ophthalmia neonatorum extends from the very beginning to the end of life.

Ophthalmia neonatorum is a purulent conjunctivitis of a new-born child. Its common cause is the inoculation into the eyes of the child at the time of birth, of some pathologic discharge from the mother's vagina. This vaginal discharge may be squeezed into the child's eyes during the passage of the head through the parturient canal; or being smeared upon the lids may, after the head is delivered and the eyes open, find its way into the conjunctival sac. In a small per cent. of cases the inoculation takes place as late as four to six days after delivery, and is then due to infection brought from the mother by means of soiled. sponges, towels, bowls, or fingers.

The vaginal discharge causing this disease is always a pathologic one, for a normal secretion does not cause the disease. The discharge is either gonorrheal or leucorrheal. Thus we have ophthalmia neonatorum divided into two types, or grades of severity; first, that due to gonorrhea, or the gonococcus of Neisser, being the severe form, and closely resembling gonorrheal ophthalmia in the adult; and secondly, the leucorrheal, or milder type. The majority of cases of ophthalmia neonatorum are due to gonorrhea in the mother, and it is safe to assume this to be true in every case until microscopic or other evidence has proven the contrary.

A study of the bacteriology of this disease brings out the interesting fact that quite a variety of germs are found to cause it. In all gonorrheal cases we have the gonococcus of Neisser, and finding these in the discharge establishes the gonorrheal nature of the disease. In non-gonorrheal cases the discharge may contain the Koch-Weeks bacillus, the staphylococcus, the streptococcus, the pneumococcus, or the Klebs-Loeffler bacillus. Ball states that in St. Louis a number of cases were found to be due to the bacillus coli communis. I know of no clinical proof of the statements often made by the laity that the disease is caused by bright light, or bathing the eyes with soap. Such theories are harmless and satisfy the laity, but the physician should not be deceived by them.

The period of incubation is about three days, so that the dis.ease usually develops on the third day after birth. Occasionally the development occurs as late as the sixth or seventh day. It is then due to infection occurring some days after birth. In rare cases the child is born with the disease already developed, the infection of the eyes having been ante-partum, and due to the rupture of the membranes some days before labor, or to a very slow labor.

Usually both eyes are involved from the start, but in those rare cases where only one is diseased I have found it impossible to prevent the infection of the other, the use of Buller's shield or other mechanical prophylaxis, so useful in the adult, not being practical in the case of an infant.

The usual symptoms of acute purulent conjunctivitis, such as swelling of the lids, redness of their margins, redness and swelling of the conjunctiva, the profuse purulent discharge, the restlessness, feverishness, and evident suffering of the child, will not be dwelt upon. The one great danger of ophthalmia neonatorum, as of every other purulent conjunctivitis, is ulceration, or sloughing of the cornea, resulting in its partial or complete destruction, with the consequent impairment or total loss of vision. This danger to the cornea is the greater the earlier in the disease the cornea becomes involved, and the lower the vitality of the child.

The diagnosis of ophthalmia neonatorum in a general way is so easy that an error need seldom or never occur. We have a new-born child, with an inflammation of its conjunctiva, and a discharge of pus from its eyes. So far, however, the diagnosis is only half made. The question now arises, "Is it a gonorrheal or a non-gonorrheal conjunctivitis with which we have to deal?" The answer to this question is important both as to prognosis and treatment. If it is gonorrheal, it will be more severe, more dangerous, more prolonged, the prognosis less favorable, and the treatment more heroic. If it is non-gonorrheal or leucorrheal, it will be less severe, of shorter duration, and of more favorable prognosis.

In settling the exact nature of the ophthalmia, a knowledge

of the mother's condition, as to whether she has or has not gonorrhea, is important, and in the absence of a microscopic examination is the most reliable evidence we have. To ascertain the condition of the mother, while usually easy, is at times a difficult or delicate matter. The easy, direct, and accurate way to settle this question is by a microscopic examination of the discharge from the child's eyes for the gonococcus of Neisser. Finding this establishes the gonorrheal nature of the disease, while its absence proves it to be non-gonorrheal.

