Prevention of Inflammatory eye disease in the newborn Information from the Maternity Clinic Leipzig by Crede [22

"I am (...) publishing the following information concerning the prevention of inflammatory eye disease in the newborn (...) in this Archive because the disease is almost invariably caused by infection during delivery and is therefore directly related to a diseased condition of the female genitals. Responsibility for prevention of the disease must also lie solely with obstetricians and midwives. I shall confine my remarks exclusively to the practical question of prophylaxis.

(...) My request for further testing of the prophylaxis I am recommending is therefore addressed to those of my colleagues who work in maternity hospitals or obstetric clinics and (. ) are frequently confronted with this condition.

Most obstetricians would probably share my view that the case of vaginal catarrh and infections that are so frequently encountered are attributable to gonorrheal infection and that the discharge remain infectious long after the specific symptoms of gonorrhea have disappeared; moreover, in some cases where there is virtually no further trace of discharge, the infection may still be considered to have occurred in the mother's vagina when an inflammatory eye condition develops in the first few days after birth.

Transmission of the infectious substance from another child with eye disease is inconceivable (...) inasmuch as every child who is suffering from inflammatory eye disease is moved with its mother to a ward that is entirely separate in all respects from the maternity ward. The possibility of mothers infecting their children, for example through fingers soiled by lochial dis charge, is also remote because the child's cot is always placed beyond reach of the mother, who only comes into contact with the child when the nurse places it on her breast.

I am therefore convinced (...) that all affected children in (...) hospital (...) were infected solely by direct transmission of vaginal discharge to the eye during delivery. The infected eye usually begins to show symptoms of disease 2 or 3 days after birth, but also sooner or later - the sooner, the more serious the condition.

(...) I have set myself the doubtless worthwhile task of finding effective ways and means of preventing this disease (...) and of detecting the infectious discharge.

I initially focused on ensuring extensive and effective treatment and cleansing of the diseased vaginas of pregnant and delivering women. But the results were poor and unsatisfactory; although there were fewer cases of eye disease (...). I then began to disinfect the children's eyes themselves and from then on the success recorded was surprisingly encouraging.

My experiments proceeded as follows: first, the vaginas of all pregnant and delivering women admitted to the hospital with gonorrhea or chronic vaginal catarrh were cleaned out with lukewarm water or a light solution (2:100) of carbolic or salicylic acid as frequently as possible - every half hour in the case of delivering women. The incidence of eye disease declined but the problem persisted (...).

In October 1879, I carried out my first test involving the introduction of prophylactic eye drops into the newborn babies immediately after birth, using a borax solution (1:60) because it seemed to be the mildest and least caustic substance. This was only done, however, in the case of children whose mothers were ill and whose vaginas had been cleansed during the whole delivery process in a manner described above. From December 1879, I replaced the borax by solutions of Argentum nitricum (1:40), which were injected into the eyes shortly after birth. The eyes were carefully washed beforehand with a solution of salicylic acid (2:100). The children of sick mothers who were treated in this way remained healthy, while other children who had not been given preventive treatment (...) still fell ill, in two cases quite seriously.

From 1 June 1880, all eyes without exception were disinfected immediately after birth by means of a weaker solution of Argentum nitricum (1:50). (...) a glass stick was used to introduce a single drop of liquid into each eye, which was gently opened by an assistant and which had been cleaned beforehand with ordinary water. Then the eyes were cooled for 24 h with a canvas cloth soaked in salicylic water (2:100). The numerous vaginal douches, on the other hand, were abandoned (. ). All children treated in this way remained free from even mild attacks of inflammatory eye disease, although many mothers showed advanced symptoms of vaginal blenorrhea (...). Only one child (...) fell ill on the 6th day with a moderate inflammation of the conjunctiva of the left eye, without swelling of the eyelid, which healed within 3 days. It emerged that, quite by chance, owing to pressure of work, the prophylactic eye drops had not been administered to this child.

To date, no adverse effect on the treated eyes has been observed. Not infrequently the administration of the eye drops is followed by a slight hyperemia and in some cases by slight increased secretion from the conjunctiva in the first 24 h. Then these symptoms disappear. They could perhaps be avoided if further tests indicate that a weaker solution of Argentum nitricum is sufficient.

