OPHTHALMIA NEONATORUM. 
By C. A. VEASEY, M D., 
Ophthalmologist to the Philadelphia Lying-in Charity 
and Nurse Training School ; Assistant Demon- 
strator of Surgery in the Jefferson Medical 
I i*l! 
College of Philadelphia, etc. OPHTHALMIA NEONATORUM. 
By C. A. VEASEY, M. D. 
OPHTHALMOLOGIST TO THE PHILADELPHIA 
LYING-IN CHARITY AND NURSE TRAIN- 
ING school; ASSISTANT DEMONSTRA- 
TOR OF SURGERY IN THE .IEFFER- 
SON MEDICAL COLLEGE OF 
PHILADELPHIA, ETC. 
A LECTURE BEFORE THE NURSE CLASS, THE 
MEDICAL STAFF, THE HOARD OF MAN- 
AGERS AND INVITED GUESTS OF THE 
PHILADELPHIA LYING-IN-CHAR- 
ITY AND NURSE TRAINING- 
SCHOOL. 
Ladies and Gentlemen.—When invited 
by the executive committee of your 
institution to deliver a lecture this even- 
ing upon “Ophthalmia, its causes pre- 
vention and treatment,” I was in doubt as 
to whether I should attempt to treat of all 
the varieties of ophthalmia, or only of some 
particular variety that you would perhaps 
come in contact with more than any other; 2 
and after due consideration I arrived at 
the conclusion that it were better to talk 
of that variety which you will see more of 
as obstetrical nurses, so that you will 
recognize it when you see it and under- 
stand its causes, prevention and treatment. 
The socket in which the eyeball is placed 
is lined by a mucous membrane known as 
the conjunctiva. This membrane com- 
mencing at the outer edge of the lids ex- 
tends backward for a considerable distance, 
and is then reflected forward on the eye- 
ball, that portion covering the lids being 
designated the palpebral conjunctiva, and 
that part covering the eyeball, the ocular 
conjunctiva. Now7, ophthalmia is a dis- 
ease of the eye, characterized by pain, 
redness, intolerance of light and excessive 
flowing of the tears, there being either a 
hyper-secretion or a genuine discharge, ac- 
cording to the variety; the inflammation for 
the most part being seated in the coats of 
the eyeball, or conjunctiva. The atfection 
is sometimes known as conjunctivitis. 
Vakieties.—The varieties of ophthal- 
mia are many, the chief among them being 3 
simple,*muco-purulent, purulent, diphthe- 
ritic and phlyctenular, the difference 
between them being more the degree of 
inflammation than the character of it. 
Simple, or as it is sometimes called pal- 
pebral conjunctivitis,is an inflammation of 
the palpebral folds of the conjunctiva, 
that portion which covers the eyeball itself 
not being affected. It is characterized by 
redness, intense itching, burning and a 
sensation as if small grains of sand were 
under the lids, causing a desire to rub the 
eye continually. The causes are numerous 
and varied—such as extremes of tempera- 
ture, this being the case when people tell 
you they have taken cold in the eyes; 
foreign bodies, as pieces of coal dust or of 
shell which are blown into the eyes as one 
walks along the street; cinders from the 
locomotive of a railway train; exposure to 
a vitiated atmosphere—a room filled with 
tobacco smoke for example; loss of sleep, 
as I am sure many of you have experienced 
after you have been nursing a tedious case 
all night without having had your sleep on 
the previous day. And one of the chief 4 
causes is working without glasses when the 
eyes need them, or working with improperly 
fitted glasses. Indeed, we frequently have 
patients come to our offices complaining of 
nothing else but the burning sensation in 
the eyes, with agglutination of the lids 
upon waking in the morning, and almost 
always there is found some error of re- 
fraction which when corrected by proper 
glasses, the other symptoms disappear. 
And these glasses should not be pre- 
scribed by an optician but by a skilled 
oculist, who has made a study of the eye 
from a medical and surgical standpoint— 
iu other words, a graduated physician who 
has made a speciality of the diseases of the 
eye. It is frequently remarked by elderly 
persons that when they were young, glasses 
were not used nearly so much as now. 
To be sure they were not. but at that time 
there were not the educational advantages 
to be enjoyed as now. The child was not 
sent to school at so tender an age, and 
urged to work day and night in its en- 
deavors to excel and gain a high degree of 
distinction. So many people did not gain 5 
a* livelihood by the constant use of the eyes 
then as now. There were fewer profes- 
sional men, fewer scholars—in other words, 
there was less eye work, and consequently 
less eye strain and glasses were not re- 
quired. 
