Reprinted from 
Annals of Gynecology and Pediatry, 
January, 1892. 
Ophthalmia Neonatorum : Its Treatment and Prophylaxis. 
BY G. E. DE SCHWEINITZ, M/D., 
Professor of Ophthalmology in the Philadelphia Polyclinic; Ophthalmic 
Surgeon to the Philadelphia Hospital. 
A Lecture Delivered at the Philadelphia Polyclinic. Ophthalmia Neonatorum : Its Treatment and Prophylaxis. 
BY G. E. DE SCHWEIN-ITZ, M.D., 
Professor of Ophthalmology in the Philadelphia Polyclinic ; Ophthalmic 
Surgeon to the Philadelphia Hospital. 
A Lecture Delivered at the Philadelphia Polyclinic. 
This afternoon we will study puru- 
lent ophthalmia, as it occurs in the 
newly-born infant. 
This inflammation is characterized 
by great swelling of the lids, serous 
infiltration of the conjunctiva, and the 
free secretion of contagious pus. 
It is caused by the introduction 
into the eye of infecting material 
from some portion of the genito- 
urinary tract of the mother at the 
time of or shortly after birth. The 
majority of cases, and probably all 
severe forms, are due to the presence 
of the gonococcus of Neisser, very 
typical examples of which you will 
see in the slide placed under the mi- 
croscope. Exceptionally, inoculation 
appears to take place in utero; and 
Mules, in his excellent essay upon 
this topic, has attributed a high de- 
gree of penetrating power to the mi- 
cro-organism, based upon his examina- 
tion of a child, who was brought to 
him eight hours after delivery, ex- 
hibiting the symptoms of the second 
stage of the disease; hence infection 
in utero must have occurred at least 
two days before birth or rupture of 
the membranes. 
The gonococci are not always pres- 
ent. They are especially numerous 
during the purulent stage. On this 
account, two varieties of the disease 
have been described-one, a severe 
type, associated with the micro-organ- 
ism, and exhibiting a tendency to 
increase in severity and attack the 
cornea; and another, a milder type, 
non-specific, and with a tendency to 
recover. Do not forget that a viru- 
lent vaginal discharge in the mother 
is not necessary to produce this con- 
dition, as it probably may arise from 
the introduction of any muco-puru- 
lent discharge during birth. Infec- 
tion after birth may be caused by 
soiled towels or sponges, and some 
have supposed that contact with the 
lochial discharges may originate a 
form of the disorder. Inoculation of 
healthy lochia, however, by Andrews, 
Zweifel and others, has failed to pro- 
duce the disease. Inoculation is more 2 
G. E. DE SCHWEINITZ 
likely to occur in retarded labors and 
with face-presentations. Boys are 
said to be more frequently attacked 
than girls, and a curious relation be- 
tween the temperature and this dis- 
ease has been demonstrated by Em- 
mert, of Berne. In cold climates 
ophthalmia neonatorum is especially 
frequent in the summer months; in 
hot countries, m the spring and 
autumn. 
You will notice that the gonococci 
surround the nuclei within the living 
cell; later they penetrate the epithe- 
lium and enter the lymph spaces. 
The shape of the micro-organism is 
not peculiar to the gonococcus of 
purulent ophthalmia, because diplo- 
cocci of exactly the same appearance 
are seen under other circumstances; 
but the arrangement of the gonococci 
within the protoplasm of the cells 'is 
characteristic of this species of micro- 
organism. You have observed how 
easy a matter it is to stain and de- 
monstrate them. I would earnestly 
advise you in all cases of purulent se- 
cretion from the conjunctiva to make 
this examination. In ophthalmia ne- 
onatorum it furnishes an important 
prognostic guide. 
Ophthalmia neonatorum usually be. 
gins on the third day after birth, but 
it may set in from twelve to forty- 
eight hours after inoculation. The 
variety which results as a secondary 
infection from soiled fingers, or 
sponges, or cloths, arises at a much 
later date. Almost always both eyes 
suffer, one being earlier and more 
decidedly affected than its fellow. 
Systematic writers divide the dis- 
ease into four stages-the stage of 
incubation, the stage of lymph forma- 
tion, the purulent stage, and the stage 
of recession. But in a typical case 
these grades shade into each other so 
easily that it is hard to distinguish 
them. 
In brief, the following are the chief 
characteristics of this very important 
disease : slight redness of the con- 
junctiva, with a trifling discharge in 
the corners of the eyes rapidly gives 
place to a great cushion-like swelling 
of the lids, with chemosis of the con- 
junctiva, severe pain and discharge. 
