« AnteriorContinuar »
OPHTHALMIA NEONATORUM; ITS CAUSE, TREAT
MENT AND PROPHYLAXIS.
BY DR. I. W. DE VOE, OF WAUSAU.
Fully one-half of the inmates of our Blind Asylums had ophthalmia when only a few days old, and its ravages have caused them a life time of suffering.
Every day the sad spectacle is presented at the various eye hospitals in our large citizes of helpless infants with one or both eyes totally destroyed by this terrible disease, and from such statistics as can be obtained, we are safe in making the statement that thirty per cent. of the blind are so from its results.
Magnus in a list of twenty-five hundred cases of blindness gives eleven per cent. Lachmann in 1843 in the Duchy of Nassau found thirteen per cent. and in the Duchy of Brunswick. twenty-eight per cent. Appia in Italy, found twenty-five per cent. St. Hilaire in twenty years, twenty-seven per cent. Rheinard in twenty-two German Asylums among twenty-two hundred inmates, thirty per cent. Asylum at Belfast thirty per cent. School at Hull, thirtyfive per cent. School at York, forty per cent.
Claisse found in the Institution at Paris forty-six per cent. Dumaus reported to the Congress at Paris, that among the blind pupils he had seen, there were due to this cause sixty-nine per cent.
We cannot appreciate the magnitude of these figures until applied to large numbers.
In Europe when the stable character of the population, and the strictness of various systems of registration render it at all possible, this estimate has been made with some approximate accuracy.
According to statistics, there are in all Europe about three hundred and fifty thousand blind. In the opinion of oculists about forty per cent. result from preventable causes (mostly ophthalmia neonatorum) so that we have the lamentable spectacle of an immense army of the blind fully 150,000 strong, produced and recruited by ignorance, criminal carelessness and neglect.
Various causes are assigned for its origin. It has been claimed that it is usually excited by contact of specific or acrid vaginal discharges with the conjunctiva during the act of parturition but there are undoubtedly many cases where there is no abnormal vaginal discharge in the mother and yet when the blenorrhea assumes a violent form, and on the other hand the children of mothers suffering from gonorrhoea, sometimes escape. Want of cleanliness in washing the child after birth, impure air, sudden changes in temperature, atmospheric poisons, defective nutrition, bright light, etc., have all been assigned as causes for this disease. Any one of these might be sufficient to account for its development. In gonorrhæa, specific vaginitis, ophthalmia neonatorum and gonorrhoeal ophthalmia of adults it is claimed by many skilled observers that it has been demonstrated that there is a characteristic micrococcus, common to all.
It is important to know the cause in all cases if possible, yet it is not essential to the treatment, for that depends on the severity of the case. The disease generally makes its appearance during the first three days of life, when either one or both eyes begin to show slight redness of the edges of the lids, and some injection of the ocular conjunctiva, together with undue moisture of the parts. The tissue of the lid being very lax in the infant, cedema of the lid soon manifests itself, especially of the upper lid which has a red, and in many cases a purple hue. The swelling of the lid shuts the eyeball from view. The secretion which at first was only small in amount and mucous, has by this time become profuse and virulent.
Frequently this purulent discharge runs down over the cheeks. The edges of the lids become agglutinated and when finally separated, the pent-up pus gushes out. It is this material which is a potent element in causing the destruction of the comea. On inspecting the eye, the palpebral conjunctiva will be found intensely injected over its entire surface; the ocular conjunctiva is also much inflamed.
The conjunctiva may only be covered with adhering pus, but frequently the exudation takes on the character of a membrane which can be stripped off, leaving a raw bleeding surface on which the membrane will form again in a few hours. On examining the cornea we find haziness or in severe cases deep sloughs, and this
may cause destruction of the entire thickness of the cornea, allowing prolapse of the iris and sometimes escape of the lens. The discharge and swelling lasts several weeks where no active treatment is followed, and the eyes are sightless or much impaired. Such is the history of a case without any treatment except “breast milk or weak tea."
In small towns or in the country these cases are subjected to most inefficient treatment or neglected. The patient is often many miles from the doctor who is not able to give the case the attention it deserves, and therefore has to entrust the treatment to an ignorant nurse or the “old woman" of the neighborhood, and when next called, perchance the infant is blind.
The question naturally arises, has science no means at her command to combat this disease? The serious results so frequently seen, are not from lack of means, but from ignorance and neglect of applying sure and safe remedies.