• The present age is one of push, energy 
and ability, and to obtain a position in, or 
near, the front ranks of the vast army of 
people who are constantly pushing forward 
in their endeavors to reach the highest 
mountain peak of success, requires much 
persevering labor. It is almost impossible 
to attain any degree of distinction, in the 
present age, without at least a moderate 
general education; and an extensive edu- 
cation in one's particular vocation is abso- 
lutely necessary. To possess this requires 
much time and considerable use of the 
eyes, and in our efforts to hasten our suc- 
cess and excel our comrades, to reach the 
summit for which we have been striving, 
as quickly as possible, we use them incon- 
siderately; hence the weak eyes of our- 
selves and our children, to remedy which 
we are compelled to prescribe glasses, 6 
which correct the defects and relieve the 
ophthalmia and the strain. Unless the 
cause of the ophthalmia be removed, the 
disease in a short time becomes chronic, 
and the treatment is more or less pro- 
longed; but if taken early, the cause 
searched for and removed, the recovery is 
rapid. 
The muco-purulent variety is really an 
exaggerated form of the simple, the differ- 
ence, as stated above, being only in degree. 
In fact the causes are the same, to which 
may be added contagion, the material 
having come from some other eye and 
having been transmitted either through 
carelessness in not cleansing the hands, or 
perhaps by means of a towel or handker- 
chief, this frequently being the method of 
inoculation. 
The purulent is an exaggerated form of 
the muco-purulent, the dose of the poison, 
as it were, having been larger, the soil 
more susceptible and the discharge being 
pus. 
The diphtheretic is a variety, fortu- 
nately for us, rarely seen in this country.  7 
As all diphtheretic inflammations it is char- 
acterized by the formation of a membrane, 
in this instance it being on the conjunc- 
tiva, and very adherent. The affection 
is inclined to be epidemic and is one of 
the utmost gravity. 
The phlyctenular has the same symptoms 
as the muco-purulent, but is especially 
characterized by the appearance of small 
phlyctenulae, or vesicles, on the ocular 
conjunctiva, and it is from these that it 
takes its name. 
The muco-purulent and the purulent va- 
rieties, when occuring in the new-born 
child, are grouped together under the 
head of Ophthalmia Neonatorum, the va- 
riety that is of particular interest to you as 
obstetrical nurses, and to all who are con- 
nected with a Lying-in Hospital; and I 
have passed over the other varieties rapidly, 
each one of which would afford material 
for a whole lecture, merely mentioning a 
few of their chief symptoms, so that we 
might discuss this one at greater length. 
To be sure, gonorrhoeal ophthalmia is to 
be classed with the above group, but as 8 
this is only purulent ophthalmia from a 
specific cause it is hardly necessary to make 
another variety. The fewer the varieties 
the more easily understood is the disease. 
As in all cases of ophthalmia, the real 
cause of ophthalmia neonatorum is a germ, 
just which particular one has not yet been 
fully determined, and the inoculation 
which takes place in one of two ways has 
been divided into the primary and secon- 
dary, the former taking place during, or 
immediately after, birth; the latter occur- 
ring in those cases in which there has been 
a sufficient length of time since the birth 
of the child to enable us to be sure that 
the affection is a result of post-partum in- 
oculation. 
The primary inoculation may be made 
in several ways. It frequently occurs in 
making manual examinations in face pre- 
sentations; the eyelids are sometimes 
opened by instruments, allowing the vag- 
inal discharge to enter; the mucous is 
sometimes retained on the lids after birth, 
sufficient care not having been taken to 
cleanse them thoroughly, and at a later 9 
period entering the eye causes the dreaded 
inflammation; and again, a very frequent 
cause is the direct introduction of the con- 
tagious material caused bv the opening of 
the eyelids by the tense perineum as the 
head is passing through the external ori- 
fice. This may at first seem to you to be 
improbable, but when you consider for a 
moment how very tense the perineum is 
and how the head is elongated, causing the 
eyes of the child to bulge forward, it is 
very easy to understand how, in passing 
over this taut, elastic structure, stretched 
to its utmost capacity, the palpebral fissure 
may be opened and the contagion intro- 
duced. Clinically it has been determined 
that males are more frequently attacked 
than females, owing to the fact that the 
head is usually larger, and the children of 
primiparae more frequently than those of 
multipara?, on account of the tediousness 
of the labor and the lesser degree of peri- 
lueal elasticity and the weak expulsive pains 
toward the end. 
