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of 2 per cent, silver nitrate in gonorrheal ophthalmia, does not
cause pain or produce irritation, and has the important advant-
age that it can be applied by the nurse, midwife, or layman
without danger. He says, however, it is of comparatively-
little value in staphylococcus and streptococcus infections. In
his service at the Sloane Maternity, in 8,000 births covering a
period of seven years he used as a prophylactic measure five
methods of treatment, with a view of selecting a solution that
would give the greatest amount of disinfection with the least
irritation. The results were as follows :



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376 PREVENTIVE TREATMENT OF OPHTHALMIA NEONATORUM.

Series i. — In i,ooo confinements, 2 per cent, silver nitrate
solution; cases of ophthalmia, thirty-four; eyes lost, one; opac-
ities, none.

Series 2. — In 1,000 confinements, i per cent, silver nitrate
solution; cases of ophthalmia, thirty-four; eyes lost, one; opac-
ities, none.

Series 3. — In 2,000 confinements, 5 per cent, protargol solu-
tion; cases of ophthalmia, fifty-three; eyes lost, one; opacities,
one.

Series 4. — In 2,000 confinements, 10 per cent, argyrol solution;
cases of ophthalmia, thirty-four; eyes lost, one; opacities, two.

Series 5. — In 2,000 confinements, 20 per cent, argyrol solution;
cases of ophthalmia, forty-three; eyes lost, none; opacities, none.

This series covered a period when there was an epidemic of
**pink eye" in the city, and as no gonococci were present in
the eyes during the month of its prevalence it was thought by
the ophthalmologist who saw the cases in consultation that they
were cases of pink eye.

Cragin says that, while with the use of ji per cent, silver ni-
trate solution and 5 per cent, protargol solution there was less
irritation, it looked as if it was gained at the expense of pro-
tection, and their use was therefore abandoned. With the
10 per cent, argyrol solution there was complete absence of
irritation; but it was found upon clinical and bacteriological in-
vestigation to be of insufl&cient strength, and therefore did not
afford complete immunity.

The 2 per cent, silver nitrate solution and the 20 per cent,
argyrol solution were proven to be absolutely bactericidal, and
the latter is to be preferred because of its freedom from irritation
and it can be applied at frequent intervals, if necessary, with
safety.

We have collected from the records of Columbia Hospital,
Washington, D. C, from 1882 to June, 1909, 205 cases of ophthal-
mia occurring in 7,236 confinements; 176 cases were reported
as cured and twenty-seven were improved at the time of leaving
the hospital, so the final result of the latter is not known. There
were two cases of blindness, one, total; in the other one eye was
lost. There were five cases with opacities of one cornea and one
with opacities of both corneas. The earlier records are wanting
in microscopical examination; but clinically a large percentage
of primary ophthalmia were diagnosed as gonorrheal, while
the infections occurring some days after birth were generally



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PREVENTIVE TREATMENT OF OPHTHALMIA NEONATORUM. 377

ascribed to other pathogenic organisms. In 1904, argyrol was
introduced, first using a 10 per cent, solution; but as this did
not prevent ophthalmia, it was increased to 25 per cent. There
had been no cases of blindness or opacities since its introduction.

Professor Zweif el speaks enthusiastically of the acetate of silver
in the prevention of ophthalmia. In a letter recently received
from him, he says that in fourteen years' experience with the
drug, blenorrhea occurred in only about 0.02 per cent, of
the cases. Irritation is not more frequent or greater than
with I per cent, silver nitrate, as was demonstrated by using the
silver nitrate in one eye and the silver acetate in the other. Seitz
has obtained a like favorable result in 1,000 births in the Miinchen
Frauenklinik and Scipiades in theTraufferschen KJinik, Budapest.

Darier and his pupil Valencon are warm advocates of protar-
gol. They employ it in 15 to 20 per cent, solution, and find it
to be less painful and irritating than silver nitrate.