The surface of the swollen lid is 
dusky red and tense; the discharge, 
which in the beginning is slightly 
turbid, soon changes to a greenish- 
yellow pus, which is secreted in great 
quantities. During the first day or 
two the conjunctiva is swollen and 
velvety, and easily detached flakes of 
lymph are found upon its surface; 
later it becomes rougher, dark-red in 
color, and spots of 'ecchymosis ap- 
pear. The chemosis of the ocular 
conjunctiva forms a hard rim around 
the cornea, and at the bottom of the 
crater-like pit thus produced this struc- 
ture is visible. The thick, cream-like 
discharge increases, and either flows 
out from beneath the overhanging lid 
or is backed up in the conjunctival 
cul-de-sac. Gradually the disease de- 
clines, the lids lose their tense char- 
acter, the conjunctiva is puckered 
into folds, the discharge becomes ad- 
mixed with blood and serum, and 
ceases in from six to eight weeks. 
The chief danger is destructive ul- 
ceration of the cornea'. This danger 
is especially prone to occur if, during 
the first day or two of the disease, 
the membrane is lustreless and hazy. 
Small, oval ulcers may form near the 
limbus, which soon are surrounded by 
an area of infiltration, and rapidly in- 
crease in size, or larger lesions develop 
directly in the centre of the corneal OPHTHALMIA NEONATORUM. 
3 
tissue. If the disease is not checked, 
the ulcer will perforate, and all of the 
complications attending this disaster 
become manifest-evacuation of the 
aqueous, incarceration of the iris in 
the wound, the formation of an adhe- 
rent leucoma or scar in the cornea, 
which, unable to resist the intraocular 
tension, bulges forward and forms, 
according to its original size, either a 
partial or total staphyloma. Finally, 
perforation may be followed by in- 
flammatory involvement of the ciliary 
body and choroid, and rapid destruc- 
tion of the eye through panophthal- 
mitis. 
Do not forget that a dense opacity 
sometimes appears in the cornea 
during convalescence. It may arise 
with great suddenness, and, when it 
occurs in the lower half of the cornea, 
a deep indentation from the pressure 
of the margin of the lid is likely to 
occur. It is quite possible that oph- 
thalmia neonatorum will not follow 
the course just described, and some- 
times this name is given to very mild 
types of conjunctivitis, which occur in 
the newly-born, and which have no 
such destructive tendencies. Do not 
allow yourselves, however, ever to be 
led into a false sense of security 
when you find pus or muco-pus in the 
eyes of a newly-born child. It may in- 
dicate a mild, non-specific type, but it 
may be the beginning of disease, 
which, if improperly or inadequately 
treated, will forever mar the sight of 
the patient. 
I will not attempt this afternoon 
to give a description of the various 
methods of treatment which have 
been pursued in this disease, but will 
briefly describe the procedure which 
has proved efficacious in my own 
hands, especially in the wards of the 
Philadelphia Hospital. This deals 
with three conditions : the inflamma- 
tory swelling of the lids, the state of 
the conjunctiva, and the corneal com- 
plications. 
During the earlier stages, when the 
lids are tense and the secretion has not 
the creamy character which it later 
assumes, in addition to absolute clean- 
liness, the 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 are 
as frequently changed as may be need- 
ful to keep up a uniform cold im- 
pression. This is far preferable to 
the use of small bladders containing 
crushed ice. The length of time oc- 
cupied with these cold applications 
must vary according to the severity 
of the case. Sometimes they may be 
almost continuously used, and some- 
times frequently for periods of half 
an hour. Later on, when corneal 
complications exist, hot fomentations 
are better than cold. These are em- 
ployed in like manner with squares 
of antiseptic gauze wrung out in car- 
bolized water at a temperature of 
120° F., and frequently changed. 
See that the discharge is constantly 
removed. Gently separate the lids, 
wipe away the tenacious secretion 
with bits of moistened lint or absorb- 
ent cotton, and irrigate the conjunc- 
tival sac freely with an antiseptic 
solution. For this purpose a solution 
of boracic acid, or one of corrosive 
sublimate, a grain to the pint, may be 
employed. You will frequently see it 
stated that boracic acid is so feeble an 
antiseptic that it is valueless for the 
purpose that I have just stated; more- 
over, it is practically without germi- 4 
G. E. DE SCHWEINITZ. 
cidal power. That it is a feeble anti- 
septic is perfectly true, but you must 
remember that its purpose in the 
present instance is to act as a slight 
astringent and a cleansing agent. 