The secondary inoculation is caused by 
failure on the part of the person receiving 10 
the new-born infant to cleanse immediately 
everything from the eyelids, in the man- 
ner which I will explain to yon later; by 
direct contact with unclean materials, 
such as towels, sponges,- etc., and in a 
manner that frequently occurs, by bathing 
the face and eyes with the same water with 
which the body has been sponged. Of 
course irritants, like soap, bay rum, bright 
lights, etc., may cause a mild type of con- 
junctivitis, but not the horrible ophthal- 
mia neonatorum of which we are speaking. 
Symptoms.—The symptoms, which may 
be divided into four stages, we are all 
familiar with. First, we have the period 
of inoculation, which usually is only a few 
hours; then a short period in which lymph, 
the exudative material that always accom- 
panies inflammation in any part of the 
body, is freely secreted, and this is fol- 
lowed by the copious discharge of pus 
which is virulently contagious. There are 
present, of course, the characteristic pain, 
redness, swelling, intolerance of light, 
and a copious discharge. But if every- 
thing goes well the fourth stage is marked 11 
by the gradual disappearance of the secre- 
tion and a recession of the inflammation. 
The pain caused by this affection is of 
the most excruciating character. To give 
you some idea how severe it is, an incident 
that happened several years ago, and has 
been recorded, is worth relating. At one 
time a slave ship sailing on the high seas 
had an outbreak of purulent ophthalmia on 
board. The ship was some distance from 
land and there were about three hundred 
slaves below the decks affected with the 
disease. Xo treatment was instituted at 
this time, but a little later some of them 
were allowed to come on deck to get some 
fresh air, and the suffering was so intense 
that most of those who had been allowed 
to come up committed suicide by jumping 
overboard. The great majority of those 
who did not meet this fate became totally 
blind. 
Progress and Termination.—If no 
complication presents itself and the disease 
does not pass into the chronic form, it 
usually lasts from three to four weeks. If 
it terminates directly in a cure, all of the 12 
symptoms gradually diminish, and the 
conjunctiva returns slowly to a healthy 
condition. If any complication arises, 
however, or if the case passes into the 
chronic form, the affection becomes one of 
the greatest gravity. Small granulations 
begin to grow on the lids and what is 
known as granular conjunctivitis super- 
venes, a disease very difficult to eradicate, 
and the results may be opacities of the 
cornea, that part of the eye through which 
we see. This, of course, causes more or 
less impairment of vision, and if the 
disease progresses it may result in a per- 
foration of the cornea, or ultimate blind- 
ness. 
Prognosis.—The prognosis of oph- 
thalmia neona rum is not so bad as one 
would at first suppose it to be. But as 
complications may, and do, arise at any 
stage of the disease, and as it is, as before 
stated, the cause of more blindness than 
any other single factor, it is almost crimi- 
nal to neglect those precautions and that 
practice which experience has shown us re- 
duces the percentage of cases almost to nil. 13 
Treatment,Prophylactic.—The treat- 
ment of this disease is divided into two 
parts prophylactic and curative. In the 
former division come all of those means 
which are used to prevent the disease. 
First of all the laity should be instructed 
concerning the great danger of ophthalmia 
and that as soon as any inflammation of the 
eye of the new-born occurs, no matter how 
slight, it should at once be reported to a 
regular practitioner. This idea is put into 
execution in many foreign countries, so 
well understood is the danger of the disease, 
and in Sheffield the eye infirmary distri- 
butes cards which read as follows: “If a 
baby’s eye run with matter and look red 
after birth, take it at once to a doctor. 
Dday is dangerous and one or both eyes 
may be destroyed if not treated immediate- 
ly.” This advice cannot be too greatly 
emphasized, and it would be an excellent 
stop towards the prevention of much 
blindness if all, or indeed some, of our in- 
firmaries followed the same practice. 
Hotter still if our municipal authorities 
would take the matter in hand and distri- 14 
bate printed circulars to each family, ex- 
plaining the dangers of the disease and 
stating what should be done in case of an 
attack of it. 
In some countries stringent regulations 
have been adopted as regards midwives and 
nurses, which are not only a protection to 
the infants but also to the nurses, as by 
following stated directions they are freed 
from all blame. In New York state the 
following has recently been enacted: 
“‘Should any midwife or nurse having 
charge of an infant in this state notice 
that one or both eyes of such infant are 
inflamed or reddened at any time within 
two weeks after its birth, it shall be the 
duty of said midwife or nurse so having 
charge of such infant to report the fact in 
writing within six hours to the nearest 
health officer, or some legally qualifiad 
practitioner of the city, town or district 
in which the parents of the infant reside.” 