Englemann, using protargol, in the Bonner Frauenklinik
observed 20 per cent, of infection, usually of mild character, in
1,000 births.

Piotrowsky, in the Hebammenlehranstalt, Krakau, noted 10
per cent, reaction in the treatment of 1,030 cases after the use of
a 10 per cent, solution of protargol.

V. Herflf, in the Frauenspitale, Basel-Stadt, in 3,009 births,
with the use of protargol, had only two late infections, but there
was 30 per cent, primary reaction.

V. Herff , in endeavoring to find a substitute for silver nitrate
possessing equal germicidal power but free from its objectionable
properties, first tried protargol. While, as just stated, there were
no primary infections, he discarded it because of the large percen-
tage of inflammatory reactions. He next tried argyrol, in 520
births, but not being entirely satisfied, he experimented with
sophol. It is a combination of formaldehyde, nucleinic acid,
and 22 per cent, silver. Sophol is a yellowish- white powder,
easily soluble in water. The solution must be prepared with
cold water, as a warm solution dissociates the loose combination
of the formaldehyde in the preparation. In over 6,000 births,
V. Herff says there were one primary and one late infection.
The early case of infection was due to inoculation in a known
gonorrheal case during labor in which a prolapsed cord was
replaced. The late infection occurred on the ninth day in an
infant whose mother was suffering with condylomata of the vulva.
There was 10 per cent, primary reaction usually of mild character.
»3



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378 PREVENTIVE TREATMENT OF OPHTHALMIA NEONATORUM.

In 1,436 births in which sophol was used, in the Miinchener
Frauenklinik, there were one primary infection (0.07 per cent.);
one late infection (0.07 per cent.), and three cases of inflamma-
tory reaction of mild intensity.

Beginning in January, 1909, Menge has employed sophol in the
Universitats-Frauenklinik, Heidelberg. The sophol solution has
been instilled into the left eye of the infant, and a i per cent,
silver nitrate solution into the right eye. He finds that irritation
occurs less frequently with sophol. Two cases of true blenor-
rhea, both late infections, have occurred this year, both in the
second week. The left eye was infected in one infant and the
right eye in the other.

Gallatia reports the use of sophol as a prophylactic in 280
births in the Landenspitales, Laibach. There was no early
infection notwithstanding that two of the mothers were suffering
with gonorrheal vaginitis at the time of delivery.

Bock and Kraus have also used sophol in inflammatory
diseases of the eyes with excellent results. Bock finds it to be
particularly effective in recent cases; but in those of long standing,
while it rapidly diminishes the discharge, in many instances it is
necessary to resort to the use of silver nitrate to effect a cure.

The committee being much inpressed with the excellent
results obtained with sophol by V. Herff and others was anxious
to give it a trial. Though the courtesy of Dr. Cabell, of the
Visiting Staff of Columbia Hospital, and Dr. Lawson, of the
Visiting Staff of Freedman's Hospital, the remedy was used in
these institutions during the past summer. A 5 per cent, solution
was employed, and it was freshly prepared every two weeks.
Altogether, the solution was instilled into the eyes of 153 in-
fants, ninety-three in Columbia Hospital and sixty in Freedman's
Hospital. Of those treated at Columbia Hospital, there were
thirteen with primary irritation, lasting from a few hours to
several days, all yielding to boric acid irrigation. There was no
primary infection, although one mother had been under treat-
ment in the Hospital for more than a week prior to the delivery
for a severe case of gonorrheal vulvovaginitis. The infant's eyes
were wide open immediately after birth and had a dull glazed
appearance, with clouded cornea. Prompt instillation was made
and no infection followed.

There were eight late infections, occurring from third to the
fourteenth day after birth. Six yielded to the sophol and boric
acid applications in from a few hours to eight days. One case



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PREVENTIVE TREATMENT OF OPHTHALMIA NEONATORUM. 379

in which the lanceolatus was found left the hospital on the
eleventh day of treatment, improved; and another in which the
microscopical examination was negative left also on the eleventh
day of treatment, improved.