The prognosis of this disease depends upon a variety of circumstances. When seen before the cornea becomes involved, and with an environment favorable for intelligent management, the prognosis is good. I formerly believed and taught that with correct treatment every case could be cured, and vision saved entire. But one case seen several years ago, and treated by me in the most conscientious manner, and which resulted in the loss of about half of each cornea, taught me that some cases, even under the most orthodox treatment, will, by virtue of their very virulent nature, result badly. Fortunately, these failures need only be very rare, and the above is the only one which I can recall in my practice. But any involvement of the cornea renders the prognosis grave, and the more so the earlier in the disease the corneal trouble occurs. Low vitality of the child is unfavorable, as under such circumstances the cornea may slough entire. Another condition which bodes evil is a degree of ignorance, apathy, or poverty on the part of the family, which renders effective treatment difficult or impossible.

The most important point about this disease is its prophylaxis. Since it is caused by the vaginal discharge getting into the child's eyes, its prophylaxis consists in either keeping the discharge from getting into the eyes, or, if it has entered, of washing it out, and disinfecting the conjunctival sac with a 2-per-cent solution of nitrate of silver. When a physician is called upon to take charge of a pregnant woman, he should not only ascertain the condition of her general health, kidneys, etc., but among other things should learn whether there is a pathologic vaginal discharge, and if it is present, he should adopt suitable means

of irrigation or medication for its arrest, so when the child is born there may be no discharge to infect its eyes. Especially should this irrigation be energetic during the first stage of labor, and combined, if need be, with the use of the speculum and cotton mops to remove all pus from the vaginal folds.

In all suspected cases, immediately upon the delivery of the child and tying the cord, Crede's prophylactic treatment should be carried out. This consists of washing the child's eyes, and irrigating the conjunctival sac to flush out the pus, and next dropping into each eye a 2-per-cent. solution of nitrate of silver, which by its germicidal property destroys any germ remaining. Crede's prophylaxis is successful with almost absolute certainty. When faithfully carried out, it will seldom fail, even when the mother has a gonorrheal vaginitis. But while Crede's method is generally understood, and its success generally admitted, yet there seems to be confusion in the minds of some as to when and in what cases it is to be used.

It is now generally used as a routine practice in all lying-in establishments. It should, of course, be used in every case where a morbid vaginal discharge, whether gonorrheal or leucorrheal, is known or even believed to be present. And it should be used in every case where there are grave suspicions or doubts. On the other hand, in private practice where the mother's condition is known to be healthy, it may be omitted. But even in these cases the eyes and surrounding skin should be washed, and the conjunctival sac irrigated before the general bath is given.

I would urge upon all those doing obstetrical work the importance of always having a bowl of sterile water and cotton sponges ready before the completion of labor, with the same regularity that they provide a ligature for the cord; that the eyes of every child be immediately cleansed and irrigated; and in addition, in all suspected cases, a few drops of the solution of nitrate of silver be instilled; that this be done by the physician himself; and that under no circumstances should the water in which the child is later given its general bath be allowed to come in contact with its eyes.

When the disease has once developed, its treatment involves

the use of three remedies, viz., cleanliness, cold, and nitrate of silver. By cleanliness I mean hourly irrigations of the conjunctival sac to remove all pus. The fluid used may be sterile water, salt solution, or boric acid solution. The composition of the fluid is of much less importance than the thoroughness with which it is used.

Cold is best applied by having small pieces of soft domestic one inch square. These are plastered over a block of ice contained in a bowl placed near the crib. These little squares of domestic are removed from the ice to the eye, where they remain only one or two minutes, and are then replaced by other squares, being themselves returned to the ice. This cold can be used interruptedly, as each alternate hour, or each alternate two hours. Cold is especially indicated in the earlier stages of the treatment, and its virtue consists in making the child more comfortable, and in lessening the severity and danger of the disease.

The solution of nitrate of silver should consist of six or eight grains to the ounce of water, and should be applied once a day, not by the nurse, but by the physician, who should evert the lids, and, after removing all pus, mop the silver solution upon the tarsal conjunctiva. Dropping solutions of silver into the eyes in the treatment of this disease I regard as pernicious, as it destroys and removes the protecting epithelial covering of the cornea, and so favors its infection and destruction. Nitrate of silver is the remedy, and I regard with much less favor the various so-called astringents, as sulphate of zinc, tannic acid, boracic acid, etc., which are in mild cases useless and in severe ones a disappointment. Leeches, blisters, and canthotomy have no place in the treatment of this disease. If corneal ulceration occurs, the pupil should be kept dilated with a weak solution of atropine.

To correctly treat a case of ophthalmia neonatorum, two nurses, one for day and one for night, are needed, and should always be provided. Intelligent and faithful nursing counts for much in this disease, and should be not only insisted upon, but demanded. Nurses and other attendants should be warned of