Some such law enacted in every state would 
cause the number of the most hopeless and 
helpless or all people, the blind, to be re- 
duced in our public institutions. 15 
In the beginning of the second stage of 
labor the vagina of the patient should be 
thoroughly irrigated with a solution of 
corrosive sublimate (strength 1-2000), or 
a solution of some other germicide as the 
obstetrician may prefer, but according to 
my belief corrosive sublimate is the best in 
use at present. The hands of the phy- 
sician and the nurse, as well as all the 
instruments employed, should be thor- 
oughly disinfected. The foetal eyes should 
be assisted to pass over the perineum with- 
out resting, for, as I have stated else- 
where, ophthalmia is frequently caused by 
the palpebral fissure being opened during 
the passage of the head over the tense 
perineum and the contagion thus intro- 
duced. The eyes can be made to pass 
over rapidly by hooking the middle finger 
of one hand over the perineum and draw- 
ing it downward. 
As soon as the head is born, if there is 
time, the eyes should be wiped with small 
pieces of absorbent cotton or wool; and if 
there is not time before the birth of the 
body, it should be done before the cord is 16 
tied. In doing this the cotton should be 
loosely packed into small pledgets and the 
eyes very gently wiped from above down- 
ward, which will facilitate the removal of 
any foreign material that may have accu- 
mulated around the eyeball. As soon as 
this is finished two drops of a five-grain 
solution of nitrate of silver should be 
dropped into each eye, though of course 
this cannot be done without the order of 
the physician in charge of the case, and I 
regret to be compelled to add that many 
do not seem to think it is necessary to take 
any such precaution, notwithstanding the 
fact that statistics show this disease to be 
the greatest known cause of blindness, and 
that when the above prophylactic treat- 
ment is used the percentage is reduced 
from ten per cent, to almost nil. 
The above is known as the Crede method, 
which has been slightly modified, the origi- 
nal being to instill one drop of a ten-grain 
solution of nitrate of silver into each eye. 
Ascertaining that as a rule this solution 
was stronger than required and excited too 
great a degree of inflammation, it is my 17 
custom to have instilled into each eye two 
drops of a five-grain solution, which, 
though it mav contain the same amount 
of silver, does not affect the conjunctiva 
so severely as does the stronger solution. 
There is another method, known as the 
Hegar-Korhn, which consists in wiping 
the face and eyes immediately after birth 
with a solution of corrosive sublimate 
(strength 1-1000), and though statistics 
show very good results, I prefer the in- 
stillation of the astringent, believing it to 
be the surer and better method of pre- 
vention. In one thousand cases treated 
by the Crede method not a single case of 
ophthalmia developed, while without it 
about 10 per cent, of all infants are af- 
fected with the disease. In the foundling 
hospitals of Paris the percentage of cases 
twenty years ago was from 80 per cent, to 
00 per cent., while to-day it is 0.2 per 
cent., it being compulsory to use the 
Crede prophylactic treatment. 
The face of the child should never, 
under any circumstances, be washed with 
the same water with which the body has 18 
been bathed, and different sponges or 
pieces of flannel should be used for the 
face and body. The reason is understood 
without being given. 
It is very important that you should al- 
ways wash your hands thoroughly after 
adjusting the mother before you touch the 
child, and you should guard against expos- 
ing it to any draughts, bright lights, etc., 
or allowing any soap to get into the eyes. 
Curative.—Should you be so unfortu- 
nate as to have the disease occur the 
child must be isolated at once, and the 
physician notified. 
If one eye only is affected the other 
should be guarded by covering it with 
a light bandage. The physician will 
instruct you to cleanse the eve every hour 
(perhaps more or less frequently than this, 
depending entirely upon the severity of 
the case) washing it first with warm water 
then with a solution of boric acid. 
The best way to do this is to have 
some one sit in front of you and hold 
the child so that its head rests be- 
tween your knees, with its face looking 19 
upward, your lap being protected with a 
piece of gum cloth or a towel. The per- 
son in front holds the child’s legs under 
her left arm and supporting the body on 
her raised knees, has her right hand at 
liberty, with which to assist you. In this 
position the eyes can be irrigated and the 
applications made to the conjunctiva with 
the least possible trouble. 