Treatment may be divided into two parts, one to be carried out by the physician, the other by the attendant. The patient should be seen daily, generally for two weeks. All secretions should be removed and the eye perfectly cleansed, after which a solution of nitrate of silver, five or ten grains to one ounce of water, is to be applied to the conjunctiva with a camel's hair pencil and the lids are to be carefully replaced. The cornea should be examined each day, and if hazy, a solution of atropine or eserine instilled. This treatment must be supplemented by proper attention to cleanliness of the eyes by the attendant; all cloths, sponges, etc., used must be destroyed at each sitting.
This is the treatment most commonly used and recommended by ophthalmologists and it is very prompt and successful in its action in skilled hands, but it has this objection, it cannot be used with safety by careless practitioners, ignorant midwives or nurses, therefore “the innocent must suffer."
For several years I have made use of the following treatment satisfactorily, especially in the country or where it was necessary to leave the detail and treatment of the case in the hands of the nurse, having no fear of cicatrices or destruction of substance resulting therefrom. I first cleanse the parts by separating the eye-lids with the finger and thumb, and wash out the matter by allowing a gentle stream of tepid water to run between them from a piece of cotton wool, held two or three inches above the eyes: this cleansing will take but a few minutes and I immediately follow it by an eight per cent. solution of Listerine containing a small per cent. of corrosive sublimate, I gr. to the pint. This cleansing I repeat or direct to be repeated every two hours, or with greater frequency if required, and I also smear along the lids and into the inner canthus a little oleate of the yellow oxide of mercury or an unguent of the oxide and vaseline 5 grs. to the ounce. This treatment I have found successful. But "it is easier to prevent than to cure.” What is the prophylaxis or preventative treatment.
We have now in our hands practical preventative measures, based upon antiseptic principles. Antiseptic vaginal injections during labor have been employed by some, but with not very great improvement. The first formal method as an advance on this was by Olshausen, who used antiseptic vaginal injections during labor and immediately after the birth of the child disinfected the eyes with a two per cent. solution of phrenic acid. His per centage fell from 12 to 3/2. Crede made extensive observations and experiments in this line. At the same time with the first bath both eyes of each child were carefully cleansed with a soft rag, and one drop of a two per cent solution of nitrate of silver was let fall into each eye by means of a glass pipette; although most of these children were born under very unfavorable conditions, in no case thus treated by Crede did the disease occur, but Konigstein of Vienna has gone over the ground covered by Crede as well as others and has added new evidences.
He had placed at his disposal the immense material of the Viennese clinic for obstetrics, in all 3400 cases.
Held under observation
Of these there were of Blenorrhagia, per cent. 4.76; Catarrh, 1.45 per cent.; Hyperæmia of Conjunctiva, 18.33 per cent.
Held under observation
with prophylaxis by the 1250 Infants.
treatment of Crede.
prophylaxis by the applica-
Krukenberg, of Bonn, had without prophylaxis, Blenorrhagia, 7 per cent.
Held under observation
Brose at the Berlin Charite Hospital had with prophylaxis, Blenorrhagia, 172 per cent.
Boyer, of Stuttgart, had without prophylaxis, Blenorrhgia, 22 per cent.
Held under observation
} 1000 Infants.
In this age of antiseptics, it is a disgrace to the medical profession that cases of Ophthalmia Neonatorum are allowed to occur in hospitals. If we sum up the prophylactic measures, we have:
Antiseptic vaginal injections during parturition.
Instillation of a two per cent. solution of nitrate of silver into the eyes of the infant soon after birth.
3. Instillation of a two per cent. solution of carbolic acid.
4. Instillation of a solution, i to 5000 parts, corrosive chloride of mercury.
5. Instillation of a solution of boracic acid.
But for the general practitioner, who has frequently to leave instructions with ignorant midwives and nurses in the country, most of these medicines and forms of treatment will not do, for nitrate of silver and carbolic acid are more or less irritating to the conjunctiva, and in ignorant hands are potent for evil. I have for several years past pursued the following plan with complete success.
Immediately after the birth of the infant, and before anything else is done, I wipe the eye-lids and all parts surrounding the eyes with a soft, dry linen rag. With tepid water I wash the parts before any other part is touched,and immediately after with an eight per cent solution of listerine containing a small per cent of corrosive sublimate, one grain to a pint; these measures can be readily carried out by physicians, mid-wives or nurses, and if generally used would bring practically all cases of labor under the protective influence of these safe-guards.