Dr. Lawson reports that sixty infants received the 5 per cent,
sophol solution at birth in Freedman's Hospital, and the results
were very satisfactory. In but one case was there anything
more than a slight inflammatory reaction observed. One baby
developed a purulent conjunctivitis, which was slight and
cleared up within five days, during which time the sophol
solution was instilled three times daily. The mother in this
case had a marked vaginal discharge at the time of confinement.

Our personal experience with the use of sophol is in accord
with that of other investigators and we regard it as a safe and
effective measure for the prevention of ophthalmia neonatorum.

Professor Von Herff states, in a recent letter, that sophol is also
effective in ophthalmia due to other germs besides the gonococcus;
that it is less painful and irritating than any of the silver prepara-
tions, save argyrol; while as regards stability, it excels them all.
In substance, sophol has remained unchanged for four years, and
a solution six months old has been found in the Munchener
Frauenklinik not to irritate any more than a fresh one. The
drug can be dispensed in tablet form as well as in solution, thereby
making it very convenient for general use.

All of the silver salts are unstable and decompose more or less
rapidly on exposure to light and air. Another drawback to the
use of silver nitrate and its organic substitutes, is the incon-
stancy of the solutions; and many cases are on record where these
preparations were increased to several times their original
strength by evaporation, and where their application caused
marked inflammatory reaction and even the loss of normal eyes.
Koch relates a case of destructive inflammation and subse-
quent blindness in which a midwife used a solution of silver ni-
trate which, owing to a defective stopper and consequent evapo-
ration, had increased in strength from 2 per cent, to 3 . 2 per cent.

Precipitation takes place in all of the silver salt solutions in a
longer or shorter time when subjected to atmospheric conditions.
In order to obviate these occurrences, the solutions should
be freshly prepared at frequent intervals, and stored in lacquered
or dark-colored bottles and kept in the dark. For individual use
the solutions should be dispensed in sterilized tubes, sealed
with paraffine.



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380 PREVENTIVE TREATMENT OF OPHTHALMIA NEONATORUM.

As the use of silver nitrate requires absolute precision to pre-
vent serious injury to the eyes, its instillation should never he
entrusted to the midwife. One of the silver substitutes, prefer-
ably sophol, argyrol or protargol, which are comparatively
free from such dangers, could with safety be used by anyone.

More than 50 per cent, of confinements are in charge of mid-
wives, and at least 30 per cent, of blindness is due to oph-
thalmia neonatorum. It has been clearly proven that gonor-
rheal ophthalmia can be prevented in the majority of cases,
and, when it does occur, early and intelligent treatment will
effect its cure with almost absolute certainty. These facts
emphasize the necessity for the enactment of laws placing the
supervisory control and licensing of midwives with boards of
health.

From the foregoing data it is seen that the use of a 2 per cent,
solution of silver nitrate is very effective in the prevention of
ophthalmia neonatorum, but is very painful and often attended
with marked inflammatory reaction; the i per cent, solution,
while less irritating, does not insure immunity. Of all the silver
preparations considered, sophol 5 per cent., argyrol 25 to 50 per
cent., and protargol 10 to 20 percent., are to be preferred because
they produce comparatively little pain and irritation, and can be
employed by the inexperienced without risk.

In conclusion, the committee recommends:

I. That immediately following birth of the infant, the eyes
should be carefully wiped with sterile gauze dipped in a saturated
solution of boric acid and then a 5 per cent, sophol, 25 to 50 per
cent, argyrol, or 10 to 20 per cent, protargol solution used as a
prophylactic against ophthalmia neonatorum.

