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 Further Studies of the Cycloplegic 
 Value of Homatropine Plus Cocaine 
 Discs as Atropine, Duboisine and 
 Hyoscine Substitutes. 
 
 BY 
 
 CASEY A. WOOD, CM., M.D., 
 
 OPHTHALMIC SUROBOMALBXI AN HOSPITAL ; OCDT.IST 
 
 AND AT7RI8T COOK COUNTY HOSPITAL AND TO TBB 
 
 BMBK.OENCY HOSPITAL, CHICAGO; PROPBSSOB. 
 
 OPHTHALMOLOGY, CHTCAOO P08T-ORAD- 
 
 UATB MBDICAL SCHOOL. 
 
 [Head before the Section of Ophthalmology, Pan- 
 American Medical Congress, Washington, D. C, 7^9J.] 
 
 3T 
 
 ■ / 
 
 DR.CM^-Y /•,'ii'OOD, ' 
 10 <i :^ > ' vf-. St., 
 
\ 
 
 ■ ^ -ki-. Biinpii iijpi nil t.\ 
 
35" 
 
 T 
 
 Kurther Studies of tlhe Cycloplegic Value 
 of Homatropine F'L'TJS Cocaine Discs 
 as Atropine, Duboisine and Hyoscine 
 Substitutes. 
 
 n 
 
 BY CASEY A. WOOD, CM., M.D., 
 
 OPHTHALMIC SURGEON ALEXIAN HOSPITAL; OCULIST AND AURIST, COOK COUNTY 
 
 HOSPITAL AND TO THE EMERGENCY HOSPITAL, CHICAGO; PROFESSOR OF 
 
 OPHTHALMOLOGY, CHICAGO POST-GRADUATE MEDICAL SCHOOL. 
 
 [Read before the Section of Ophtiialmology, Pan-American Medical 
 Congress, Washington, D. C, 1893. 
 
3t) 
 
 FURTHER STUDIES OF THE CYCLOPLEGIC VALUF 
 OF HOMATROPINE PLUS COCAINE DISCS 
 AS ATROPINE, DUBOISINE AND HYOSCINE 
 SUBSTITUTES. 
 
 BY CASEY A. WOOD, CM., M.D., 
 
 OPHTHALMIC SURGEON ALEXIAN HOSPITAL ; OCULIST AND ADRIST COOK COUNTY 
 
 HOSPITAL AND TO THE EMERGENCY HOSPITAL, CHICAGO ; PROFESSOR OK 
 
 OPHTHALMOLOGY, CHICAGO POST-GRADUATE MEDICAL SCHOOL. 
 
 [Read before the Section of Ophthalmology, Pan-American Medical Congress, 
 
 Washington. D. C, 1893.I 
 
 
 
 NearIvY three years ago, in an article contributed to the American 
 Journal of Ophthalmology^ I gave the results of some experiments I had 
 made with mixtures of Homatropine ^/«J Cocaine, and with solutions of 
 Atropia and Duboisine for the purpose of comparing their relative merits 
 as Cycloplegics. The conclusions I then arrived at were these : 
 
 1. In the shape of watery solutions probably less than ten per cent, 
 of the dissolved alkaloid becomes absorbed in such a way as to affect the 
 eye, the remaining ninety per cent, or more being carried off into the 
 nasal duct or flowing over the cheek with the tears. 
 
 2. Mixtures prepared with Vaseline, Cosmoline, Sanitas Jelly, I^an- 
 oline and similar menstrua or, as in Lang and Barrett's* experiments, 
 Castor Oil, are much longer retained in the conjunctival sac. The drugs 
 thus longer kept in contact with the ocular and palpebral surfaces 
 undergo, as Green suggests, a much more extensive absorption and pro- 
 duce a still more pronounced effect. 
 
 3. They are absorbed by the blood vessels and other absorbents of the 
 cornea and conjunctiva and not by those of the nose and throat. But 
 such oily and greasy mixtures have this serious drawback : they leave a 
 thin film upon the corneal surface which interferes with the examination 
 of the eye especially when one wishes to determine its refractive condition. 
 
 * I<ANG AND Barrett : The action of Myotics and Mydriatics. Oph. 
 Reports, vol. xi., pp. 130 and 219. 
 
 Hos. 
 
31 
 
 J .' 
 
 TY 
 
 4. The form of gelatine lamellae or discs appears to be the most use- 
 ful one in which to apply agents to the eye for the purpose of securing 
 their fullest mydriatic and cycloplcgic action. These undergo a slow, 
 regiilar and complete absorption when put into the conjunctival sac. 
 