As has been shown, the procedure is simple, (...) completely without risk and seemingly reliable in terms of its effect.

(...) my set of observations is (...) still sufficiently extensive and striking to warrant further urgent application of the procedure. I wish to lay special emphasis on the finding that the desired effects are achieved through disinfection of the eyes themselves rather than the vagina. It is to be hoped that the future will tell whether the eye procedure that I have been using is the best and most reliable one (...). For the time being, I have no reason to deviate from my own method.

Needless to say, the successful banishment of inflammatory eye diseases at least from maternity hospitals and clinics would constitute a major achievement in many respects.

Lastly, I wish to present some figures for cases of inflammatory eye disease observed in this maternity hospital in recent years. (...).

Year

Number of births

Number of cases of inflammatory eye disease

Percentage

1874

323

45

13.6

1875

287

37

12.9

1876

367

29

9.1

1877

360

30

8.3

1878

353

35

9.8

1879

389

36

8.2

1880 (until 31 May)

187

14

7.6

1880 (from 1 June to 8 December)

200

1*

0.6

*This is the case in which the eyes were not disinfected; the figure should therefore read 0.0%

*This is the case in which the eyes were not disinfected; the figure should therefore read 0.0%

In the first paper (1881; [19]) Crede strictly focused on practical aspects of prophylaxis of ophthalmia neonatorum. It was recognized that the way of transmission was by direct contact with vaginal excretions. He described hygienic procedures of cleaning the vagina, described several interim stages of eye drops applied to the newborn, and ended up with the abandonment of vaginal douches/extensive cleaning of the vagina and introduction of the consequent direct eye prophylaxis in every delivered newborn with a single drop of 2% silver nitrate solution per eye applied to the middle of the cornea by a glass rod from June 1st 1880 onwards. This prophylactic method was declared as highly efficacious, easy to handle and without adverse effects apart from a slight hyperemia and some increased secretion from the conjunctiva within the first 24 h in some cases. Already in this paper Crede recommended that this procedure of eye prophylaxis should also be put into the hands of midwives. Etiologically, Crede only mentioned an "Infektionsstoff" (contagious agent) as reason for the disease; further microbiological aspects - including Neisser's new discovery of 1878/1879

- are not addressed.

The second paper (1881; [20]) verified the effectiveness of this procedure by reports of an additional 400 new cases (first paper [19]: 200 cases) including 300 newborns treated with a simplified regimen. In contrast to the method described first, in the simplified regimen, the cord was cut and the newborn was washed. Thereafter the eyes were wiped clean with water, and a 2% silver nitrate solution was applied by the same way as mentioned before. In contrast, no consecutive treatment/manipulations at the eyes were performed. None of the 400 newborns developed ophthalmia neonatorum. In this paper, Crede highlighted that the application of 2% silver nitrate solution directly into the newborn's eye has to be performed immediately after the first manipulations, as mentioned above, after delivery. Further, for the first time, Crede addressed the aspect of introducing this method of eye prophylaxis to general practitioners active in obstetrics for prophylaxis of corresponding newborn outpatients. In particular, the need for putting the prophylaxis into the hands of midwives was stressed again. In addition, the aspect of treatment for ophthalmia neonatorum by stronger solutions of silver nitrate was addressed for the first time. The most critical/political aspect coming up in this paper was the suggestion - as mentioned before

- of giving the prophylaxis into the hands of midwives, which meant breaking with a prestigious medical privilege in obstetrics by apparently by-passing the outstanding authority of the physician/obstetrician. Crede suggests that every midwife should obtain a bottle of 2% silver nitrate solution and a corresponding glass rod. His interest was that hereby ophthalmia neonatorum could be eradicated. Microbiologically, the disease was attributed to a "Contagium" as the causative agent without more detailed discussions and without presentation of Neisser's actual new insights.

The third paper (1883; [21]) gave a synopsis of Crede's overall experiences on ophthalmia neonatorum and was divided into two parts. The first part focused on the aspect of prevention and the second part on the aspect of etiology of ophthalmia neonatorum.