Since late infection comprises one-fourth of the cases of oph-
thalmia neonatorum and may be due to faulty application of
the prophylactic, or latent gonorrhea, but is more often the
result of contamination from the vaginal secretion because of
lack of vigilance, or ignorance on the part of attendant or mother;
therefore the nurse should be instructed to thoroughly scrub
her hands with soap and water and disinfect them before wash-
ing the infant's eyes, dressing the navel, and bathing the mother.
The mother's hands should be cleansed several times daily, par-
ticular attention being given to the nails, and she should be
repeatedly warned as to the danger of the lochia. By careful
attention to these precautions the morbidity from ophthalmia
can be greatly reduced if not entirely controlled.



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PREVENTIVE TREATMENT OF OPHTHALMIA NEONATORUM. 381

2. That the solutions be dispensed in amber-colored sterile
tubes sealed with paraflSne for use by mid wives; a small quantity
of sterile gauze be placed in the prophylactic package.

3. That suitable instructions as to technic be printed on the
birth certificates.

4. That legislation be enacted for the control of midwives.

5. That midwives be compelled to make report of births
within 24 hours following delivery.

6. That the health department furnish the drugs gratuitously
to indigent cases.

7. That in cases of ophthalmia occurring in patients under
the charge of midwives they be required to summon a physician
immediately or notify the health department promptly.

Finally what is needed to control this scourge is a hearty co-
operation of the medical profession with the health authorities.

The committee is greatly indebted to Drs. Breckenridge,
Maclay, and Neale, internes, Columbia Hospital, and Drs.
Quander, Ish, and Henry, internes, Freedman's Hospital, for
their co-operation and report.
Respectfully,

(Signed) Jno. F. Moran, M. D.

W. M. Sprigg, M. D.

BIBLIOGRAPHY.

1. Axenfeld. Ueber nicht gonorrhoische Blenorrhoea des Con-
junctiva. Deutsche medizin. Wochenschr., 1898, No. 44, S. 293.

2. Bock. Sophol in der Augenheilkunde. Wochenschr, fiir
Therapie und Hygiene des Auges, No. 32.

3. Cragin. Transactions Am. Gyn. Society, 1907.

4. Cred6. Die Verhiitung der Augenentztindung der Neuge-
bornen. Arch, fiir Gyndk,, Bd. xvii, 1881, S. 50; Bd. xviii,
1881, S. 367; Bd. xxi, S. 179.

5. Darier. Protargol bei Conjunctivitis blenorrhoica. Die
ophthalm. Klinik, No. 7; Frommels Jahresbericht, Bd. xii;
Centralhl.f. Gyndk., 1905, p. 86.

6. Derby. Boston Med. and Surg. /., Boston, 1908, 149,
825-827.

7. Englemann. Nochmals das Protargols bei der Cred6schen
Augeneintrauflung. Zentralhl. f. Gyndk., 1900, No. 51. Ueber
die Verwendung des Protargols an Stelle des Argent nitr. bei
der Cred^schen Eintrauflung. Zentralhl. f. Gyn., 1899, No. 51.

8. Feulner. Ueber die preventive Behandlung der Augenei-
terung der Neugebornen mit Berticksichtigung der neuen Mittel,
besonders des Sophols. Inaugural Dissertation, Miinchen, 1909.

9. Ford. Hospital, London, 1908, 43, 573.

10. Gallatin. Sophol als Vorbeugungsmittel, bei Ophthalmo-



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382 REVIEW.

blenorrhoea neonatorum. Wiener medizin. Wochenschr., No. 6,
1908.

11. Greef. Berliner klin, Wochenschr., 1901, No. 6; Therap.
d. Gegenw., Berlin, 1908, 49, 27-30.

12. V. Herff. Kann man die Zahl der Erkrankungen an
Ophthalmo-blenorrhoea gonorrhoica verringen. Gyndkologische
Rundschau, 1907, No. 19. Sophol; Zentralhl. f. Gyn., Leipzig,
1908, No. 42. Zur Behandlung der Augengonorrhoea, 1908,
No. 46. Zur Verhiitung der gonorrhoischen Ophthalmoblenor-
rhoea mit Sophol. Munchen. medizin., Wochenschr., 1906, No. 20.

