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Ophthalmia Neonatorum. -- This is an inflammation of the conjunctiva, characterized in its usual form by great swelling of the lids, serous infiltration of the bulbar conjunctiva, and the free secretion of contagious pus.

Causes. -- The affection is caused by the introduction into the eye of the infecting material, from some portion of the genitourinary tract of the mother, at the time of or shortly after birth. The majority of cases, and all severe forms, are associated with a special micro-organism -- the gonococcus of Neisser. Exception ally, inoculation appears to occur in utero, owing, perhaps, to the high degree of penetrating power which has been ascribed to the gonococcus.

Inasmuch as this micro-organism is not invariably present, two forms of the disease have been distinguished -- a severe type, supplied with the micro-organism, with a tendency to increase in severity and invade the cornea; and a milder type, non-specific, with a tendency to recover. Hence a virulent vaginal discharge is not necessary to produce this condition, except in intense degree, and it probably may arise from the contamination of any muco-purulent discharge during birth. Careless bathing of the child after birth, and the use of soiled towels and sponges, are fruitful sources of infection. It is possible that later contact with the lochial discharge may originate the disorder, although in the hands of several observers inoculation with healthy lochia has failed to produce the disease.

The exact time of inoculation has not been determined. Infection is more likely to occur in face presentations and during retarded labors. Boys are attacked more frequently than girls. The disease is said to be more common during summer months in cold climates; in hot countries, during the spring and autumn.

Symptoms. -- Ophthalmia neonatorum usually begins on the third day after birth, but may set in as early as from twelve to forty-eight hours after inoculation, or, when it is the result of a secondary infection from soiled fingers, sponges or clothes, be delayed to a much later date. Almost always both eyes suffer, the one being earlier, and frequently more decidedly affected than its fellow.

Four stages of the disease are common, but, as these vary in different eases, and more or less rapidly shade one into the other, no very sharp lines need be drawn.

A slight redness of the conjunctiva, with a trifling discharge in the corner of the eye, is rapidly succeeded by great, cushion-like swelling of the lids, with intense chemosis and congestion of the conjunctiva, accompanied by severe pain and discharge. The surface of the swollen lid is hot, dusky red, and tense; the upper lid overhangs the lower, and at first can only with difficulty be everted. The discharge, which in the beginning is slightly turbid, soon changes to a yellow or greenish yellow pus, and is secreted in great quantities.

If the lids are everted during the first day or two of the disease, the conjunctiva will be found to be swollen, red, and velvety, and that upon the eyeball intensely injected; upon the surface easily detached flakes of lymph are found; later, the conjunctiva becomes rough and of a dark-red color, spots of ecchymosis appear, or it is succulent and bleeds easily. Marked chemosis and infiltration of the ocular conjunctiva succeed, forming a hard rim; at the bottom of the crater-like pit thus produced, the cornea may be seen. The thick, cream-like discharge increases, and either flows out from beneath the overhanging upper lid on to the cheek, or is packed up in the conjunctival cul-de-sac. (Fig. 81.) The lids now may lose much of their tense character, and can be more easily everted; the conjunctiva is puckered into folds and papilla-like elevations, and the discharge contains an admixture of blood and serum. Gradually the disease declines, and in from six to eight weeks the discharge ceases. The relaxed palpebral conjunctiva is thick and granular, looking like the granulation tissue which surrounds wounds. The ocular conjunctiva is also thickened, and positive cicatricial changes may remain.

The chief risk is destruction of the vitality of the cornea, the danger of which is materially increased if this membrane becomes lustreless, dull, and hazy within the first day or two of the disease. Frequently small, oval ulcers form near the limbus, either transparent or surrounded by an area of cloudy infiltration, which rapidly increase in size; or larger areas of ulceration develop in a more central situation. In many mild cases the cornea escapes without harm. The changes which take place in the cornea are due in part to strangulation of its nutrient vessels by the swollen tissue, but largely to direct infection by the discharge.

After the formation of a corneal ulcer, either its healing and regeneration of the corneal tissue takes place, or else perforation occurs.