 5. The addition of Cocaine to almost all the alkaloids used in ophthal- 
 mic practice undoubtedly increases tlieir peculiar effects. (See also 
 the reports of Maklakoff* and the experiments of Lang and Barrett 
 aforementioned. ) 
 
 6. From the foregoing results and after much experimentation on the 
 subject, I concluded that the most decided cycloplegic effects of Homa- 
 tropine are obtainable from its employment in the gelatine disc form, 
 associated with Cocaine. 
 
 In their most convenient and stable shape these discs cannot be made 
 to hold more than gr. 1/25 of these alkaloids ; hence I was necessarily 
 restricted to the use of gr. 1/50 each of Merck's Homatropine and Cocaine. 
 
 Since the publication of my original paper I have not lost sight of 
 the purpose I then had in view, viz : the attempt to find some cyclo- 
 plegic less objectionable than Atropine for the measuring of refractive 
 errors. I happen to be a firm believer in the doctrine that it is necessary 
 to know the absolute refractive condition before one can intelligently 
 prescribe glasses, and I further believe that it is requisite to paralyze 
 the accommodation as the best means of obtaining that information in 
 the majority of patients under, and is some instances over, forty years 
 of age. 
 
 For the past year I have been engaged in this line with tlie gelatine 
 discs aforesaid, with discs containing gr. 1/25 of Homatropine alone, 
 and with various solutions in water of Tropa-cocaine, Homatropine plus 
 Cocaine, Duboisine Sulphate, Atropine Sulphate, Hyoscin Hydrobromate 
 and Hyoscyamin Sulphate. 
 
 Without troubling you with details I may say, briefly, that for the 
 determination of the refractive condition and with the idea of making the 
 conditions of the comparative test as constant as possible I chose those 
 patients in whom I could employ a number of agents at proper intervals 
 and whose refractive state would be most likely to afford reliable tests. 
 These were put under the influence of the particular cycloplegic and their 
 refractive state determined by skiascopy. Every case was carefully 
 worked out by my assistant. Dr. T. A. Woodruff, who is an expert 
 skiascopist. 
 
 *Sajou's Annual, vol. iv., p. 157, 1889. 
 
 3 
 
3% 
 
 Sometimes one agent wns used first, sometimes another, but in every 
 instance the effect of the previous cycloplegic was allowed to pass off 
 before the second was employed. Using all possible care to avoid sources 
 of error, the refraction of thirty-four selected eyes, furnishing sixty-eight 
 principle meridia was tlius detenniued. The results I have here drawn 
 up in chart form : 
 
 
 Atropia. 
 
 llyoicln. 
 
 II.&C. Disci 
 
 
 Atropia. 
 
 Ilynscin. 
 
 11. *C. Dies, 
 
 I. 
 
 +3. 
 
 -13-25 
 
 -t-3. 
 
 35. 
 
 4-5. 
 
 1 4.50 
 
 4-5. 
 
 2. 
 
 + 1-75 
 
 + 1-75 
 
 +1.75 
 
 36. 
 
 t 6.50 
 
 4-6.50 
 
 46.50 
 
 3- 
 
 +2.75 
 
 42.50 
 
 4 2.50 
 
 37. 
 
 15. 
 
 +S' 
 
 4-5. 
 
 4- 
 
 +1.50 
 
 4 1-50 
 
 4 1.50 
 
 38. 
 
 +6. 
 
 4-550 
 
 4-6. 
 
 5- 
 
 +0.75 
 
 -i 0.50 
 
 I 0.50 
 
 39- 
 
 4-5. 
 
 
 44.50 
 
 6. 
 
 +4. 
 
 +4-25 
 
 +4. 
 
 40. 
 
 4 8. 
 
 
 +8. 
 
 7- 
 
 +2.25 
 
 + 2.25 
 
 +2. 
 
 41. 
 
 4450 
 
 
 4-4. 
 
 8. 
 
 +3-25 
 
 +3-50 
 
 43-25 
 
 42. 
 
 4-6. 
 
 
 46. 
 
 9- 
 
 + 1.25 
 
 4- 1.75 
 
 4 1.55 
 
 43. 
 
 4-8. 
 
 
 4-8. 
 
 ID. 
 
 + 2.50 
 
 +2.75 
 
 + -1 2.75 
 
 44. 
 
 4-9- 
 
 
 4-9- 
 
 II. 
 
 +1.50 
 
 +1.50 
 
 -f 1.50 
 
 45- 
 
 4-10. 
 
 
 -f9-50 
 
 12. 
 
 +2.75 
 
 +3. 
 
 4 2.75 
 
 46. 
 
 + 11. 
 
 
 4-10.50 
 
 13- 
 
 +2.75 
 
 
 4-2.50 
 
 47. 
 
 4-1.25 
 
 
 4-1.25 
 
 14. 
 
 +2.75 
 
 
 +2.50 
 
 48. 
 
 4-1.50 
 
 
 4-1.50 
 
 15. 
 
 +2.75 
 
 
 +2.50 
 
 49. 
 