You cannot kill the gonococci that 
have penetrated within the cells with 
a solution; at least, you cannot use 
a solution of sufficient germicidal 
strength that will not at the same 
time be deleterious to the cornea. 
Although bichloride of mercury is 
constantly employed, and, although 
I always employ it myself, it is by no 
means certain that, as it is ordinarily 
used, it has any pronounced germicidal 
value in this disease, because it has 
been shown that bacteria, in the pres- 
ence of albumin, have the power to re- 
duce it to calomel. I have found it very 
useful to use both boracic acid and bi- 
chloride of mercury alternately every 
half hour or every hour, according to 
the amount of secretion. Let the ir- 
rigation be kept up day and night if 
necessary; only be sure that you keep 
the surfaces as clean as possible. 
Many other drugs have been used : 
alum, sulphate of zinc, weak solutions 
of nitrate of silver, creolin, perman- 
ganate of potash, aqua chlorini, per- 
oxide of hydrogen and pyoktanin. 
Do not use pyoktanin. In spite of 
the high reputation of its patron 
saint, it is valueless, in my judgment, 
in this disease. My colleague, Dr. 
Gould, and myself have demonstrated 
this to dur satisfaction in the Phila- 
delphia Hospital. 
The application of nitrate of silver 
at the proper stage is, perhaps, the 
most important procedure. It must 
not be used early, before free dis- 
charge 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 is 
covered with a gray film or false mem- 
brane. When the secretion is free 
and creamy, when the lids are relaxed, 
when the conjunctiva is dark-red and 
puckered into folds, the time for its 
application has come. Once a day 
carefully evert the lids, free the con- 
junctiva from all adherent secretion, 
and brush it over carefully with a 
solution of nitrate of silver, 10-20 
grains to the ounce. In severe cases 
it may be necessary to use the miti- 
gated stick, care being taken to neu- 
tralize the excess with common salt: 
As long as the discharge is abundant, 
the use of this caustic is indicated. 
It has a double action, viz., that of a 
germicide and that of an astringent. 
Unlike bichloride of mercury, its 
germicidal value is potent, because it 
destroys the superficial layer of epi- 
thelial cells and probably many of the 
contained micrococci. 
At the first appearance of corneal 
haze, a solution of atropine, four 
grains to the ounce, may be dropped 
into the eye two or three times a day. 
If the ulcer is marginal and if danger 
of perforation is imminent, or if there 
is a very distinct sloughing in the 
cornea and the iris is uninflamed, 
eserine is the better drug. This 
may be used in a strength from a 
quarter to a half grain to the ounce, 
and, as it is somewhat irritating to the 
ciliary body, there is no objection to 
using atropine at night. The former 
drug may be employed four or five 
times a day, and the latter once or 
twice in the evening. 
The attendants of a case should be 
impressed with the responsibility 
which devolves upon them. The con- 
tagious nature of the pus should be 
explained to them, and they should OPHTHALMIA NEONATORUM. 
5 
take great care to destroy all rags, 
cotton, etc., which have been used in 
the treatment of the disease. It is 
said that Stellwag was wont to declare 
that he never lost a case of acute 
blennorrhoea of the conjunctiva if he 
was assisted by an old and tried nurse, 
but that if it was necessary to change 
nurses disaster was sure to result. 
And now a word or two in regard 
to its prophylaxis. 
According to the Report of the 
Royal Commission of the Blind, the 
statistics of Professor Magnus, of 
Breslau, demonstrated that 71.99 per 
cent, of all who become blind during 
the first year of life are rendered 
sightless by purulent ophthalmia. In 
other words, he has shown that of 
every 10,000 children under five years 
of a'ge, 428 are blinded by this type of 
conjunctivitis. The proportion of 
blind from this cause in the asylums 
of Switzerland is 26 per cent.; in Spain 
and Belgium, about 12 per cent.; and 
in the United Kingdom, 30 per cent, 
of the inmates of institutions and 
7,000 persons have lost their sight 
from the same disease. Riviere, of 
Bordeaux, forcibly exclaims that puru- 
lent ophthalmia alone is responsible 
for nearly one-third of the cases of 
blindness, and has placed in the care 
of Europe well-nigh 100,000 victims. 
More than 32 per cent, of blind in our 
own country own their affliction to 
ophthalmia neonatorum ; and Howe, 
of Buffalo, in a collection of 8,574 
cases of labpr conducted without pre- 
ventive methods, found 8.66 per cent, 
of blennorrhoeas. 