The result of perforation will depend upon the amount and character of the destruction of the corneal tissue. When the ulcer is central and perforates, the aqueous humor escapes, the lens is pressed forward against the posterior surface of the cornea, and the opening becomes closed with lymph. This renders the re-collection of the aqueous possible, and, when it occurs, the lens returns to its proper position, carrying with it upon the anterior capsule a little mass of lymph. Thus the formation of a pyramidal cataract results. (See page 395.)

Perforation of an ulcer peripherally situated, especially below, is followed by adhesion of the iris to the opening. The aqueous escapes, and, as the iris and the lens fall forward, the former becomes entangled in the perforation, and is fixed by inflammatory exudation. The adhesion is either on the posterior surface, or in the cicatrix, and the resulting dense white scar receives the name, adherent leucoma.

If the region of the scar is bulged forward because it is unable to resist the intraocular tension, anterior staphyloma results. Extensive sloughing of the corneal tissue, with total prolapse of the iris, matting together of the parts by exudation, and protrusion of the cicatrix, constitute a total anterior staphyloma.

Finally, perforation may be followed by inflammatory involvement of the ciliary body and choroid, and the rapid destruction of the eye through panophthalmitis, or a slower shrinking of the tissues, with atrophy of the bulb. Dense opacity occasionally appears in the cornea during convalescence, and may go on to ulceration, or clear up perfectly. It may arise with great suddenness, and, when it occurs in the lower half of the cornea, a deep indentation, owing to the pressure of the margin of the lid, is likely to occur.

The appearance of the conjunctiva differs materially in different cases. Its surface may be covered over, not merely with easily detached flakes of lymph, but with a gray, false membrane. More rarely, a deep infiltration develops, like that seen in diphtheritic conjunctivitis.

Restlessness, fever, and other constitutional disturbances are sometimes present, and synovitis of the knee and wrists may arise, of the same character as similar complications occurring in adults during gonorrhea.

Ophthalmia neonatorum does not always follow this course, because the term is made to include affections of the conjunctiva in the newborn, other than the types just described -- mild catarrhal ophthalmias, hyperemias, and that variety which, according to Noyes, presents the character of a granular, rather than of a purulent conjunctivitis, and which may continue for weeks without danger of corneal complication.

Some hyperemia of the conjunctiva, with a little yellowish discharge in the corners of the eye, and slight swelling of the lower lid, is common in babies for a few days after birth, and may be attributed either to uncleanliness, or to change of temperature.

Diagnosis. -- The onset and character of the disease, its symptoms and course, render a mistake in regard to its nature practically impossible. Close attention should be given to what at first appears to be a trivial inflammation in the eyes of a new-born child, because a virulent and destructive inflammation may follow with great rapidity.

Prognosis. -- This is always grave, the gravity increasing in direct proportion to the violence of the inflammation and the condition of the cornea. The attendants of newborn children should be impressed with the necessity of seeking capable medical advice at the very moment of the appearance of any conjunctival trouble. If, as only too frequently is the case, treatment has been neglected until extensive sloughing of the cornea has occurred, no form of medication can do more than relieve the violence of the inflammation, which, when it subsides, leaves the child with sight hopelessly marred, perhaps destroyed.

Prophylaxis. -- The present high standard of scientific midwifery includes such cautious vaginal antisepsis during labor, that the risk of contamination is distinctly less than in former times, but still some preventive method should be employed.

Crede's plan, commonly adopted, yields excellent results. This consists in dropping into the conjunctival sac one or two drops of a two per cent, solution of nitrate of silver, the lids having previously been wiped dry. Other materials recommended for the same purpose are aqua chlorini (Schmidt-Rimpler), and bichloride of mercury. The hands of the mother, nurse, and child should be searched for sources of infection, and, in addition to the usual antiseptic precautions during labor, if gonorrhea is known to exist in the mother, the child should be removed from the immediate surroundings of the lying-in woman.

Treatment. -- If the type is mild, the applications described under simple ophthalmia are indicated; if severe, three conditions demand attention: The inflammatory swelling of the lids, the state of the conjunctiva, and the corneal complications.

(1.) During the earlier stages, when the lids are tense and the secretion lacking in its later creamy character, in addition to absolute cleanliness, local application of cold is the most useful agent.