 4-2. 
 
 
 + 1.75 
 
 16. 
 
 +2.75 
 
 
 4-3. 
 
 50. 
 
 4-2.25 
 
 
 4-2.25 
 
 17- 
 
 +5. 
 
 +5.50 
 
 4-5- 
 
 51- 
 
 4-2.25 
 
 
 4-2.25 
 
 18. 
 
 +5. 
 
 +6. 
 
 4-5-50 
 
 52. 
 
 4-2.25 
 
 
 -f2.25 
 
 19. 
 
 +6.25 
 
 +5.50 
 
 4-6. 
 
 53- 
 
 4-7. 
 
 
 4-7. 
 
 20. 
 
 +7. 
 
 +7. 
 
 4-6.50 
 
 54. 
 
 4-II. 
 
 
 -fll. 
 
 21. 
 
 + 1.75 
 
 
 4-1.25 
 
 55- 
 
 4-6.50 
 
 
 4-6.50 
 
 22. 
 
 + 1.25 
 
 
 4-1.25 
 
 56. 
 
 4- 10. 
 
 
 -f9-5o 
 
 23- 
 
 + 1.50 
 
 
 4-1.25 
 
 57- 
 
 4-3.25 
 
 
 4-3. 
 
 24. 
 
 + I-7S 
 
 
 4-1.50 
 
 58. 
 
 -f3. 
 
 
 4-3. 
 
 25. 
 
 +3.75 
 
 +3-75 
 
 4-3-75 
 
 59. 
 
 43.25 
 
 
 4-3.25 
 
 26. 
 
 +5-50 
 
 +5. 
 
 -K5-50 
 
 60. 
 
 4-3. 
 
 
 4-3. 
 
 27. 
 
 +2.50 
 
 +2.75 
 
 +2.50 
 
 61. 
 
 4 1.50 
 
 
 4-1.50 
 
 28. 
 
 +3-50 
 
 +3-25 
 
 4-3-50 
 
 62. 
 
 4-3.50 
 
 
 4-3.50 
 
 29. 
 
 +6.50 
 
 +7. 
 
 +6.25 
 
 63. 
 
 4-3.75 
 
 
 +3-75 
 
 30. 
 
 +6.50 
 
 +7. 
 
 +6.50 
 
 64. 
 
 4-2. 
 
 
 +2. 
 
 31- 
 
 +2.25 
 
 
 +2. 
 
 65. 
 
 — I. 
 
 — I. 
 
 — I. 
 
 32. 
 
 +2. 
 
 
 4-1.50 
 
 66. 
 
 4-1.25 
 
 4-1.25 
 
 + 0.50 
 
 33- 
 
 + 1.50 
 
 
 4-1.50 
 
 67. 
 
 4-4.50 
 
 4-4.- 
 
 +4.50 
 
 34- 
 
 +1.50 
 
 
 4-1.50 
 
 68. 
 
 -f5.5o 
 
 4-5.50 
 
 +3-75 
 
 In these observations (166 in all), two drops of a one per cent, solution 
 of Atropia Sulphate were dropped into each eye three times daily after 
 meals for two days, and tlie examination made in from one to three hours 
 after the last instillation. Of the Hyoscin and Hyoscyamin two drops of 
 
 4 
 
 '*. 
 
 fi/ 
 
 '1 
 
1 
 
 A 
 
 a four grain solution were instilled into each eye three times, at intervals 
 of twenty minutes, and the examination made in from one to two hours 
 after the last dose. 
 
 The discs were employed as hereafter described. Every precaution 
 was taken to prevent poisoning by the Hyoscin and Hyoscyamin. 
 
 Atropia, Hyoscin and the discs were used for the examination of the 
 same meridia in thirty instances. In sixteen of these the refraction was 
 exactly the same, or the highest differed from the lowest not more than 
 0.25 D. In ten instances the difterence was 0.50 D. In only two instances 
 out of the thirty was there a greater tlifference than 0.50 D., a case to be 
 afterwards referred to. 
 
 In these thirty cases Atropia showed the highest refraction, or was 
 one of the highest in nineteen instances ; Hyoscin in twenty-two instances 
 and Homatropine and Cocaine discs in fifteen instances. 
 
 Coming now to the tests of Atropia and Homatropine plus Cocaine 
 discs we found that they were the same or did not vary more than 0.25 in 
 fifly-eight out of sixty-eight meridia. In the remaining ten the result 
 varied -f 0.50 in eight cases, and in two instances there was a radical dif- 
 ference, to be again referred to. Speaking generally Atropia showed a 
 higher refractive condition than the discs in twenty-one out of sixty-eight 
 cases, while the discs showed an increased refraction over Atropia in four 
 instances. In a single instance of mixed astigmatism, before referred to, 
 did the refraction of two principal meridia amount to more than -f-0.50, 
 viz : 0.75 D. and 1.75 D. greater in the case of Atropia than that shown by 
 the discs. In this case the discs were first used. That this may happen 
 in a second trial of any cycloplegic (in relieving a spasm of the accommo- 
 dation) is well known. I have recently had a case, which well illustrates 
 this fact, where a second trial with Atropia revealed a much greater 
 difference. 
 