In the relatively short first part of this paper, Crede stated that he considered the issue of prophylaxis for ophthalmia neonatorum as solved. The method suggested by him appeared easy to handle, safe and effective. He gave the advice not to deviate from this proposed method, as in some insti tutions, where modified procedures were performed, poorer results were achieved.

The second part of this paper was announced to focus on etiological aspects of ophthalmia neonatorum. Indeed, this was only partly the issue, and this part of the paper was in many perspectives highly political.

The transmission of ophthalmia neonatorum via direct vaginal contact was reaffirmed and aspects such as duration of the delivery period, gender of the newborn, etc., were discussed from the etiological perspective. Crede stated that he considered the "Diplococcus Neisser" the most probable causative pathogen ("specifisch gonorrhoeisches Virus Diplococcus Neisser"). This one sentence of his series of publications was Crede's only hint at Neisser's tremendous achievements concerning the etiology of gonorrhea (Neisser's second comprehensive publication on the etiology of gonorrhea had been published 1 year before in 1882).

In the following part, Crede stated that it was his achievement, having obtained the insight that vaginal douches were almost ineffective and that the contagious agent had to be destroyed sufficiently, that the prophylactic efforts, which had not been performed before, were put into place. As a method for the sufficient destruction of the contagious agent he stated again the administration of 2% silver nitrate solution directly into the eyes of every newborn child, including consecutive hygienic precautions to prevent a later inoculation of the child's eye by vaginal discharge from the mother.

As dose justification for the 2% silver nitrate solution he cites a study from Hecker [24], who performed the eye prophylaxis with a 1% silver nitrate solution. Of 133 children, 4 developed ophthalmia neonatorum in this study, although even Hecker pointed out that compliance was poor within this study, and it still remained unclear to the reader if the eyes were washed with NaCl solution afterwards, as described in the paper in case of treatment for ophthalmia neonatorum with aqueous silver nitrate solution. Crede ignored all of this argumentation and insisted that the 1% silver nitrate solution was ineffective for the prophylaxis of gonorrheal ophthalmia neonatorum, which he considered as an undisputable justification for his 2% regimen.

Afterwards, a long, enthusiastic plea for giving the prophylaxis into the hands of midwives was given again. It was discussed that even potential misuse by midwives could not cause significant disadvantages in contrast to the tremendous advantages of a broad application of this prophylaxis. A lot of concerns against giving the prophylaxis into the hands of midwives, which were brought forward by physicians, were cited, discussed and declared invalid.

At the end of this manuscript, Crede highlighted that on January 31st 1883 his prophylactic eye regimen was enforced by law for cases of hospital deliveries in Austria. The procedure should - by law - be performed only by physicians; indeed, Crede did not oppose in this special case. Nevertheless, he encouraged every country to release such a law.

The complementary booklet on this issue (fourth publication), written in English language (1884; [23]), gave a comparable synopsis on gonorrheal ophthalmia neonatorum and its prophylaxis such as given in the third paper.

Fascinating is, how extremely precise and concerned Credé was with issues he was dealing with. In the English publication, for example, he gave a very detailed description of the solution, its storage and the glass rod being applied. It was described that the solution of silver nitrate should be kept in a dark bottle made of glass with a glass stopper. The glass rod to be used should be 15 cm in length, 3 mm thick and rounded at both ends. The little bottle and glass rod had to be stored in a small drawer in the swaddling table. The solution had to be renewed every 6 weeks, but it was pointed out that it was not critical, concerning safety and efficacy, if the solution was accidentally used for a longer period of time. No room for personal freedom was left open concerning this issue. This description was an excellent reflection of Credé's personality. With him, nothing was left open to accident and/or to spontaneous occurrence.

Pregnancy Diet Plan

Pregnancy Diet Plan

The first trimester is very important for the mother and the baby. For most women it is common to find out about their pregnancy after they have missed their menstrual cycle. Since, not all women note their menstrual cycle and dates of intercourse, it may cause slight confusion about the exact date of conception. That is why most women find out that they are pregnant only after one month of pregnancy.

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