To reduce the inflammation cold com- 
presses are used. 1 prefer to have these 
made out of small pieces of lint, about the 
size of the one I show you here, and kept 
on ice, which cools them more thoroughly 
than water. They should be placed on 
the eye four in thickness and at first they 
should be changed every minute, the time 
between the applications being gradually 
lengthened. The compresses not only re- 
duce the inflammation by processes which 
I will not describe to you this evening, 
and which are readily understood by every 
practitioner; but it is also claimed that 
they either destroy or prevent the devel- 
opment of the germ that causes ophthal- 
mia, it having been proved by experiment 20 
that the said germ cannot develop at, or 
below, a temperature of 32° F. 
The eyelids are everted at stated inter- 
vals by the physician and applications of a 
solution of nitrate of silver made to the 
mucous membrane, great care being taken 
to apply it to all the folds. This stops 
the growth of the germs and substitutes 
a healthy for non-healthy inflammation. 
Other applications rather than nitrate 
of silver are frequently made, among them 
being insufflations of iodoform, calomel 
and solutions of tannin, corrosive subli- 
mate, peroxide of hydrogen and many 
others too numerous to mention. In my 
own experience.. I have always found the 
solution of nitrate of silver to be the best, 
though it should not be used indiscrimin- 
ately, nor applied, as many advise, with a 
camel’s hair brush; but small pieces of 
cotton should be rolled on the end of a 
stick, as I show you here, dipped into the 
solution and touched to all parts of the 
conjunctiva, one being used for each eye, 
and burned immediately afterward, as 
should be all the pieces of cotton or lint 21 
which come in contact with the eye. But 
no method will be of avail unless the phy- 
sician is ably supported by the nurse in 
the thorough and frequent cleansing of the 
eye; for no matter what the character of 
the applications may be they will not rid 
the eye of the micro-organisms nor pre- 
vent their multiplication unless the nurse, 
with whom the case is entrusted, keeps the 
organ cleansed of all discharge during 
the intervals between the applications. 
And when you have become tired and 
weary and exhausted from nursing such a 
case and feel disposed to neglect it, even if 
only for a few moments, let me beg of you 
to look at the subject from a humane 
point of view, for 1 know of no act of 
charity or benevolence more praiseworthy 
than that of saving the eyesight of an in- 
fant unable to help itself, and thus pre- 
serving its future usefulness for its family, 
for mankind at large and for its Maker; 
and in after years when that same infant, 
now grown to manhood or womanhood, is 
able to realize the escape it had from blind- 
ness, much of which was due to your care- 22 
fill nursing and your faithful attention, 
though you may not be aware of it, he 
will heap upon your head heartfelt bless- 
ings and praises, such as we all desire and 
can only obtain through our own efforts. 
I have added to these remarks some sug- 
gestions collected from various sources 
which I have placed together as so many 
rules. In giving them to you I do so in 
part as a recapitulation, and perhaps am 
guilty of repetition; but if in so doing I 
am enabled to impress upon your minds 
some important facts relating to the disease 
and its prevention, so that you will in the 
future use them, I feel quite confident 
that you will assist very much to lessen 
the number of cases of ophthalmia neona- 
torum, and thereby in reducing the num- 
ber of blind in our public institutions; and 
the purpose of my lecture will have been 
accomplished. 
1. Before making a vaginal examination 
always cleanse the hands thoroughly with 
soap and warm water, followed by some 
antiseptic solution, taking care not to for- 
get the finger-nails. 23 
2. During labor assist the eves to pass 
rapidly over the perineum. 
3. Always cleanse the eyes of the infant 
in the manner I have explained to you im- 
mediately after birth. 
4. I)o not use the same water, for bath- 
ing the face and eyes, with which the 
body has been bathed, and always use 
different sponges or pieces of flannel. 
5. Never employ one towel for two per- 
sons. Let everybody have his own. 
6. He careful not to allow any soap or 
bay rum to enter the eyes. 
?. Keep the light in the lying-in 
chamber very dim, or have it shaded with 
some dark material, green being the least 
trying and the most restful to the eyes. 
8. Always burn immediately everything 
that has come in contact with the ophthal- 
mic discharge. 
9. Instruct the laity, whenever the op- 
portunity presents itself, of the great 
danger of ocular affections of the new- 
born, and the necessity of consulting a 
physician as soon as they are discov- 
ered. 24 
And to the members of the profession 
present I would add: 
10. Always use the Crede, Hegar-Korlm 
or some such method of cleansing and 
stimulating the eyes of a new-horn infant.