 A boy, aged 16, with V. = % — and marked astigmatism in each eye, 
 
 was atropinized in the usual way with a one per cent. solutir>u and the 
 
 skiascopy result was : 
 
 +2-75 +3-50 
 +2-50 +3-25- 
 
 A week later he was found to have, with full correction, 9/6 nearly in 
 
 either eye. My suspicion being aroused by this early acceptance of his 
 
 glasses, I again atropinzed his eyes and the result was : 
 
 +4. +4.75 
 
 +4.50 +5-25 
 i. e. an advance of between 1.25 D. and 2. D. in the four meridia Ten days 
 
 5 
 
HO 
 
 afterwards he obtained vision 6/6 — in either eye. A montli afterwards liis 
 vision in each eye was 6/6 | with all symptoms relieved. 
 
 As a result of these and other experiments I have reached tlic follow- 
 ing conclusions, some of which are mo<lifications of the propositions con- 
 tained in niy first article: 
 
 I. If two gelatine discs containing gr. 1/50 each of Ilonrntropine^/wj 
 Cocaine be placed in the conjunctival sac at an interval of twenty minutes, 
 l/ie eye being all the while kept closed, the ciliary muscle will in most 
 instances be found to be fully paralyzed in from seventy to one hundred 
 minutes after the introduction of the first disc. 
 
 a. In persons imdcr twenty-five years of age, or whenever ciliary 
 spasm is suspected, the best results are obtained by the use in another 
 twenty minutes of a third disc or ov. containing gr. ij^s 0/ Homatr opine 
 alone, the examination in that case being best niade between ninety and 
 one hundred and twenty minutes after using tlic first disc. The first two 
 discs containing Cocaine are sufficient to furnish the chief advantage 
 which in my opinion resides in thni alkaloid, viz : of increasing the 
 absorbing powers of the cornea for agents combined witli it, while tlic 
 increased dose of Homatropine produces a more thorough relaxation of 
 the ciliary muscle. 
 
 An eserine disc (gr. i/iooo) inserted tlie following morning will enable 
 the patient to do near work within an hour or two. 
 
 3. The discs should be inserted on the tip of a damp camcl's-hair brush 
 and should always be applied to the ocular conjunctiva at its inferior and 
 outer surface, the patient looking up and in, while the lower lid is drawn 
 down. Any adlierent or sticky gelatine may be easily wiped off the pal- 
 pebral edges with a damp cloth or a piece of wet absorbent cotton, before 
 making the examination. 
 
 In my preference for these discs over any solution of Atropial wish 
 to state that I do so only on the grounds of the quicker and more evanes- 
 cent cycloplegic action of the former. 
 
 / always use Atropia whenever I possibly can, and particularly if, 
 in my judgment, the patient would be benefited by ciliary rest, as many of 
 our cases are. But for the business man, the clerk, the book-keeper, the 
 doctor, the school teacher, et hoc genus omne ten days of ciliary or any 
 other kind of rest is usually impossible. It is with them either an exam- 
 ination for glasses of the optician-and-jewelry-store order or a transient 
 cycloplegia. 
 
 In the list of dangerous cycloplegics I would place Duboisin, Hyoscin 
 and Hyoscyamin. They are all, especially the last two, much prompter 
 
 (■k 
 
 M' 
 
 
h-i 
 
 and more fiercely active cycloplegics than Atropia or these discs. If 
 Hyoscin and Hyottcyamin arc used in solution and in doses strong enough 
 to insure ciliary paresis — i. e. in doses somewhat less tlian Atropia and 
 Duhoisin they are certain to produce toxic symptoms more or less pro- 
 nounced in about one quarter of the cases. If used at all they should be 
 instilled in the oculist's office, and in my experiments I found this to be 
 the only safe plan to pursue. 
 
 If this be done the refractive condition can be readily determined in 
 one day, the ciliary paresis passing off in from seventy-two to ninety-six 
 hours. Upon their cycloplcgic action single discs of Eserine have little 
 or no permanent effect. 
 
 ,^ Tropa-cocaine has, so far as my experiments went, no cycloplegic 
 advantages over Cocaine while its mydriatic action seemed to me to l)e 
 less than that of Cocaine. 
 
 I take pleasure in stating that the Discs used in my experiments were 
 made for me by Messrs. John Wykth & Brother, the well-known 
 Manufacturing Chemists of Philadelphia. 
 
 103 East Adams Street, Chicago.