13. Harman. Prevention of Blindness, etc. Public Health,
1908-9, 22, I 15-122.

14. Koch. Zeitschr, f. med. Beamte, 1901, Suppl.

15. Kraus. Sophol. Die Heilkunde (see Munch, med. Woch-
enschr,, 1908, No. 39.

16. Leopold. Berliner klin, Wochenschr., 1906, p. 846;
Miinchener med. Wochenschr., 1906, p. 769.

17. Moetier. Ophthalmoscope, London, 1908, 6, 2-8.

18. Piotrowsky. Die Verwendung des Protargols zur Verhii-
tung der Augeneiterung des Neugebornen. Zentralhl, /. Gyn,,
1901, No. 31.

19. Pinard. Ann, de Gyn, et d'Obstet., 1902, Jan. and Feb.

20. V. Porter Erfolge der Cred6schen Prophylaxe an der
Heidelberg. Frauenklinik, Heidelberg, 1908.

21. Scipiades. Volkmannsche Sammlung, No. 345, 1904.

22. Stephenson. Med. Press and Circular, 1904.

23. Wharton. Ophthalmoscope, London, 1909, 7, 19-23.

24. Wheeler. Control of Ophthalmia Neonatorum. North
American J, Homeopathy, N. Y., 1909, 17, 71-78.

25. V. Zweifel. Centralbl. f, Gyndk., 1900, 1361 and i486.

26. Report of Committee on Ophthalmia Neonatorum of the
American Med. Association. See Journal A, M, A,, May 23,
1908.

27. New York Association for the Blind, Special Committe
on Prevention of Blindness, No. 2.



REVIEW.



Functional Nervous Disorders in Childhood. By Leonard
Guthrie, M. D., F. R. C. P., Senior Physician, Paddington
Green Children's Hospital; Physician to the Hospital for
Paralysis and Epilepsy, Maida Vale, etc. Pp. 300, i plate.
$3.00. Oxford University Press, American Branch, 35 West
Thirty-second Street, New York.

This volume which the author modestly disclaims as an ex-
haustive treatise, but states has been elaborated and built up
upon the nucleus of various addresses and papers, is not to hie
judged by the ordinary criteria applied to medical works in



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BRIEF OF CURRENT LITERATURE. 383

general designed to be used as text-books. But to the practi-
tioner who is frequently called upon to advise with reference
to the management of nervous or emotional children it opens
new avenues of thought, for its somewhat discursive style allows
a broader treatment of the subject than would be possible in the
usual manual upon nervous diseases. Nevertheless, as we read
the pages we are soon convinced that the author writes with a
wide experience of the subjects of which he treats. We do not,
as a rule, expect to find humor in books of serious purpose nor
are we more especially prepared to find it among British writers.
Here, however, there is a surprise before us. The description of
the life history of the individual who begins as an unemotional
child is a delightful bit of humorous writing, all the more so be-
cause the accurate drawing of the type is obvious. It forms an
excellent foil by contrast to the subsequent pictures of the emo-
tional phases of childhood. To the American reader the scattered
references to life in the English public schools and its influence
upon neurotic children inevitably make us thankful that many of
these features have no place in our foremost educational institu-
tions. One is also left with the suspicion that when the art of
feeding infants and children attains in England to some of the
dignity and importance which has been accorded it among the in-
telligent classes of this country there will be a proportionate
reduction of functional nervous disorders in their ranks. Of
treatment per se the volume perhaps contains little, but of wise
suggestion much. Altogether it is a book which no one will re-
gret reading or wish to lay down and the enjoyment is augmented
by the use by the printer of the light English paper which makes
a sizable book, easy to carry or hold.

T. S. S.



BRIEF OF CURRENT LITERATURE.



DISEASES OF CHILDREN.