This should be applied in the following manner: Upon a block of ice, square compresses of patent lint are laid, which, in turn, are placed upon the swollen lids and as frequently changed as may be needful to keep up a uniform cold impression. This is far preferable to the use of small bladders containing crushed ice; indeed, the use of ice for infants is not advisable. The length of time occupied with these cold applications must vary according to the severity of the case. Sometimes they may be used almost continuously, and sometimes frequently for periods of half an hour at a time.

On the other hand, hot fomentations are occasionally better than cold, especially when corneal complications exist, or the surface of the conjunctiva is covered with a gray film. These are applied with squares of antiseptic gauze wrung out in carbolized water of a temperature of 120 degrees F., and frequently changed.

(2.) Constant removal of the discharge must be practised.

The lids are to be gently separated, the tenacious secretion wiped away with bits of moistened lint or absorbent cotton, and the conjunctival sac freely irrigated with an antiseptic fluid. For this purpose a saturated solution of boracic acid (which is feebly antiseptic, but very cleansing and slightly astringent), or one of corrosive sublimate, a grain to a pint (it is stated that a solution of one to ten thousand will retard the vitality of the coccus), may be employed. (1) Special and ingenious forms of lid irrigators have been devised. The cleansing process must be repeated at least every hour, day and night, and, if necessary, much more frequently.

The remedies mentioned on page 219 have found favor with some surgeons. In addition to these may be mentioned carbolic acid (one-half to five per cent.), nitrate of silver (one to two per cent.), alcohol and bichloride of mercury solutions, iodoform ointment (four per cent.), and aqua chlorini. Peroxide of hydrogen acts efficiently in cleansing away the purulent secretion. The frequent insertion of vaseline beneath the lids is highly commended.

(3.) The local application of nitrate of silver to the conjunctiva must not be made in the earlier stages before free discharge is established, nor in those cases, no matter what the stage, when the lids are tense and board-like, and the surface of the conjunctiva covered with a gray film, or a false membrane.

When the secretion is free and creamy, when the lids are relaxed, when the conjunctiva is dark-red and puckered into papilla-like excrescences, the time for its application has come. Once a day the palpebral conjunctiva and retrotarsal folds should be brushed over with a solution, ten or twenty grains to the ounce, its surface first having been carefully freed from any adherent discharge, and afterwards all excess of the drug washed away with water. In severe cases the mitigated stick, and even the solid pencil of nitrate of silver may be employed, great care being taken to neutralize the excess with a solution of common salt. All strong applications must be made by the surgeon himself. Ulceration of the cornea does not alter the treatment described, except that pressure upon the globe while manipulating the eye is to be avoided. So long as the discharge is abundant the use of the caustic is indicated. (2)

At the first appearance of corneal haze, a four-grain solution of atropine is to be dropped into the eye two or three times daily. If, however, a marginal ulcer forms, and danger of perforation is imminent, or even if this has occurred, good results are obtained with eserine. The use of eserine requires considerable care, lest any co-existing hyperemia of the iris be aggravated by the drug, and iritis ensue. For this reason many surgeons prefer not to employ it, although its great efficacy in preventing sloughing of the cornea cannot be denied.

Persistent swelling of the conjunctiva is sometimes treated by scarification. Division of the outer commissure to relieve pressure, leeching, and, indeed, any form of treatment followed by decided loss of blood, are hardly suited to young infants, although they may be indicated in adults.

If one eye alone is affected, suitable protection for the sound eye should be provided. This may be accomplished by antiseptic bandaging of the uninflamed organ (Buller's shield is difficult of application in infants). The daily use in the unaffected eye of a drop of a two per cent, solution of lunar caustic has been suggested.

Reduction of the inflammation with cold applications, for which, under the conditions named, hot affusions are substituted; absolute cleanliness; frequent irrigation with antiseptic and slightly astringent solutions; and at the proper stage nitrate of silver, will meet with the best results.

The attendants must be impressed with the fact that upon their faithful carrying out of directions and upon their unremitting care much, if not all, of the hope of bringing the case to a successful termination depends. The attendants must further be impressed with the contagious nature of the pus; all bits of rag and pledgets of lint used in the treatment must be destroyed, and after each treatment the hands of those engaged must be thoroughly washed and then disinfected with a solution of bichloride of mercury.