In the face of these facts, the 
measures to prevent ophthalmia neo- 
natorum rank in importance with 
those employed against smallpox and 
tuberculosis, and demand the as- 
siduous practice of means which ex- 
perience has taught to be effective. 
The day should not be far distant 
when stringent legislative regulations 
will be in force militating against this 
appalling cause of blindness. 
The following words, quoted from 
the Report of the Committee on the 
Causes and Prevention of Blindness 
of the American Ophthalmological 
Society, are of great importance : 
" The fact that nurses and midwives 
in most States have a very irrespon- 
sible position which enables them to 
do much harm-the fact that a very 
little neglect or delay with this class 
of cases often results most disas- 
trously to the patient, and the fact 
that the duty of nurses in this respect 
in foreign countries has already been 
established, and at least by one State 
in the Union-inspires the hope that 
creditable reformation may take place 
in other parts of our own land." 
And, again, " Finally, the Committee 
would strongly recommend in the 
medical colleges throughout the 
country that more attention be given 
by the faculties to the course of 
ophthalmology, making it as long and 
thorough as the requirements of other 
branches will admit." 
In the absence of distinct govern- 
mental interference, it is the evident 
duty of physicians, nurses and direc- 
tors of public charities to instil among 
the poorer classes a knowledge of the 
dangers of the disease and the neces- 
sity for prompt treatment. 
It would be very interesting to trace 
from the beginning the first methods 
of prophylaxis which were employed, 
but time will not permit. Crede, of 
Leipsic, deserves the credit of having 
secured, by the use of nitrate of silver, 
a rational preventive treatment. His G. E. DE SCHWEINITZ. 
6 
method, as you know, consists of the 
instillation of two drops of a two per 
cent, solution of nitrate of silver in 
the eyes of the newly-born child, 
which, as soon as it is expelled from 
the maternal passages, and before the 
cord is cut, is placed upon its back in 
the bed, the eyelids parted, and the 
drug introduced. This in some in- 
stances is repeated on the second day. 
In the meantime, small compresses 
soaked in a solution of salicylic acid 
are laid upon the closed lids. 
Previous to the nitrate of silver 
treatment, 10.7 per cent, of ophthal- 
mias occurred ; after the introduction 
of the method among 1,160 cases of 
labor, the percentage of ophthalmia 
fell to 0.31. 
Very many other methods besides 
Crede's have been tried, and obstetri- 
cians like Kaltenbach have advocated 
that no local application be made to 
the eyes other than that of distilled 
water, but that during the labor per- 
sistent vaginal douches of bichloride 
of mercury be employed ; and Korn 
also concludes that painstaking clean- 
liness during birth and also in child- 
bed will reduce the possibility of this 
disease to a minimum. 
The method of Hegar-Kohrn has 
been largely advocated, which consists 
in employing Van Swieten's liquid 
(corrosive sublimate, 1 part, alcohol, 
100 parts, water, 900 parts) in order 
to cleanse the eyes of the newly-born 
child, as well as all of the surrounding 
areas-the root of the nose, the mar- 
gins of the lids and eyebrows. It is 
true that the instillation of the silver 
solution sometimes causes hyperaemia 
of the conjunctiva, but this usually 
disappears in a day or two. Very 
occasionally severe haemorrhage has 
followed its instillation. Pomeroy 
and myself have reported instances 
of this character. These, however, 
are insignificant complications com- 
pared with the vast benefit which this 
preventive treatment entails. Schmidt- 
Rimpler believes that aqua chlorini, 
which is unirritating, is quite as effi- 
cacious as the nitrate of silver. It 
matters little, perhaps, in the pre- 
ventive treatment what remedy is 
employed : nitrate of silver, bichloride 
of mercury, aqua chlorini, or scrupul- 
ous antisepsis during labor; but cer- 
tainly one or other of these should be 
used. If in spite of it, or because 
of lack of it, within twelve hours 
after birth, a little redness of the eyes 
begins to develop and a slight secre- 
tion gathers in the corners, do not 
permit the surrounding attendants to 
deceive you with the belief that this 
is a "cold in the eye," or a natural 
consequence of the change in the 
baby's environment. Do not allow 
the good old nurse, who now, happily, 
is being relegated to the background, 
to wash the eye with milk because she 
has washed the eyes of babies during 
forty years of experience with the 
same collyrium. Remember, this may 
be the incipient stage of a destructive 
inflammation which will destroy the 
baby's eyesight if it is not properly 
treated, and which ought to destroy 
forever your peace of itiind if you 
permit yourselves to neglect the warn- 
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