Morphine in Infant Therapeutics. — Ch. Laubry (La Trib.
Mid., September i8, 1909) believes that the danger of the use of
morphine in infants has been greatly exaggerated, and that
properly used it is of great value. The author employs a syrup
of morphine made in the following proportions: 100 c.c. of water
with 2 to 3 grm. of syrup of morphine. Of this the dose
varies from 2 to 18 grm. according to the age of the child. The
tolerance is perfect, only slight vomiting having occurred in a
few cases. It is of value in the agitation of eruptive fevers;
in spasmodic affections of the respiratory tract, such as pertussis,
asthma, and laryngitis stridulus and in acute gastroenteritis.
In whooping-cough it seems to lessen the violence of the attacks
and their frequency and improves the general condition, while
vomiting ceases and appetite improves. In croup it acts as a



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384 BRIEF OF CURRENT LITERATURE.

cardiac tonic, lessens the respiratory excitability, and the liability
to need intubation. Other authors deny these effects. Mor-
phine and codeine are better borne than opium.

Anterior Poliomyelitis Limited to Lower Dorsal Region. — ^A
marked contrast to the ordinary type of case is presented by
that of a boy of eight years whose history is recorded by C. P.
Lapage (Brit. Jour. Child, Dis,, Nov., 1909). There was at
first slight apparent weakness of one leg for a short time only.
Twelve weeks after the onset of the illness he was very weak
and unable to raise himself into a sitting posture. The most
striking symptom was ballooning of the abdomen, combined
with a falUng-in of the lower part of the chest- wall, and a general
kyphosis of the dorsal region of the spine. The abdominal
muscles did not react to the faradic current, and constipation
was an obstinate and a troublesome symptom. Eighteen
months later the abdominal muscles were found completely
paralyzed except for two narrow bands about one-eighth inch in
width, stretching, one from the tenth rib on the left to the
umbilicus and the other from the umbilicus to Poupart's
ligament on the right. These bands showed marked fibrillary
contractions and were very excitable. During respiration the
abdomen ballooned out obove and below these narrow strips of
unparalyzed muscle, and the lower part of the chest-wall was
depressed. The lower three or four intercostal muscles were
also paralyzed. The erector spinae over the lower dorsal and
upper lumbar regions were much wasted. The psoas muscles
on each side were hypertrophied, and when the patient struggled
into a sitting posture, these muscles could be felt as large tense
bands in each iliac fossa.

Appendicitis in Children. — ^A. H. Bogart (L. /. Med, Jour.,
November 1909) has a mortality record of 17 1/3 per cent, in
forty-six cases. He finds that other writers report an average
of 16 per cent., much higher than in adults. Appendicitis in
children is a comparatively frequent disease, insidious in its
onset and rapid in its development, with a decided tendency
toward the development of general peritonitis, with a fatal
termination if neglected; and whatever holds good with regard
to immediate operation in the adult is doubly true in children,
and no case should be permitted to go for three days without
operation. Adhesions are less common than in adults and
are extremely friable, so great care must be used not to break
through into the peritoneal cavity. Protecting sponges should
be avoided when possible as their use endangers adhesions and
often spreads infection. Although he used drainage in thirty
of his cases, the writer says that it should be omitted if possible.



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THE AT^rmTtTriAxr

JOURNAL OF OBSTETRICS

AND

DISEASES OF ¥OMEN AND CHILDREN.

VOL LXL MARCH. 1910. NO. 3

ORIGINAL COMMUNICATIONS.



INTRAMURAL ABSCESS OF THE PUERPERAL
UTERUS.*

BY
JOHN A. SAMPSON, M. D.,

Albany. N. Y.
(With thirteen illustrations.)

Judging by the meager account of this condition in the text-
books on gynecology and obstetrics (not mentioned at all in
some) and also by the small number of cases reported in the
literature, one would infer that it is of very rare occurrence.

In the year 1901, von Franqu^ reviewed the subject of uterine
abscess in an excellent monograph (Uterusabscess und Metritis
diseccans, Sammlung klinischer Vortrage, New Series, No. 316).



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 39 of 109)