There is a super interesting 1992 paper of Jacobson/Feinstein oxygen as a cause of blindness in premature infants: “autopsy” of a decade of errors in clinical epidemiologic research While it is quite obvious to recognize such an epidemic at a late stage (as in the thalidomide scandal) it needs quite a lot of oversight at the early phase.
it took more than a decade-1942 to 1954-to end an iatrogenic epidemic in which high-dose oxygen therapy led to retrolental fibroplasia (RLF) in premature infants, blinding about 10,000 of them. The autopsy revealed a museum of diverse intellectual pathology. When first noted, RLF was regarded as neither a new disease nor a postnatal effect. In early investigations, the ophthalmologists did not establish explicit criteria for diagnosis and confused RLF with malformations previously seen in full-term infants. Because the patients were not referred until months after birth, the ophthalmologists assumed that the lesion, which resembled an embryologic structure, must have occurred prenatally.