fol- lowing the lead taken by New York in this matter. In Boston, the employment of midwives is, I understand, a very much less common practice than formerly, since the establishment of the " Out-Patient Department" 4 in connection with the Lying-in Hospital. In other parts of this State it is probably still considerably practised, and if an act for the " prevention of blind- ness " should be adopted by the legislature of Massa- chusetts and properly enforced, some good would un- doubtedly result. The nurse and midwife cannot, however, be held ac- countable for every unfortunate case. The physician is, in many instances, directly responsible in that pre- cautions are not taken lor the prevention of the dis- ease, or it is not properly treated when found to exist. The result of bad treatment in diseases of the eye is apt to be more apparent, both to the physician and pa- tient, than are errors of equal gravity in other situa- tions ; and it is probably for this reason that the study of ophthalmology is more neglected by the general practitioner than are the other special branches of med- icine, it being thought unnecessary to give much atten- tion to a subject, whose practice is regarded both by the profession and laity, as best confined principally to the hands of the specialist. There are, however, a certain class of cases, and first among them purulent ophthal- mia neonatorum, that may be properly considered in the light of emergency cases, and which every practi- tioner should be as well qualified to treat as he is pneumonia, dysentery, scarlet fever and the various other troubles that are usually considered as falling more within his province. The physician in or near the city can, if he choose, transfer the responsibility of these cases to the oculist, but in the country he must take entire charge, and will be held accountable for any unfortunate result. It is of the first importance, therefore, that the value of prophylactic measures, and the necessity of a thorough and intelligent treatment of the disease, should be more generally recognized by members of the profession. The large number of out- 5 patients that come under the supervision of the Boston Lying-in Hospital, offers, it seems to me, an excep- tional opportunity for the practical illustration of the points in question ; and if certain regulations could be introduced and systematically carried out, I am confident that results published at the end of five years would em- phasize their importance, in this vicinity at least, as no other method would be capable of doing. The custom of washing the vagina before and during labor, as prac- tised in this institution, is certainly to be commended; and if, in addition, a single drop of a two per cent, so- lution of nitrate of silver could be dropped into the the eyes, after they have been thoroughly cleaned, as recommended by Crede, the chances of this disease making its appearance would be still further lessened. A moderate amount of irritation is usually produced by this procedure, the eyes being red and watery for two or three days. If, however, but one or two drops have been used, nothing more serious is to be looked for. Dr. Noyes, in his text-book on " Diseases of the Eye," expresses the opinion that a one per cent, solu- tion can be employed with equally good results, and in the hands of the inexperienced it would probably be safer to use it. If, in spite of these precautions, a purulent inflammation develops, the child might be referred at once to the Massachusetts Charitable E\e and Ear Infirmary, or some other institution, where a record could be kept of the case, as to the severity of the inflammation, condition of the eyes at time of dis- charge, etc., and made use of later, if desirable. It would not be difficult to arrange some such system and it would undoubtedly produce satisfactory results, not only in directly preventing a few cases of blindness, but also in impressing upon the minds of future prac- titioners, the fact that purulent ophthalmia neonatorum is a serious trouble and one that must not be neglected. 6 There is very little difference of opinion as to the value of nitrate of silver in the treatment of this dis- ease, and if this agent is properly used, in connection, of course, with thorough cleanliness, that is, in keep- ing the eye as free as possible from the purulent discharge, the results will be almost invariably satisfac- tory. Its daily application in a one or two per cent, solution to the palpebral conjunction, as long as the lids remain infiltrated, and there is the least purulent discharge, seems to me of the utmost importance. It is not at all unusual to meet with cases where this treatment has been discontinued too early, and the in- flammation again becomes decidedly active in conse- quence. It is certainly a safer plan to continue its use for a few days after the discharge has entirely ceased. -THE BOSTON MedicalandSurgical Journal. A FIRST-CLASS WEEKLY MEDICAL NEWSPAPER. PUBLISHED EVERY THURSDAY. Two Volumes yearly, beginning with the first'Nos. in January and July. But Subscriptions may begin at any time. This Journal has been published for more than sixty years as a weekly journal under its present title. Still it is incumbent upon th;s Journal, no less than upon others to assure its patrons from time to time, as the occasion arises, of its desire, ability, and determination to meet all the requirements of the most active medical journalism of the day, without sacrificing any of that enviable reputation which is an inheri- tance from the past. It is under the editorial Management of Dr. George B. 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